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Amin R, Suvarna V, Neelapala YVR, Parmar ST, Vaishali K. Use of telerehabilitation platforms for delivering patient education among patients with asthma: a scoping review. Curr Med Res Opin 2024; 40:1421-1430. [PMID: 38994747 DOI: 10.1080/03007995.2024.2380006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Revised: 07/04/2024] [Accepted: 07/10/2024] [Indexed: 07/13/2024]
Abstract
OBJECTIVE Use of tele-technology for monitoring symptoms, functional parameters, and quality-of-life of people with asthma is essential. Delivering this information among patients is mandated for a better outcome and made possible via patient education (PE). This review aims to summarize the types of telerehabilitation modalities, dosage, and outcome measures used to assess the effectiveness of PE among people with asthma. METHODS We adopted a scoping review methodology. Thematic analysis was used to synthesize the data. The Preferred Reporting System for Meta-Analysis for Scoping Reviews (PRISMA-ScR) was followed during the review process. RESULTS PubMed, Embase, and Scopus were searched, with 34 studies meeting inclusion criteria. Results are presented in three themes: telerehabilitation platforms used to deliver PE among patients with asthma; content, duration, and frequency of the PE administered; and patient-reported outcome measures used to evaluate the effectiveness of PE. CONCLUSION This scoping study detailed the types of telerehabilitation modalities, dosage, and outcome measures used to assess the effectiveness of PE in people with asthma. This review will be especially beneficial to those considering where additional research or implementation of telerehabilitation for asthma patients is required. The studies emphasized the involvement of several healthcare experts, emphasizing the significance of a multidisciplinary approach to efficient PE delivery and possible improvements in asthma management through telerehabilitation. Although a range of telerehabilitation platforms were generally accepted, hybrid models that integrate online and in-person sessions could further enhance patient satisfaction and quality-of-life. Comprehensive economic analyses are also required, and solving technology issues is essential to maximizing the efficacy of these initiatives.
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Affiliation(s)
- Revati Amin
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
| | - Vaishnavi Suvarna
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
| | | | | | - K Vaishali
- Department of Physiotherapy, Manipal College of Health Professions, Manipal Academy of Higher Education, Manipal, India
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Satar S, Sahin ME, Ergun P. Factors Affecting the Success of Pulmonary Rehabilitation in Asthma. J Asthma 2022; 60:912-919. [PMID: 35930532 DOI: 10.1080/02770903.2022.2109163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Objective: The majority of patients with asthma limit their physical activity due to the fear of exercise dyspnea. Regular exercise, on the other hand, is currently suggested as one of the non-pharmaceutical treatment alternatives for patients with asthma since it improves their quality of life and symptom control. This study aimed to investigate the indicators of success in patients with asthma receiving pulmonary rehabilitation (PR). Methods: A total of 131 patients with the diagnosis of asthma were included in the study. All patients attended an 8-week comprehensive, multidisciplinary, outpatient and individualized PR program. Results: The factors related to the gains in dyspnea perception, exercise capacity, peripheral muscle strength, respiratory muscle strength and quality of life were evaluated. In the multivariate linear regression analysis, the gain in dyspnea perception is related to baseline dyspnea. The gain in exercise capacity is related to baseline exercise capacity and the amount of smoking. The gain in peripheral muscle strength is related to gender. The gain in respiratory muscle strength is related to age, and finally the gain in quality of life is related to baseline dyspnea and anxiety levels. Conclusion: Especially men, young people, heavy smokers, and those with low initial exercise capacity, high perception of dyspnea, and high anxiety are more likely to benefit from PR.
