Personality profiles and breathlessness perception in outpatients with different gradings of asthma

Complaints of dyspnea and their associations with personality traits in patients referred to psychotherapy in a day hospital

BACKGROUND

Breathing difficulties are present in different medical conditions, yet seem to be underresearched in psychiatric patients.

AIM

Assessment of prevalence of dyspnea complaints and their associations with personality traits in patients with neurotic or personality disorders referred to psychotherapy.

METHODS

Retrospective chart review of medical records of 2450 patients with diagnoses F4-F6 (ICD-10). Analyses of associations between dyspnea reported in a symptom checklist SCL-O and pathological scores in the Neurotic Personality Questionnaire were carried out using univariate and multivariate regression analyses with ORs and 95%CI estimated with licensed STATISTICA 13 (StatSoftPL) software, and R version 4.1.0, RStudio version 1.4.1717 software.

RESULTS

Dyspnea was reported by 46.3% women and 36.6% men (14.5% and 10.1% respectively assessed it as severely burdensome). Univariate regression analysis revealed several significant associations between reporting dyspnea or its extreme intensity and pathological scores in the NPQ. Multivariate regression analyses in women confirmed the importance of impulsiveness and exaltation for dyspnea occurrence, and feeling of being dependent on the environment, demobilization, and narcissistic attitude for its extreme intensity. In men impulsiveness, sense of being in danger, irrationality, and ponderings were associated with the presence of dyspnea, and sense of being in danger and envy with its extreme intensity.

CONCLUSIONS

Complaints of dyspnea were pretty frequent. Several personality traits measured by the NPQ questionnaire were predictors of their occurrence and feeling of extreme burden.

Dissociating breathlessness symptoms from mood in asthma

It is poorly understood why asthma symptoms are often discordant with objective medical tests. Differences in interoception (perception of internal bodily processes) may help explain symptom discordance, which may be further influenced by mood and attention. We explored inter-relationships between interoception, mood and attention in 63 individuals with asthma and 30 controls. Questionnaires, a breathing-related interoception task, two attention tasks, and standard clinical assessments were performed. Questionnaires were analysed using exploratory factor analysis, and linear regression examined relationships between measures. K-means clustering also defined asthma subgroups. Two concordant asthma subgroups (symptoms related appropriately to pathophysiology, normal mood) and one discordant subgroup (moderate symptoms, minor pathophysiology, low mood) were found. In all participants, negative mood correlated with decreased interoceptive ability and faster reaction times in an attention task. Our findings suggest that interpreting bodily sensations relates to mood, and this effect may be heightened in subgroups of individuals with asthma.

The Impact of Tobacco Smoking on Adult Asthma Outcomes

Background: Tobacco smoking is associated with more severe asthma symptoms, an accelerated decline in lung function, and reduced responses to corticosteroids. Our objective was to compare asthma outcomes in terms of disease control, exacerbation rates, and lung function in a population of asthmatic patients according to their smoking status. Methods: We compared patients’ demographics, disease characteristics, and lung-function parameters in current-smokers (CS, n = 48), former-smokers (FS, n = 38), and never-smokers (NS, n = 90), and identified predictive factors for asthma control. Results: CS had a higher prevalence of family asthma/atopy, a lower rate of controlled asthma, impaired perception of dyspnea, an increased number of exacerbations, and poorer lung function compared to NS. The mean asthma control questionnaire’s (ACQ) score was higher in CS vs. NS and FS (1.9 vs. 1.2, p = 0.02). Compared to CS, FS had a lower rate of exacerbations, a better ACQ score (similar to NS), a higher prevalence of dyspnea, and greater lung-diffusion capacity. Non-smoking status, the absence of dyspnea and exacerbations, and a forced expiratory volume in one second ≥80% of predicted were associated with controlled asthma. Conclusions: CS with asthma exhibit worse clinical and functional respiratory outcomes compared to NS and FS, supporting the importance of smoking cessation in this population.

Cohort profile: he East London Health and Care Partnership Data Repository: using novel integrated data to support commissioning and research

PURPOSE

The East London Health and Care Partnership (ELHCP) Data Repository was established to support commissioning decisions in London. This dataset comprises routine clinical data for the general practitioner (GP)-registered populations of two London boroughs, Tower Hamlets and City and Hackney, and provides a rich source of demographic, clinical and health service use data of relevance to clinicians, commissioners, researchers and policy makers. This paper describes the dataset in its current form, its representativeness and data completeness.

PARTICIPANTS

There were 351 749 and 344 511 members of the GP-registered population in the two boroughs, respectively, for the financial year 2017/2018. Demographic information and prevalence data were available for 9 mental health and 15 physical health conditions. Prevalence rates from the cohort were compared with local and national data. In order to illustrate the health service use data available in the dataset, emergency department use across mental health conditions was described. Information about data completeness was provided.

FINDINGS TO DATE

The ELHCP Data Repository provides a rich source of information about a relatively young, urban, ethnically diverse, population within areas of socioeconomic deprivation. Prevalence data were in line with local and national statistics with some exceptions. Physical health conditions were more common in those with mental health conditions, reflecting that comorbidities are the norm rather than the exception. This has implications for integrated care. Data completeness for risk factors (eg, blood pressure, cholesterol) was high in patients with long-term conditions.

FUTURE PLANS

The data are being further cleaned and evaluated using imputation, Bayesian and economic methods, principally focusing on specific cohorts, including type II diabetes, depression and personality disorder. Data continue to be collected for the foreseeable future to support commissioning decisions, which will also enable more long-term prospective analysis as data become available at the end of each financial year.

Evaluation and Management of Difficult-to-Treat and Severe Asthma: An Expert Opinion From the Korean Academy of Asthma, Allergy and Clinical Immunology, the Working Group on Severe Asthma

Severe asthma (SA) presents in about 3%-5% of adult asthmatics and is responsible for over 60% of asthma-related medical expenses, posing a heavy socioeconomic burden. However, to date, a precise definition of or clear diagnostic criteria for SA have not been established, and therefore, it has been challenging for clinicians to diagnose and treat this disease. Currently, novel biologics targeting several molecules, such as immunoglobulin E, interleukin (IL)5, and IL4/IL13, have emerged, and many new drugs are under development. These have brought a paradigm shift in understanding the mechanism of SA and have also provided new treatment options. However, we need to agree on a precise definition of and its diagnostic criteria for SA. Additionally, it is necessary to explain the diagnostic criteria and to summarize current standard and additional treatment options. This review is an experts' opinion on SA from the Korean Academy of Asthma, Allergy, and Clinical Immunology, the Working Group on Severe Asthma, and aims to provide a definition of and diagnostic criteria for SA, and propose future direction for SA diagnosis and management in Korea.

