A new perspective on concepts of asthma severity and control

Ultrasonographic Evaluation of the Fetal Thymic-Thoracic Ratio in Pregnant Women With Asthma

PURPOSE

To investigate the thymic-thoracic ratio (TTR) in pregnant women with asthma to determine whether fetal thymus size is affected in this condition.

METHODS

A total of 139 patients, 69 patients diagnosed with asthma and 70 controls were prospectively included in the study at a single tertiary center. Eighteen of the patients diagnosed with asthma experienced at least one asthma attack, while 51 patients did not have any asthma attacks during pregnancy. TTR was calculated from the anterior-posterior dimensions of the thymus and intrathoracic mediastinal measurements.

RESULTS

TTR was found to be statistically significantly lower in patients with asthma compared to the controls (p < 0.001). The rate of neonatal intensive care unit admission was higher and the TTR value was lower among the cases presenting with an asthma attack during pregnancy compared to patients without asthma attack and controls (p = 0.043 and p = 0.001, respectively). A statistical difference was found between patients with and without asthma attacks regarding the use of medication for asthma (p < 0.05).

CONCLUSION

The fetal thymus has been found to be affected in patients with asthma. The TTR is lower in patients who have asthma attacks during pregnancy and in patients taking medication for treatment, which may be related to chronic inflammatory process as well as to the use of exogenous steroids.

Corticosteroid prescription in children with respiratory symptoms: A real-life study

Asthma is one of the most common childhood diseases. Most children respond to low doses of corticosteroids and/or anti-leukotrienes. However, a small percentage remain symptomatic. They require high doses of inhaled corticosteroids (ICS) and anti-leukotrienes, sometimes with long-acting bronchodilators (LABA) and occasionally systemic corticosteroids (SC). However, we frequently observe that the only treatment they receive for exacerbations is short-acting beta-agonists (SABA) and oral corticosteroids (OC) without adding ICS as a maintenance treatment to prevent new episodes. This leads to frequent exacerbations, airflow limitation, and significant alterations in the quality of life. In addition, this results in high resource consumption, frequent emergency room visits, and school absenteeism, leading to absence from work for caregivers. A descriptive, retrospective, observational, and multicenter study was carried out on patients under 12 years of age, who attended pediatric allergy consultations for the first time. The main objective was to determine the consumption of SCs because of respiratory exacerbations in the year before the first consultation. Data were obtained from 144 children, 58.3% male, with a median age of 5 years. It was found that during the year before attending our clinic, 70% had perennial symptoms and were only prescribed with salbutamol on demand when they presented with respiratory symptoms. They had not been prescribed with ICS or anti-leukotrienes. They required attention in the emergency room of their nearest health center or hospital on an average of three times per year. During these exacerbations, almost 75% received SCs(prednisolone), with an average of 2.6 annual cycles (0-12) prescribed in more than half of the cases in the emergency room. In over 80% of the cases, the effects of SC abuse were not previously monitored. The overuse of SC in atopic children with respiratory symptoms was confirmed in our group, which requires considering behavioral changes.

Early clinical remission and its role in lung function decline and exacerbation in adult Korean patients with asthma

INTRODUCTION

Despite advancements in asthma management, many patients continue to experience poor disease control, lung function decline, and frequent exacerbations. Clinical remission (CR) has been proposed as a novel treatment target and surrogate marker for long-term outcomes. This study evaluates whether early CR at 1 year after inhaled corticosteroid (ICS) initiation influences lung function decline and exacerbation risk in asthma.

METHODS

This retrospective cohort study evaluated 492 asthma patients treated with ICS at two teaching hospitals. Patients were classified into early CR and non-early CR groups. Early CR was defined based on a composite set of criteria, including sustained absence of exacerbations, no systemic corticosteroid use, symptom control and stable or improved lung function in the first year following ICS initiation. Study outcomes were the annual forced expiratory volume in one second (FEV1) decline and the moderate-to-severe exacerbations.

RESULTS

Early CR was significantly associated with slower annual FEV1 decline (4-component CR, adjusted β=31.6 mL/year, p=0.001; 3-component CR, adjusted β=15.7 mL/year, p=0.043). The benefits of early 4-component CR on attenuating annual FEV1 decline were more pronounced in specific phenotypes, including type-2 high asthma, persistent airflow limitation, severe asthma and patients requiring add-on long-acting muscarinic antagonists. Early 4-component CR had a reduced risk of moderate-to-severe (adjusted HR (aHR)=0.591, p=0.011) and severe exacerbations (aHR=0.508, p=0.025).

CONCLUSIONS

Achieving CR within 1 year of ICS initiation was associated with improved lung function preservation and reduced exacerbation risk. These findings suggest the importance of achieving early CR as a clinical target in asthma management.

Association of obstructive sleep apnea risk with allergic asthma: A systematic review and meta-analysis

BACKGROUND

There is a close relationship between asthma and obstructive sleep apnea (OSA), and the mechanisms of these 2 diseases are overlapped. However, the relationship between OSA and allergic asthma remains to be analyzed through systematic review and meta-analysis.

METHODS

A systematic search was conducted using Scopus, PubMed, ISI, Google Scholar, and Cochrane Library by utilizing the keywords Allergic asthma, Obstructive sleep apnea, and OSA. Hazard ratio, odds ratio (OR), and risk ratio with 95% confidence interval, fixed and Mantel-Haenszel methods were calculated. Statistical software Stata was used for the evaluation of this meta-analysis.

RESULTS

Finally, 19 articles were included in this study. The prevalence of OSA in allergic asthma patients was 35.25% (19.92%, 50.57%), which was statistically significant, and pooled analysis of ORs observed in individual studies showed that the odds of OSA prevalence were 2.24 (1.32, 3.12) (P < 0.001). Also, the prevalence of OSA risk in allergic asthma patients was 30.08% (19.73%, 40.43%), which was statistically significant, and pooled analysis of ORs observed in individual studies showed that the odds of OSA risk were 3.46 (2.96, 4.94) (P < 0.001).

CONCLUSION

The present meta-analysis showed that the prevalence of OSA as well as the OSA risk in patients with asthma were significantly higher compared with healthy people.

Machine learning-based screening of asthma biomarkers and related immune infiltration

Introduction

Asthma has an annual increasing morbidity rate and imposes a heavy social burden on public healthcare systems. The aim of this study was to use machine learning to identify asthma-specific genes for the prediction and diagnosis of asthma.

Methods

Differentially expressed genes (DEGs) related to asthma were identified by examining public sequencing data from the Gene Expression Omnibus, coupled with the support vector machine recursive feature elimination and least absolute shrinkage and selection operator regression model. Gene Ontology (GO), Kyoto Encyclopedia of Genes and Genomes (KEGG), Gene set enrichment analysis and correlation analyses between gene and immune cell levels were performed. An ovalbumin-induced asthma mouse model was established, and eukaryotic reference transcriptome high-throughput sequencing was performed to identify genes expressed in mouse lung tissues.

Results

Thirteen specific asthma genes were obtained from our dataset analysis (LOC100132287, CEACAM5, PRR4, CPA3, POSTN, LYPD2, TCN1, SCGB3A1, NOS2, CLCA1, TPSAB1, CST1, and C7orf26). The GO analysis demonstrated that DEGs linked to asthma were primarily related to positive regulation of guanylate cyclase activity, gpi anchor binding, peptidase activity and arginine binding. The renin-angiotensin system, arginine biosynthesis and arginine and proline metabolism were the key KEGG pathways of DEGs. Additionally, the genes CEACAM5, PRR4, CPA3, POSTN, CLCA1, and CST1 expression levels were positively associated with plasma cells and resting mast cells. The mouse model revealed elevated nos2 and clca1 expression in the asthmatic mouse group compared with that in normal mice, which was consistent with the findings in asthmatic patients.

Discussion

This study identified new marker genes for the prediction and diagnosis of asthma, which can be further validated and applied clinically.

Supraventricular tachycardia diagnosis in asthma patients is associated with adverse health outcomes

INTRODUCTION

Supraventricular tachycardia (SVT) can occur during treatment of an acute asthma exacerbation. There are, however, no data on the long-term outcomes of children who are diagnosed with both asthma and SVT. This study aims to analyze the impact of SVT in asthmatic children on mortality and/or cardiac arrest, hypothesizing asthmatic subjects with SVT have increased mortality and/or cardiac arrest compared to asthmatic subject with no-SVT.

METHODS

This was a retrospective cohort study, utilizing the TriNetX© electronic health record (EHR) database that included asthmatic subjects 2-18 years of age. The study population was divided into two groups (subjects with SVT diagnosis and no-SVT diagnosis). Data related to demographics, diagnostic, procedural, and medication codes were collected. The primary outcome was any death and/or cardiac arrest in a patient after the first asthma diagnosis date.