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Affiliation(s)
- Seher Satar
- Health Sciences University Ankara Atatürk Sanatorium Training and Research Hospital, Chronic Respiratory Disease Clinic - Pulmonary Rehabilitation Center, Ankara, TURKEY
| | - Mustafa Engin Sahin
- Health Sciences University Ankara Atatürk Sanatorium Training and Research Hospital, Chronic Respiratory Disease Clinic - Pulmonary Rehabilitation Center, Ankara, TURKEY
| | - Pinar Ergun
- Health Sciences University Ankara Atatürk Sanatorium Training and Research Hospital, Chronic Respiratory Disease Clinic - Pulmonary Rehabilitation Center, Ankara, TURKEY
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3
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Fieten KB, Drijver‐Messelink MT, Cogo A, Charpin D, Sokolowska M, Agache I, Taborda‐Barata LM, Eguiluz‐Gracia I, Braunstahl GJ, Seys SF, den Berge M, Bloch KE, Ulrich S, Cardoso‐Vigueros C, Kappen JH, Brinke AT, Koch M, Traidl‐Hoffmann C, da Mata P, Prins DJ, Pasmans SGMA, Bendien S, Rukhadze M, Shamji MH, Couto M, Oude Elberink H, Peroni DG, Piacentini G, Weersink EJM, Bonini M, Rijssenbeek‐Nouwens LHM, Akdis CA. Alpine altitude climate treatment for severe and uncontrolled asthma: An EAACI position paper. Allergy 2022; 77:1991-2024. [PMID: 35113452 PMCID: PMC9305916 DOI: 10.1111/all.15242] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2021] [Revised: 01/14/2022] [Accepted: 01/30/2022] [Indexed: 12/30/2022]
Abstract
Currently available European Alpine Altitude Climate Treatment (AACT) programs combine the physical characteristics of altitude with the avoidance of environmental triggers in the alpine climate and a personalized multidisciplinary pulmonary rehabilitation approach. The reduced barometric pressure, oxygen pressure, and air density, the relatively low temperature and humidity, and the increased UV radiation at moderate altitude induce several physiological and immunological adaptation responses. The environmental characteristics of the alpine climate include reduced aeroallergens such as house dust mites (HDM), pollen, fungi, and less air pollution. These combined factors seem to have immunomodulatory effects controlling pathogenic inflammatory responses and favoring less neuro‐immune stress in patients with different asthma phenotypes. The extensive multidisciplinary treatment program may further contribute to the observed clinical improvement by AACT in asthma control and quality of life, fewer exacerbations and hospitalizations, reduced need for oral corticosteroids (OCS), improved lung function, decreased airway hyperresponsiveness (AHR), improved exercise tolerance, and improved sinonasal outcomes. Based on observational studies and expert opinion, AACT represents a valuable therapy for those patients irrespective of their asthma phenotype, who cannot achieve optimal control of their complex condition despite all the advances in medical science and treatment according to guidelines, and therefore run the risk of falling into a downward spiral of loss of physical and mental health. In the light of the observed rapid decrease in inflammation and immunomodulatory effects, AACT can be considered as a natural treatment that targets biological pathways.
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4
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Fieten KB, John SM, Nowak D. Secondary and Tertiary Prevention: Medical Rehabilitation. Handb Exp Pharmacol 2021; 268:449-470. [PMID: 34196810 DOI: 10.1007/164_2021_511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Allergies are a major public health burden, and targeted measures are required in terms of prevention and treatment. The most common allergic conditions encompass atopic dermatitis (AD), food allergy (FA), allergic asthma (AA), and allergic rhino-conjunctivitis (AR). Primary prevention aims at preventing the onset of allergic disease, before the disease process begins. Secondary prevention aims at preventing progression and exacerbation of allergic disease whereas tertiary prevention aims at reducing disease burden in patients with established disease, by allergen immunotherapy (AIT) or medical rehabilitation. Rehabilitation programs are used for treatment of AA and AD and usually consist of extensive patient assessment, optimization of treatment management, patient education, and behavioral interventions, ideally involving a multidisciplinary treatment team and sometimes provided in a specific climate, usually alpine or maritime. Similarly, prevention of occupational skin diseases requires interdisciplinary approaches on the level of secondary and tertiary preventive intervention; if this is provided, then prevention programs have proven highly (cost-) effective. Unfortunately, the recently published Minimal Standards of Prevention of these dermatoses, underlining especially the importance of meticulous allergological diagnosis and subsequent multidisciplinary patient education, are so far being adhered to only in very few European countries.
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Affiliation(s)
- Karin B Fieten
- Swiss Institute of Allergy and Asthma Research (SIAF), Davos, Switzerland.
| | | | - Dennis Nowak
- Munich Center of Health Sciences, Munich, Germany
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5
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Burge AT, Rodrigues JC, Abramson MJ, Cox NS, Bondarenko J, Webb E, Marceau T, Handley E, Macdonald H, Askin A, Calasans GASA, do Amaral DP, Dreger J, Dal Corso S, Holland AE. Application of the Modified Incremental Step Test for Pulmonary Rehabilitation. Phys Ther 2021; 101:6124134. [PMID: 33528020 DOI: 10.1093/ptj/pzab044] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Revised: 09/23/2020] [Accepted: 12/31/2020] [Indexed: 11/13/2022]
Abstract
OBJECTIVE A Modified Incremental Step Test (MIST) performed in the home may facilitate entirely home-based pulmonary rehabilitation programs. The aims of this study were to investigate the reliability and responsiveness, and the utility of the MIST for exercise prescription in people with stable chronic lung disease. METHODS The MIST was undertaken at the center and home in random order, before and after pulmonary rehabilitation, with 2 tests at each time point. Reliability was assessed using intraclass correlation coefficient. Responsiveness was evaluated as effect size. The minimal important difference was appraised using distribution and anchor-based methods. In a substudy, physiological responses to MIST were measured by a portable metabolic system, followed by a constant step rate test at 60% of peak oxygen uptake (VO2peak), to evaluate utility for exercise prescription. RESULTS Forty-six participants were recruited (29% of eligible candidates). There was excellent reliability for number of steps recorded in home- and center-based settings (intraclass correlation coefficient = 0.954, 95% CI = 0.915-0.976). A small-moderate effect size was demonstrated following pulmonary rehabilitation (0.34), and the minimal detectable change was 7 steps. All participants in the substudy achieved 60% of VO2peak and achieved steady state by the fourth minute, with 60% of VO2peak corresponding to a mean 37% (95% CI = 29-44) of the MIST final level. CONCLUSIONS The MIST is reliable and responsive to pulmonary rehabilitation in people with stable chronic respiratory disease. It provides new opportunities to assess exercise capacity, prescribe exercise training, and reassess exercise program outcomes in environments where established field walking tests are not feasible. IMPACT Pulmonary rehabilitation is a highly effective treatment that is underutilized worldwide. Home-based pulmonary rehabilitation may improve access for patients and deliver equivalent clinical outcomes but is limited by the availability of a robust exercise test that can be used at home to assess exercise capacity and prescribe training intensity. This study tested the clinimetric properties of the MIST and demonstrated a new way to assess exercise capacity, prescribe exercise training of an appropriate intensity, and reassess exercise capacity in environments where established field walking tests are not feasible.