Asthma

This review provides an evidence-based guide for the diagnosis, evaluation, and treatment of patients with asthma. It addresses typical questions that arise in the clinic-based care of patients with asthma and provides a basic and comprehensive resource for asthma care.

Mechanisms, measurement and management of exertional dyspnoea in asthma: Number 5 in the Series "Exertional dyspnoea" Edited by Pierantonio Laveneziana and Piergiuseppe Agostoni

Asthma is a heterogeneous condition, with dyspnoea during exercise affecting individuals to a variable degree. This narrative review explores the mechanisms and measurement of exertional dyspnoea in asthma and summarises the available evidence for the efficacy of various interventions on exertional dyspnoea. Studies on the mechanisms of dyspnoea in asthma have largely utilised direct bronchoprovocation challenges, rather than exercise, which may invoke different physiological mechanisms. Thus, the description of dyspnoea during methacholine challenge can differ from what is experienced during daily activities, including exercise. Dyspnoea perception during exercise is influenced by many interacting variables, such as asthma severity and phenotype, bronchoconstriction, dynamic hyperinflation, respiratory drive and psychological factors. In addition to the intensity of dyspnoea, the qualitative description of dyspnoea may give important clues as to the underlying mechanism and may be an important endpoint for future interventional studies. There is currently little evidence demonstrating whether pharmacological or non-pharmacological interventions specifically improve exertional dyspnoea, which is an important area for future research.

Personalising care of adults with asthma from Asia: a modified e-Dephi consensus study to inform management tailored to attitude and control profiles

REALISE Asia—an online questionnaire-based study of Asian asthma patients—identified five patient clusters defined in terms of their control status and attitude towards their asthma (categorised as: ‘Well-adjusted and at least partly controlled’; ‘In denial about symptoms’; ‘Tolerating with poor control’; ‘Adrift and poorly controlled’; ‘Worried with multiple symptoms’). We developed consensus recommendations for tailoring management of these attitudinal–control clusters. An expert panel undertook a three-round electronic Delphi (e-Delphi): Round 1: panellists received descriptions of the attitudinal–control clusters and provided free text recommendations for their assessment and management. Round 2: panellists prioritised Round 1 recommendations and met (or joined a teleconference) to consolidate the recommendations. Round 3: panellists voted and prioritised the remaining recommendations. Consensus was defined as Round 3 recommendations endorsed by >50% of panellists. Highest priority recommendations were those receiving the highest score. The multidisciplinary panellists (9 clinicians, 1 pharmacist and 1 health social scientist; 7 from Asia) identified consensus recommendations for all clusters. Recommended pharmacological (e.g., step-up/down; self-management; simplified regimen) and non-pharmacological approaches (e.g., trigger management, education, social support; inhaler technique) varied substantially according to each cluster’s attitude to asthma and associated psychosocial drivers of behaviour. The attitudinal–control clusters defined by REALISE Asia resonated with the international panel. Consensus was reached on appropriate tailored management approaches for all clusters. Summarised and incorporated into a structured management pathway, these recommendations could facilitate personalised care. Generalisability of these patient clusters should be assessed in other socio-economic, cultural and literacy groups and nationalities in Asia.

Development and Validation of an Attitudinal-Profiling Tool for Patients With Asthma

Purpose

To develop a profiling tool which accurately assigns a patient to the appropriate attitudinal cluster for the management of asthma.

Methods

Attitudinal data from an online survey of 2,467 patients with asthma from 8 Asian countries/region, aged 18-50 years, having had ≥2 prescriptions in the previous 2 years and access to social media was used in a discriminant function analysis to identify a minimal set of questions for the Profiling Tool. A split-sample procedure based on 100 sets of randomly selected estimation and validation sub-samples from the original sample was used to cross-validate the Tool and assess the robustness of its predictive accuracy.

Results

Our Profiling Tool contained 10 attitudinal questions for the patient and 1 GINA-based level of asthma control question for the physician. It achieved a predictive accuracy of 76.2%. The estimation and validation sub-sample accuracies of 76.7% and 75.3%, respectively, were consistent with the tool's predictive accuracy at 95% confidence level; and their 1.4 percentage-points difference set upper-bound estimate for the degree of over-fitting.

Conclusions

The Profiling Tool is highly predictive (>75%) of the attitudinal clusters that best describe patients with asthma in the Asian population. By identifying the attitudinal profile of the patient, the physician can make the appropriate asthma management decisions in practice. The challenge is to integrate its use into the consultation workflow and apply to areas where Internet resources are not available or patients who are not comfortable with the use of such technology.

Psychological characteristics of patients with asthma

INTRODUCTION

Psychological distress of patients with asthma may be reduced when they learned to live with their illness. Asthma can change the psychological and personality characteristics. We aim to investigate the psychological and personality characteristics of patients with asthma using MMPI (Minnesota Multiphasic Personality Inventory).

METHODS

Thirty-three adult patients with asthma (23 female and 10 male) and 20 healthy controls (14 females and 6 males) were enrolled in this study. Psychometric evaluation was made with the Turkish version of the MMPI. The patients were separated into two groups according to the duration of symptoms (recent-onset asthma < 10 years, long-standing asthma ≥10 years).

RESULTS

Patients with asthma compared with control group had significantly higher the rate of clinical elevation on depression, hysteria, psychasthenia and social introversion. Patients with recent-onset asthma compared with long-standing asthma have significantly higher the rate of clinical elevation on depression, hysteria, psychopathic deviate, psychasthenia and social introversion. MMPI mean t score in patients with recent-onset asthma was higher than patients with long-standing asthma. MMPI mean t score in patients with asthma was negatively associated with the symptom duration in multivariate model.