RESULTS

This study included 91,066 asthmatic subjects (244 [0.27%] with SVT and 90,822 [99.73%] with no-SVT). Multivariable logistic regression analysis demonstrated that after controlling for demographic and clinical features, the odds of all-cause death and/or cardiac arrest after the first reported asthma exacerbation was significantly higher in asthmatic children with SVT compared to no-SVT (odds ratio [OR]: 4.30, confidence interval [CI]: 2.50-7.39, p < .001).

CONCLUSIONS

Our large nationwide EHR study suggests that asthmatic pediatric patients with documented SVT diagnosis at any point in their EHR may be at increased risk of adverse health outcomes compared to no-SVT. Further studies are needed to determine the factors contributing to the increased risk of mortality and/or cardiac arrest in children with asthma and SVT.

Prevalence, symptomatology and factors associated with asthma in adolescents aged 13-14 years from rural Sri Lanka: an analytical cross-sectional study

BACKGROUND

Asthma is the most common chronic disease affecting children. However, the epidemiology of asthma in adolescents from rural geographies is lacking.

METHODS

An analytical cross-sectional study was conducted in secondary schools located in the municipal council area of the rural district of Anuradhapura, Sri Lanka. Random sampling was used to select 32 grade 8 classes from 6 out of 9 schools. The prevalence and symptomatology of asthma were determined using the validated International Study of Asthma and Allergy in Childhood (ISAAC) questionnaire and asthma symptom control using the asthma control test (ACT) translated into Sinhalese.

RESULTS

The study sample consisted of 1029 participants aged 13-14 years, including 528 (51.3%) boys and 501 (48.7%) girls. The prevalence of wheeze ever, current wheeze and wheeze while playing was 32.6% (n=335), 23.7% (n=244) and 25.2% (n=259), respectively. The prevalence of parent-reported physician-diagnosed asthma was 19.0% (n=196; 95% CI 16.7 to 21.6). Severe asthma was reported by 157 (15.3%; 95% CI 13.1 to 17.6) adolescents. The independent factors associated with severe asthma were sleeping on a cloth laid on the floor instead of a bed (p<0.02, adjusted-OR 9.72; 95% CI 1.56 to 60.78), cooking using sawdust (p=0.04, adjusted-OR 8.71; 95% CI 1.10 to 68.69) eczema (p<0.01; adjusted-OR 7.39; 95% CI 3.34 to 16.39) and allergic rhinitis (p<0.01; adjusted-OR 5.50; 95% CI 3.80 to 7.98). While having a cemented floor in the house (p<0.04; adjusted-OR 0.68; 95% CI 0.47 to 0.99) was a protective factor. Poor control of asthma symptoms was detected in 29 (29.9%) adolescents which was associated with comorbid allergic rhinitis (p<0.01; unadjusted-OR 5.40; 95% CI 1.84 to 15.82).

CONCLUSION

Almost one in four adolescents had current wheeze, and 15.3% had severe asthma. Severe asthma was independently associated with allergic rhinitis, eczema, cooking using sawdust as fuel and sleeping on a cloth on the floor instead of a bed. Poor symptom control was found in 29.9% of severe asthmatics which was associated with comorbid allergic rhinitis.

Level of Compliance with Spanish Guideline Recommendations in the Management of Asthma

Objective

To describe the clinical management of asthmatic patients and the level of compliance with the Guía Española para el Manejo del Asma (GEMA, Spanish Guidelines for Asthma Management) in the influential al area of Virgen de la Victoria University Hospital, Málaga (Spain).

Materials and Methods

Descriptive, cross-sectional study in asthma patients from the Virgen de la Victoria University Hospital influential area, Málaga (Spain). Asthma Control Test (ACT) results, demographic and clinical characteristics, and GEMA indicators of quality asthma care were obtained from each participating patient.

Results

Two hundred and eighty-eight patients (64.2% woman, mean age 48.6 years) were included in the study. The evaluation of the level of compliance with the GEMA quality indicators showed that in 20.8% of the patients the diagnosis of asthma was confirmed by spirometry and bronchodilator test, and 52.5% of the patients with suspicion of allergic asthma performed a sensitization test. Among the smoker patients, 76.3% were recommended to stop smoking; 14.2% of the patients received a paper-based educational plan. Regarding asthma treatment, 92.3% of patients with persistent asthma received inhaled glucocorticoids (IGC). IGC and LABA were the most common treatments for asthma, used in combination (ICG + LABA) in 139 (48.3%) patients; 32.6% discontinued SABA treatment during the study period. Asthma was well controlled in 54.9% of the patients (ACT score ≥20), and 13.9% of the patients registered exacerbations during the previous year with a mean (SD) of 1.38 (0.74) events.

Conclusion

Most of the GEMA quality indicators of asthma care are not followed in real-world clinical practice. Specialists select the best option among the available treatments but there is an unmet need for training plans in other relevant aspects, such as diagnosis and/or disease monitoring.

Exploring the concept of disease control in chronic cough

Background

Disease control in chronic diseases is an overarching concept that reflects the degree to which the goals of therapy are met. However, to date, there is no consensus on the definition of disease control in chronic cough. This study aimed to provide a conceptual exploration of patient-reported cough control in chronic cough.

Methods

This research is comprised of two subanalyses. First, patients with chronic cough receiving care at referral clinics were evaluated. Correlation analyses were performed between patient-reported cough control (a 5-point Likert scale), cough-specific patient-reported outcomes (PROs) and generic health PRO scores. Second, a survey was conducted among patients with refractory chronic cough and physicians to identify factors pertinent to cough control.

Results

The analysis of 341 patients (mean age: 55.5±15.1 years; female: 66.6%) revealed that cough control rating was moderately correlated with cough severity visual analogue scale and Leicester Cough Questionnaire scores, while demonstrating weaker correlations with cough-associated throat symptoms, cough-related complications or general health-related quality of life (QoL). In the survey of patients and physicians, both groups considered certain factors, such as cough frequency, severity and impact on QoL, to be relevant to the concept of cough control. However, patients rated "need for cough rescue drug" notably higher than physicians.

Conclusion

Patient-reported cough control was associated with cough severity or impact on QoL; however, cough control may not be fully captured by conventional cough PRO measurement tools. Further studies are warranted to define the consensus and tools to measure disease control in chronic cough.

A Simulation Study of the Effect of Clinical Characteristics and Treatment Choice on Reliever Medication Use, Symptom Control and Exacerbation Risk in Moderate-Severe Asthma

INTRODUCTION

The relationship between immediate symptom control, reliever medication use and exacerbation risk on treatment response and factors that modify it have not been assessed in an integrated manner. Here we apply simulation scenarios to evaluate the effect of individual baseline characteristics on treatment response in patients with moderate-severe asthma on regular maintenance dosing monotherapy with fluticasone propionate (FP) or combination therapy with fluticasone propionate/salmeterol (FP/SAL) or budesonide/formoterol (BUD/FOR).

METHODS

Reduction in reliever medication use (puffs/24 h), change in symptom control scores (ACQ-5), and annualised exacerbation rate over 12 months were simulated in a cohort of patients with different baseline characteristics (e.g. time since diagnosis, asthma control questionnaire (ACQ-5) symptom score, smoking status, body mass index (BMI) and sex) using drug-disease models derived from large phase III/IV clinical studies.

RESULTS

Simulation scenarios show that being a smoker, having higher baseline ACQ-5 and BMI, and long asthma history is associated with increased reliever medication use (p < 0.01). This increase correlates with a higher exacerbation risk and higher ACQ-5 scores over the course of treatment, irrespective of the underlying maintenance therapy. Switching non-responders to ICS monotherapy to combination therapy after 3 months resulted in immediate reduction in reliever medication use (i.e. 1.3 vs. 1.0 puffs/24 h for FP/SAL and BUD/FOR, respectively). In addition, switching patients with ACQ-5 > 1.5 at baseline to FP/SAL resulted in 34% less exacerbations than those receiving regular dosing BUD/FOR (p < 0.01).

CONCLUSIONS

We have identified baseline characteristics of patients with moderate to severe asthma that are associated with greater reliever medication use, poor symptom control and higher exacerbation risk. Moreover, the effects of different inhaled corticosteroid (ICS)/long-acting beta agonist (LABA) combinations vary significantly when considering long-term treatment performance. These factors should be considered in clinical practice as a basis for personalised management of patients with moderate-severe asthma symptoms.