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Affiliation(s)
- Angela T Burge
- Physiotherapy, Alfred Health, Melbourne, Australia.,Physiotherapy, La Trobe University, Melbourne, Australia.,Institute for Breathing and Sleep, Melbourne, Australia.,Department of Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
| | | | | | - Narelle S Cox
- Physiotherapy, La Trobe University, Melbourne, Australia.,Institute for Breathing and Sleep, Melbourne, Australia.,Department of Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
| | - Janet Bondarenko
- Physiotherapy, Alfred Health, Melbourne, Australia.,Department of Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia.,Hospital Admission Risk Program, Alfred Health, Melbourne, Australia
| | - Elizabeth Webb
- School of Public Health and Preventive Medicine, Monash University
| | - Tunya Marceau
- Hospital Admission Risk Program, Alfred Health, Melbourne, Australia
| | - Emma Handley
- Hospital Admission Risk Program, Alfred Health, Melbourne, Australia
| | | | | | | | | | - Julianna Dreger
- Physiotherapy, La Trobe University, Melbourne, Australia.,Department of Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
| | | | - Anne E Holland
- Physiotherapy, Alfred Health, Melbourne, Australia.,Physiotherapy, La Trobe University, Melbourne, Australia.,Institute for Breathing and Sleep, Melbourne, Australia.,Department of Allergy, Clinical Immunology and Respiratory Medicine, Monash University, Melbourne, Australia
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Grosbois JM, Fry S, Tercé G, Wallaert B, Chenivesse C. [Physical activity and pulmonary rehabilitation in adults with asthma]. Rev Mal Respir 2021; 38:382-394. [PMID: 33744072 DOI: 10.1016/j.rmr.2021.02.065] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 10/26/2020] [Indexed: 11/24/2022]
Abstract
Physical activity is reduced in people with asthma compared to the general population, especially in situations where patients have uncontrolled asthma symptoms, persistent airflow obstruction and other long-term medical problems, in particular obesity and anxiety. Exertional dyspnea, which is of multifactorial origin, is the main cause of reduced physical activity reduction and draws patients into a vicious circle further impairing quality of life and asthma control. Both the resumption of a regular physical activity, integrated into daily life, adapted to patients' needs and wishes as well as physical and environmental possibilities for mild to moderate asthmatics, and pulmonary rehabilitation (PR) for severe and/or uncontrolled asthmatics, improve control of asthma, dyspnea, exercise tolerance, quality of life, anxiety, depression and reduce exacerbations. A motivational interview to promote a regular programme of physical activity in mild to moderate asthma (steps 1 to 3) should be offered by all health professionals in the patient care pathway, within the more general framework of therapeutic education. The medical prescription of physical activities, listed in the Public Health Code for patients with long-term diseases, and pulmonary rehabilitation should be performed more often by specialists or the attending physician. Pulmonary rehabilitation addresses the needs of severe asthma patients (steps 4 and 5), and of any asthmatic patient with poorly controlled disease and/or requiring hospitalized for acute exacerbations, regardless of the level of airflow obstruction, and/or with associated comorbidities, and before prescribing biological therapies.
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Affiliation(s)
- J-M Grosbois
- FormAction Santé, zone d'activité du bois, rue de Pietralunga, 59840 Pérenchies, France; CH Béthune, service de réadaptation respiratoire et de pneumologie, 62400 Béthune, France; Alvéole, groupe de travail de la SPLF, exercice et réadaptation respiratoire, 75006 Paris, France.
