1
|
Kaminsky DA, He J, Henderson R, Dixon AE, Irvin CG, Mastronarde J, Smith LJ, Sugar EA, Wise RA, Holbrook JT. Bronchodilator response does not associate with asthma control or symptom burden among patients with poorly controlled asthma. Respir Med 2023; 218:107375. [PMID: 37536444 DOI: 10.1016/j.rmed.2023.107375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 07/26/2023] [Accepted: 07/27/2023] [Indexed: 08/05/2023]
Abstract
PURPOSE The purpose of this study was to determine how four different definitions of bronchodilator response (BDR) relate to asthma control and asthma symptom burden in a large population of participants with poorly controlled asthma. PROCEDURES We examined the baseline change in FEV1 and FVC in response to albuterol among 931 participants with poorly controlled asthma pooled from three clinical trials conducted by the American Lung Association - Airways Clinical Research Centers. We defined BDR based on four definitions and analyzed the association of each with asthma control as measured by the Asthma Control Test or Asthma Control Questionnaire, and asthma symptom burden as measured by the Asthma Symptom Utility Index. MAIN FINDINGS A BDR was seen in 31-42% of all participants, depending on the definition used. There was good agreement among responses (kappa coefficient 0.73 to 0.87), but only 56% of participants met all four definitions for BDR. A BDR was more common in men than women, in Blacks compared to Whites, in non-smokers compared to smokers, and in non-obese compared to obese participants. Among those with poorly controlled asthma, 35% had a BDR compared to 25% of those with well controlled asthma, and among those with a high symptom burden, 34% had a BDR compared to 28% of those with a low symptom burden. After adjusting for age, sex, height, race, obesity and baseline lung function, none of the four definitions was associated with asthma control or symptom burden. CONCLUSION A BDR is not associated with asthma control or symptoms in people with poorly controlled asthma, regardless of the definition of BDR used. These findings question the clinical utility of a BDR in assessing asthma control and symptoms.
Collapse
Affiliation(s)
- David A Kaminsky
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA.
| | - Jiaxian He
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert Henderson
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Anne E Dixon
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | - Charles G Irvin
- Pulmonary and Critical Care, University of Vermont Larner College of Medicine, Burlington, VT, USA
| | | | - Lewis J Smith
- Northwestern University School of Medicine, Chicago, IL, USA
| | - Elizabeth A Sugar
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| | - Robert A Wise
- Pulmonary and Critical Care, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Janet T Holbrook
- Epidemiology, Johns Hopkins University Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
2
|
Kaminsky DA, Cockcroft DW, Davis BE. Respiratory System Dynamics. Semin Respir Crit Care Med 2023; 44:526-537. [PMID: 37429331 DOI: 10.1055/s-0043-1770058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/12/2023]
Abstract
While static mechanical forces govern resting lung volumes, dynamic forces determine tidal breathing, airflow, and changes in airflow and lung volume during normal and abnormal breathing. This section will examine the mechanisms, measurement methodology, and interpretation of the dynamic changes in airflow and lung volume that occur in health and disease. We will first examine how the total work of breathing can be described by the parameters of the equation of motion, which determine the pressure required to move air into and out of the lung. This will include a detailed description of airflow characteristics and airway resistance. Next, we will review the changes in pressure and flow that determine maximal forced inspiration and expiration, which result in the maximal flow-volume loop and the clinically important forced expired volume in 1 second. We will also assess the mechanisms and interpretation of bronchodilator responsiveness, dynamic hyperinflation, and airways hyperresponsiveness.