Management of Chronic Asthma in Adults

Asthma is characterized by chronic inflammation and respiratory symptoms such as wheezing and coughing. In the United States, it affects 25 million people annually. Chronic smokers, poor adherence to medications, incorrect use of inhalers, and overall poor asthma control are known risk factors that lead to poorly controlled chronic asthmatics. Although asthma is traditionally categorized by severity, treatment by primary care providers is guided by the Global Initiative for Asthma or the National Asthma Education and Prevention Program. As more research is available, shared decision-making between health care providers and patients will lead to improved outcomes in managing chronic asthma.

Development and validation of a new asthma questionnaire to help achieve a high level of control in school-age children and adolescents

BACKGROUND

Maintaining good asthma control minimizes the risk of exacerbations and lung function decline and is a primary goal of asthma management. The Japanese Pediatric Asthma Guidelines (JPGL) employs different classification criteria for control status from other guidelines, stressing a higher level of control. Based on JPGL, we previously developed a caregiver-completed questionnaire for assessing and achieving best asthma control in preschoolers. In this study, we aimed to develop a questionnaire for school-age children and adolescents.

METHODS

A working questionnaire comprising 14 items for patients and 34 items for caregivers was administered to 362 asthma patients aged 6-15 years and their caregivers. Separately, physicians filled out a questionnaire to determine JPGL-defined control. Logistic regression analysis was performed to construct a model to predict control levels using data from a randomly selected set of completed questionnaires from two-thirds of the subjects. Validation was performed using the remaining questionnaires.

RESULTS

A set of 7 questions, encompassing self-assessed control status at the time of the visit and in the past month, and nocturnal/early morning asthma symptoms for patients and frequency of asthma symptoms, dyspnea, rescue beta-agonist use, and asthma hospitalization for caregivers, were selected and the 7-item model showed a good statistical fit with AIC of 110.5. The model has been named the Best Asthma Control Test for School Children and Adolescents (Best ACT-S). Best ACT-S scores differed significantly in the hypothetical direction among the groups of different JPGL-defined control levels, step-up/down treatment decisions, and presence/non-presence of exacerbations in the previous year.

CONCLUSIONS

The Best ACT-S is a valid questionnaire for children/adolescents aiming for best asthma control.

Cost-effectiveness analysis of dupilumab versus omalizumab, mepolizumab, and benralizumab added to the standard of care in adults with severe asthma in Colombia

BACKGROUND

Cost-effectiveness studies evaluate health technologies and help choose treatments. The current study compared dupilumab to omalizumab, mepolizumab, and benralizumab in Colombian adults with severe uncontrolled type 2 asthma.

METHODS

Over a 5-year period, a Markov model was utilized to assess the costs of biological treatments and management of exacerbations, comparing various doses of exacerbations, comparing various doses of dupilumab, omalizumab, mepolizumab, and benralizumab as add-on treatments. It included a 5% annual discount rate per local HTA, and set willingness-to-pay at three times GDP per capita per quality-adjusted life year (QALY) in Colombia.

RESULTS

Dupilumab (200 mg) exhibited greater QALYs and reduced overall costs compared to mepolizumab (100 mg), benralizumab (30 mg), and omalizumab (450 mg and 600 mg), with the incremental cost-effectiveness ratio (ICER) per QALYgained being -$5.429, -$6.269, -$196.567 and -$991.007, respectively. Dupilumab had greater QALYs and costs versus omalizumab 300 mg (ICERof $200.653 per QALY, above the willingness-to-pay threshold of 3 × GDP per capita). Sensitivity analyses were consistent with base case results.

CONCLUSIONS

Dupilumab 200 mg was strongly dominant versus omalizumab 450 mg and 600 mg, mepolizumab 100 mg, and benralizumab 30 mg; however, cost-effectiveness was not demonstrated versus omalizumab 300 mg. These results could assist healthcare professionals in choosing an appropriate biologic for treating severe type 2 asthma.

Sleep and allergic diseases among young Chinese adults from the Singapore/Malaysia Cross-Sectional Genetic Epidemiology Study (SMCGES) cohort

BACKGROUND AND OBJECTIVE

Sleep disruption has been shown to affect immune function and thus influence allergic disease manifestation. The specific effects of sleep on allergic diseases, however, are less well-established; hence, in a unique population of young Chinese adults, we investigated the association between sleep and allergic disease.

METHODS

Young Chinese adults recruited from Singapore in the Singapore/Malaysia Cross-Sectional Genetic Epidemiology Study (SMCGES) were analyzed. We used the International Study of Asthma and Allergies in Childhood (ISAAC) protocol and a skin prick test to determine atopic dermatitis (AD), allergic rhinitis (AR), and asthma status. Information regarding total sleep time (TST) and sleep quality (SQ) was also obtained.

RESULTS

Of 1558 participants with a mean age of 25.0 years (SD = 7.6), 61.4% were female, and the mean total sleep time (TST) was 6.8 h (SD = 1.1). The proportions of AD, AR, and asthma were 24.5% (393/1542), 36.4% (987/1551), and 14.7% (227/1547), respectively. 59.8% (235/393) of AD cases suffered from AD-related sleep disturbances, 37.1% (209/564) of AR cases suffered from AR-related sleep disturbances, and 25.1% (57/227) of asthma cases suffered from asthma-related sleep disturbances. Only asthma cases showed a significantly lower mean TST than those without asthma (p = 0.015). Longer TST was significantly associated with lower odds of AR (OR = 0.905, 95% CI = 0.820-0.999) and asthma (OR = 0.852, 95% CI = 0.746-0.972). Linear regression analyses showed that lower TST was significantly associated with asthma (β =  - 0.18, SE = 0.076, p-value = 0.017), and AR when adjusted for AR-related sleep disturbances (β =  - 0.157, SE = 0.065, p-value = 0.016). Only sleep disturbances due to AR were significantly associated with a poorer SQ (OR = 1.962, 95% CI = 1.245-3.089).

CONCLUSIONS

We found that sleep quality, but not sleep duration was significantly poorer among AD cases, although the exact direction of influence could not be determined. In consideration of the literature coupled with our findings, we posit that TST influences allergic rhinitis rather than vice versa. Finally, the association between TST and asthma is likely mediated by asthma-related sleep disturbances, since mean TST was significantly lower among those with nighttime asthma symptoms. Future studies could consider using objective sleep measurements coupled with differential expression analysis to investigate the pathophysiology of sleep and allergic diseases.

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Physical Activity Enforces Well-being or Shame in Children and Adolescents With Asthma: A Meta-ethnography

Asthma symptoms and experiences of dyspnea challenge participation in physical activity (PA). Therefore, in-depth understanding of experiences with PA is essential. In this meta-ethnography, we synthesized published qualitative studies of experiences of children and adolescents with asthma that influenced, or limited, participation in PA. We followed Noblit and Hare's 7 phases of meta-ethnography. We searched relevant databases by December 18, 2023 for published peer-reviewed studies (Medline (OVID), Embase (OVID), PsycINFO (OVID), CINAHL (EBSCHOhost), SPORTDiscus (EBSCHOhost), SocINDEX (EBSCHOhost), and Social Science Citation Index (WoS)) and theses (ProQuest Nursing & Allied Health Source, ProQuest Healthcare Administration Database, and ProQuest Public Health Database). We conducted study selection and assessment of methodological quality and data extraction using Joanna Briggs Institute's methodology. Sixteen reciprocally related qualitative studies, representing experiences of 238 children and adolescents aged 4 to 18 years were included. We translated primary study concepts and findings into 3 themes covering relationships with others, emotions, and behaviors related to PA participation: (1) feeling related to and connected with friends and family in PA; (2) acquiring and managing new PA and asthma skills; and (3) enjoying PA and experiencing well-being. We also defined 3 themes covering aspects related to PA limitations: (4) feeling misunderstood and penalized in relation to PA; (5) experiencing nervousness, embarrassment, shame, and sadness during PA; and (6) withdrawing from PA due to asthma, environment, and/or socially imposed attitudes. The themes were synthesized into the following lines of argument: children and adolescents with asthma experience that PA enforces empathic/non-empathic relationships, vulnerability, and awareness; PA enhances resilient participation and well-being, or reinforces resignment to isolation and shame. From the outset of either relatedness or being penalized, youngsters with asthma either manage well and experience well-being, or experience shame and withdrawal.Registration: PROSPERO No. 164797.

Based on what parameters is safe to discontinuate inhaled corticosteroids in children with asthma?

OBJECTIVE

Remission of childhood asthma has not been widely studied. Patients in clinical remission continue to have some degree of bronchial hyperresponsiveness (BHR). The aim of this study was to investigate whether clinical parameters and lung function test are good parameters for discontinuation of inhaled corticosteroids (ICS) in asthmatic children, including patients with persistent BHR, as measured by the methacholine challenge test (MCT).