| | - S Fry
- CHU Lille, service de pneumologie et immuno-allergologie, université Lille, institut Pasteur de Lille, U1019, UMR 9017, Center for Infection and Immunity of Lille (CIIL), 59000 Lille, France; CRISALIS, F-CRIN INSERM network, Lille, France
| | - G Tercé
- CH Béthune, service de réadaptation respiratoire et de pneumologie, 62400 Béthune, France
| | - B Wallaert
- Alvéole, groupe de travail de la SPLF, exercice et réadaptation respiratoire, 75006 Paris, France; CHU Lille, service de pneumologie et immuno-allergologie, université Lille, institut Pasteur de Lille, U1019, UMR 9017, Center for Infection and Immunity of Lille (CIIL), 59000 Lille, France
| | - C Chenivesse
- CHU Lille, service de pneumologie et immuno-allergologie, université Lille, institut Pasteur de Lille, U1019, UMR 9017, Center for Infection and Immunity of Lille (CIIL), 59000 Lille, France; CRISALIS, F-CRIN INSERM network, Lille, France
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- Alvéole, groupe de travail de la SPLF, exercice et réadaptation respiratoire, 75006 Paris, France
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7
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de Nijs SB, Krop EJM, Portengen L, Rijssenbeek-Nouwens LH, de Vries D, Weersink EJM, Heijerman HGM, Heederik DJJ, Lammers JWJ. Effectiveness of pulmonary rehabilitation at high-altitude compared to sea-level in adults with severe refractory asthma. Respir Med 2020; 171:106123. [PMID: 32846334 DOI: 10.1016/j.rmed.2020.106123] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Revised: 08/15/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Beneficial effects of pulmonary rehabilitation at high-altitude (HAPR) in patients with severe refractory asthma have been reported earlier, but evidence for the effectiveness is limited. AIM To investigate the effectiveness of high-altitude pulmonary rehabilitation to comparable treatment at sea-level (LAPR) on patient outcome parameters. METHODS Adults with severe refractory asthma living in The Netherlands were included. Treatment consisted of a 12-week personalized multidisciplinary rehabilitation program either at high-altitude (Davos Switzerland) (n = 93) or in a tertiary lung center at sea-level in The Netherlands (n = 45). At baseline, after treatment, and during 12 months follow-up asthma related quality of life (AQLQ), asthma control (ACQ), pulmonary function and OCS-dose were assessed. Patients could not be randomized resulting in different asthma populations. Groups were compared using linear regression analysis (ANCOVA) adjusted for baseline values, in addition to age, atopy, smoking history, BMI and gender. RESULTS After treatment, and at 12 months follow-up, improved AQLQ(0.92,p < 0.001 and 0.82,p = 0.001, respectively), ACQ(-0.87,p < 0.001 and -0.69,p = 0.008, respectively) and lower maintenance OCS dose (Unadjusted linear regression analysis-5.29 mg, p = 0.003 and Crude Odds Ratio-1.67, p = 0.003, respectively) were observed in the HAPR-group compared to the LAPR group. Patients receiving HAPR also had less asthma exacerbations (≥1 exacerbation: 20% vs 60%,p < 0.001) and showed improvement in lung function (%predFEV1 3.4%,p = 0.014) compared to the LAPR group, but at 12 months no differences between groups were observed. CONCLUSION HAPR resulted in a larger improvement in patient outcome parameters compared to LAPR, on the long run the improvement in patient reported symptoms and lower maintenance OCS-dose persists. Underlying factors that explain this observed effect need to be investigated.
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Affiliation(s)
- S B de Nijs
- Department of Respiratory Medicine, University Medical Center Utrecht, the Netherlands; Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands
| | - E J M Krop
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands
| | - L Portengen
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands
| | | | - D de Vries
- Merem Asthma Center Heideheuvel, Hilversum, the Netherlands
| | - E J M Weersink
- Department of Respiratory Medicine, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - H G M Heijerman
- Department of Respiratory Medicine, University Medical Center Utrecht, the Netherlands.
| | - D J J Heederik
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands
| | - J W J Lammers
- Department of Respiratory Medicine, University Medical Center Utrecht, the Netherlands
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8
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Scichilone N, Barnes PJ, Battaglia S, Benfante A, Brown R, Canonica GW, Caramori G, Cazzola M, Centanni S, Cianferoni A, Corsico A, De Carlo G, Di Marco F, Gaga M, Hawrylowicz C, Heffler E, Matera MG, Matucci A, Paggiaro P, Papi A, Popov T, Rogliani P, Santus P, Solidoro P, Togias A, Boulet LP. The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians. J Clin Med 2020; 9:jcm9082397. [PMID: 32727032 PMCID: PMC7463666 DOI: 10.3390/jcm9082397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
Severe asthma is an important topic in respiratory diseases, due to its high impact on morbidity and mortality as well as on health-care resources. The many challenges that still exist in the management of the most difficult-to-treat forms of the disease, and the acknowledgement of the existence of unexplored areas in the pathophysiological mechanisms and the therapeutic targets represent an opportunity to gather experts in the field with the immediate goals to summarize current understanding about the natural history of severe asthma and to identify gaps in knowledge and research opportunities, with the aim to contribute to improved medical care and health outcomes. This article is a consensus document from the “International Course on Severe Asthma” that took place in Palermo, Italy, on May 10–11, 2019. Emerging topics in severe asthma were addressed and discussed among experts, with special focus on patient’s needs and research opportunities, with the aim to highlight the unanswered questions in the diagnostic process and therapeutic approach.
