The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi initiative for asthma - 2024 update: Guidelines for the diagnosis and management of asthma in adults and children

The Saudi Initiative for Asthma 2024 (SINA-2024) is the sixth version of asthma guidelines for the diagnosis and management of asthma for adults and children that was developed by the SINA group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up-to-date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA Panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is aligned for age groups: adults, adolescents, children aged 5-12 years, and children aged <5 years. SINA guidelines have focused more on personalized approaches reflecting a better understanding of disease heterogeneity with the integration of recommendations related to biologic agents, evidence-based updates on treatment, and the role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and the current situation at national and regional levels. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Immune cell ratio and coagulation markers in assessing prognosis of asthma: a cross-sectional study from Saudi Arabia

Asthma affects a significant number of individuals in Saudi Arabia, with increasing prevalence worldwide, leading to a considerable impact on their quality of life and frequent hospitalizations. In this study, we aimed to explore the relationship between the immune cell ratio and coagulation markers, specifically to identify the occurrence of coagulation abnormalities associated with asthma. To achieve this, we assessed asthma history and severity using a questionnaire while analyzing coagulation biomarkers through venous blood samples. The biomarkers examined included d-dimer, prothrombin time (PT), partial thromboplastin time (PTT), and the international normalized ratio (INR). In addition, we evaluated various hematological parameters such as blood cell counts and hemoglobin (HGB) levels. Our findings revealed compelling evidence, showing significantly elevated levels of d-dimer and the eosinophil-to-neutrophil (ENR) ratio in asthma cases compared to the controls. Moreover, we observed a positive correlation between d-dimer levels and the ENR, with each unit increase in d-dimer associated with a 0.0006 increase in the ENR among asthma cases. These results highlight the potential of assessing ENR and d-dimer levels as predictive indicators for disease prognosis and the development of coagulation abnormalities in individuals with asthma. By shedding light on the relationship between immune cell ratios and coagulation markers in the context of asthma, our study contributes to a better understanding of disease progression and the associated complications. These insights can potentially lead to improved management strategies and better outcomes for asthma patients.

Primary Healthcare in Saudi Arabia: An Evaluation of Emergent Health Trends

Introduction

The Kingdom of Saudi Arabia (KSA) is experiencing an increasing demand for healthcare due to a growing population and unhealthy changes in lifestyle, fostering the need for critical examination of the current status of primary healthcare in the KSA with analysis of health-related trends among its growing population.

Methods

A review of the literature was therefore undertaken, followed by a survey of primary healthcare centers at three facilities in Riyadh, to assess the current activities, understand challenges, compare existing practices with international best practices, and asses the level of patient satisfaction. The level of satisfaction with primary care services was examined by using observational surveys and retrospective reviews from the previous 20 years.

Results

The more rural areas with populations with lower education and income ranked factors such as cleanliness, competence of staff, and environment the highest (82-95%), whereas urban areas with populations with higher education and income rated their level of satisfaction lower (74-82%). The influence of population diversity and the country's unique cultural sensitivities on the awareness and uptake of cancer surveillance services available in the community was examined. The incidence of diabetes, asthma, obesity, along with breast and cervical cancer trends, has illustrated the importance of health education and disease prevention.

Conclusion

An investment in resources for primary healthcare staff and medical facilities is strongly recommended to support primary care providers in becoming the accepted and preferred community frontline for healthcare needs' assessment and care delivery. With its nursing staff comprised predominantly of expatriates, the emphasis needs to be on recruitment and training of a Saudi national workforce in line with succession planning strategy toward a sustainable Saudi workforce.

Assessment of Asthma Control Among Asthmatic Patients at Primary Healthcare Centers in Makkah, Saudi Arabia

Introduction

Asthma is the most common respiratory disease worldwide. In Saudi Arabia, asthma is considered as a major public health concern and has a negative impact in the life of patients, their families, and the community, including lost days of work, absence from school, and poor quality of life, which can eventually lead to frequent emergency department visits, hospitalizations, and sometimes, to death. Thus, the objectives of this study were to evaluate asthma control status among asthmatic patients in primary health care centers (PHCCs) in Makkah, Saudi Arabia and to identify factors associated with poor asthma control.

