Patterns of asthma death and near-death in an inner-city tertiary care teaching hospital

Factors affecting ability to achieve asthma control in adult patients with moderate to severe persistent asthma

OBJECTIVE

Despite the use of optimal therapy and guidelines, the rate of asthma control is suboptimal in adult populations. Purpose of this study is to describe factors associated with ability to achieve well-controlled asthma over time for adult patients treated in a tertiary medical center-based asthma outpatient specialty clinic.

METHODS

Existing clinical data collected for 320 adult patients enrolled in a hospital-based outpatient asthma specialty clinic from July 1, 2003 through June 30, 2011 evaluated time to achieve well-controlled asthma and factors associated with well-controlled asthma such as adherence and lack of previous exacerbations.

RESULTS

Adherence to prescribed therapy (p = 0.004) and no previous asthma related ED visits (p = 0.004) were associated with well-controlled asthma for moderate persistent baseline. BMI on a continuous spectrum (p = 0.120) and the diagnosis of allergic rhinitis (p = 0.769) were not independently significant. Body-mass-index (BMI) in combination with adherence did influence ability to achieve well-controlled asthma (p < 0.05). Adherence (p = 0.615), allergic rhinitis (p = 0.172), BMI continuous scale (p = 0.074) and visit interval <90 days (p = 0.653) were not independently associated with likelihood of achieving well-controlled asthma in severe persistent asthmatics. Significance of particular factors in combination (adherence, allergic rhinitis, sex, BMI) showed dependency on other variables in achieving well-controlled asthma.

CONCLUSIONS

Different factors are associated with asthma control for different patient subpopulations. Adherence to standard therapy did not improve obese (BMI > 30) patients' ability to achieve asthma control. Female patients were less likely to obtain well-controlled asthma per unit increase of BMI. Multiple factors must be addressed to optimize attaining asthma control.

Inner-city asthma: special considerations for management

PURPOSE OF REVIEW

Asthma is prevalent in inner-city populations, exhibiting significant morbidity and mortality. This review focuses on the consequential findings of recent literature, providing insight into onset of asthma, complicating factors, prediction of exacerbations, and novel treatment strategies.

RECENT FINDINGS

Analyses of environmental influence on inner-city children demonstrated novel interactions, implicating potentially protective benefits from early life exposures to pests and pets and isolating detrimental effects of air pollution on asthma morbidity. Through detailed characterization of inner-city asthmatics, predictors of seasonal exacerbations surfaced. Focused, season-specific treatment of inner-city asthmatics with omalizumab identified those most likely to benefit from season-tailored therapy. Comparative studies of urban and rural populations revealed that race and household income, rather than location of residence, impose the greatest risk for increased asthma prevalence and morbidity.

SUMMARY

Challenging previously conceived exposure-disease relationships, recent literature has elucidated new avenues in the complex interplay between immunologically active exposures and their effects on inner-city asthma. These findings, and improved understanding of other relevant exposures, could steer the direction of primary (and secondary) disease prevention research. Moreover, careful identification of asthma characteristics has effectively established predictors of exacerbations, highlighting individuals for which additional therapies are warranted and for whom such treatments are most likely to be effective.

The Latino paradox in neighborhood context: the case of asthma and other respiratory conditions

OBJECTIVES

Evidence indicates that foreign-born Latinos have a health advantage compared with US-born persons of the same socioeconomic status. An explanation for this paradox has remained elusive. We examined the extent to which this paradox exists for the prevalence of asthma and other respiratory conditions. We then explored the role of neighborhood social context in understanding any observed advantage. We invoked theories of social organization, collective efficacy, and the urban ethnic enclave.

METHODS

We combined data from the Project on Human Development in Chicago Neighborhoods Community Survey with 2 other data sources and used hierarchical generalized linear modeling techniques.

RESULTS

We found a distinctly graded effect for asthma and other breathing problems among foreign-born Latinos, depending on community composition. Foreign-born Latinos embedded in a neighborhood that had a high percentage of foreign-born residents experienced a significantly lower prevalence of asthma and other breathing problems; those in communities that had a low percentage of foreign-born residents had the highest prevalence overall (even when compared with African Americans).