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Affiliation(s)
- Nicola Scichilone
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
- Correspondence: ; Tel.: +39-091-655-2146
| | - Peter John Barnes
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK;
| | - Salvatore Battaglia
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Alida Benfante
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Robert Brown
- Department of Anesthesiology and Critical Care Medicine, Medicine, Department of Medicine, Division of Pulmonary Medicine, Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD 21287, USA;
| | - Giorgio Walter Canonica
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Gaetano Caramori
- Respiratory Medicine Unit, Department of Biomedical Sciences, Dentistry and Morphological and Functional Imaging (BIOMORF), University of Messina, 98122 Messina, Italy;
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics – University of Pavia, 27100 Pavia, Italy;
| | - Giuseppe De Carlo
- The European Federation of Allergy and Airways Diseases Patients Associations (EFA), 1000 Brussels, Belgium;
| | - Fabiano Di Marco
- Respiratory Unit, ASST - Papa Giovanni XXIII Hospital, Bergamo, University of Milan, 24127 Milan, Italy;
| | - Mina Gaga
- 7th Respiratory Medicine Dept, Asthma Cen, Athens Chest Hospital, 11527 Athens, Greece;
| | - Catherine Hawrylowicz
- Division of Asthma, Allergy and Lung Biology, King’s College London, Guy’s Hospital, London SE1 9RT, UK;
| | - Enrico Heffler
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, 50139 Florence, Italy;
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, 56126 Pisa, Italy;
| | - Alberto Papi
- Research Center on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Todor Popov
- Clinic of Occupational Diseases, University Hospital Sv. Ivan Rilski, 1431 Sofia, Bulgaria;
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Pierachille Santus
- Division of Respiratory Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy;
| | - Paolo Solidoro
- Pneumology Unit U, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy;
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, MD 20814, USA;
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Moonie S, Hogan MB. Challenges for the Clinician: Physical Activity Among Severe Asthmatic Patients with Comorbid Obesity. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 6:823-824. [PMID: 29747985 DOI: 10.1016/j.jaip.2017.11.036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 11/29/2017] [Accepted: 11/30/2017] [Indexed: 12/20/2022]
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10
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Saxer S, Schneider SR, Appenzeller P, Bader PR, Lichtblau M, Furian M, Sheraliev U, Estebesova B, Emilov B, Sooronbaev T, Bloch KE, Ulrich S. Asthma rehabilitation at high vs. low altitude: randomized parallel-group trial. BMC Pulm Med 2019; 19:134. [PMID: 31340793 PMCID: PMC6657156 DOI: 10.1186/s12890-019-0890-y] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2018] [Accepted: 07/02/2019] [Indexed: 12/14/2022] Open
Abstract
Background To investigate the effect of asthma rehabilitation at high altitude (3100 m, HA) compared to low altitude (760 m, LA). Methods For this randomized parallel-group trial insufficiently controlled asthmatics (Asthma Control Questionnaire (ACQ) > 0.75) were randomly assigned to 3-week in-hospital rehabilitation comprising education, physical-&breathing-exercises at LA or HA. Co-primary outcomes assessed at 760 m were between group changes in peak expiratory flow (PEF)-variability, and ACQ) from baseline to end-rehabilitation and 3 months thereafter. Results 50 asthmatics were randomized [median (quartiles) LA: ACQ 2.7(1.7;3.2), PEF-variability 19%(14;33); HA: ACQ 2.0(1.6;3.0), PEF-variability 17%(12;32)]. The LA-group improved PEF-variability by median(95%CI) -7%(− 14 to 0, p = 0.033), ACQ − 1.4(− 2.2 to − 0.9, p < 0.001), and after 3 months by − 3%(− 18 to 2, p = 0.103) and − 0.9(− 1.3 to − 0.3, p = 0.002). The HA-group improved PEF-variability by − 10%(− 21 to − 3, p = 0.004), ACQ − 1.1(− 1.3 to − 0.7, p < 0.001), and after 3 months by − 9%(− 10 to − 3, p = 0.003) and − 0.2(− 0.9 to 0.4, p = 0.177). The additive effect of HA vs. LA directly after the rehabilitation on PEF-variability was − 6%(− 14 to 2), on ACQ 0.3(− 0.4 to 1.1) and after 3 months − 5%(− 14 to 5) respectively 0.4(− 0.4 to 1.1), all p = NS. Conclusion Asthma rehabilitation is highly effective in improving asthma control in terms of PEF-variability and symptoms, both at LA and HA similarly. Trial registration Clinicaltrials.gov: NCT02741583, Registered April 18, 2016. Electronic supplementary material The online version of this article (10.1186/s12890-019-0890-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Stéphanie Saxer
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland.,Department of Health Sciences & Health Policy, University of Lucerne, Lucerne, Switzerland
| | - Simon R Schneider
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland
| | - Paula Appenzeller
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland
| | - Patrick R Bader
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland
| | - Mona Lichtblau
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland
| | - Michael Furian
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland
| | - Ulan Sheraliev
- National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Bermet Estebesova
- National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Berik Emilov
- National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Talant Sooronbaev
- National Center for Cardiology and Internal Medicine, Bishkek, Kyrgyzstan
| | - Konrad E Bloch
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland
| | - Silvia Ulrich
- Department of Pulmonology, UniversityHospital Zurich, Rämistrasse 100, CH-8091 , Zurich, Switzerland.