METHODS

One year after discontinuation of inhaled corticosteroids (ICS), MCT was performed in a group of 40 asthmatic children to confirm or exclude BHR. In all patients, ICS treatment was discontinued based on the same parameters: symptoms, spirometry, daily PEF, and negative bronchodilator test. After achieving complete asthma control for at least 6 to 12 months, ICS treatment was stepped down and discontinued. Clinical course and spirometry were followed up after ICS discontinuation.

RESULTS

Positive MCT was found in 50% of the patients. There was no statistically significant difference between the positive and negative MCT groups in age at initiation and discontinuation of ICS therapy, duration of ICS therapy, duration of stepping down period, FEV1, and PEF at the time of withdrawal of ICS and one year later. ICS treatment had to be restarted in two patients from the positive MCT group, due to recurrence of asthma symptoms.

CONCLUSION

Clinical parameters, normal spirometry, daily PEF values, and a negative bronchodilator test are good parameters for discontinuing ICS treatment in asthmatic children, even in patients with persistent BHR. Children should continue to be monitored, as symptoms may recur.

Brittle Asthma: Still on Board?

(1) Background: "Brittle Asthma" was considered an asthma clinical phenotype and deemed to be life-threatening in the early 2000s; then, this definition disappeared. The purpose of this review is to examine what has historically been referred to as this term and see whether it may be applied to modern clinical practice, thus acquiring fresh relevance and meaning. (2) Methods: A non-systematic search of the literature was conducted using both MeSH and free-text phrases. No limitations on the research design or type of publication were applied. (3) Results: Reliable data regarding "Brittle Asthma" are lacking due to the paucity of current data and the few studies available. After a few years of reworking, it was divided into two sub-classes: one characterized by a wide PEF variability despite high-dose therapy and the other by sudden acute attacks in otherwise apparently normal airway functions or well-controlled asthma. Their characteristics were hardly defined because of their low prevalence. Data regarding risk factors, atopy, mechanisms, and treatments were analyzed. (4) Conclusions: Over time, different terminology has been introduced to define asthma severity and control. It would be worth investigating whether the term "Brittle Asthma" previously used may be helpful to find new hints to stratify patients and improve disease management.

Determinants of physician assessment of chronic rhinosinusitis disease control using EPOS 2020 criteria and the importance of incorporating patient perspectives of disease control

BACKGROUND

We identify chronic rhinosinusitis (CRS) manifestations associated with how rhinologists assess CRS control, with a focus on patient perspectives (patient-reported CRS control).

METHODS

Fifteen rhinologists were provided with real-world data from 200 CRS patients. Participating rhinologists first classified patients' CRS control as "controlled," "partly controlled," and "uncontrolled" using seven CRS manifestations reflecting European Position Paper on Rhinosinusitis and Nasal Polyps (EPOS) CRS control criteria (nasal obstruction, drainage, impaired smell, facial pain/pressure, sleep disturbance, use of systemic antibiotics/corticosteroids in past 6 months, and nasal endoscopy findings) and patient-reported CRS control. They then classified patients' CRS control without knowledge of patient-reported CRS control. Interrater reliability and agreement of rhinologist-assessed CRS control with patient-reported CRS control and EPOS guidelines were determined.

RESULTS

CRS control classification with and without knowledge of patient-reported CRS control was highly consistent across rhinologists (κw  = 0.758). Rhinologist-assessed CRS control agreed with patient-reported CRS control significantly better when rhinologists had knowledge of patient-reported CRS control (κw  = 0.736 vs. κw  = 0.554, p < 0.001). Patient-reported CRS control, nasal obstruction, drainage, and endoscopy findings were most strongly associated with rhinologists' assessment of CRS control. Rhinologists' CRS control assessments weakly agreed with EPOS CRS control guidelines with (κw  = 0.529) and without (κw  = 0.538) patient-reported CRS control. Rhinologists classified CRS as more controlled than EPOS guidelines in almost 50% of cases.

CONCLUSIONS

This study directly demonstrates the importance of patient-reported CRS control as a dominant influence on rhinologists' CRS control assessment. Knowledge of patient-reported CRS control may better align rhinologists' CRS control assessments and treatment decisions with patients' perspectives.

Addressing therapeutic inertia for asthma biologics: Lessons from the KOFU study

Despite evidence-based guidelines and the availability of five biologics in Japan to treat severe asthma, approximately one-third of patients with severe asthma continue to have uncontrolled disease. This lack of appropriate evidence-based treatment is a complex issue resulting from therapeutic inertia, a lack of treatment intensification according to evidence-based guidelines for patients who are considered eligible but not receiving therapy, and is often driven by complex factors involving patients, physicians, and healthcare systems. The KOFU study, the largest cross-sectional Internet Survey for severe asthma in Japan, addressed potential barriers to starting biologic treatment and sought a solution for therapeutic inertia regarding asthma biologics. Although the burden of high medical costs is the largest barrier to initiating biologic treatment for patients, other important barriers were also revealed, including an incorrect perception of asthma severity or a poor recognition of the need for treatment intensification, a lack of proper communication with patients or a lack of confidence in the physicians, initiating biologics together with the complicated process of the insurance systems to ease the burden of high medical costs or strict criteria for the approval of biologics for health care insurance systems. Increased awareness and understanding of these barriers to biologic treatment may facilitate an optimal recommendation process to individualize treatment in patients with severe asthma.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Quality indicators in the rational management of severe asthma: A Spanish multidisciplinary consensus

AIM

Severe asthma is a complex, heterogeneous condition that can be difficult to control despite currently available treatments. Multidisciplinary severe asthma units (SAU) improve control in these patients and are cost-effective in our setting; however, their implementation and development can represent an organizational challenge. The aim of this study was to validate a set of quality care indicators in severe asthma for SAU in Spain.

METHODS

The Carabela initiative, sponsored by SEPAR, SEAIC, SECA and SEDISA and implemented by leading specialists, analyzed the care processes followed in 6 pilot centers in Spain to describe the ideal care pathway for severe asthma. This analysis, together with clinical guidelines and SEPAR and SEAIC accreditation criteria for asthma units, were used to draw up a set of 11 quality of care indicators, which were validated by a panel of 60 experts (pulmonologists, allergologists, and health-policy decision-makers) using a modified Delphi method.

RESULTS

All 11 indicators achieved a high level of consensus after just one Delphi round.

CONCLUSIONS

Experts in severe asthma agree on a series of minimum requirements for the future optimization, standardization, and excellence of current SAUs in Spain. This proposal is well grounded on evidence and professional experience, but the validity of these consensus indicators must be evaluated in clinical practice.

Comparison of Asthma Control among Children 5-18 Years of Age by Asthma Control Test Questionnaire of Global Initiative for Asthma 2017 (GINA-2017) Against Spirometry

OBJECTIVE

To compare asthma control by Asthma Control Test (ACT)/Childhood Asthma Control Test (cACT) Questionnaire of Global Initiative for Asthma 2017 (GINA-2017) against spirometry in children, 5-18 y of age, with asthma.

METHODS

A prospective observational study was conducted between July 2017 and March 2019 in pulmonology OPD of a tertiary care center. Children with asthma aged 5-18 y, falling under the inclusion criteria had spirometry and cACT/ACT questionnaire before starting inhaled corticosteroids. After 12 wk, symptom control was reassessed by ACT/cACT and spirometry. Chi-square/Fischer exact test and paired t-test/Mann-Whitney U test used for qualitative and quantitative data, respectively.

RESULTS

ACT/cACT pretreatment score was 12.76 (2.521), and at follow-up the score was 23.94 (1.941) (p < 0.001). Control by GINA increased from 2.04% to 91.84% at follow-up (p < 0.001). Significant improvement in forced expiratory volume in first second (FEV1), forced expiratory volume/forced vital capacity (FEV1/FVC), forced expiratory flow between 25 and 75% of FVC (FEF25-75) and peak expiratory flow rate (PEFR) between pretreatment and follow-up seen were -71.86%, 106.84%, 101.82%, and 97.51% vs. 82.2%, 109.55%, 110.38%, and 107.00%, respectively. Positive correlation between ACT/cACT and FEV1 (r = 0.26, p ≤ 0.05), PEFR (r = 0.30, p ≤ 0.05).

CONCLUSIONS

There is a good correlation of symptom control between ACT/cACT and spirometry with significant positive correlation for FEV1, PEFR.

Rudin R, Sulca Flores J, Goolkasian G, Sousa J, Rodriguez J, Lipsitz S, Foer D, K. Dalal A. Assessing Equitable Recruitment in a Digital Health Trial for Asthma

OBJECTIVE

This study aimed to assess a multipronged strategy using primarily digital methods to equitably recruit asthma patients into a clinical trial of a digital health intervention.