CONCLUSIONS

Foreign-born Latinos have a respiratory health advantage only in enclave-like settings. Contexts such as these may provide the cohesiveness critical for effective prevention.

A systematic review of the psychological risk factors associated with near fatal asthma or fatal asthma

Psychological factors such as anxiety, depressive disorders and/or personality disorders may predispose patients with asthma to near fatal asthma (NFA) or fatal asthma (FA). NFA is defined by an asthma exacerbation resulting in respiratory arrest requiring mechanical ventilation or a pCO(2) >or=45 mm Hg. Most studies have used the case-control study design. Several studies analyzing the effects of psychological factors on the risk of NFA or FA have shown conflicting results. We reviewed all of the literature found by the systematic search done of psychological factors on the risk NFA or FA. A MEDLINE search identified 423 articles between 1960 and March 2006. Seven case-controlled studies were identified following strict applications of the inclusion and exclusion criteria. Due to the significant heterogeneity in the measurement of the psychological factors, a summary statistic was not calculated. The trial characteristics were tabulated and qualitative trends were observed to explain the heterogeneity in the results of the studies. Recommendations on future studies in the field are outlined in detail. Following a systematic assessment of all published studies, we cannot conclude that psychological factors increase the risk of NFA and FA.

Relationships of asthma knowledge, self-management, and social support in African American adolescents with asthma

Despite nationwide efforts to manage asthma, the adverse outcomes of asthma continue to increase, especially in African American adolescents. The purpose of this study was to examine the relationships among asthma knowledge, self-management, and social support in African American adolescents with asthma. A correlational descriptive study was conducted using a convenience sample of 53 identified asthmatic adolescents from the Southern metropolitan school system in Alabama. Asthma knowledge was measured by the Parcel Knowledge about Asthma Questionnaire, social support by the Norbeck Social Support Questionnaire, and asthma self-management behaviors by the Asthma Behavioral Assessment Questionnaire. Both asthma knowledge and social support had significant positive relationships (r=0.31, r=0.30, respectively) with asthma self-management behaviors and accounted for 14% of self-management behaviors variability. Further studies are needed to understand how to better manage asthma in adolescents.

Predictors of disease severity in children with asthma in Hartford, Connecticut

Childhood asthma is a major public health problem in the United States, particularly among minority populations. The aim of our study was to examine the relationship among ethnicity, allergen sensitization, spirometric measures, and asthma severity in children with mild to severe asthma who received their medical care in Hartford, Connecticut. Four hundred thirty-eight children aged 4-18 years who were enrolled in an asthma care program (Easy Breathing) in Hartford and who were referred for spirometry and allergy skin testing participated in this cross-sectional study. Risk factors for increased asthma severity as defined by National Asthma Education and Prevention Program (NAEPP) guidelines were determined using multinomial logistic regression. Of 438 children, 383 (87.4%) had mild to moderate asthma, and 292 (66.7%) had at least one positive skin test to allergens. Forced expiratory volume in 1 sec/forced vital capacity (FEV1/FVC) was significantly decreased in children with severe vs. mild asthma (80.7 vs. 87.3, respectively). In a multivariate analysis, predictors of severe asthma included African-American ethnicity (odds ratio (OR)=3.70, 95% confidence interval (CI)=1.10-12.42), Puerto Rican ethnicity (OR=3.55, 95% CI=1.18-10.67), sensitization to cockroach allergen (OR=4.34, 95% CI=1.73-10.86), and decreased FEV1/FVC (OR for every 1% decrease in FEV1/FVC=1.06, 95% CI=1.02-1.11). In conclusion, among children with asthma in Hartford and its surrounding communities, predictors of disease severity included African-American ethnicity, Puerto Rican ethnicity, sensitization to cockroach allergen, and decreased FEV1/FVC. Our findings suggest that FEV1/FVC is a useful indicator of asthma severity in children.

Identifying environmental risk factors for asthma emergency care" a multilevel approach for ecological study

This ongoing empirical study suggests a model for evaluating a combination of environmental risk factors to explain neighborhood differences in adult use of Harlem Hospital's Asthma Emergency Department services. A multilevel or "nested" model incorporates methods for hypothesis testing using geographic information systems (GIS) and existing data from Harlem Hospital Center, city agencies, and other sources to measure variables on both building and street segment levels. Selection of the best geographic scale by which to measure housing conditions, neighborhood physical quality, income indicators, and access to healthcare is an important strategy toward identifying neighborhood socioenvironmental patterns contributing to geographic clustering of asthma emergencies. Specific community interventions may then be defined to improve the health outcomes of residents with asthma.