Methods

This was a cross-sectional study conducted from March to May 2016 in selected PHCCs in Makkah, Saudi Arabia. Data was collected from five PHCCs which were selected using a stratified random sample technique from a total of 47 PHCCs to represent the different geographic regions of the city. The 167 asthmatic patients, aged four years and above, presented during the study period were included. Each respondent completed two tools: the first is a self-administrated questionnaire and the second is the asthma control test. Statistical analyses were performed with SPSS version 21 software (IBM Corp, Armonk, USA). Qualitative variables were analyzed with the Chi-square test or Fisher's exact test as appropriate.

Results

Around one-third (34.1%) of all asthmatic patients were categorized as having uncontrolled asthma and about one-quarter (24.6%) were partially controlled asthma. Dust (91.6%), exposure to incense, detergent and essence (86.8%), common cold (82%) and cold weather (79.6%) were the factors that trigger or exacerbate asthma attacks. Physical activity/exercise and cold weather were the commonest factors that significantly exacerbate asthma attacks particularly among children and were mostly uncontrolled. More than one-third (36.5%) of the asthmatic patients in the PHCCs were cared for by general practitioners.

Conclusion

Poor asthma control was observed in a high proportion of asthmatic children, adolescents and adults in the Makkah region and they were mostly from non-specialized PHCCs. The poor asthma control among the respondents affects their quality of sleep ( i.e., frequent awakening at night), recurrent absences from work and school, increased hospitalizations, emergency and unscheduled visits to the hospital. 

Allergy and related clinical symptoms among medical students and interns

OBJECTIVES

To determine the prevalence, types, clinical presentations, triggers, and predictors of allergic disorders among medical students and interns at King Abdulaziz University (KAU), Jeddah, Saudi Arabia.

METHODS

A cross-sectional design was used for this study in which 600 medical students and interns were selected by a multistage stratified random sampling. A validated, confidential, self-administered questionnaire was used during 2016 / 2017. It asked about the previous diagnosis of allergic disorders, associated factors, types, clinical symptoms and the triggering allergenic. Descriptive & inferential statistics were done and logistic regression analysis was conducted.

RESULTS

The overall prevalence of diagnosed allergic disorder(s) among the participants was 36.2%.The commonest types of allergy were skin (33.8%) followed by respiratory (29.5%) presentations. The most frequently reported allergenic triggers were the house dust (45.6%) and smoke (30.4%). The first allergy predictor was family history of allergic disorders (aOR= 4.35, 95 % CI: 2.96-6.39), followed by female gender. Regarding the outcome of allergy on students' life, 16.1% occasionally missed classes, and 28.6% had sleep disturbance during allergic attacks.

CONCLUSION

Allergy represents an important problem among medical students and interns. Family history and female gender were the predictors of allergy. Skin and respiratory allergies were the most common types. House dust and smoke were the commonest allergenic triggers. Detection of allergens and management of cases of allergy among medical students and interns are needed. Education and conduction of awareness campaigns about allergy are needed.

The Saudi Initiative for Asthma - 2019 Update: Guidelines for the diagnosis and management of asthma in adults and children

This is the fourth version of the updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of the SINA is to have guidelines that are up to date, simple to understand, and easy to use by healthcare workers dealing with asthma patients. To facilitate achieving the goals of asthma management, the SINA panel approach is mainly based on the assessment of symptom control and risk for both adults and children. The approach to asthma management is now more aligned for different age groups. The guidelines have focused more on personalized approaches reflecting better understanding of disease heterogeneity with integration of recommendations related to biologic agents, evidence-based updates on treatment, and role of immunotherapy in management. The medication appendix has also been updated with the addition of recent evidence, new indications for existing medication, and new medications. The guidelines are constructed based on the available evidence, local literature, and current situation at national and regional levels. There is also an emphasis on patient–doctor partnership in the management that also includes a self-management plan.