METHODS

We approached eligible patients using at least one of eight recruitment strategies. We recorded approach dates and the strategy that led to completion of a web-based eligibility questionnaire that was reported during the verbal consent phone call. Study team members conducted monthly sessions using a structured guide to identify recruitment barriers and facilitators. The proportion of participants who reported being recruited by a portal or nonportal strategy was measured as our outcomes. We used Fisher's exact test to compare outcomes by equity variable, and multivariable logistic regression to control for each covariate and adjust effect size estimates. Using grounded theory, we coded and extracted themes regarding recruitment barriers and facilitators.

RESULTS

The majority (84.4%) of patients who met study inclusion criteria were patient portal enrollees. Of 6,366 eligible patients who were approached, 627 completed the eligibility questionnaire and were less frequently Hispanic, less frequently Spanish-speaking, and more frequently patient portal enrollees. Of 445 patients who consented to participate, 241 (54.2%) reported completing the eligibility questionnaire after being contacted by a patient portal message. In adjusted analysis, only race (odds ratio [OR]: 0.46, 95% confidence interval [CI]: 0.28-0.77, p = 0.003) and college education (OR: 0.60, 95% CI: 0.39-0.91, p = 0.016) remained significant. Key recruitment barriers included technology issues (e.g., lack of email access) and facilitators included bilingual study staff, Spanish-language recruitment materials, targeted phone calls, and clinician-initiated "1-click" referrals.

CONCLUSION

A primarily digital strategy to recruit patients into a digital health trial is unlikely to achieve equitable participation, even in a population overrepresented by patient portal enrollees. Nondigital recruitment methods that address racial and educational disparities and less active portal enrollees are necessary to ensure equity in clinical trial enrollment.

A systematic review of questionnaires measuring asthma control in children in a primary care population

Several questionnaires are used to measure asthma control in children. The most appropriate tool for use in primary care is not defined. In this systematic review, we evaluated questionnaires used to measure asthma control in children in primary care and determined their usefulness in asthma management. Searches were performed in the MEDLINE, Embase, Web of Science, Google Scholar and Cochrane databases with end date 24 June 2022. The study population comprised children aged 5-18 years with asthma. Three reviewers independently screened studies and extracted data. The methodological quality of the studies was assessed, using the COSMIN criteria for the measurement properties of health status questionnaires. Studies conducted in primary care were included if a minimum of two questionnaires were compared. Studies in secondary or tertiary care and studies of quality-of-life questionnaires were excluded. Heterogeneity precluded meta-analysis. Five publications were included: four observational studies and one sub-study of a randomized controlled trial. A total of 806 children were included (aged 5-18 years). We evaluated the Asthma Control Test (ACT), childhood Asthma Control Test (c-ACT), Asthma APGAR system, NAEPP criteria and Royal College of Physicians' '3 questions' (RCP3Q). These questionnaires assess different symptoms and domains. The quality of most of the studies was rated 'intermediate' or 'poor'. The majority of the evaluated questionnaires do not show substantial agreement with one another, which makes a comparison challenging. Based on the current review, we suggest that the Asthma APGAR system seems promising as a questionnaire for determining asthma control in children in primary care.

Mild asthma: Lessons learned and remaining questions

Patients living with mild disease represent the largest proportion of asthma patients. There are significant challenges in proposing a definition that would best describe these patients, while also accurately identifying at-risk individuals. Current literature suggests considerable inflammatory and clinical heterogeneity within this group. Research has shown that these patients are at risk of poor control, exacerbations, lung function decline, and death. Despite conflicting data on its prevalence, eosinophilic inflammation appears to be a predictor of poorer outcomes in mild asthma. There is an immediate need to better understand phenotypic clusters in mild asthma. It is also important to understand factors that influence disease progression and remission, as it is evident that both vary in mild asthma. Guided by robust literature that supports inhaled corticosteroid-based strategies over short-acting beta-agonist (SABA) reliant regimens, the management of these patients has evolved considerably. Unfortunately, SABA use remains high in clinical practice despite strong advocacy from the Global Initiative for Asthma. Future mild asthma research should explore the role of biomarkers, develop prediction tools based on composite risk scores, and explore targeted therapies at least for at-risk individuals.

Benralizumab Effectiveness in Severe Eosinophilic Asthma with Co-Presence of Bronchiectasis: A Real-World Multicentre Observational Study

Introduction: The co-presence of bronchiectasis (BE) in severe eosinophilic asthma (SEA) is common. Data about the effectiveness of benralizumab in patients with SEA and BE (SEA + BE) are lacking. Aim: The aim of this study was to evaluate the effectiveness of benralizumab and remission rates in patients with SEA compared to SEA + BE, also according to BE severity. Methods: We conducted a multicentre observational study, including patients with SEA who underwent chest high-resolution computed tomography at baseline. The Bronchiectasis Severity Index (BSI) was used to assess BE severity. Clinical and functional characteristics were collected at baseline and after 6 and 12 months of treatment. Results: We included 74 patients with SEA treated with benralizumab, of which 35 (47.2%) showed the co-presence of bronchiectasis (SEA + BE) with a median BSI of 9 (7-11). Overall, benralizumab significantly improved the annual exacerbation rate (p < 0.0001), oral corticosteroids (OCS) consumption (p < 0.0001) and lung function (p < 0.01). After 12 months, significant differences were found between SEA and SEA + BE cohorts in the number of exacerbation-free patients [64.1% vs. 20%, OR 0.14 (95% CI 0.05-0.40), p < 0.0001], the proportion of OCS withdrawal [-92.6% vs. -48.6, p = 0.0003], and the daily dose of OCS [-5 mg (0 to -12.5) vs. -12.5 mg (-7.5 to -20), p = 0.0112]. Remission (zero exacerbations + zero OCS) was achieved more frequently in the SEA cohort [66.7% vs. 14.3%, OR 0.08 (95% CI 0.03-0.27), p < 0.0001]. Changes in FEV₁% and FEF_25-75% were inversely correlated with BSI (r = -0.36, p = 0.0448 and r = -0.41, p = 0.0191, respectively). Conclusions: These data suggest that benralizumab exerts beneficial effects in SEA with or without BE, although the former achieved less OCS sparing and fewer respiratory-function improvements.

Questions in Mild Asthma: An Official American Thoracic Society Research Statement

Background: Patients with mild asthma are believed to represent the majority of patients with asthma. Disease-associated risks such as exacerbations, lung function decline, and death have been understudied in this patient population. There have been no prior efforts from major societies to describe research needs in mild asthma. Methods: A multidisciplinary, diverse group of 24 international experts reviewed the literature, identified knowledge gaps, and provided research recommendations relating to mild asthma definition, pathophysiology, and management across all age groups. Research needs were also investigated from a patient perspective, generated in conjunction with patients with asthma, caregivers, and stakeholders. Of note, this project is not a systematic review of the evidence and is not a clinical practice guideline. Results: There are multiple unmet needs in research on mild asthma driven by large knowledge gaps in all areas. Specifically, there is an immediate need for a robust mild asthma definition and an improved understanding of its pathophysiology and management strategies across all age groups. Future research must factor in patient perspectives. Conclusions: Despite significant advances in severe asthma, there remain innumerable research areas requiring urgent attention in mild asthma. An important first step is to determine a better definition that will accurately reflect the heterogeneity and risks noted in this group. This research statement highlights the topics of research that are of the highest priority. Furthermore, it firmly advocates the need for engagement with patient groups and for more support for research in this field.

Management of Chronic Asthma in Adults

Asthma is characterized by chronic inflammation and respiratory symptoms such as wheezing and coughing. In the United States, it affects 25 million people annually. Chronic smokers, poor adherence to medications, incorrect use of inhalers, and overall poor asthma control are known risk factors that lead to poorly controlled chronic asthmatics. Although asthma is traditionally categorized by severity, treatment by primary care providers is guided by the Global Initiative for Asthma or the National Asthma Education and Prevention Program. As more research is available, shared decision-making between health care providers and patients will lead to improved outcomes in managing chronic asthma.