Collapse
Affiliation(s)
- David A Kaminsky
- Division of Pulmonary and Critical Care, Department of Medicine, University of Vermont Larner College of Medicine, Burlington, Vermont
| | - Donald W Cockcroft
- Division of Respirology, Critical Care and Sleep Medicine, University of Saskatchewan College of Medicine, Saskatoon Saskatchewan, Canada
| | - Beth E Davis
- Division of Respirology, Critical Care and Sleep Medicine, University of Saskatchewan College of Medicine, Saskatoon Saskatchewan, Canada
| |
Collapse
|
3
|
Chan A, De Simoni A, Wileman V, Holliday L, Newby CJ, Chisari C, Ali S, Zhu N, Padakanti P, Pinprachanan V, Ting V, Griffiths CJ. Digital interventions to improve adherence to maintenance medication in asthma. Cochrane Database Syst Rev 2022; 6:CD013030. [PMID: 35691614 PMCID: PMC9188849 DOI: 10.1002/14651858.cd013030.pub2] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND Asthma is the most common chronic lung condition worldwide, affecting 334 million adults and children globally. Despite the availability of effective treatment, such as inhaled corticosteroids (ICS), adherence to maintenance medication remains suboptimal. Poor ICS adherence leads to increased asthma symptoms, exacerbations, hospitalisations, and healthcare utilisation. Importantly, suboptimal use of asthma medication is a key contributor to asthma deaths. The impact of digital interventions on adherence and asthma outcomes is unknown. OBJECTIVES To determine the effectiveness of digital interventions for improving adherence to maintenance treatments in asthma. SEARCH METHODS We identified trials from the Cochrane Airways Trials Register, which contains studies identified through multiple electronic searches and handsearches of other sources. We also searched trial registries and reference lists of primary studies. We conducted the most recent searches on 1 June 2020, with no restrictions on language of publication. A further search was run in October 2021, but studies were not fully incorporated. SELECTION CRITERIA We included randomised controlled trials (RCTs) including cluster- and quasi-randomised trials of any duration in any setting, comparing a digital adherence intervention with a non-digital adherence intervention or usual care. We included adults and children with a clinical diagnosis of asthma, receiving maintenance treatment. DATA COLLECTION AND ANALYSIS We used standard methodological procedures for data collection. We used GRADE to assess quantitative outcomes where data were available. MAIN RESULTS We included 40 parallel randomised controlled trials (RCTs) involving adults and children with asthma (n = 15,207), of which eight are ongoing studies. Of the included studies, 30 contributed data to at least one meta-analysis. The total number of participants ranged from 18 to 8517 (median 339). Intervention length ranged from two to 104 weeks. Most studies (n = 29) reported adherence to maintenance medication as their primary outcome; other outcomes such as asthma control and quality of life were also commonly reported. Studies had low or unclear risk of selection bias but high risk of performance and detection biases due to inability to blind the participants, personnel, or outcome assessors. A quarter of the studies had high risk of attrition bias and selective outcome reporting. We examined the effect of digital interventions using meta-analysis for the following outcomes: adherence (16 studies); asthma control (16 studies); asthma exacerbations (six studies); unscheduled healthcare utilisation (four studies); lung function (seven studies); and quality of life (10 studies). Pooled results showed that patients receiving digital interventions may have increased adherence (mean difference of 14.66 percentage points, 95% confidence interval (CI) 7.74 to 21.57; low-certainty evidence); this is likely to be clinically significant in those with poor baseline medication adherence. Subgroup analysis by type of intervention was significant (P = 0.001), with better adherence shown with electronic monitoring devices (EMDs) (23 percentage points over control, 95% CI 10.84 to 34.16; seven studies), and with short message services (SMS) (12 percentage points over control, 95% CI 6.22 to 18.03; four studies). No significant subgroup differences were seen for interventions having an in-person component versus fully digital interventions, adherence feedback, one or multiple digital components to the intervention, or participant age. Digital interventions were likely to improve asthma control (standardised mean difference (SMD) 0.31 higher, 95% CI 0.17 to 0.44; moderate-certainty evidence) - a small but likely clinically significant effect. They may reduce asthma exacerbations (risk ratio 0.53, 95% CI 0.32 to 0.91; low-certainty evidence). Digital interventions may result in a slight change in unscheduled healthcare utilisation, although some studies reported no or a worsened effect. School or work absence data could not be included for meta-analysis due to the heterogeneity in reporting and the low number of studies. They may result in little or no difference in lung function (forced expiratory volume in one second (FEV1)): there was an improvement of 3.58% predicted FEV1, 95% CI 1.00% to 6.17%; moderate-certainty evidence); however, this is unlikely to be clinically significant as the FEV1 change is below 12%. Digital interventions likely increase quality of life (SMD 0.26 higher, 95% CI 0.07 to 0.45; moderate-certainty evidence); however, this is a small effect that may not be clinically significant. Acceptability data showed positive attitudes towards digital interventions. There were no data on cost-effectiveness or adverse events. Our confidence in the evidence was reduced by risk of bias and inconsistency. AUTHORS' CONCLUSIONS Overall, digital interventions may result in a large increase in adherence (low-certainty evidence). There is moderate-certainty evidence that digital adherence interventions likely improve asthma control to a degree that is clinically significant, and likely increase quality of life, but there is little or no improvement in lung function. The review found low-certainty evidence that digital interventions may reduce asthma exacerbations. Subgroup analyses show that EMDs may improve adherence by 23% and SMS interventions by 12%, and interventions with an in-person element and adherence feedback may have greater benefits for asthma control and adherence, respectively. Future studies should include percentage adherence as a routine outcome measure to enable comparison between studies and meta-analysis, and use validated questionnaires to assess adherence and outcomes.