Medicinal benefits of Nigella sativa in bronchial asthma: A literature review

Nigella sativa L. (NS) seeds, known as black seed, is a spice and a traditional herbal medicine used in various diseases including bronchial asthma. This review aimed to assess the studies supporting the medicinal use of NS in asthma and to highlight future research priorities. Various medical databases were searched for the effects of NS and its active secondary metabolites in asthma inflammation and outcomes. There were fourteen preclinical studies describing multiple effects of NS in animal or cellular models of asthma including bronchodilation, anti-histaminic, anti-inflammatory, anti-leukotrienes and immunomodulatory effects. Furthermore, seven clinical studies showed improvements in different asthma outcomes including symptoms, pulmonary function and laboratory parameters. However, often these studies are small and used ill-defined preparations. In conclusion, NS could be therapeutically beneficial in alleviating airway inflammation and the control of asthma symptoms, but the evidence remains scanty and is often based on poorly characterised preparations. Accordingly, well-designed large clinical studies using chemically well characterised NS preparation are required.

Use of Global initiative for asthma (GINA) guidelines in asthma management among paediatric residents in a Sub Saharan African country: a cross-sectional descriptive study

Introduction

Clinical practice guidelines are systematically developed statements to assist practitioner and patient decisions about appropriate health care for specific clinical circumstances. Despite abundance of asthma guidelines, prevalence has continued to increase globally. There is need to assess how the contents of asthma guidelines are put to clinical use by doctors in the management of children with asthma. This study aims at evaluating the clinical practice of paediatric residents in applying GINA guidelines.

Methods

Cross-sectional descriptive study of paediatric residents from 23 university teaching hospitals in Nigeria using structured questionnaire. Data analyses were with Statistical Package for Social Sciences (SPSS) version 19 (Chicago IL). Chi square was used to assess for any significant associations between categorical variables. A p < 0.05 was regarded to be statistically significant.

Results

Sixty-six paediatric residents aged 27- 40 years were enrolled into the study (37 females and 29 males). One-third had spent more than three years in residency training. Fifty-eight residents (87.9%) were aware of the GINA guidelines while 46 (69.7%) were familiar with its contents. Only 39 (59.1%) residents adhered to the GINA guidelines. Twenty of the 35 junior residents (57.1%) compared to 26 of 31 (83.9%) senior residents were familiar with the GINA guidelines (p=0.031) while 15 of 35 junior residents (42.9%) compared to 24 of 31 senior residents (77.4%) consistently follow the GINA guidelines (p=0.006). Adherence to GINA guidelines was not influenced significantly by years of graduation or training (p>0.05).

Conclusion

The use of the GINA guidelines was poor among paediatric residents. Application of contents rather than just availability of asthma guidelines may partly account for increasing asthma prevalence globally.

Risk factors hindering asthma symptom control in Saudi children and adolescents

BACKGROUND

Maintaining good control of asthma symptoms can help to prevent exacerbations and its associated complications. The Asthma Control Test (ACT) can rapidly assess the effectiveness of asthma management plan and therapy. The aim of this study was therefore to identify risk factors associated with uncontrolled asthma symptoms in young Saudi asthmatic children (3-17 years old).

METHODS

In this cross-sectional hospital-based survey, the ACT was administered to 297 asthmatic children/adolescents, recruited at the emergency department (ED) of two major hospitals.

RESULTS

Most recruited patients had intermittent (63.5%) and mild persistent (27.6%) asthma; few had moderate persistent (8.9%) and none had severe asthma. These patients visited the ED four times (3.9 ± 3.2), on average. Almost half of the patients stated that they had not received education about asthma (47%) or education about medication use (43%). Most patients (60.3%) had uncontrolled symptoms (ACT score ≤19), of whom the intermittent asthma patients had better scores than those with more severe symptoms. Children ≤6 years old, with symptoms diagnosed <5 years previously and who were not attending school, had significantly worse control than older patients. Poor medication compliance and inappropriate inhaler device use were ascribed to younger patients (<12 years old) and worse scores; particularly in relation to stopping inhaled corticosteroid therapy when their symptoms improve. Patients with poor control also stated that they had not received education about inhaler device use.

