Evidence-based asthma guidelines

Weekly self-measurement of FEV1 and PEF and its impact on ACQ (asthma control questionnaire)-scores: 12-week observational study with 76 patients

The “Asthma Control Questionnaire” (ACQ) is a very common questionnaire for assessing asthma control. This study compares different ACQ versions in a self-monitoring program over a 12-week period combining them with patients' self-measurements of peak expiratory flow (PEF) and forced expiratory volume in one second (FEV1). The objective was to test the feasibility of FEV1-self-measurements and to compare ACQ versions regarding possible additional information given by lung function. In this prospective multicenter observational study 100 adult asthma patients, recruited at six family practices and two pulmologists' private practices in Germany, completed the ACQ weekly, performing self-measurements of PEF and FEV1. Seventy-six patients were included into final analysis with only 3% missing values. Scores for all ACQ versions improved significantly (all P-values < 0.05) with reductions of 32% for ACQ5, 31% for ACQ6, 22% for ACQ7-FEV1, and 21% for ACQ7-PEF with high Pearson’s correlation coefficients of all scores (r between 0.96 and 0.99). ACQ7-FEV1 scores were significantly higher than others. Separated courses of lung function parameters showed nearly no change, but ACQ5 and ACQ6 as scores for symptoms and reliever medication improved constantly. ACQ5 and ACQ6 revealed higher percentages of patients classified as “controlled” than ACQ7-scores. In conclusion, with only a few missing data points, our results suggest feasibility of FEV1-self-measurements. Courses of symptom-related and lung function-related ACQ items differ clearly. Our results support the GINA recommendations to consider symptoms and lung function separately. FEV1-self-measurements for research purposes may be included with the ACQ, but in clinical practice seem to measure a different domain to symptomatic asthma control.

Lung function tests taken by patients at home is doable, but yields different information than self-reports of disease control. Christoph Werner and colleagues from the Technical University of Munich, Germany, tested the feasibility of collecting lung function data from patients who measured forced expiratory volume in one second by themselves. These same patients also completed the Asthma Control Questionnaire (ACQ), which describes symptom severity and medication use. Looking at data from 76 participants, the researchers found that people did well measuring forced expiratory volume in one second, but they could not say whether this test was superior to another metric of lung function that considers peak expiratory flow. The results also showed that symptom scores and lung function assays seem to capture different aspects of the disease, meaning they’re worth considering separately rather than lumping together in a single test.

Validation of asthma control questionnaire and risk factors affecting uncontrolled asthma among the Lebanese children's population

OBJECTIVES

To validate the Arabic version of the Asthma Control Test (ACT) in asthmatic children in Lebanon and identify risk factors that might affect asthma control in these children.

METHODS

This study, conducted between December 2015 and April 2016, included 300 children.

RESULTS

A high Cronbach's alpha was found for the full scale (0.959). The correlation factors between each item of the ACT scale and the whole scale ranged between 0.710 and 0.775(p < 0.001 for all items). Low mother's educational level as well as the history of asthma in the mother and the father would significantly increase the risk of uncontrolled asthma (p = 0.001; Beta = 1.862; p < 0.001; Beta = 3.534; p < 0.001; Beta = 1.885respectively). Cigarette smoking during breastfeeding and waterpipe smoking by the mother during pregnancy were both significantly associated with uncontrolled asthma (p = 0.005; Beta = 2.105 and p = 0.041; Beta = 2.325 respectively). The high mother's level of education was significantly associated with more asthma control (p = 0.008; Beta = -0.715).

CONCLUSION

The Arabic version of the asthma control questionnaire is a valid tool to use in pediatric patients in the Lebanese population to assess asthma control. Waterpipe smoking during pregnancy and cigarette smoking during breastfeeding, as well as the lower education level are risk factors for uncontrolled asthma. Spreading awareness among health care professionals, as well as reinforcing health education seem to be an important step toward a better asthma control.

Bronchodilator response as a hallmark of uncontrolled asthma: a randomised clinical trial

INTRODUCTION

The goal of this study is to determine whether bronchodilator (BD) response can be used as a reliable measure of asthma control by analyzing the effects of a short course of oral corticosteroids (OC) or placebo (P) on spirometry, sputum cytology and BD response in controlled asthma patients scoring less than 1.5 on the ACQ5.

METHODS

Seventy patients with moderate to severe asthma who were undergoing combination therapy and were considered to be controlled based on ACQ5 scores, but who exhibited persistent positive BD response, were randomly assigned to two groups, one receiving OC and the other P. Patients were evaluated before and after 2 weeks of treatment. Intervention response (comparison of FEV(1) before and after OC or P treatment) was used as a measure of intervention efficacy, with values equal to or greater than 200 mL considered positive.