CONCLUSIONS

Patients with asthma have relatively more inactivity, anergia, guilt, pessimism, nonspecific physical complaints, irrational fears and introvert. Patients with long-standing asthma have less psychological distress, suggesting that learned to cope with his illness.

The Interpretation of Dyspnea in the Patient with Asthma

Physicians have noted dyspnea in severely ill asthmatic patients to be associated with fright or panic; in more stable patients dyspnea may reflect characteristics including lung function, personality and behavioral traits. This study evaluates the symptom of dyspnea in 32 asthmatic patients twice: first when acutely ill and again after an initial response to therapy. Spirometry was performed, dyspnea quantified (Borg scale), and panic assessed with a specialized measure of acute panic (the acute panic inventory (API)) in the 32 patients before and again after treatment. After treatment, questionnaires to evaluate somatization and panic disorder were also administered. When acutely ill, both the API and all spirometric measures (PEFR; FEV1; IC) correlated with dyspnea. Multiple linear regression showed that measures of the API, the peak expiratory flow rate, and female sex taken together accounted for 41% of dyspnea in acute asthma. After treatment, the API again predicted dyspnea while spirometric data did not. Those subjects who described themselves as having chronic panic disorder reported high grades of dyspnea after treatment also. We conclude that interpretations of the self-report of asthma differ between acutely ill and stable asthmatic patients.

Depression's influence on the Asthma Control Test, Japanese version

BACKGROUND

Depression has been linked to poorer asthma control in asthmatic patients. Although the Japanese version of the Asthma Control Test (ACT-J) is frequently used as a simple, practical evaluation tool in clinical care settings in Japan, knowledge regarding its efficacy for assessing asthma control in asthmatic patients with depression is limited. Thus, we retrospectively investigated cut-off values of the ACT-J for well-controlled asthma, and explored depression's influence on the test with a questionnaire survey.

METHODS

Data were analyzed on 1,962 adult asthmatic patients who had completed both the ACT-J and the Japanese version of the Patient Health Questionnaire-9 (J-PHQ-9) in 2008 questionnaire survey conducted by the Niigata Asthma Treatment Study Group. Patients were classified into low (LD: J-PHQ-9 score of 0-4) or high depression (HD: J-PHQ-9 score of 5-27) groups. In both groups, the efficacy of the ACT-J was confirmed. We then compared the optimal cut-off points for uncontrolled asthma in both groups by performing a receiver operating characteristic (ROC) analysis, using the original classification referred to the GINA classification as the "true" classification.

RESULTS

Cronbach's alpha in the LD and HD group was 0.808 and 0.740 respectively. In both groups, the sub-group with existence of work absenteeism or frequent attacks during the previous 12 months scored lower on the ACT-J. The area under the curve and optimal cut-off point for patients with LD and HD were 0.821 and 0.846, and 23 and 20 respectively.

CONCLUSIONS

The efficacy of the ACT-J was confirmed in depressive patients with asthma. Because asthma control as evaluated with the ACT-J can be worse than actual control under depressive states, physicians should also pay attention to a patient's depressive state at evaluation. Further investigations focus on the association between the ACT-J and depression are required.

Anxiety, depression and personality traits in severe, prednisone-dependent asthma

BACKGROUND

Anxiety and depression are prevalent in patients with asthma, and associated with more exacerbations and increased health care utilization. Since psychiatric intervention might improve asthma control, we examined whether patients with severe, prednisone-dependent asthma are at higher risk of these disorders than patients with severe non-prednisone dependent asthma or mild-moderate asthma, and whether they exhibit different personality traits.

METHODS

Sixty-seven adults with severe prednisone-dependent asthma, 47 with severe non-prednisone dependent and 73 patients with mild-moderate asthma completed the HADS depression and anxiety subscale and the NEO-FFI for personality traits. In addition, asthma duration, body mass index and FEV1 were measured.

RESULTS

The prevalence of clinically significant depressive symptoms (9% vs. 0 vs. 0%; p = 0.009) and anxiety symptoms (19% vs. 6.4 vs. 5.5%; p = 0.01), was higher in patients with severe, prednisone-dependent asthma than in patients with severe non-prednisone dependent or mild-moderate asthma. Patients with prednisone-dependent asthma were respectively 3.4 (95%CI: 1.0-10.8 p = 0.04) and 3.5 (95%CI: 1.3-9.6 p = 0.01) times more likely to have significant depression symptoms and 1.6 (95%CI: 0.7-3.7, p = 0.2) and 2.5 (95%CI: 01.1-5.5, p = 0.02) times more likely to have symptoms of anxiety than patients with severe non-prednisone dependent or mild-moderate asthma. There were no differences found in personality traits between the 3 groups.

CONCLUSION

Patients with severe, prednisone-dependent asthma have more often psychological distress as compared to patients with severe non-prednisone dependent or mild-moderate asthma.

The Asthma Control Test, Japanese version (ACT-J) as a predictor of Global Initiative for Asthma (GINA) guideline-defined asthma control: analysis of a questionnaire-based survey

BACKGROUND

The 2006 Global Initiative for Asthma (GINA 2006) guidelines emphasize the importance of evaluating the control rather than the severity of asthma. The Asthma Control Test (ACT) is well known to be an excellent tool for evaluating asthma control in the clinical setting. This study aimed to evaluate the ACT, Japanese version (ACT-J) as a predictor of asthma control as defined by the GINA 2006 guidelines in actual clinical practice.

METHODS

A cross-sectional analysis comparing the ACT-J score and GINA classification of asthma control among 419 patients of primary care physicians and specialists was performed using the data from a 2010 questionnaire-based survey conducted by the Niigata Asthma Treatment Study Group.

RESULTS

The optimal cut-off point of the ACT-J score for predicting GINA-defined asthma control was 23, with ACT-J scores of ≥23 and ≤22 predicting controlled and uncontrolled asthma with area under the receiver operating characteristics curve values of 0.76 [95% confidence interval (CI): 0.72-0.81] and 0.93 [95% CI: 0.90-0.97], respectively.

CONCLUSIONS

ACT scores of ≥23 and ≤22 are useful for identifying patients with controlled and uncontrolled asthma, respectively, as defined by GINA 2006, and the latter is more strongly predictive than the former. The reason for the higher cut-off point of the ACT-J relative to other versions of the ACT is unclear and warrants further investigation.