CONCLUSIONS

Most Saudi asthmatic children/adolescents visiting the ED had poor control of symptoms; indeed, none achieved complete control, which is related to deficient medication compliance and improper medication inhaler device use; deficient knowledge about asthma was also another factor hindering control.

Sensitization to Common Aeroallergens in Asthmatic Children in the Eastern Region of Saudi Arabia

Background:

Allergic disorders, particularly bronchial asthma, are one of the most common chronic childhood diseases. Bronchial asthma is more prevalent among children of the Eastern Province of Saudi Arabia compared with the other provinces. Environmental factors play major roles in the disease pathogenesis in genetically predisposed hosts. In this study, we characterize the pattern of allergenicity in asthmatic children in the Eastern Province of Saudi Arabia.

Materials and Methods:

This study is a retrospective, cross-sectional analysis of skin sensitization profiles of 100 Saudi asthmatic children living in Al-Khobar, Saudi Arabia. The group compromised 32 females and 68 males, aged 5–14 years with a mean age of 8.98 ± 2.93 years. Skin prick tests were performed in a regional tertiary center, in the period between January 2011 and December 2012, using a variety of indoor and outdoor allergens.

Results:

The most common indoor sensitizing allergens found were the house dust mite (54%), cat fur (53%) and the German cockroach (26%). Among outdoor allergens, Salsola kali was the most common (48%), followed by Timothy grass (23%) and Chenopodium album (23%). Among trees, Prosopis glandulosa was found to be the most prevalent sensitizer (19%). Among the molds, Alternaria and Aspergillus species were the most prevalent (21% each).

Conclusion:

A high rate of sensitization to aeroallergens was found in asthmatic children living in Al-Khobar city. The pattern of sensitization found in our study reflects the newly altered nature of an ancient humid desert that has been influenced by the recent artificial modernization of the region.

Long-term treatment in pediatric asthma: an update on chemical pharmacotherapy

INTRODUCTION

Asthma is the most common chronic disease in childhood, affecting approximately 10% of all children, and is the leading cause of hospitalization in developed countries. In this paper we aimed to review the evidence on chemical pharmacotherapy for long-term treatment of pediatric asthma, according to the latest updates. Area covered: Long-term treatment, essential for controlling symptoms and reducing future risks including exacerbations and decline in lung function, includes control agents such as inhaled corticosteroids, long-acting beta2-adrenergic agonists, and leukotriene modifiers. More recent strategies based on the use of a biological drug such as omalizumab, which is a monoclonal antibody directed against immunoglobulin E (IgE), can be considered in selected patients with severe asthma. Expert opinion: In the near future, the challenge of childhood asthma treatment will be to improve the chemical drugs that already exist as well as to carefully characterize the several different asthma subtypes, with special regard to children with severe disease. A better definition of patient features, made possible by the current advanced knowledge of the pathobiology of severe asthma, can ultimately allow the identification of specific phenotypes and endotypes of severe asthma, aimed to personalize pharmacological treatment.

Lower prevalence and greater severity of asthma in hot and dry climate

OBJECTIVE

To estimate asthma prevalence, severity, and associated factors in adolescents who live in a low relative humidity environment.

METHODS

In this cross-sectional study, adolescents aged 13-14 years from the city of Petrolina located in the Brazilian semiarid region answered the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire. The possible explanatory variables of the study were gender, family income, mother's education, smokers in the household, parental history of asthma, personal history of allergic rhinitis or atopic dermatitis, and physical activity level. Poisson regression analysis was used to assess the association between asthma and the explanatory variables.

RESULTS

A total of 1591 adolescents participated in the study, of whom 49.7% were male. The prevalence of active asthma, severe asthma, and physician-diagnosed asthma were 14.0%, 10.4%, and 17.8%, respectively. Adolescents with asthma missed more school days than their peers (33 vs. 22 days/year; p<0.03). Associated factors that remained significant after adjustment were history of asthma in parents (PR=2.65, p<0.001) and personal diagnosis of allergic rhinitis (PR=1.96, p<0.001) and/or atopic dermatitis (PR=2.18, p<0.001).