Near-fatal asthma: a population-based study of risk factors

BACKGROUND

The study of near-fatal asthma (NFA) may provide a means to further our understanding of fatal asthma. Studies of NFA often are derived from a single ICU rather than from a defined population. We therefore aimed to identify factors distinguishing NFA patients (cases) from those persons treated in an emergency department (ED) [ED control subjects] and in the community (community control subjects [CCs]).

METHODS

This was a population-based case-control study conducted over 20 months of 45 NFA patients (age range, 5 to 50 years), 197 ED control subjects treated in an ED, and 303 CCs, all of whom were residents of Alberta.

RESULTS

The age distribution was similar between NFA patients and control subjects, with the majority being < 22 years of age (NFA patients, 68.9%; ED control subjects, 71.3%; CCs, 60.7%). Those patients with NFA were significantly more likely to have received a diagnosis before 5 years of age (66.6%), compared to ED control subjects (39.6%) and CCs (28.7%). The NFA group was significantly more likely to report moderate-to-severe disease and more frequent symptoms than the other groups. Therapy with bronchodilators was used most frequently by the NFA group compared to the ED control subjects and CCs (p < 0.001), as was therapy with inhaled steroids (p < 0.001) and oral steroids (p < 0.001). NFA patients had higher scores for vulnerability and were most likely to admit to stress as an asthma trigger. All groups had high exposure to cigarette smoke and pets.

CONCLUSION

NFA patients have many modifiable risk factors and many similarities to ED control subjects and CCs with asthma. General measures to improve asthma control and awareness of risks are required in all groups.

Influence of sociodemographics on the health-related quality of life of pediatric patients with asthma and their caregivers

The relationship between socioeconomic variables and the health-related quality of life (HQL) of children with asthma and their caregivers was examined. The Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and Pediatric Asthma Caregivers Quality of Life Questionnaire (PACQLQ) were administered to 99 pediatric asthmatic patients and caregivers in two specialty clinics. Sociodemographic data was obtained from medical records and additional questions. The relationship between sociodemographic variables and HQL was determined using multiple linear regression. The mean patient age was 12.6+/-2.1 years, more were male and from a minority race. The mean age of caregivers was 41.2+/-8.5 years; most were female and were fom a minority race. Patients tended to rate their asthma severity as mild to moderate, while caregivers tended to rate patients in the moderate to severe category. Based on prescribed medications, most patients had mild to moderate asthma. Household income was consistently associated with patient-perceived HQL. Less consistent associations were seen with other variables. Household income and the caregiver's perception of asthma severity were associated with all caregiver HQL domains. It was concluded that household income was most consistently associated with the HQL of asthmatic pediatric patients and their caregivers.

Cardiovascular side effects of inhaled salbutamol in hypoxic asthmatic patients

BACKGROUND

Beta-2 adrenoceptor agonists have been associated with sudden death in asthma patients but the cause and underlying mechanism are unclear. Animal experiments indicate that the combination of hypoxia and beta2 agonists may result in detrimental cardiovascular effects. A study was undertaken to investigate the effect of hypoxia on the systemic vascular effects of salbutamol in patients with asthma who are hypoxic by assessing forearm blood flow (FBF) as a measure of peripheral vasodilatation.

METHODS

Eight men with mild asthma underwent the following treatments: normoxia + placebo (NP), normoxia + salbutamol (NS), hypoxia + placebo (HP), and hypoxia + salbutamol (HS). The period of mask breathing started at t=0 minutes, lasted for 60 minutes, and at 30 minutes 800 microg salbutamol was inhaled. The experiment was completed 30 minutes after the inhalation (t=60 minutes). For the hypoxia treatment the SpO2 level was 82%. Differences between treatments were sought using factorial ANOVA on percentage change from the pretreatment value.