Dyspnea and emotional states in health and disease

Anxiety and depression can increase the intensity of dyspnea out of proportion to the impairment in cardiorespiratory function and may contribute to the degree of disability associated with dyspnea. The effect of anxiety/depression on the sensory and affective components of reported dyspnea in patients with respiratory disorders might be of particular importance in improving the accuracy of the diagnostic process. However, the exact cause-relationship between dyspnea and anxiety/depression are unclear. A multidimensional model of dyspnea subsuming sensory components (i.e. intensity and quality) and affective components has recently been proposed. Affective responses drive patients to seek treatment which can cause them to alter their lifestyle to avoid dyspnea. Brain imaging techniques help identify distinct cortical structures involved in processing the discrete components of dyspnea.

Psychiatric Factors in Asthma

Emotional factors are an obstacle in the diagnosis and management of asthma. This review discusses three problem patterns: negative emotions in relatively normal patients with asthma; patients presenting possible functional symptoms and; patients presenting asthma in conjunction with psychiatric deviations. Negative emotions influence the symptoms and management of asthma, even in relatively normal patients. Psychogenic symptoms appear normal, but culminate in functional symptoms in a minority of patients. Diagnosing and treating asthma in patients with comorbid asthma and psychiatric symptoms is very difficult. On the one hand, treating asthma may often be just treating the emotions. On the other hand, negative emotions make the treatment of asthma guesswork. Physicians should estimate emotional influences in their patients' symptoms for an optimal evaluation of medication efficacy. Assessment and analysis of emotional factors surrounding exacerbations seems essential, e.g. emotional precipitants of asthma and asthma-evoked negative emotions. Moreover, patients should be informed about stress-induced breathlessness and the consequences of overuse of bronchodilators. When patients present with atypical symptoms, or do not properly respond to asthma medication, functional symptoms should be suspected. Psychiatric analysis may often lead to the conclusion that symptoms have a functional basis. In patients with comorbid asthma and anxiety disorders, asthma should be the focus for treatment since difficult-to-control asthma often causes anxiety problems in the first place. Moreover, panic-like symptoms in asthma are often related to sudden onset asthma exacerbations. However, in patients with comorbid asthma and depression, depression should become the focus of treatment. The reason is that optimal treatment of depressive asthmatics is probably impossible. Special issues include specific problems with children, compliance problems, and physicians' dilemmas regarding the simultaneous treatment of asthma and psychiatric symptoms.

Dyspnea perception in asthma: role of airways inflammation, age and emotional status

OBJECTIVES

Dyspnea perception in asthmatics differs between subjects. Poor perception is usually associated with increased risk of asthma attack/exacerbation. The advanced stage of the disease and the presence of eosinophilic airways inflammation have been recently recognized as being responsible for poor dyspnea perception. However, few studies are available on this topic.

DESIGN

The aim of this study was to analyse the influence of inflammatory pattern, age and affective status on dyspnea perception in asthmatic subjects.

SUBJECTS AND INTERVENTIONS

Seventy-one consecutive asthmatic patients were recruited and underwent induced sputum, exhaled NO measurement and breath condensate collection. Perception of dyspnea was evaluated as a BORG-VAS/FEV(1) slope before and after the broncho-reversibility test and correlated with the stage of asthma, inflammatory markers, age and depression scale.

RESULTS

Dyspnea perception decreases with the worsening of asthma, with the advance of age and of depression status. Furthermore, airways inflammation plays a key role in the decline of dyspnea perception as proved by the negative correlation observed between inflammatory cells in sputum, exhaled pH and NO and BORG-VAS/FEV(1) slope.

CONCLUSIONS

The results of our study suggested that airways inflammation, depression status, advance age and severity of asthma influence dyspnea perception and suggest a straight control to identify and better manage poor preceptor asthmatics.

Desempenho de uma escala analógica visual legendada na determinação do grau de dispneia durante teste de broncoespasmo induzido por exercício em crianças e adolescentes asmáticos

OBJETIVO: Existe uma relação indireta entre a obstrução das vias aéreas em asma e a intensidade de falta de ar (dispneia). Uma escala visual analógica legendada de dispneia com escore de 0-3 pontos tem sido amplamente utilizada na avaliação da broncoconstrição, embora a percepção de tal obstrução seja muito variável. O objetivo deste estudo foi determinar se crianças e adolescentes são capazes de perceber a broncoconstrição aguda induzida por exercício (BAIE), bem como medir o poder discriminatório de uma escala visual analógica legendada de dispneia em relação à intensidade de BAIE. MÉTODOS: Estudo transversal com 134 crianças e adolescentes asmáticos que foram submetidos a um teste de broncoespasmo induzido por seis minutos de exercício em um cicloergômetro. A intensidade da dispneia foi determinada utilizando-se uma escala visual analógica legendada de dispneia antes de cada determinação de VEF1. A escala tem um escore de 0-3 pontos, com desenhos em uma sequência lógica variando entre "sem sintomas" e "dispneia grave". As variáveis foram determinadas no momento basal, assim como em 5, 10 e 20 minutos após o término do teste de exercício. A acurácia da escala de dispneia em detectar o grau de BAIE foi determinada através de curvas ROC para a queda de VEF1 após o exercício, usando pontos de corte de 10%, 20%, 30% e 40%. RESULTADOS: Dos pacientes selecionados, 111 completaram o estudo, e 52 (46,8%) apresentaram BAIE. A área sob a curva ROC progressivamente aumentou com o aumento do grau de broncoconstrição. CONCLUSÕES: Em crianças e adolescentes asmáticos, a acurácia desta escala de dispneia melhora com o aumento do percentual de queda em VEF1 após o exercício. Entretanto, o valor preditivo da escala é subótimo quando a porcentagem de queda em VEF1é menor.

Impact of comorbidities on asthma

Asthma is a common and serious illness with suboptimal outcomes of care. Epidemiological studies show certain comorbidities occurring more frequently than expected with asthma, with some being associated with poor control and a differential response to therapy options. This review summarizes the evidence of clinically important comorbidities, focusing on the best-explored conditions, including rhinitis and rhinosinusitis, anxiety and depression, obesity, gastroesophageal reflux, smoking and dysfunctional breathing. The evidence of epidemiological and pathophysiological associations for these comorbidities is explored, and the practical therapeutic implications are considered. Comorbidities are important for clinicians treating asthma as they may be markers of patients at risk of poor outcomes, they may point to specific effective treatment options and they are important to researchers as possible confounding factors in clinical trials.