CONCLUSION

Asthma prevalence in this low-humidity environment was lower, but more severe than those reported in other Brazilian cities. The dry climate might hamper disease control and this may have contributed to the higher school absenteeism observed. The association of asthma with allergic rhinitis and atopic dermatitis as well as a history of asthma in parents suggests that atopy is an important risk factor for asthma in this population.

Asthma control among adults in Saudi Arabia. Study of determinants

Objectives:

To explore the determinants of uncontrolled asthma in Saudi Arabia.

Methods:

A consecutive series of adult asthma patients attending 3 pulmonary primary care clinics in Riyadh, Saudi Arabia for a scheduled appointment were interviewed. A multiple logistic regression analysis was used.

Results:

The proportion of patients with uncontrolled asthma was 68.1% (177/260). Daily tobacco smoking or monthly household income less than 15,000 Saudi Arabian Riyals were associated with a 4.6 (95% confidence interval [CI]=1.3-16.4) and 3.4 (95% CI=1.8-6.6) times increase in the odds of having uncontrolled asthma. Patients with less than a graduate degree (odds ratio [OR]=3.1; 95% CI=1.0-9.5) or patients who were unemployed, disabled, or too ill to work (OR=3.1; 95% CI=1.4-6.9) had poorer asthma control. Having heartburn during the past 4 weeks decreased the odds of asthma control by 2.5 (95% CI=1.3-4.9), and having chronic sinusitis during the past 4 weeks decreased the odds of asthma control by 2.0 (95% CI=1.0-4.0) times. Being female (OR=2.0; 95% CI=1.0-4.0) or ≥35 years of age (OR=2.0; 95% CI=1.0-3.9) was also associated with having uncontrolled asthma.

Conclusion:

Our findings suggest that most respondents had uncontrolled asthma. Less modifiable socio-demographic factors (for example, income, education, occupation, gender, and age) significantly increased the odds of having uncontrolled asthma. However, modifiable risk factors such as tobacco smoking and clinical factors such as heartburn and chronic sinusitis could also be targeted for intervention.

TOLERABILITY OF PREDNISOLONE AND DEXAMETHASONE IN CHILDREN IN SAUDI ARABIA

BACKGROUND

Corticosteroids are used to treat a variety of medical conditions including acute asthma and croup where they are often given in short-courses. Epidemiological studies in Saudi Arabia show an increasing prevalence of respiratory diseases such as asthma in the past three decades.1 This study aimed to evaluate the tolerability and palatability of oral prednisolone and dexamethasone in children in Saudi Arabia. Both drugs are available in different formulations from different pharmaceutical companies.

METHODS

Prospective observational and interview study. The palatability of the oral corticosteroids was evaluated by asking children and their parent's opinions of the taste and acceptability of the medication soon after drug administration. Children were asked to point at the appropriate face on a 10-cm visual analogue scale depicting five degrees of pleasure: 1 'dislike very much, 2 'dislike a little', 3 'not sure', 4 'like a little' and 5 'like very much'.2 The tolerability of the drugs, in particular nausea, vomiting and abdominal pain was also evaluated by direct questioning of the parent/patients after each drug administration, and at the end of the course. Data was collected over three months, February to April 2015. Patients aged 2-18 years with any condition being treated with oral prednisolone or dexamethasone in hospital were approached to participate.

RESULTS

122 patients (89 with asthma and 33 with croup) age range 2-11 years (mean=4.3) were recruited. 52 patients were given prednisolone base tablets, 37 patients were given prednisolone sodium phosphate syrup and 33 patients dexamethasone oral solution.The palatability score was lowest for the prednisolone base tablet (Mean rating=1.12), (prednisolone sodium phosphate group, Mean=1.62, 95% CI -0.75, -0.26; P=0.000001) (dexamethasone group, Mean=1.97, 95% CI -1.11, -0.6; P=0.000001). Dexamethasone was rated the most palatable (prednisolone sodium phosphate, 95% CI 0.08, 0.62; P=0.012). Nausea and vomiting occurred only in patients given prednisolone base tablets (24 and five patients respectively). Both were statistically more frequent when compared with the prednisolone sodium phosphate group (only four patients had nausea) (95% CI 0.19, 0.52; P=0.000001 and 95% CI 0.1, 0.18; P=0.024 respectively). In the dexamethasone group only two patients had nausea. Abdominal pain was reported in 13 patients given prednisolone sodium phosphate syrup compared to eight patients in the prednisolone tablet group (95% CI 0.02, 0.38; P=0.032). In the dexamethasone group eight patients had abdominal pain.