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11
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[Role of non pharmacological Interventions for asthma]. Presse Med 2019; 48:282-292. [PMID: 30871852 DOI: 10.1016/j.lpm.2019.02.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 12/27/2018] [Accepted: 02/13/2019] [Indexed: 12/14/2022] Open
Abstract
Smoking cessation remains a major issue for asthmatic smokers. Respiratory rehabilitation and respiratory physiotherapy have shown a benefit in controlling symptoms, preventing exacerbations and improving the quality of life. The control of the environment is crucial and must be approached in a global way. Management of obesity and psychological disorders should be systematically proposed. Allergen immunotherapy may be discussed in allergic persistent asthma to house dust mites. Certain dietary interventions or alternative medicines have not proved their worth.
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12
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Bellocq A, Gaspard W, Couffignal C, Vigan M, Guerder A, Ambard J, Caruana S, Similowski T, Garcia G, Taillé C. Outpatient pulmonary rehabilitation for severe asthma with fixed airway obstruction: Comparison with COPD. J Asthma 2019; 56:1325-1333. [PMID: 30693816 DOI: 10.1080/02770903.2018.1541351] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background: The benefit of exercise has been demonstrated in asthma, but the role of pulmonary rehabilitation (PR) in people with severe asthma, especially with airway obstruction, has been less investigated. The activity limitation mechanisms differ in asthma and COPD, so the effect of a PR program not specific to asthma is unclear. Methods: We retrospectively compared the effect of an ambulatory PR program in nonsmoking patients with severe asthma and airway obstruction (FEV1/FVC ratio <70% and FEV1 < 80% measured twice, not under an exacerbation) and sex-, age-, FEV1-, and BMI-matched COPD controls. Results: We included 29 patients, each with asthma and COPD. Airway obstruction was moderate (median FEV1 57% [44-64]). VO2 at peak was higher for asthma than COPD patients (19.0 [15.7-22.2] vs 16.1 [15.3-19.6] ml.min-1.kg-1, p = 0.05). After PR, asthma and COPD groups showed a significant and similar increase in constant work cycling test of 378 [114-831] s and 377 [246-702] s. Changes in Hospital Anxiety and Depression Scale (HAD) total score were similar (-2.5 [-7.0 to 0.0] vs -2.0 [-5.0 to 2.0], p > 0.05). Quality of life on the St. George's Respiratory Questionnaire (SGRQ) was significantly improved in both groups (-14.0 [-17.7 to -2.0], p < 0.005 and -8.3 [-13.0 to -3.6], p < 0.0001). Conclusion: Outpatient PR is feasible and well tolerated in patients with severe asthma with fixed airway obstruction. A nondedicated program strongly improves HAD and SGRQ scores and constant work-rate sub-maximal cycling, with similar amplitude as with COPD.
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Affiliation(s)
- Agnès Bellocq
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service d'Explorations Fonctionnelles de la Respiration, de l'Exercice et de la Dyspnée du Département R3S, Paris, France.,Sorbonne Université, INSERM, UMRS1158, Paris, France
| | - Wanda Gaspard
- Service des Maladies Respiratoires, Hôpital d'Instruction des Armées Percy, Clamart, France
| | - Camille Couffignal
- Assistance Publique-Hôpitaux de Paris, Department of Epidemiology, Biostatistic and Clinical Research, Bichat Hospital, Paris, France
| | - Marie Vigan
- Assistance Publique-Hôpitaux de Paris, Department of Epidemiology, Biostatistic and Clinical Research, Bichat Hospital, Paris, France
| | - Antoine Guerder
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et de Réanimation Médicale du Département R3S, Paris, France
| | - Julien Ambard
- Réseau Recup'Air, Agence Régionale de Santé Ile de France, Paris, France
| | - Sylvie Caruana
- Réseau Recup'Air, Agence Régionale de Santé Ile de France, Paris, France
| | - Thomas Similowski
- Assistance Publique-Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et de Réanimation Médicale du Département R3S, Paris, France
| | - Gilles Garcia
- Assistance Publique-Hôpitaux de Paris, Hôpital de Bicêtre, Service de Pneumologie, Le Kremlin-Bicetre, France
| | - Camille Taillé
- Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, DHU FIRE, Service de Pneumologie, INSERM UMR1152, Université Paris Diderot, Labex Inflamex, Paris, France
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13
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An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly. Ann Am Thorac Soc 2017; 13:2064-2077. [PMID: 27831798 DOI: 10.1513/annalsats.201608-658st] [Citation(s) in RCA: 69] [Impact Index Per Article: 9.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.