Ethnic differences in perception of lung function: a factor in pediatric asthma disparities?

RATIONALE

Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non-Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process.

OBJECTIVES

To determine (1) if differences exist between Latino and non-Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes.

METHODS

Five hundred and twelve children, aged 7-16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use.

MEASUREMENTS AND MAIN RESULTS

Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non-Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity.

CONCLUSIONS

Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non-Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.

Perception of breathlessness by a 3-minute respiratory exerciser test predicts asthma exacerbations: a prospective cohort study

We prospectively evaluated the use of a simple 3-Minute Respiratory Exerciser Test (3MRET) that estimates perception of dyspnea to identify patients at risk of asthma exacerbations. A total of 146 stable asthmatics (42 under-perceivers, 69 normal perceivers, and 35 over-perceivers) received follow-up for 12 months. The mean (SD) unscheduled visits to doctors among under-, normal, and over-perceivers were 1.8 (1.2), 2.2 (1.8), and 3.1 (2.3), respectively (p = 0.008). The mean (SD) hospital admissions among the groups were 1.3 (0.5), 1.2 (0.6), and 1.7 (1.3), respectively (p = 0.026). Compared to normal perceivers, over-perceivers had increased risks of unscheduled visits (OD: 5.12; 95% CI = 1.59 to 16.47) and hospital admissions (OD: 0.31; 95% CI = 0.23 to 0.41), defined as > or =2 events in 12 months. The association between over-perceiver and unscheduled visits remained significant after adjusting for forced expiratory volume in 1 second (FEV(1)). Sensitivity and specificity of over-perceivers are 77% and 47%, respectively, for unscheduled visits and 37% and 78%, respectively, for hospital admissions, with significantly better area under ROC for unscheduled visits (0.67 [95% CI = 0.56 to 0.77]; p = 0.003) than for hospital admissions (0.58 [0.471 to 0.70]; p = 0.127). We conclude that the 3MRET may have a role in identifying asthmatic patients with over-perception of dyspnea at risk of clinically important asthma exacerbations.

Perception of airflow obstruction in patients hospitalized for acute asthma

BACKGROUND

Little is known about the perception of airflow obstruction in patients hospitalized for acute asthma.

OBJECTIVES

To evaluate patient perception of airflow obstruction at hospital discharge and at a 2-week follow-up visit and to determine whether symptom control and/or severity of airflow obstruction identified patients at risk for acute asthma after discharge.

METHODS

In a prospective cohort study of inner-city adults hospitalized for acute asthma from April 1, 2001, through October 31, 2002, symptom control (Asthma Control Questionnaire) and airflow obstruction (forced expiratory volume in 1 second [FEV1] percentage predicted) were evaluated at discharge and 2 weeks after discharge. We evaluated perception of airflow obstruction (symptom control vs FEV1 percentage predicted) and perception of change in airflow obstruction (change in symptom control vs percentage change in FEV1) between the 2 visits. Acute asthma after discharge was defined as an emergency department visit or hospitalization for asthma within 90 days of discharge.

RESULTS

In fifty-one participants, symptom control was not significantly associated with airflow obstruction at hospital discharge (P = .30), indicating poor perception of airflow obstruction. Among the 41 participants (80.4% of those enrolled) who completed the follow-up visit, change in symptom control was not significantly associated with change in airflow obstruction (P = .20), indicating poor perception of change in airflow obstruction. Greater airflow obstruction at follow-up (P = .02) and a smaller improvement in airflow obstruction (P = .03), but not symptom control, were associated with a higher risk of acute asthma after discharge.

CONCLUSIONS

Patients hospitalized for acute asthma have poor perception of airflow obstruction and change in airflow obstruction. Objective measurements of lung function should guide treatment decisions after discharge in this population.

Complementary therapy in asthma: inhaled corticosteroids and what?

PURPOSE OF REVIEW

For optimal asthma control, complementary strategies are advocated to cover several aspects of the disease. This mini-review highlights different complementary strategies with special focus on the combined use of inhaled corticosteroids (ICSs) and long-acting beta2 agonists and as an alternative, the combination of ICSs and antileukotrienes.

RECENT FINDINGS

New data show that combinations of ICSs/long-acting beta2 agonists or ICSs with antileukotrienes improve disease stability with concomitant control of the underlying airway inflammation. Moreover, there is some evidence that combination therapy may prevent some aspects of airway remodelling. The use of a fixed combination of both a reliever and a controller medication may have certain advantages compared with a fixed dose regime with as-needed separate reliever therapy. Alternatively, in some asthma phenotypes, such as combined allergic rhinitis and asthma syndrome, the combination of ICSs with antileukotrienes offers a complementary anti-inflammatory treatment in combination with controller effects on both airway compartments.

SUMMARY

This review compares different strategies of complementary therapy in asthma with special focus on how to achieve the best clinical control also aimed at controlling the underlying airway inflammation. We have chosen to focus on two major topics: the use of ICSs and long-acting beta2 agonists in two different strategies, that is, a symptom-driven versus a fixed symptom-preventive approach; and the use of ICSs with a long-acting beta2 agonist versus ICSs and a leukotriene receptor antagonist. What regime should be chosen is highly dependent on the individual phenotype and defined treatment goal.

Evaluating combination therapies for asthma: pros, cons, and comparative benefits

Combination therapies with inhaled corticosteroids (ICS) and either long-acting beta2 agonists (LABA) or leukotriene receptor antagonists (LTRA) are commonly used to help patients maintain control of their asthma. LABA and LTRA have different mechanisms of action and both provide complementary benefits when combined with ICS. This paper compares the two regimens based on recent clinical trial data, evaluates their efficacy on various clinical and quality of life outcomes, and discusses the importance of therapy choice in people with specific asthma phenotypes. The potential of new dosing strategies, including adjustable maintenance therapy and single-inhaler maintenance and reliever therapy is also reviewed. Given the variety of outcomes, phenotypes, and treatment strategies that must be considered, the importance of individualized management is emphasized.