RESULTS

There were no significant differences in blood pressure and potassium levels between the treatments. After 60 minutes the increase in FBF was 13% (95% CI -12 to 39) more for HP treatment than for NP, 21% (95% CI -5 to 46) more for NS than for NP, and 32% (95% CI 7 to 58) more for HS than for HP (p=0.016). The inhalation of salbutamol during hypoxia resulted in a significant increase in FBF of 45% (95% CI 20 to 71) compared with NP (p=0.001).

CONCLUSION

Patients with asthma who are hypoxic and inhale beta2 agonists have serious systemic vascular side effects which may be an additional explanation for the association between asthma treatment and sudden death.

Cardiovascular side effects of inhaled salbutamol in hypoxic asthmatic patients

BACKGROUND

Beta-2 adrenoceptor agonists have been associated with sudden death in asthma patients but the cause and underlying mechanism are unclear. Animal experiments indicate that the combination of hypoxia and β2 agonists may result in detrimental cardiovascular effects. A study was undertaken to investigate the effect of hypoxia on the systemic vascular effects of salbutamol in patients with asthma who are hypoxic by assessing forearm blood flow (FBF) as a measure of peripheral vasodilatation.

METHODS

Eight men with mild asthma underwent the following treatments: normoxia + placebo (NP), normoxia + salbutamol (NS), hypoxia + placebo (HP), and hypoxia + salbutamol (HS). The period of mask breathing started at t=0 minutes, lasted for 60 minutes, and at 30 minutes 800 μg salbutamol was inhaled. The experiment was completed 30 minutes after the inhalation (t=60 minutes). For the hypoxia treatment the Spo2 level was 82%. Differences between treatments were sought using factorial ANOVA on percentage change from the pretreatment value.

RESULTS

There were no significant differences in blood pressure and potassium levels between the treatments. After 60 minutes the increase in FBF was 13% (95% CI –12 to 39) more for HP treatment than for NP, 21% (95% CI –5 to 46) more for NS than for NP, and 32% (95% CI 7 to 58) more for HS than for HP (p=0.016). The inhalation of salbutamol during hypoxia resulted in a significant increase in FBF of 45% (95% CI 20 to 71) compared with NP (p=0.001).

CONCLUSION

Patients with asthma who are hypoxic and inhale β2 agonists have serious systemic vascular side effects which may be an additional explanation for the association between asthma treatment and sudden death.

Prevalence of asthma among schoolchildren in Patras, Greece: three surveys over 20 years

BACKGROUND

The aim of the present study was to compare the prevalence of asthma among schoolchildren in 1978, 1991, and 1998 in Patras, Greece.

METHODS

The study populations of the three comparable cross sectional surveys comprised third and fourth grade public school children in Patras, Greece. Sample sizes in 1978, 1991, and 1998 were 3735, 2952 and 3397 children and response rates were 80.4%, 81.9%, and 90.6%, respectively. Prevalence of current, non-current, and lifetime asthma or recurrent wheezing was determined by parental questionnaire. Personal communication with the parents of asthmatic children in 1991 and 1998 provided data on lost schooldays.

RESULTS

Prevalence rates of current asthma or wheezing in 1978, 1991, and 1998 were 1.5%, 4.6%, and 6.0%, respectively (1978-91: p=0.01, 1991-98: p=0.02, 1978-98: p=0.03). Lifetime prevalences of asthma or wheezing in 1991 and 1998 were 8.0% and 9.6%, respectively (p=0.03). Current diagnosed asthma increased proportionally to diagnosed wheezing during 1991-98. The number of schooldays lost in the previous 2 years because of asthma did not change (p>0.1) between 1991 (0.31 per child) and 1998 (0.34 per child).

CONCLUSIONS

Our results support a true increase in the prevalence of current and lifetime asthma in the last 20 years among pre-adolescent children in Patras, Greece.

A community-based study of near-fatal asthma

BACKGROUND

The purpose of this study was to describe the community-based impact of near-fatal asthma within the District of Columbia (Washington, DC).

METHODS

The design was a prospective cohort study. Subjects included all persons in 1993 who presented to Washington, DC hospitals alive, requiring intubation for respiratory failure (including subjects who subsequently died in the hospital). Washington, DC hospitals were contacted on a biweekly basis to identify subjects. Patients were contacted by mail, followed by an interview with the subject or proxy.