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14
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Candemir I, Ergun P, Kaymaz D. Efficacy of a multidisciplinary pulmonary rehabilitation outpatient program on exacerbations in overweight and obese patients with asthma. Wien Klin Wochenschr 2017; 129:655-664. [PMID: 28894957 DOI: 10.1007/s00508-017-1258-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2017] [Accepted: 08/17/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Even though many studies have investigated the effectiveness of weight loss interventions, the efficacy of pulmonary rehabilitation (PR) has not yet been proven in obese patients with asthma. The aims of this study were to investigate the efficacy of PR on asthma exacerbations in the first year after PR and to evaluate the efficacy of PR in exercise capacity, quality of life, psychosocial symptoms and control of asthma in overweight patients. METHODS The exercise capacity, health-related quality of life scores, psychosocial symptoms, asthma control test (ACT) data, number of emergency admissions and hospitalizations of 35 overweight patients with asthma who completed a 1-year multidisciplinary PR program were recorded and analyzed. RESULTS Of the participants 30 were female, the mean age was 45 ± 9 years, 13 (37%) patients were overweight and 22 (63%) were obese. The average number of emergency admissions (from 1.2 ± 1.1 to 0.3 ± 0.8) and hospitalizations (from 0.6 ± 0.9 to 0.0 ± 0.1) decreased significantly 1 year after PR (both p<0.001). After PR, statistically significant improvements in exercise capacity as measured by the incremental shuttle walking test (ISWT) from 281 ± 104 m to 339 ± 95 m (p < 0.001), the endurance shuttle walking test (ESWT) from 13.3 ± 7.4 min to 17.5 ± 4.5 min (p = 0.005), quality of life measured by the St. George's respiratory questionnaire (SGRQ total from 64 ± 14 to 28 ± 10, p < 0.001), dyspnea sensation with the Medical Research Council (MRC) scale (from 2.6 ± 0.6 to 2.1 ± 0.4, p <0.001) and hospital anxiety depression scores (HADS, anxiety score from 9.9 ± 1.6 to 7.1 ± 2.1, depression score from 9.4 ± 1.9 to 7.2 ± 2.3, both p < 0.001) were found. A reduction in body mass index (BMI) was found in obese patients only, but the fat-free mass index (FFMI) improved in both overweight and obese patients (from 19.00 ± 1.90 to 19.45 ± 2.04, p = 0.01). The mean ACT score increased significantly (from 18 to 21 points, p < 0.001). The number of patients with poorly controlled asthma decreased from 21 (60%) to 10 (28%). CONCLUSION This study showed that comprehensive multidisciplinary PR was associated with a decreased number of emergency admissions and hospitalizations for asthma exacerbations in 1 year, and improvements of dyspnea sensation, quality of life, exercise capacity, and psychosocial status in overweight and obese patients.
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Affiliation(s)
- Ipek Candemir
- Ataturk Chest Diseases and Surgery Education and Research Hospital, Ankara, Turkey. .,Ataturk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi, Sanatoryum caddesi, Kecioren, Ankara, 06280, Türkiye.
| | - Pinar Ergun
- Ataturk Chest Diseases and Surgery Education and Research Hospital, Ankara, Turkey
| | - Dicle Kaymaz
- Ataturk Chest Diseases and Surgery Education and Research Hospital, Ankara, Turkey
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15
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Schultz K, Seidl H, Jelusic D, Wagner R, Wittmann M, Faller H, Nowak D, Schuler M. Effectiveness of pulmonary rehabilitation for patients with asthma: study protocol of a randomized controlled trial (EPRA). BMC Pulm Med 2017; 17:49. [PMID: 28274210 PMCID: PMC5343403 DOI: 10.1186/s12890-017-0389-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2017] [Accepted: 02/28/2017] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND Asthma patients are enrolled in multimodal pulmonary rehabilitation (PR) programs. However, available data for the effectiveness of PR in asthma are sparse. Therefore, the primary aim of this randomized control trial (RCT) is to evaluate short-term (end of rehabilitation) and intermediate-term effectiveness (3 months after rehabilitation) of PR for patients with asthma regarding asthma control (primary outcome) and other outcomes. Secondly, moderator effects of gender, age, baseline asthma control, quality of life, and anxiety will be examined. Thirdly, a longitudinal follow-up study will explore the course of the outcomes over one year and the annual costs. METHODS The EPRA study is a single-center randomized controlled waiting-list trial in the Bad Reichenhall Clinic. Inclusion criteria include a referral diagnosis for uncontrolled asthma, no cognitive impairment and no very severe co-morbidities that indicate significantly greater illness morbidity than asthma alone. In the intervention group (IG), participants will start PR within 4 weeks after randomization; participants of the control group (CG) will start PR 20 weeks after randomization. Data will be assessed at randomization (T0), after 4 weeks (T1; IG: begin of PR), 7 weeks (T2; IG: end of PR), and 20 weeks (T3, CG: begin of PR). The primary outcome is asthma control at T2/T3. Secondary outcomes are health-related quality of life, functional exercise capacity, dyspnea, anxiety, depression, subjective self-management skills, illness perceptions, sick leave and subjective work ability. Outcomes will be analyzed with analysis of covariance, including baseline values of the respective outcomes as covariates. Healthcare costs will be analyzed with a gamma model with a log-link. A longitudinal follow-up study will generate additional data at 3/6/9/12 months after PR for both IG and CG. Latent change models will be used to analyze the course of the primary and secondary outcomes. Annual cost differences before and after rehabilitation will be compared by paired t-test. DISCUSSION This RCT will determine the effectiveness of a complex inpatient PR for asthma patients concerning asthma control. Furthermore, important medical and economic information regarding the effectiveness of PR as part of the long-term management of patients with uncontrolled asthma will be generated. TRIAL REGISTRATION German Clinical Trials Register ( DRKS00007740 , May 15, 2015). Protocol version: 1.0 (December, 23, 2016).