RESULTS

Patients who received OC showed significant improvement in FEV(1), and no longer exhibited a positive BD response. Those in the P group showed no change. In addition, sputum eosinophil counts significantly decreased in the OC group.

CONCLUSIONS

BD response can be used as a reliable measure of asthma control. This study suggests that ACQ5 scores alone are not sufficient to fully assess asthma control, and that BD response should be included as an essential measurement in any algorithm of asthma control evaluation.

Towards excellence in asthma management (TEAM): a populational disease-management model

Asthma management is not always optimal, and deficiencies such as inadequate treatment and insufficient patient education are often reported. Towards Excellence in Asthma Management (TEAM) is a four-phase disease management program of the Quebec Asthma Education Network (QAEN), to be carried out over a 5-year period. The program aims to achieve a continuous improvement of asthma management by caregivers and patients. The first phase, completed in January 2000, consisted of determining the actual level of asthma-associated morbidity and mortality in various Quebec regions. The second phase, which began in September 1999, included three parts: 1. Definition of the burden of asthma, taking into account the socioeconomic consequences of the disease and the quality of life of the patients, 2. Comparison of current medical practices with the Canadian Asthma Consensus Guidelines for adult and pediatric populations, 3. Evaluation of the level of compliance with medical treatment and with the environmental changes recommended to asthmatic patients. This phase is carried out via a cohort study of physicians, mainly general practitioners and pediatricians, generating a patient cohort study, in addition to substudies evaluating specific aspects of asthma care. Once the care gap is identified, it will be possible to define, apply, and evaluate a series of interventions for physicians, other health professionals, and patients. The interventions will be particularly targeted at regions where asthma incidence and morbidity are higher. We hope that this model of disease management will progressively reduce the burden associated with asthma, and potentially other chronic diseases, and will result in the more effective use of health services.

Risk factors for near-fatal asthma. A case-control study in hospitalized patients with asthma

We prospectively recruited patients admitted to the hospital with severe asthma to comprehensively evaluate the association of historical and physiologic features with the risk of near-fatal asthma (NFA). A case-control study design was used. All patients admitted with NFA (cases) were identified prospectively and compared with asthma patients admitted during the same period without respiratory failure (controls). Nineteen cases (age: 40.2 +/- 12.0 yr) (mean +/- SD) and 80 controls (age: 36 +/- 13.5 yr) were enrolled. Duration of asthma, gender, smoking status, ethnicity, and prevalence of atopy were similar in the case and control groups. More than 80% of patients in both groups reported worsening symptoms for more than 48 h before admission, and more than 50% were worse for longer than 7 d. There was no difference in degree of airways obstruction or bronchial hyperresponsiveness (PC20). Perception of dyspnea was similar in the cases and controls, but among cases the males had greater impairment than the females (Borg score: 1.9 +/- 1. 4 versus 3.9 +/- 1.2: p = 0.05). Univariate analysis identified a history of previous mechanical ventilation (OR: 27.5; 95% CI: 6.60 to 113.7), admission to the intensive care unit (ICU) (OR: 9.9; 95% CI: 3.0 to 32.9), history of worse asthma during January and February (OR: 3.5; 95% CI: 1.0 to 11.8), and use of air-conditioning (OR: 15.0; 95% CI: 1.3 to 166) as risk factors for NFA. Of concern was the dependence of most patients (59.8%) on the emergency department (ED) for initial care, and the small number of cases (16%) in which patients visited a physician before admission to the hospital. We have confirmed risk factors identified previously in retrospective studies of fatal and NFA, and have also shown that hospitalized patients with asthma, irrespective of severity of their asthma, share several characteristics, especially in terms of their failure to respond to worsening asthma.

