Asthma and adolescents: review of strategies to improve control

An Integrative Review of Yoga and Mindfulness-Based Approaches for Children and Adolescents with Asthma

PROBLEM

Asthma affects almost 15% of children in the United States. Despite the availability of treatments and educational methods, children with asthma continue to report an impaired quality of life, including symptoms of anxiety and inability to participate in physical activity. As complementary health approaches are becoming more popular and show promise in the management of many chronic diseases, the purpose of this integrative review is to examine the state of the science regarding popular complementary health approaches- yoga and mindfulness- for children and adolescents with asthma.

ELIGIBILITY CRITERIA

A comprehensive search of five databases for peer reviewed articles was performed to identify experimental and non-experimental studies. The search for each database was performed from the inception of each to January 2020 and limited to the English language. The search included terminology that addressed the concepts of "asthma", "yoga" and "mindfulness".

SAMPLE

A total of eleven articles met the criteria for review from the years 1991 to 2019.

RESULTS

Nine publications focused on the use of yoga in children and adolescents with asthma and two publications focused on mindfulness in adolescents with asthma.

CONCLUSIONS

Interventions involving either mindfulness or yoga may be effective in reducing stress and anxiety and improving quality of life and lung function in this population.

IMPLICATIONS

Mindfulness intervention studies in the pediatric and adolescent asthma population are warranted as are additional studies that include the use of yoga with skills in mindfulness in order to evaluate their physiological and psychological effects.

Physicians' perceptions of mobile technology for enhancing asthma care for youth

This study assessed physicians' receptivity to using mobile technology as a strategy in patient care for adolescents with asthma. Understanding physicians' perceived barriers and benefits of integrating mobile technology in adolescents' asthma care and self-management is an initial step in enhancing overall patient and disease outcomes. We conducted in-depth interviews with second- and third-year pediatric residents and attending physicians who oversee pediatric residents in training (N = 27) at an academic medical center in the southeastern United States. We identified both benefits from and barriers to broader use of mobile technologies for improving asthma outcomes in adolescents. Resident physicians demonstrated greater readiness for integrating these technologies than did attending physicians. Prior to adoption of mobile technologies in the care of adolescent asthma patients, barriers to implementation should be understood. Prior to widespread adoption, such systems will need to be evaluated against traditional care for demonstration of patient outcomes that improve on the current situation.

A randomised dose-ranging study of tiotropium Respimat® in children with symptomatic asthma despite inhaled corticosteroids

BACKGROUND

A considerable number of children with asthma remain symptomatic despite treatment with inhaled corticosteroids, resulting in significant morbidity, reduced quality of life, increased healthcare costs and lost school days. The aim of our study was to assess the efficacy, safety and tolerability of once-daily tiotropium Respimat® 5 μg, 2.5 μg and 1.25 μg add-on to medium-dose inhaled corticosteroids, with or without a leukotriene modifier, in children aged 6-11 years with symptomatic asthma.

METHODS

In this Phase II, double-blind, placebo-controlled, incomplete-crossover, dose-ranging study, patients were randomised to receive three of the four treatments evaluated: once-daily tiotropium Respimat® 5 μg, 2.5 μg or 1.25 μg or placebo Respimat®, in the evening during the 12-week (three × 4-week) treatment period.

RESULTS

In total, 76, 74, 75 and 76 patients aged 6-11 years received tiotropium Respimat® 5 μg, 2.5 μg, 1.25 μg and placebo Respimat®, respectively. For the primary end point (peak forced expiratory volume in 1 second measured within 3 hours post-dosing), the adjusted mean responses with tiotropium Respimat® 5 μg (272 mL), 2.5 μg (290 mL) and 1.25 μg (261 mL) were significantly greater than with placebo Respimat® (185 mL; p = 0.0002, p < 0.0001 and p = 0.0011, respectively). The safety and tolerability of all doses of tiotropium Respimat® were comparable with those of placebo Respimat®, with no serious adverse events and no events leading to discontinuation.

CONCLUSIONS

Tiotropium Respimat® add-on to medium-dose inhaled corticosteroids, with or without a leukotriene modifier, was efficacious in paediatric patients with symptomatic asthma and had comparable safety and tolerability with placebo Respimat®.