Formulating an effective and efficient written asthma action plan

Written asthma action plans (WAAPs) are recommended by national and international guidelines to help patients recognize and manage asthma exacerbations. Despite this recommendation, many patients with asthma do not have a WAAP. In addition, WAAPs vary widely in their readability and usability. To promote issuance and patient use, the WAAP should clearly define the decision (action) points, expected response, and expected time of response. The WAAP should also be easily integrated into a physician's busy practice. Herein, we describe the key elements of an effective WAAP, including concise, detailed recommendations regarding asthma exacerbation recognition (patient self-monitoring) and treatment.

Achieving asthma control in practice: understanding the reasons for poor control

Achieving asthma control remains an elusive goal for the majority of patients worldwide. Ensuring a correct diagnosis of asthma is the first step in assessing poor symptom control; this requires returning to the basics of history taking and physical examination, in conjunction with lung function measurement when appropriate. A number of factors may contribute to sub-optimal asthma control. Concomitant rhinitis, a common co-pathology and contributor to poor control, can often be identified by asking a simple question. Smoking too has been identified as a cause of poor asthma control. Practical barriers such as poor inhaler technique must be addressed. An appreciation of patients' views and concerns about maintenance asthma therapy can help guide discussion to address perceptual barriers to taking maintenance therapy (doubts about personal necessity and concerns about potential adverse effects). Further study into, and a greater consideration of, factors and patient characteristics that could predict individual responses to asthma therapies are needed. Finally, more clinical trials that enrol patient populations reflecting the real world diversity of patients seen in clinical practice, including wide age ranges, presence of comorbidities, current smoking, and differing ethnic origins, will contribute to better individual patient management.

Differing reports of asthma symptoms in African Americans and Caucasians

OBJECTIVE

This pilot study explores the reported symptoms in African Americans and Caucasians with asthma.

METHODS

Asthma patients in an inner-city pulmonary clinic were given a brief questionnaire of asthma symptoms and the BORG scale, followed by spirometry.

RESULTS

African Americans were less likely to report nocturnal awakenings (67% vs. 100%; p = 0.037), complain of dyspnea (33% vs. 75%; p = 0.038), or experience chest pain (13% vs. 75%; p = 0.002) than Caucasians.

CONCLUSIONS

This is the first study to demonstrate that there are clinically significant differences in the reporting of asthma symptoms between African Americans and Caucasians.

Descriptors and perception of dyspnea in African-American asthmatics

OBJECTIVE

This study explores self-reported perception of asthma symptoms in African-Americans.

METHODS

Qualitative methodology was used to analyze the responses from African-Americans within focus groups from Nashville, Tennessee.

RESULTS

Common symptoms were chest tightness, "breathing problems," and wheeze. Less commonly reported symptoms included cough, chest pain, dizziness, sweating, and "short of breath." A single participant reported nocturnal wheezing.

CONCLUSIONS

This study provides insight into the descriptors and perception of asthma symptoms in African-Americans. Understanding the descriptors of symptoms and disease severity in African-American patients may lead to more accurate diagnosis, treatment, and reduced mortality within this high-risk population.

Adrenergic responsiveness: FEV1 and symptom differences in Whites and African Americans with mild asthma

Decision-making about inhaler use is, in part, determined by the ability of asthmatic patients to compare their symptoms over time and to recall the previous response to the bronchodilator during an episode of asthma. The perception of airway symptoms across varied ethnic and cultural groups are poorly understood. Study purpose was (1) to determine if African Americans and Whites with mild asthma could accurately perceive bronchodilation and (2) to identify the word descriptors they used to describe their breathing. Sixteen African American and 16 White patients (34.5 +/- 9.7 years old, mean+/-SD) with mild atopic asthma (FEV1 > or =70% predicted normal) were given increasing doses of an inhaled bronchodilator (Albuterol) after a methacholine challenge. Albuterol (180 microg) was given, by spacer, at 15 min intervals until the FEV1 increased < 5%. Borg, VAS, and Word Descriptors were collected at baseline and after each dose of Albuterol. Baseline FEV1 after Methacholine provocation was 1.94 +/- .39 L for African Americans and 2.13 +/- .70 L for Whites. After 180 microg and again after 360 microg Albuterol, FEV1 increased to 2.88 +/- 0.48 L for African Americans and 3.37 +/- 0.91 L for Whites. But after 540 microg Albuterol, FEV1 decreased significantly (16%) to 2.42 +/- 1.19 L for African Americans while increasing only slightly to 3.47 +/- 0.95 L for Whites. After this dose, 10/16 African Americans felt "tight at the base of throat" (p < 0.01); 7/16 felt "speech-voice-tight" (p < 0.03) suggesting persistent airway discomfort despite marked improvement in FEV1, Borg and VAS scores compared with baseline values. Word descriptors by African Americans' are a more reliable measure of airway symptoms compared to FEV1, Borg or VAS.

Dyspnea and symptom amplification in asthma

BACKGROUND

The severity of a patient's asthma and the intensity with which he describes his dyspnea do not correlate.

OBJECTIVES

There is an indirect relationship between airway function in asthma and the intensity of dyspnea; this relationship is found only when the measure of a patient's general tendency to exaggerate the intensity of any somatic symptom is considered simultaneously.

METHODS

Lung function, including spirometry (forced expiratory volume in 1 s, FEV(1)) and plethysmography (airway resistance, R(aw)), dyspnea (Borg scale score) and the tendency to exaggerate (the somatosensory amplification scale score, SSAS) have been quantified in 42 stable asthmatic patients.

RESULTS

There was no correlation between the Borg score and any spirometric or plethysmographic measure in these subjects. By contrast, there was a moderate correlation between the Borg score and the SSAS (r = 0.36, p = 0.03). However, when FEV(1) or R(aw) (abscissa) and Borg scores (ordinate) were converted to residuals, there was a moderate correlation between the residuals and the SSAS score (for FEV(1), r = 0.33 and p = 0.05; for R(aw), r = -0.36 and p = 0.03).

CONCLUSION

A physician may make a reasonable estimate of an asthmatic patient's lung function from the intensity of his complaint only if he - the physician - considers the patient's tendency to symptom amplify as well.

