War-time asthma: lessons from Syria

Respiratory health and the Syrian conflict: a scoping literature review

Conflict adversely affects respiratory health in both direct and indirect ways among populations whose health is already compromised through the compounding effects of conflict. Our aim is to review academic and grey literature relevant to respiratory health in the Syrian conflict (now more than a decade in duration) to explore its impacts on populations across Syria. We performed a scoping literature review of academic and grey literature on respiratory health in Syria between March 2011 (taken as the start of the conflict for practicality) and December 2023. Of 11,472 papers screened, 34 met the inclusion criteria, of which 29 were peer reviewed. Key themes identified included the impact of conflict on asthma diagnosis and management; the burden of respiratory tract infections (RTIs) and COVID-19; the impact of chemical weapon use and the impact of destruction and interruptions to the health system(s) across Syria on respiratory health. This review highlights the need for more in-depth exploration of the impact of conflict on respiratory health in Syria with focus on social determinants, for example, shelter, public health interventions, smoking cessation, and supporting early diagnosis and treatment of respiratory conditions to counter the effects that conflict has had on respiratory health.

Asthma, classical conditioning, and the autonomic nervous system - a hypothesis for why children wheeze

Paediatric asthma is an increasing global healthcare problem for which current treatments are not always effective. This review explores how abnormal triggering of the autonomic diving reflex might be important in explaining research findings and the real-world experience of asthma. It hypothesises that the way in which stress during pregnancy is associated with childhood asthma could be through effects on the developing nervous system. This results in increased parasympathetic responsiveness and specifically, excessive triggering of the diving reflex in response to wetting and cooling of the face and nose as occurs with upper airway infections and allergic rhinitis. In aquatic mammals the reflex importantly includes the contraction of airway smooth muscle to minimise lung volume and prevent nitrogen narcosis from diving at depth. Misfiring of this reflex in humans could result in the pathological airway narrowing that occurs in asthma. The diving reflex, and possibly also smooth muscle, is a vestigial remnant of our aquatic past. The hypothesis further suggests that classically conditioned reflex responses to neutral cues and contexts that were present at the same time as the stimuli that initially caused symptoms, become of themselves ongoing triggers of recurrent wheeze. Symptoms occurring in this way, irrespective of the presence of allergens and ongoing airway sensitisation, explain why allergen avoidance is poorly effective in alleviating wheeze and why asthma is made worse by stress. Interventions to suppress the diving reflex and to prevent reflex conditioned wheezing could result in more effective asthma management.

Improving the quality of hospital care provided for asthma out-patients in a country in turmoil: a report from Syria

Background

In low resources settings, especially during periods of turmoil, asthma care becomes emergency-oriented, and adherence to international asthma management guidelines such as long-term inhaled corticosteroids (ICS) prescription is limited. The role of education for inhaler technique to guarantee treatment efficacy is neglected and follow up is hampered by war-related displacement. In Syria, asthma care is not included in primary care, and frequently, internal medicine general hospital outpatient clinics are the first contact. The main objective of our study was to evaluate the adequacy of prescription of controller medications (ICS/LABA) by residents on initial contact with patients, and the effect of regular onsite personalized supervision and coaching by a trainer pulmonologist on improving their practice. The second objective was to evaluate the efficacy of mobile training for inhaler technique, and asthma mobile follow up.

Methods

We developed an audit form to assess initial prescription of ICS/LABA by residents. Filled forms were reviewed by a trainer pulmonologist for compliance with international guidelines. When discrepancies were noted, onsite training was provided. Auditing of new presenting asthma patients is continual to evaluate improvement of initial prescription by the same residents. In parallel, video-mobile education of patients for inhaler technique, and mobile interviewing follow up were tested.

Results

Implementation of these strategies resulted in improved adherence of residents to ICS dosing guidelines (P=0.002), optimal inhaler technique by patients, and efficacy of mobile follow up.

Conclusions

WHO programs for CRD in developing countries, especially in regions of conflict and war, should include auditing of care by residents with onsite coaching by trainer pulmonologists, and mobile education for technology of inhaler and patient follow up.