Asthma control among treated US asthma patients in Practice Fusion's electronic medical record research database

This study investigated burden of 'not well-controlled' asthma, overall and by Global Initiative for Asthma (GINA) Step, among treated asthma patients in Practice Fusion's research database. Asthma control (Asthma Control Test [ACT]) was stratified by GINA Step; prevalence ratios were estimated using Poisson regression with robust variance controlled for confounders. ACT scores ≤19 reflect not well-controlled; >19 reflect 'well-controlled' asthma. Of 15,579 patients, 30% had not well-controlled asthma at index date. The proportion of patients with not well-controlled asthma increased from GINA Step 1 (29%) to Step 5 (45%). Compared with Step 1, the proportion of patients with not well-controlled asthma was 0.87-times lower in Step 2, 1.10-times greater in Step 4, and 1.37-times greater in Step 5. Results suggest that despite available treatments, patients remain symptomatic across GINA Steps in real-world primary care and specialist outpatient practices, with incremental disease burden and unmet medical need in these populations.

The role of ferroptosis-related genes in airway epithelial cells of asthmatic patients based on bioinformatics

It has been reported that airway epithelial cells and ferroptosis have certain effect on asthma. However, the action mechanism of ferroptosis-related genes in airway epithelial cells of asthmatic patients is still unclear. Firstly, the study downloaded the GSE43696 training set, GSE63142 validation set and GSE164119 (miRNA) dataset from the gene expression omnibus database. 342 ferroptosis-related genes were downloaded from the ferroptosis database. Moreover, differentially expressed genes (DEGs) between asthma and control samples in the GSE43696 dataset were screened by differential analysis. Consensus clustering analysis was performed on asthma patients to classify clusters, and differential analysis was performed on clusters to obtain inter-cluster DEGs. Asthma-related module was screened by weighted gene co-expression network analysis. Then, DEGs between asthma and control samples, inter-cluster DEGs and asthma-related module were subjected to venn analysis for obtaining candidate genes. The last absolute shrinkage and selection operator and support vector machines were respectively applied to the candidate genes to screen for feature genes, and functional enrichment analysis was performed. Finally, a competition endogenetic RNA network was constructed and drug sensitivity analysis was conducted. There were 438 DEGs (183 up-regulated and 255 down-regulated) between asthma and control samples. 359 inter-cluster DEGs (158 up-regulated and 201 down-regulated) were obtained by screening. Then, the black module was significantly and strongly correlated with asthma. The venn analysis yielded 88 candidate genes. 9 feature genes (NAV3, ITGA10, SYT4, NOX1, SNTG2, RNF182, UPK1B, POSTN, SHISA2) were screened and they were involved in proteasome, dopaminergic synapse etc. Besides, 4 mRNAs, 5 miRNAs, and 2 lncRNAs collectively formed competition endogenetic RNA regulatory network, which included RNF182-hsa-miR-455-3p-LINC00319 and so on. The predicted therapeutic drug network map contained NAV3-bisphenol A and other relationship pairs. The study investigated the potential molecular mechanisms of NAV3, ITGA10, SYT4, NOX1, SNTG2, RNF182, UPK1B, POSTN, SHISA2 in airway epithelial cells of asthmatic patients through bioinformatics analysis, providing a reference for the research of asthma and ferroptosis.

Approaches to Management of Asthma: Guidelines for Stepped Care and Self-Monitoring

While the twentieth century brought rapid changes to the diagnosis and management of asthma, consensus guidelines did not exist until the mid-1980s. Over the subsequent four decades, guidelines evolved from expert-based recommendations to comprehensive, evidenced-based references. The main two guidelines to be discussed in this chapter are the expert panel reports (EPR) published by the United States National Heart, Lung, and Blood Institute (NHLBI) and the Global Strategy for Asthma Management and Prevention Report (GINA) published by the NHLBI and World Health Organization (WHO). While these guidelines both focus on evidence-based approaches to the diagnosis and management of asthma, there are significant differences in both organization and recommendations. Just as the introduction of evidence-based guidelines was revolutionary to asthma management over the last 20 years, we anticipate further development of recommendations specific to precision medicine based on ongoing cutting-edge clinical research.

Current expert opinion and attitudes to optimize telemedicine and achieve control in patients with asthma in post-pandemic era: The COMETA consensus

OBJECTIVE

To collect perspectives and explore consensus for expert recommendations related to asthma control and the use of telemedicine among professionals who manage patients with asthma.

DESIGN

A Delphi-like questionnaire was designed to analyse the level of agreement about several recommendations formulated by an expert scientific committee about asthma control and the use of telemedicine with this purpose. A dedicated scientific committee validated the questionnaire, which included questions about the participants' profile and the use of technological tools at a personal level or in clinical practice. The experts expressed their agreement with a Likert-scale of 9 values: 1-3 was considered no agreement, 4-6 neutral, and 7-9 agreement. A rate ≥70% with the same answer was considered consensus. SITE: The questionnaire was programmed and distributed as an internet-based survey.

PARTICIPANTS

A pre-selected sample of 75 experts with experience in telemedicine (pulmonology, allergology, family medicine, nursing and community pharmacy) responded to a Delphi-like questionnaire composed by six questions and 52 items.

INTERVENTIONS

Consultation was performed in two consecutive waves: the first wave was carried out from 12th of July to 8th of September of 2021; the second wave, from 25th of October to 12th of November of 2021.

MAIN MEASUREMENTS

Three questions about asthma control (actions for achieving or maintaining control of asthma at every visit, current problems that affect asthma control, and potential solutions to offset such problems), and three questions about the impact of telemedicine in asthma control (potential benefits of telemedicine, and potential reticence about telemedicine among both patients and healthcare professionals) were included.

RESULTS

From the 52 items inquired, 35 were agreed by consensus. The actions for achieving or maintaining control of asthma, the problems that affect asthma control, and their potential solutions were agreed by consensus. The potential benefits of telemedicine were validated by consensus. None of the potential reservations of patients about telemedicine were validated, while five out of 14 potential reservations of healthcare professionals were agreed by consensus.

CONCLUSIONS

The COMETA consensus provides a current picture of the main problems for achieving asthma control, the benefits and the reservations about the use of telemedicine in the Spanish setting, and offers solutions. A wide interest in implementing telemedicine has been observed, although current limitations need to be overcome.

Variables associated with asthma control among adult patients

Objective: Asthma is one of the most prevalent chronic diseases with a substantial impact on the health status of affected patients. Further research is necessary to identify factors contributing to poor asthma control. The current study aimed to investigate the factors associated with poor asthma control among adult asthmatic patients.Methods: In this case-control study, the Asthma Control Test (ACT) was translated into Arabic and distributed to adults with asthma attending two hospitals in Jordan to evaluate the degree of asthma control. The following variables were collected for each patient: sociodemographic information, comorbidities, appropriate use of inhaler technique, spirometric measurements, and medications use. Binary regression was used to evaluate factors associated with asthma control.Results: A total of 314 participants with a mean age of 51.47 years (±16.37) completed the study. ACT score had a mean of 16.68 (±4.86). The majority of asthmatic patients had insufficiently controlled asthma (64.6%). Binary regression results showed that previous respiratory infection history (p = 0.014, OR = 0.473 (95%CI 0.261-0.857)), higher exposure to irritants (p = 0.010, OR = 0.747 (95%CI 0.598-0.933)) decreased the odds of being in the controlled asthma group. Patients receiving inhaled corticosteroids (ICS) had higher odds of being in the controlled asthma group (p = 0.039, OR = 2.372 (95%CI 1.043-5.392)).Conclusions: The majority of asthma patients had insufficiently managed disease. The main factors that contributed to poor asthma control were respiratory infection history, increased exposure to asthma symptoms triggers, and ICS nonuse.

Derivation of asthma severity from electronic prescription records using British thoracic society treatment steps

Background:

Asthma severity is typically assessed through a retrospective assessment of the treatment required to control symptoms and to prevent exacerbations. The joint British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) guidelines encourage a stepwise approach to pharmacotherapy, and as such, current treatment step can be considered as a severity categorisation proxy. Briefly, the steps for adults can be summarised as: no controller therapy (Step 0), low-strength Inhaled Corticosteroids (ICS; Step 1), ICS plus Long-Acting Beta-2 Agonist (LABA; Step 2), medium-dose ICS + LABA (Step 3), and finally either an increase in strength or additional therapies (Step 4). This study aimed to investigate how BTS/SIGN Steps can be estimated from across a large cohort using electronic prescription records, and to describe the incidence of each BTS/SIGN Step in a general population.

Methods:

There were 41,433,707 prescriptions, for 671,304 individuals, in the Asthma Learning Health System Scottish cohort, between 1/2009 and 3/2017. Days on which an individual had a prescription for at least one asthma controller (preventer) medication were labelled prescription events. A rule-based algorithm was developed for extracting the strength and volume of medication instructed to be taken daily from free-text data fields. Asthma treatment regimens were categorised by the combination of medications prescribed in the 120 days preceding any prescription event and categorised into BTS/SIGN treatment steps.