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Affiliation(s)
- Konrad Schultz
- Klinik Bad Reichenhall, Center for Rehabilitation, Pulmonology and Orthopedics, Bad Reichenhall, Germany
| | - Hildegard Seidl
- Institute of Health Economics and Health Care Management, Helmholtz Zentrum München (GmbH) - German Research Center for Environmental Health, Comprehensive Pneumology Center Munich (CPC-M), Member of the German Center for Lung Research (DZL), Munich, Germany
| | - Danijel Jelusic
- Klinik Bad Reichenhall, Center for Rehabilitation, Pulmonology and Orthopedics, Bad Reichenhall, Germany
| | - Rupert Wagner
- Klinik Bad Reichenhall, Center for Rehabilitation, Pulmonology and Orthopedics, Bad Reichenhall, Germany
| | - Michael Wittmann
- Klinik Bad Reichenhall, Center for Rehabilitation, Pulmonology and Orthopedics, Bad Reichenhall, Germany
| | - Hermann Faller
- Department of Medical Psychology and Psychotherapy, Medical Sociology and Rehabilitation Sciences Section, University of Würzburg, Würzburg, Germany
| | - Dennis Nowak
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, LMU University of München, member DZL, German Centre for lung Research, Munich, Germany
| | - Michael Schuler
- Department of Medical Psychology and Psychotherapy, Medical Sociology and Rehabilitation Sciences Section, University of Würzburg, Würzburg, Germany
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16
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Tri JA, DeSimone CV, Daniels C, Asirvatham RS, Mikell SB, Ladewig DJ, Krajnick K, Asirvatham SJ. Electroporation ablation of bronchial smooth muscle cells: A novel non-thermal asthma therapy. ACTA ACUST UNITED AC 2016; 1. [PMID: 28261673 DOI: 10.15761/pccm.1000120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Asthma is a common disease which places significant burden on the US healthcare system and which can be associated with significant patient morbidity and mortality. Current medical therapies are costly and not curative. A new approach for a more permanent asthma treatment is the use of radiofrequency ablation. However, this radiofrequency approach is thermal-based and can result in deleterious effects to the airways, such as stenosis or ulceration. We describe a novel, improved therapeutic approach for smooth muscle ablation using non-thermal DC electroporation ablation. METHODS We developed and tested prototype electroporation ablation devices that access the airways both endoscopically and via a bronchoscope. We tested the feasibility of this approach and demonstrated proof-of-concept in 2 mongrel dogs. In order to assess for smooth muscle function, we performed functional studies pre and post ablation with methacholine challenge to assess for airway reversibility. We also evaluated bronchial lesions via direct vision with bronchoscopy. RESULTS We developed novel electroporation catheters to delivery energy to the bronchial smooth muscle through an endoscopic approach. We tested these catheters in 2 acute canine studies and successfully demonstrated the ability to destroy smooth muscle tissue via novel prototypes and saline irrigation for widespread non-thermal electroporation ablation. Our functional studies demonstrate the efficacy of this approach. CONCLUSION We report a novel method for non-thermal bronchial smooth muscle ablation using novel prototypes and electroporation with normal saline. These early findings require further evaluation in larger, chronic canine studies to assess for use as a potential curative therapy.
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Affiliation(s)
- Jason A Tri
- Mayo Clinic Summer Externship Program, Mayo Clinic, Rochester, Minnesota
| | - Christopher V DeSimone
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | - Craig Daniels
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota; Department of Pediatrics and Adolescent Medicine, Mayo Clinic, Rochester, Minnesota
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