Is headache related to asthma, hay fever, and chronic bronchitis? The Head-HUNT Study

OBJECTIVES

To examine the relationship between migraine and nonmigrainous headache and asthma, hay fever, and chronic bronchitis in a large cross-sectional population-based study.

BACKGROUND

Associations between prevalence of migraine and asthma or allergy have been demonstrated in clinic-based and epidemiologic studies whereas studies on chronic bronchitis are scarce.

METHODS

A total of 51,383 subjects completed a headache questionnaire and constituted the "Head-HUNT" Study. Of these 50,401 (98.1%) answered the questions about asthma and chronic bronchitis, and 47,029 (91.5%) answered the question about hay fever. Associations were assessed in multivariate analyses, estimating prevalence odds ratios (ORs) with 95% confidence intervals (CI).

RESULTS

Both migraine and nonmigrainous headache were approximately 1.5 times more likely among those with current asthma, asthma related symptoms, hay fever, and chronic bronchitis than those without. The association increased with increasing headache frequency.

CONCLUSIONS

This large questionnaire-based study confirms that migraine and other headaches are associated with respiratory and allergic disorders. The magnitude of the association between headache and asthma, hay fever, and chronic bronchitis tended to be in the same order. Headache frequency seems to have a greater impact on the association with respiratory or allergic conditions than headache diagnoses. Whether it is a causal relationship is uncertain, but the results underline the importance of considering comorbid disorders among patients with frequent headache.

Perception of airway obstruction and airway inflammation in asthma: a review

Dyspnea has a multifactorial nature and the exact mechanism that causes breathlessness in asthma is not fully understood. There is compelling evidence that factors other than merely mechanical ones take part in the pathophysiology of breathlessness. Some recent reports attribute airway inflammation, which may contribute to the unexplained variability in the perception of dyspnea associated with bronchoconstriction. Eosinophil airway inflammation has been proposed as a determinant of breathlessness via mechanisms affecting either the mechanical pathways that control breathlessness or the afferent nerves involved in perception of dyspnea. In this review, data on the interrelation between inflammation and dyspnea sensation and the impact of treatment on dyspnea sensation are discussed. We conclude that regardless of whether mechanical or chemical inflammatory factors are involved, much variability in dyspnea scores remains unexplained.

The Use of Nebulized Opioids in the Management of Dyspnea: Evidence Synthesis

PURPOSE/OBJECTIVES

To analyze the evidence about the use of nebulized opioids to treat dyspnea using the Priority Symptom Management (PRISM) level-of-evidence framework and to make a practice recommendation.

DATA SOURCES

Computerized database and manual search for articles and abstracts that included experimental trials, chart reviews, and case studies.

DATA SYNTHESIS

20 articles with evaluable evidence were identified. Analysis was complex because of heterogeneous variables and outcome measures. A major limitation is small sample sizes. The majority of PRISM level I and II studies indicated unfavorable evidence.

CONCLUSIONS

Scientific data supporting the use of nebulized opioids to treat dyspnea in patients with chronic pulmonary disease, including malignancy, are lacking.

IMPLICATIONS FOR NURSING

Insufficient data identify a need for further research with random crossover designs involving larger samples that are stratified according to prior opioid use. Consistency of study variables should be emphasized.

A test of the symptom amplification hypothesis in patients with asthma

The present study sought to measure the accuracy of symptom reporting in patients with asthma by calculating the difference between a subjective rating of illness severity and an objective test of lung function (forced expiratory volume in 1 second). At issue was the hypothesis that self-reported "symptom amplification" or sensory awareness accounts for differences in the accuracy of symptom reporting. Spirometric examination was performed, and psychological tests of symptom amplification, emotional distress, and neuroticism were administered. Participants consisted of 42 consecutive patients seeking medical treatment of asthma. The disparity between symptom perception (assessed by a Borg scale) and a corresponding measure of lung capacity allowed us to identify patients who overreported their symptoms (amplifiers) along with those who underreported them (minimizers). After controlling for the effects of sex and psychological distress, a self-report measure of symptom amplification explained 15% of the variability in reporting accuracy. Related constructs such as somatization and neuroticism could not explain differences in reporting ability.

Symptom perception in childhood asthma: the role of anxiety and asthma severity

This study tested the relationship of anxiety and asthma severity to symptom perception. Eighty-six children diagnosed with mild or moderate asthma had symptom perception and pulmonary function measured throughout methacholine challenge (to induce bronchoconstriction). Higher trait anxiety was associated with heightened symptom perception (controlling for pulmonary function) at baseline. Greater asthma severity was associated with blunted symptom perception (controlling for pulmonary function) at the end of methacholine challenge and with a slower rate of increase in symptom perception across methacholine challenge. These results suggest that anxiety plays a role when children's symptoms are mild, whereas medical variables such as severity play a role in perception of changes in asthma symptomatology as bronchoconstriction worsens.

[Difficult asthma]

Difficult asthma is a major issue in pulmonary medicine today because of its cost for patients and society. Difficult asthma is asthma that remains uncontrolled despite optimal specialist management. The validity of the diagnosis must be reconsidered in these cases: associated or differential diagnoses may be involved in the lack of control, and it is always necessary to assess the patient's treatment adhesion. Sufficient time--at least a year--must be taken to get to know the patient and to meet the objectives set. The standard asthma therapies should be tested objectively. Severe asthma is the reality of difficult asthma that endures despite a reaffirmed diagnosis, optimal compliance and controlled comorbidities. Better knowledge is needed of the pathophysiology of these patients' asthma. Improved knowledge of these phenotypes will make it possible to develop innovative treatments. They will need to be validated in clinical research for subsequent use that is wider but more rational because targeted at phenotypes likely to benefit from them.

Breath-holding test in subjects with near-fatal asthma. A new index for dyspnea perception

RATIONALE

Identification of asthmatic subjects with low perception of dyspnea (POD) that are at higher risk of hospitalization, near-fatal and fatal asthma could improve their management.

OBJECTIVE

Create a simple procedure that facilitate the recognition of low POD.

METHODS

We enrolled near fatal asthma (NFA) subjects and a wide spectrum of non-NFA subjects. Each subject was asked to stop breathing at end-expiration. Dyspnea was assesssed by a modified Borg scale. To design the new index, we combined the Borg score at the end of the voluntary breath-holding maneuver with the airway limitation. The equation was as follows: FEV(1)/FVC%/(breath-holding time in seconds/final Borg score minus basal Borg score).