Results:

Almost 4.5 million ALHS prescriptions were for asthma controllers. 26% of prescription events had no inhaled corticosteroid prescriptions in the preceding 120 days (Step 0), 16% were assigned to BTS/SIGN Step 1, 7% to Step 2, 21% to Step 3, and 30% to Step 4. The median days spent on a treatment step before a step-down in treatment was 297 days, whereas a step-up only took a median of 134 days.

Conclusion

We developed a reproducible methodology enabling researchers to estimate BTS/SIGN asthma treatment steps in population health studies, providing valuable insights into population and patient-specific trajectories, towards improving the management of asthma.

Level of asthma control and its determinants among adults living with asthma attending selected public hospitals in northwestern, Ethiopia: using an ordinal logistic regression model

Background

Asthma is a major public health challenge and is characterized by recurrent attacks of breathlessness and wheezing that vary in severity and frequency from person to person. Asthma control is an important measure of health outcomes of the patients with asthma and reflecting the impact of an illness and its treatment from the patient’s perspective. Therefore, this study assessed the asthma control levels and their determinants among adults living with asthma in selected public referral hospitals in northwestern Ethiopia.

Materials and method

A multicenter institutional-based cross-sectional study was conducted in North-western Ethiopia, from October to December 2021. A systematic random sampling technique was employed to recruit the study participants. Bi-variable and multivariable ordinal logistic regression was used to determine the independent predictors of asthma control levels. A p-value of < 0.05 was considered as statistically significant.

Result

A total of 409 patients were included in the final analysis. Asthma was controlled by 28.9% with 95%CI (24.7, 33.5) people who have asthma. Regarding the potential predictor of asthma control level, being male (AOR = 6.5, 95%CI (1.28, 32.44), Married (AOR = 3.62, 95%CI (1.28, 10.27), healthcare provider adherence to guideline usage (AOR = 8.4,95%CI (2.7, 26) and non-fuel users (AOR = 6.0, 95%CI (1.5, 22.5) were variables that increase asthma control. However, non-adherent to medication (AOR = 0.16, 95%CI (0.059, 0.48), low level of patient enablement (AOR = 0.19, (95%CI) (0.08, 0.49) and poor relationship with healthcare provider (AOR = 0.024,95%CI (0.02, 0.23) were variables that significantly decreased asthma control level.

Conclusion

The findings indicated that asthma control remains suboptimal in a large proportion of patients with asthma in the study setting. Socio-demographic, clinical, healthcare-related, and medication-related variables were significantly associated with asthma control. Therefore, our study highlights multifaceted interventions, including comprehensive asthma education along with an integrated treatment plan to improve asthma control and quality of life.

Documento de consenso de asma grave en adultos. Actualización 2022

Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.

Reducing short-acting beta-agonist overprescribing in asthma: lessons from a quality-improvement prescribing project in East London

BACKGROUND

Excess prescription and use of short-acting beta-agonist (SABA) inhalers is associated with poor asthma control and increased risk of hospital admission.

AIM

To quantify the prevalence and identify the predictors of SABA overprescribing.

DESIGN AND SETTING

A cross-sectional study using anonymised clinical and prescribing data from the primary care records in three contiguous East London boroughs.

METHOD

Primary care medical record data for patients aged 5-80 years, with 'active' asthma were extracted in February 2020. Explanatory variables included demography, asthma management, comorbidities, and prescriptions for asthma medications.

RESULTS

In the study population of 30 694 people with asthma, >25% (1995/7980), were prescribed ≥6 SABA inhalers in the previous year. A 10-fold variation between practices (<6% to 60%) was observed in the proportion of patients on ≥6 SABA inhalers/year. By converting both SABAs and inhaled corticosteroids (ICSs) to standard units the accuracy of comparisons was improved across different preparations. In total, >25% of those taking ≥6 SABAs/year were underusing ICSs, this rose to >80% (18 170/22 713), for those prescribed <6 SABAs/year. Prescription modality was a strong predictor of SABA overprescribing, with repeat dispensing strongly linked to SABA overprescribing (odds ratio 6.52, 95% confidence interval = 4.64 to 9.41). Increasing severity of asthma and multimorbidity were also independent predictors of SABA overprescribing.

CONCLUSION

In this multi-ethnic population a fifth of practices demonstrate an overprescribing rate of <20% a year. Based on previous data, supporting practices to enable the SABA ≥12 group to reduce to 4-12 a year could potentially save up to 70% of asthma admissions a year within that group.

Breathing Exercises for Asthma Patients in Specialist Care: A Multicenter Randomized Trial

Rationale

Moderate to severe asthma is associated with impaired asthma control and quality of life (QoL) despite access to specialist care and modern pharmacotherapy. Breathing exercises (BrEX) improve QoL in incompletely controlled mild asthma, but impact in moderate to severe asthma is unknown.

Objectives

To investigate the effectiveness of BrEX as adjuvant treatment on QoL in patients with uncontrolled moderate to severe asthma.

Methods

Adult patients with incompletely controlled asthma attending respiratory specialist clinics were randomized to usual specialist care (UC) or UC and BrEX (UC + BrEX) with three individual physiotherapist-delivered sessions and home exercises. Primary outcome was asthma-related QoL (Mini-Asthma Quality of Life Questionnaire [Mini-AQLQ]) at 6 months on the basis of intention-to-treat analysis. Secondary outcomes: Mini-AQLQ at 12 months, lung function, 6-minute-walk test, physical activity level, Nijmegen Questionnaire, Hospital Anxiety and Depression Scale, and adverse events. Repeated-measures mixed-effects models were used to analyze data. Poisson regression models were used to analyze adverse event incidence rate ratio.

Results

A total of 193 participants were allocated to UC + BrEX (n = 94) or UC (n = 99). UC + BrEX was superior in the primary outcome (adjusted mean change difference, 0.35; 95% confidence interval [CI], 0.07 to 0.62). Superiority in Mini-AQLQ was sustained at 12 months (0.38; 95% CI, 0.12 to 0.65). A minor improvement in Hospital Anxiety and Depression Scale depression score at 6 months favoring UC + BrEX (−0.90; 95% CI, −1.67 to −0.14) was observed. Asthma-related adverse events occurred similarly in UC + BrEX and UC participants: 14.9% versus 18.1% (P = 0.38).

Conclusions

BrEX as add-on to usual care improve asthma-related QoL in incompletely controlled asthma regardless of severity and with no evidence of harm.

Clinical trial registered with www.clinicaltrials.gov (NCT 03127059).

Challenges and recommendations for the management of asthma in the Middle East and Africa

Clinical presentation of asthma is variable, and its diagnosis can be a major challenge in routine health-care practice, especially in low-and-middle-income countries. The aim of asthma management is to achieve optimal asthma control and to reduce the risk of asthma exacerbations and mortality. In the Middle East and in Africa (MEA), several patient- and physician-related factors lead to misdiagnosis and suboptimal management of asthma. A panel of experts comprising of specialists as well as general health-care professionals met to identify challenges and provide recommendations for the management of asthma in MEA. The major challenges identified for diagnosis of asthma were lack of adequate knowledge about the disease, lack of specialized diagnostic facilities, limited access to spirometry, and social stigma associated with asthma. The prime challenges for management of asthma in MEA were identified as overreliance on short-acting β-agonists (SABAs), underprescription of inhaled corticosteroids (ICS), nonadherence to prescribed medications, and inadequate insurance coverage for its treatment. The experts endorsed adapting the Global Initiative for Asthma guidelines at country and regional levels for effective management of asthma and to alleviate the overuse of SABAs as reliever medications. Stringent control over SABA use, discouraging over-the-counter availability of SABA, and using as-needed low-dose ICS and formoterol as rescue medications in mild cases were suggested to reduce the overreliance on SABAs. Encouraging SABA alone-free clinical practice in both outpatient and emergency department settings is also imperative. We present the recommendations for the management of asthma along with proposed regional adaptations of international guidelines for MEA.

Caregiver-perceived neighborhood safety and pediatric asthma severity: 2017-2018 National Survey of Children's Health

OBJECTIVE

To examine the association between caregiver-perceived neighborhood safety and pediatric asthma severity using a cross-sectional, nationally representative sample.

STUDY DESIGN

Using data from the 2017-2018 National Survey of Children's Health, children aged 6-17 years with primary caregiver report of a current asthma diagnosis were included (unweighted N = 3209; weighted N = 3,909,178). Perceived neighborhood safety, asthma severity (mild vs. moderate/severe), demographic, household, and health/behavioral covariate data were collected from primary caregiver report. Poisson regression with robust error variance was used to estimate the association between perceived neighborhood safety and caregiver-reported pediatric asthma severity.