TRIAL REGISTRATION

ClinicalTrials.gov identifier NCT01383499.

Asthma coalition effects on vulnerable sub groups of children: the most frequent users of health care and the youngest

OBJECTIVE

To examine the impact of Allies Against Asthma, community-based coalitions working to improve asthma outcomes, on vulnerable children: those with the most urgent health care use and those of youngest age.

METHODS

Allies zip codes were matched with comparison communities on demographic factors. Five years of Medicaid data (n = 26,836) for significant health care events: hospitalizations, ED and urgent care facility visits, were analyzed. Longitudinal analyses using generalized estimating equations and proportional hazards models compared Allies and comparison group children.

RESULTS

In the two start-up years of Allies, odds of having a significant event were greater for Allies children than for comparison children (p < 0.05). During the third and fourth years when Allies activities were fully implemented, for frequent health care users at baseline, odds of an asthma event were the same for both Allies and comparison children, yet in the less frequent users, odds of an event were lower in Allies children (p < 0.0001). In the initial year of Allies efforts, among the youngest, the Allies children had greater odds than comparison children of an event (p < 0.01), but by the fourth year the Allies group had lower odds (p = 0.02) of an event. Hazard ratios over all years of the study for the youngest Allies children and most frequent baseline users of urgent care were lower than for comparison children (p = 0.01 and p = 0.0004).

CONCLUSION

Mobilizing a coalition of diverse stakeholders focused on policy and system change generated community-wide reductions over the long-term in health care use for vulnerable children.

Asthma medication adherence among urban teens: a qualitative analysis of barriers, facilitators and experiences with school-based care

OBJECTIVE

Teens with persistent asthma do not always receive daily preventive medications or do not take them as prescribed, despite established clinical guidelines. The purpose of this study was to understand urban teens' experiences with asthma management, preventive medication adherence and participation in a school-based intervention.

METHODS

Teens (12-15 years) with persistent asthma, and prescribed preventive medication, participated in a pilot study that included daily observed medication therapy at school and motivational interviewing. Semi-structured interviews occurred at final survey. Qualitative content analysis enabled data coding to identify themes.

RESULTS

Themes were classified as "general asthma management" or "program-specific." For general management, routines were important, while hurrying interfered with taking medications. Forgetfulness was most commonly linked to medication nonadherence. Competing demands related to school preparedness and social priorities were barriers to medication use. Independence with medications was associated with several benefits (e.g. avoiding parental nagging and feeling responsible/mature). Program-specific experiences varied. Half of teens reported positive rapport with their school nurse, while a few felt that their nurse was dismissive. Unexpected benefits and barriers within the school structure included perceptions about leaving the classroom, the distance to the nurse's office, the necessity of hall passes and morning school routines. Importantly, many teens connected daily medication use with fewer asthma symptoms, incenting continued adherence.

CONCLUSIONS

Teens with asthma benefit from adherence to preventive medications but encounter numerous barriers to proper use. Interventions to improve adherence must accommodate school demands and unique teen priorities. The school nurse's role as an ally may support teens' transition to medication independence.

A prospective examination of asthma symptom monitoring: provider, caregiver and pediatric patient influences on peak flow meter use

OBJECTIVE

This study examined whether provider, caregiver and child communication predicted peak flow meter (PFM) use one month later.

METHODS

Five practices, 35 providers and 296 children with persistent asthma and their caregivers comprised the study sample. Audio-recorded provider-caregiver-child communication during the baseline medical visit captured discussion of the PFM; and child and caregiver baseline interviews after the medical visit collected factors associated with PFM use. Child- and caregiver-reported PFM availability and use, and observed child use of PFM were collected one-month later in the family's home.

RESULTS

During the medical visit, provider communication about PFM use was infrequent (10% maximum) and child- or caregiver-initiated communication was nearly absent (0%-2%). Despite this, children demonstrated good use of the PFM one month later. Children were significantly more likely to perform at least six PFM steps correctly one month later when there was more communication about PFM during the medical visit. Few other factors predicted availability and use.

CONCLUSIONS

Few providers discussed use of a PFM; observed performance was predicted by having talked about it with the child's provider. Provider communication should be targeted in future interventions to improve asthma management skills.