Collapse
Affiliation(s)
- Amy Chan
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
- Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Anna De Simoni
- Wolfson Institute of Population Health, Centre for Primary Care Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Vari Wileman
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Lois Holliday
- Wolfson Institute of Population Health, Centre for Primary Care Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Chris J Newby
- Research Design Service, University of Nottingham, Queen's Medical Centre, Nottingham, UK
| | - Claudia Chisari
- Centre for Behavioural Medicine, Department of Practice and Policy, UCL School of Pharmacy, University College London, London, UK
| | - Sana Ali
- School of Pharmacy, Faculty of Medical and Health Sciences, The University of Auckland, Auckland, New Zealand
| | - Natalee Zhu
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | | | | | - Victoria Ting
- School of Pharmacy, The University of Auckland, Auckland, New Zealand
| | - Chris J Griffiths
- Asthma UK Centre for Applied Research, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| |
Collapse
|
4
|
Kaminsky DA, Irvin CG. The Physiology of Asthma-Chronic Obstructive Pulmonary Disease Overlap. Immunol Allergy Clin North Am 2022; 42:575-589. [DOI: 10.1016/j.iac.2022.04.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
5
|
Thamrin C, Robinson PD, Farah CS, King GG. Technical standards for respiratory oscillometry and bronchodilator response cut-offs. Eur Respir J 2022; 59:13993003.02663-2021. [DOI: 10.1183/13993003.02663-2021] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2021] [Accepted: 12/21/2021] [Indexed: 11/05/2022]
|
6
|
Response. Chest 2021; 158:2698-2699. [PMID: 33280752 DOI: 10.1016/j.chest.2020.07.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2020] [Accepted: 07/19/2020] [Indexed: 11/24/2022] Open
|
7
|
Cottee AM, Seccombe LM, Thamrin C, King GG, Peters MJ, Farah CS. Response. Chest 2021; 158:1283-1284. [PMID: 32892864 DOI: 10.1016/j.chest.2020.03.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 03/27/2020] [Indexed: 10/23/2022] Open
Affiliation(s)
- Alice M Cottee
- Department of Respiratory Medicine, Concord Repatriation General Hospital, NSW, Australia; Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia.
| | - Leigh M Seccombe
- Department of Respiratory Medicine, Concord Repatriation General Hospital, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia
| | - Cindy Thamrin
- Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, NSW, Australia
| | - Gregory G King
- Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia; Department of Respiratory Medicine, Royal North Shore Hospital, NSW, Australia
| | - Matthew J Peters
- Department of Respiratory Medicine, Concord Repatriation General Hospital, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia; Faculty of Medicine and Health Sciences, Macquarie University, NSW, Australia
| | - Claude S Farah
- Department of Respiratory Medicine, Concord Repatriation General Hospital, NSW, Australia; Woolcock Emphysema Centre and Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, NSW, Australia; Faculty of Medicine and Health, University of Sydney, NSW, Australia; Faculty of Medicine and Health Sciences, Macquarie University, NSW, Australia
| |
Collapse
|
8
|
Roig J, Domingo C, Burdon J, Michaelis S. Irritant-induced Asthma Caused by Aerotoxic Syndrome. Lung 2021; 199:165-170. [PMID: 33719009 PMCID: PMC7956869 DOI: 10.1007/s00408-021-00431-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 02/20/2021] [Indexed: 10/28/2022]
Abstract
PURPOSE Case series on respiratory features of Aerotoxic Syndrome (AS). The term AS has been coined to describe the spectrum of clinical manifestations after aircraft fume events. Among these manifestations, neurological and respiratory symptoms are the most frequently reported complaints. METHODS Three cases of AS with relevant respiratory features are presented. RESULTS Cough and shortness of breath for 6 to12 months were the predominant symptoms in the first two cases. The first case also developed neurological symptoms affecting his central nervous system. In the third case, the patient complained for nine years about an unbearable cough triggered by odors, smells, and a variety of indoor and outdoor irritants, among other symptoms of multiple chemical sensitivity. In all three cases, the respiratory symptoms resolved after appropriate treatment. CONCLUSION Our report aims at raising awareness on AS and calls for actions to improve the management of patients suffering from this syndrome.
Collapse
Affiliation(s)
- Jorge Roig
- Department of Pulmonary Medicine, Clínica Creu Blanca, Barcelona, Spain.
| | - Christian Domingo
- Department of Pulmonary Medicine, Corporació Sanitària Parc Taulí, Sabadell, Spain.,Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Jonathan Burdon
- Consultant Respiratory Physician, St Vincent's Hospital Melbourne, Fitzroy, VIC, Australia
| | - Susan Michaelis
- Occupational and Environmental Health Research Group, School of Health Sciences, University of Stirling, Stirling, UK
| |
Collapse
|