RESULTS

Approximately one-third of children studied had moderate/severe asthma. A total of 42% of children with mild asthma and 52% of children with moderate/severe asthma identified as Hispanic or non-Hispanic Black. Nearly 20% of children with mild asthma and 40% of children with moderate/severe asthma were from families living below the federal poverty level (FPL). Children living in neighborhoods perceived by their caregiver to be unsafe had higher prevalence of moderate/severe asthma compared to those in the safest neighborhoods (adjusted prevalence ratio: 1.34; 95% confidence interval: 1.04-1.74). This association was found to be independent of race/ethnicity, household FPL, household smoking, and child's physical activity level after adjusting for covariates.

CONCLUSIONS

Children living in neighborhoods perceived by their caregiver to be unsafe have higher prevalence of moderate or severe asthma. Further investigation of geographic context and neighborhood characteristics that influence childhood asthma severity may inform public health strategies to reduce asthma burden and improve disease outcomes.

Upsides and downsides of a telecounselling model of integrated asthma management between general practitioners and specialists

BACKGROUND

Asthma control, one of the most important goals in the management of asthmatic patients, requires good adherence to guidelines and support at a territorial level, in particular on the part of general practitioners (GPs). A territorial hospital alliance can become a strength in asthma management, where control by GPs can also be carried out through a spirometric examination.

METHODS

The realisation of a telecounselling model management of asthma between GPs and specialists was the aim of this study, to understand how to obtain good asthma control. A specific digital platform, the PneumoApp platform, was used for the insertion of clinical data and flow volume (F-V) curves, performed in asthmatic patients by GPs, and for the subsequent evaluation of these data by specialists.

RESULTS

GPs have shown to be able to perform a check-up of respiratory function well using a portable spirometer, but the analysis of the collected data showed that GP assessment of the severity level of asthma is incorrect in patients with moderate-severe asthma.

CONCLUSIONS

The effectiveness of a telecounselling collaboration between hospital and territory in the management of asthma patients can be improved by greater diffusion of the use of Global Initiative for Asthma (GINA) guidelines at a local level.

[Translated article] Spanish Asthma Management Guidelines (GEMA) v.5.1. Highlights and Controversies

In this fifth phase of development, the contents of the Spanish Asthma Management Guidelines (GEMA), which include versions 5.0 and 5.1, have undergone a thorough review. The aim here is to set the main changes in context. These could be summarized as follows: DIAGNOSIS: new FENO cut-off and severity classification based on treatment needed to maintain control; INTERMITTENT ASTHMA: a more restrictive concept and treatment extended to include a glucocorticoid/adrenergic combination as needed; MILD ASTHMA: glucocorticoid/adrenergic therapy as needed as an alternative in case of low therapeutic adherence to conventional fixed-dose steroids; SEVERE ASTHMA: readjustment of phenotypes, incorporation of triple therapy in a single inhaler, and criteria for selection of a biologic in severe uncontrolled asthma; OTHERS: specific scoring in childhood asthma, incorporation of certain organizational aspects (care circuits, asthma units, telemedicine), new sections on COVID-19 and nasal polyposis.

Clinical characteristics, cytokine profiles and plasma IgE in adults with asthma

Asthma is a disease with complicated network of inflammatory responses of cytokines and ImmunoglobulinE (IgE). The aim of this study was to explore the clinical characteristics, cytokine profile and plasma IgE in the Malaysian population. This is a cross-sectional study involving physician-diagnosed asthma patients (n = 287) recruited from the Chest Clinic, University of Malaya Medical Centre (UMMC). Blood (8 mL) was taken after consent was obtained. The peripheral blood leucocytes (PBL) were cultured in presence of a mitogen for 72 h to quantify cytokines [Interleukin-5(IL-5), Interleukin-9 (IL-9), Interleukin-12 Beta (IL-12ꞵ) and granulocyte-macrophage colony-stimulating factor (GM-CSF)] and plasma was used to quantify IgE levels with commercial ELISA kits. Results were compared against the same biomarkers in healthy subjects (n = 203). In addition, the amount of the biomarkers in the asthma patients were compared with their disease severity and clinical characteristics. Statistical tests in the SPSS software (Mann-Whitney U test and the Kruskal Wallis) were used to compare cytokine production and plasma IgE levels. The mean plasma IgE level was markedly higher (p < 0.0001) in asthmatics compared to controls. There were higher levels of IL-5, IL-9, IL-12ꞵ and GM-CSF (p < 0.0001) produced by cultured PBL from asthma patients compared to controls. However, our results did not expose a significant association between these cytokine levels and severity and clinical symptoms of asthma. However, there was a marked association between asthma severity and blood lymphocyte count [ꭓ²(2) = 6.745, p < 0.05]. These findings support the roles played by cytokines and IgE in the airway inflammation in asthma. The findings of this study provide new information about inflammatory cytokines in Malaysian asthma patients.

Newly diagnosed asthma in China: initial severity and changes over a 1-year management period

Background

There are no large sample, epidemiological data describing initial asthma severity and change. We used a large health care database to examine asthma severity at initial diagnosis, and the changes in severity over the first year of management.

Methods

The clinical data of patients diagnosed with asthma for the first time were collated from the SuValue electronic medical database. The following inclusion criteria were applied: (I) patients who were 14 years or older at the time of first diagnosis; (II) initial diagnosis occurred between Jan 2001 and Mar 2019; (III) patients were followed up for at least 12 months; (IV) patients had follow-up visits every 3 months. Disease severity at diagnosis and at each follow-up visit, medications prescribed were collated and analyzed.

Results

A total of 7,654 adult patients with newly diagnosed asthma from tertiary hospitals (26.38%) and secondary hospitals (73.62%), who were followed up for at least 12 months, were included in this retrospective analysis. Approximately 54% of patients were females and the largest age group was over 60 years old (37.66%). Nearly 16% of patients were moderate to severe asthma initially. The proportions of patients with moderate and severe asthma decreased during the first 6 months, and remained stable thereafter. At the end of the 1-year follow-up period, 2.7% of patients had severe asthma. Patients with mild asthma tended to continue to have mild asthma in the following 3 months (>76.19%). However, of the patients with mild or moderate asthma at 3 months, 92.85% and 75.1%, respectively, experienced maintenance and reduction in severity and had mild asthma by 12 months. 1.26% and 3.15% of patients with mild or moderate asthma, respectively, progressed to severe asthma by 12 months.

Conclusions

Patients with mild asthma did not progress but rather, remained stable with mild asthma over the year. A proportion of patients diagnosed with moderate and severe asthma remained stable over a 1-year period. Further studies should be conducted to examine the clinical features of newly diagnosed patients with severe asthma without reduction in severity in order to facilitate intensive treatment and reduce the disease burden for these patients.

Impact of Socioeconomic Status on Adult Patients with Asthma: A Population-Based Cohort Study from UK Primary Care

Introduction

Asthma morbidity and health-care utilization are known to exhibit a steep socioeconomic gradient. Further investigation into the modulators of this effect is required to identify potentially modifiable factors.

Methods

We identified a cohort of patients with asthma from the Optimum Patient Care Research Database (OPCRD). We compared demographics, clinical variables, and health-care utilization by quintile of the UK 2011 Indices of Multiple Deprivation based on the location of the patients’ general practice. Multivariable analyses were conducted using generalized linear models adjusting for year, age, and sex. We conducted subgroup analyses and interaction tests to investigate the impact of deprivation by age, sex, ethnicity, and treatment step.

Results

Our analysis included 127,040 patients with asthma. Patients from the most deprived socio-economic status (SES) quintile were more likely to report uncontrolled disease (OR: 1.54, 95% CI: 1.16, 2.05) and to have an exacerbation during follow-up (OR: 1.27, 95% CI: 1.13, 1.42) than the least deprived quintile. They had higher blood eosinophils (ratio: 1.03; 95% CI: 1.00, 1.06) and decreased peak flow (ratio: 0.95, 95% CI: 0.94, 0.97) when compared to those in the least deprived quintile. The effect of deprivation on asthma control was greater among those aged over 75 years (OR = 1.81, 95% CI: 1.20, 2.73) compared to those aged less than 35 years (OR: 1.22, 95% CI: 0.85, 1.74; p_interaction=0.019). Similarly, socioeconomic disparities in exacerbations were larger among those from ethnic minority groups (OR: 1.94, 95% CI: 1.40, 2.68) than white patients (OR: 1.24, 95% CI: 1.10, 1.39; p_interaction=0.012).

Conclusion

We found worse disease control and increased exacerbation rates among patients with asthma from more deprived areas. There was evidence that the magnitude of socioeconomic disparities was elevated among older patients and those from ethnic minority groups. The drivers of these differences require further exploration.