RESULTS

Of the 35 case subjects identified, 31 (88.6%) were interviewed. Sixty-one percent of the subjects were female; 84% were African-American; and 45.2% were less than 18 years old. Forty-five percent had asthma for 10 or more years. Twenty-three percent reported the emergency department as their usual source of health care, and 32% saw a provider on a weekly basis. Fifty-two percent were taking four or more prescription medications, and 29% were taking no anti-inflammatory medications. In the 24 hours before the event, 77% reported difficulty breathing, but only 64% reported contacting a health care provider.

CONCLUSIONS

Community-based investigation of near-fatal asthma may lead to a better characterization of risk factors associated with this event. Findings from this study suggest that some of the factors associated with near-fatal events may be different from those associated with fatal asthma and that up to one third of the events may have been preventable.

Adverse asthma outcomes among children hospitalized with asthma in California

OBJECTIVE

To use administrative data to determine whether adverse asthma outcomes for pediatric asthma hospitalizations are related to specific clinical and nonclinical patient characteristics.

DESIGN

Cross-sectional study.

SETTING

All pediatric (0 to 17 years of age) asthma-related hospital discharges, 1986 to 1993, in California.

PATIENTS

A total of 113 974 eligible patients with asthma-related discharges.

MAIN OUTCOME MEASURE

Adverse asthma outcomes (intubation, cardiopulmonary arrest, and death).

RESULTS

Adverse asthma outcomes occurred in 0.48% of subjects. The frequency of adverse asthma outcomes increased during the 1990s compared with 1986. After controlling for differences in gender, age, specific comorbid conditions, year, race, and insurance type, adverse asthma outcomes were more likely to occur in the 5- to 11-year-old group (odds ratio [OR]: 1.39; 95% confidence interval [CI]: 1.13-1.69) and in the 12- to 17-year-old group (OR: 4.48; CI: 3.20-6.21) compared with those children in the 0 to 4-year-old age group. Asian Pacific-American children were more likely (OR: 1.59; CI: 1.24-2.59) than were white children to experience an adverse asthma outcome. Children who had a secondary diagnoses of pneumonia (OR: 1.54; CI: 1. 19-2.00) also were more likely to experience an adverse asthma outcome. The odds of an adverse outcome increased progressively after 1986, becoming significant after 1989. Gender and insurance type were not associated with increased odds of experiencing an adverse asthma outcome.

CONCLUSIONS

Adverse asthma outcomes among hospitalized children are increasing in the 1990s and are associated with specific clinical and nonclinical patient characteristics.

Racial differences in emergency department use persist despite allergist visits and prescriptions filled for antiinflammatory medications

BACKGROUND

African-American children use the emergency department (ED) for asthma care more than their Caucasian counterparts.

OBJECTIVE

We sought to compare ED utilization for asthma care by race, adjusting for prescriptions filled for antiinflammatory medications, type of index visit (specialist vs nonspecialist), and demographic variables.

METHODS

An index asthma visit was identified for a cohort of managed care enrollees aged 4 to 11 years. Information on asthma encounters and drug claims data was evaluated during a prospective observation period of 12 months.

RESULTS

African-American race was associated with one or more ED visits during the observation period (relative risk [RR] = 1.8, 95% CI = 1.3 to 2.5, p < 0.01). After adjusting for index visit type, prescriptions filled, and selected demographic variables, African-American race remained associated with post-index ED utilization (adjusted RR = 1.6, 95% CI = 1.0 to 2.4, p = 0.05). Additional findings included an inverse relationship between African-American race and antiinflammatory medications among children with nonspecialist index visits (RR = 0.5, 95% CI = 0.3 to 0.9, p = 0.02) and a positive relationship between African-American race and hospitalization after an ED visit for asthma care (RR = 10.2, 95% CI = 1.4 to 74.8, p < 0.01).

CONCLUSION

African-American children were more likely to use ED asthma care even after adjusting for the type of index visit, prescriptions filled for antiinflammatory medications, and selected demographic variables. Racial differences in ED utilization for asthma care could be caused by a higher prevalence of uncontrolled or undertreated disease among African-American children not receiving specialty care.