RESULTS

Eleven NFA subjects (4 females) aged 21-73yr and 55 non-NFA (14 severe, 18 moderate and 23 mild asthmatic subjects) completed the study. The threshold value of the index that could predict POD is <12. The mean (+/-sd) of the new index perception was significantly lower in NFA group (n=11; 5.21+/-3.59; vs. n=55; 13.67+/-11.08; P=0.006). This threshold value had 100% sensitivity and it best discriminated between mild and NFA groups. The negative likelihood ratio (when the index > or = 12) was zero. A result > or = 12 represented an almost null probability of poor POD.

CONCLUSION

The breath-holding test is simple and rapid. Its negative likelihood ratio was zero. Accordingly, a test result of 12 or greater might exclude the probability of poor perception of dyspnea in subjects with stable asthma.

The current status of asthma in Korea

A systematic review of English and Korean articles published between 1990 and 2004 and a search of database and various online resources was conducted to determine the prevalences, mortality rates, socioeconomic burden, quality of life, and treatment pattern of asthma in Korean adults and children. Asthma morbidity and mortality in Korea are steadily increasing. The prevalence of asthma in Korea is estimated to be 3.9% and its severity is often underestimated by both physicians and patients. Mortality resulting from chronic lower respiratory diseases including asthma increased from 12.9 to 22.6 deaths per 100,000 of the population between 1992 and 2002. Disease severity, level of control, and symptom state were all found to negatively impact the quality of life of asthmatics. Although international and Korean asthma management guidelines are available, familiarity with and implementation of these guidelines by primary care physicians remain poor.

Personality characteristics of asthma patients

INTRODUCTION

Asthma, similarly to other chronic conditions, is strongly influenced by psychological factors. Previous studies have not established the personality characteristics of adult asthma patients as compared to non-patients.

OBJECTIVES

To study the psychological characteristics of adult asthma patients in comparison to a pattern drawn up for the Portuguese population. To study the relationships between the personality and the severity and duration of the disease.

METHODS

Outpatients of the Immunallergology and Pulmonology units of the São João Hospital suffering from asthma responded to the Revised NEO Personality Inventory (NEO-PI-R). Patients with co-morbidity factors were not excluded. The doctor who attended them classified the severity of the asthma according to the Global Initiative for Asthma (GINA). Relationships between the personality and the severity/duration of the disease were analysed using the ANOVA models.

RESULTS

300 asthma patients aged between 17 and 79 were studied. Of these, 75% were female; the great majority had intermittent/light persistent asthma (71%); 17% had moderate persistent asthma and 12% had severe persistent asthma. The duration of the disease was less than 10 years in 34% and over 23 years in 35%. The asthma patients had higher Neuroticism scores (p < 0.001), with the other facets (except impulsiveness) equally high. All the remaining domains--Extroversion, Openness to Experience, Conscientiousness and Agreeableness--had lower scores than the control group (p < 0.001). Both Extroversion and Openness to Experience decrease with growth in the severity (p = 0.003; p = 0.009) and the duration of the disease (p = 0.006; p = 0.013). Neuroticism increases in tandem with the severity of the disease.

CONCLUSION

This study shows the predominance of Neurotic characteristics and lowered Extroversion, Openness to Experience, Agreeableness and Conscientiousness characteristics in asthmatics as compared to the general Portuguese population. Decreased Extroversion and Openness to Experience are observed as the severity and duration of the disease increase. Further studies are necessary to clarify the relationships between personality and the severity and duration of the disease.

Defining and investigating difficult asthma: developing quality indicators

BACKGROUND

There is no agreed definition of 'difficult asthma' or what investigations should be available to investigate these patients. Patients with difficult asthma remain symptomatic on high levels of treatment and are high users of medical resources.

AIM

To develop a set of quality indicators for the definition and investigation of difficult asthma.

METHOD

Modified RAND Appropriateness Method was used. An expert panel composed of nine hospital asthma specialists who run 'difficult' asthma clinics and were identified from a short list of key workers in the field. Indicators were rated as necessary to define and investigate difficult asthma.

RESULTS

Difficult asthma was defined as 'symptoms persisting beyond therapy consistent with step 4 of the British Thoracic Society (BTS) guidelines' (high dose inhaled corticosteroids and long acting beta(2)-agonists). Eighty-three indicators were identified (40 relating to definition and 43 relating to investigations). Of these 32 (39%) were rated as necessary: 7 out of 40 (18%) for defining difficult asthma and 23 out of 43 (53%) for investigations. Indicators of high medical resource usage were characteristic of the 'difficult' nature of the management of patient with difficult asthma. A framework for the investigation of these patients was created.

CONCLUSION

The listed performance indicators identify a range of requirements that are necessary to define difficult asthma. Targeting of real needs in this group of patients will lead to better patient care and reduction of 'waste' in provision of healthcare.

Cortical substrates for the perception of dyspnea

Dyspnea is a common, unpleasant, and impairing symptom in various respiratory diseases and other diseases. Despite growing understanding of the multiple peripheral mechanisms giving rise to dyspnea, little is known about the cortical mechanisms underlying its perception. The results of neuroimaging studies have shown that distinct brain areas process the dyspneic sensation, among which the anterior insular seems to be the most important. Based on the findings of the first relevant neuroimaging studies, this review describes the cortical structures associated with the perception of dyspnea. Moreover, similarities to the perception of pain are discussed, and implications for future research are provided.

Psychological implications of respiratory health and disease

The possibility that a subject's psychological status may influence respiratory sensations and that chronic respiratory disease may have psychological consequences has sparked great interest among clinicians and researchers. This paper reviews the existing research on the association between respiratory symptom perception and the psychological status and between chronic respiratory diseases, such as asthma and chronic obstructive pulmonary disease, and psychological disturbances. Moreover, it focuses on the role of stressful events in determining asthma exacerbations. The recent literature suggests that in patients with chronic respiratory diseases, the evaluation of breathlessness perception, psychological disturbances and the recording of any stressful events should be considered as relevant as the physical and functional assessment of respiration.