A randomized trial comparing peak expiratory flow and symptom self-management plans for patients with asthma attending a primary care clinic

Great emphasis is placed on educating asthmatics to use action plans to achieve better control of symptoms. The use of peak flow meters (PFM) has been recommended as an important part of self-management plans. We studied 92 (47 F) adult patients with asthma in a primary care setting to compare the effectiveness of action plans using either peak flow monitoring or symptoms to guide self-management. Each patient was instructed in the use of the action plan in the context of a 6-mo asthma education program taught by a nurse. Patients were already using inhaled corticosteroids or were newly prescribed corticosteroids by their family physician. Forty-four patients were randomized to the PFM group and 48 to the symptoms group. Spirometry, symptom scores, quality of life, medication use, and measures of health care utilization and morbidity (emergency department visits, hospitalizations, unscheduled doctor visits, and days lost from work or school) were recorded at baseline and throughout the study period. PC20 methacholine was measured at the first and at the final visits. There were significant improvements within groups for FEV1, symptoms score, PC20 methacholine, and quality of life, but no between-group differences. A significant shift from higher to lower daily use of beta-agonists (p < 0.008 for both groups) and significant shifts to higher daily doses of inhaled steroids (p < 0.001) occurred in each group. Adherence to the self-management plans was only 65% in the PFM group and 52% in the symptoms group. Outcomes for health care utilization were similar except for fewer patients making unscheduled doctor visits within the PFM group. Our findings show that education, regular follow-up, and an action plan are effective in improving asthma control and quality of life, but the routine use of PFM to guide interventions is not the only way to accomplish these objectives.

Roxithromycin, clarithromycin, and azithromycin attenuate the injurious effects of bioactive phospholipids on human respiratory epithelium in vitro

The effects of the bioactive phospholipids (PL), platelet-activating factor (PAF), lyso-PAF, and lysophosphatidylcholine (LPC) on the beat frequency and structural integrity of human ciliated respiratory epithelium were studied in vitro, in the presence or absence of polymorphonuclear leukocytes (PMNL), the antimicrobial agents, roxithromycin, clarithromycin, and azithromycin and the antioxidative enzymes catalase and superoxide dismutase (SOD). All three PL caused dose-dependent slowing of ciliary beat frequency (CBF) and epithelial damage (ED) at concentrations > or = 1 microgram/ml, which were unaffected by inclusion of the antimicrobial agents and antioxidative enzymes. When epithelial strips were exposed to the combination of PMNL and PL, there was significant potentiation of ciliary dysfunction and ED, which was ameliorated by pretreatment of the PMNL with the antimicrobial agents or by inclusion of catalase, but not SOD. These results demonstrate that LPC, PAF, and lyso-PAF cause epithelial damage by direct mechanisms which are oxidant-independent, as well as by indirect mechanisms involving phagocyte-derived reactive oxidants. Macrolides and azalide antimicrobial agents may have beneficial effects on airway inflammation in asthma and microbial infections by protecting ciliated epithelium against oxidative damage inflicted by PL-sensitized phagocytes.

Delivering asthma education to special high risk groups

Patients at high risk from their asthma and therefore worthy of more focused asthma education are those at risk of fatal and near fatal asthma(NFA). In recent years the characteristics of these patients have been better defined. The most important risk factor appears to be a prior history of NFA. Other important features include prior emergency room visits or hospitalization for asthma. Excess use of beta-agonists, especially in the absence of inhaled corticosteroids, also confers increased risk. High risk groups also share similar psychosocial barriers as well as economic deprivation. The benefits of asthma education in these groups have been assessed in a number of studies. In general, asthma education has been shown to have an impact on these patients. Greater effects have been achieved where there has been consistent follow-up by the same physician. Patients require frequent reinforcement of their asthma management, especially regarding their response to acute exacerbations. A sub-group of patients with more severe asthma appear to have a problem perceiving dyspnoea and may therefore benefit from peak flow monitoring but the problem of compliance with this intervention is significant. Behaviour modification plays an important role as does ensuring the patient has adequate resources to purchase medications especially the more expensive anti-inflammatory therapy. Future studies should focus on optimizing the potential benefits of educating high risk patients as they are not only those at greatest risk of death but also consume a disproportionate amount of health care resources.

[Recommendations for systematization of national guidelines for treatment of bronchial asthma in adulthood in Germany]

BACKGROUND

Medical guidelines provide boundaries that are established for the medical community, within which clinical practice is considered to be acceptable. The main purpose for such guidelines is to improve the quality of care for patients. This can only be accomplished, however, if these documents are accepted and used effectively. In turn, acceptance of therapy guidelines essentially depends on both the structure and the presentation of the contents. GUIDELINES FOR THE TREATMENT OF ASTHMA were first issued in 1994 by the Deutsche Atemwegsliga. Since then, almost 4 years have passed, and our knowledge of the pathogenesis of asthma and drug efficacy has improved significantly. In addition, new classes of antiasthmatic drugs will be soon available. These developments make it necessary to adapt the guidelines to current knowledge.

PROPOSALS FOR IMPROVEMENT

The paper proposes several aspects on improving the present guidelines and aims at fueling future discussions.