CONCLUSIONS

Dexamethasone was the most palatable preparation though it did cause abdominal pain in nearly one quarter of patients. Prednisolone base tablets were rated the least palatable preparation and were also the least well tolerated.

The use of inhaled corticosteroids in pediatric asthma: update

Despite the availability of several formulations of inhaled corticosteroids (ICS) and delivery devices for treatment of childhood asthma and despite the development of evidence-based guidelines, childhood asthma control remains suboptimal. Improving uptake of asthma management plans, both by families and practitioners, is needed. Adherence to daily ICS therapy is a key determinant of asthma control and this mandates that asthma education follow a repetitive pattern and involve literal explanation and physical demonstration of the optimal use of inhaler devices. The potential adverse effects of ICS need to be weighed against the benefit of these drugs to control persistent asthma especially that its safety profile is markedly better than oral glucocorticoids. This article reviews the key mechanisms of inhaled corticosteroid action; recommendations on dosage and therapeutic regimens; potential optimization of effectiveness by addressing inhaler technique and adherence to therapy; and updated knowledge on the real magnitude of adverse events.

Asthma quality of life in Saudi Arabia: Gender differences

OBJECTIVES

To explore potential gender differences in the factors associated with asthma-specific quality of life (AQL).

METHODS

A cross-sectional study of consecutive series of adult patients attending primary care centers at three major hospitals in Riyadh, Saudi Arabia, was performed. AQL was measured using a standardized version of the AQL questionnaire (min = 1, max = 7), with higher scores indicating a better AQL. Multiple linear regression analysis was performed.

RESULTS

The mean AQL was 4.3 (standard deviation [SD] = 1.5) for males and 4.0 (SD = 1.3) for females (p = 0.113). With each unit increase in asthma control, the AQL improved by 0.19 points (95% confidence interval [CI] = 0.14-0.23) in men and by 0.21 points (95% CI = 0.16-0.25) in women. Daily tobacco smoking was associated with a 0.72 point (95% CI = 0.14-1.30) decrease in the AQL among males. Women who had a household member who smoked inside the house had a significantly lower AQL (B = -0.59, 95% CI = -1.0 - -0.19). A monthly household income of 25,000 Saudi Riyals or more was associated with a better AQL among men (B = 0.51, 95% CI = 0.01-1.01), whereas being employed exhibited a protective effect in women (B = 0.48, 95% CI = 0.11-0.84). Higher levels of perceived asthma severity were associated with better AQL in women (B = 0.82, 95% CI = 0.36-1.28).

CONCLUSIONS

Our findings revealed gender-specific differences in the correlates of AQL in Saudi Arabia, particularly in tobacco exposure, socio-economic factors and perceived asthma severity.

The Saudi Thoracic Society pneumococcal vaccination guidelines-2016

Streptococcus pneumoniae (pneumococcus) is the leading cause of morbidity and mortality worldwide. Saudi Arabia is a host to millions of pilgrims who travel annually from all over the world for Umrah and the Hajj pilgrimages and are at risk of developing pneumococcal pneumonia or invasive pneumococcal disease (IPD). There is also the risk of transmission of S. pneumoniae including antibiotic resistant strains between pilgrims and their potential global spread upon their return. The country also has unique challenges posed by susceptible population to IPD due to people with hemoglobinopathies, younger age groups with chronic conditions, and growing problem of antibiotic resistance. Since the epidemiology of pneumococcal disease is constantly changing, with an increase in nonvaccine pneumococcal serotypes, vaccination policies on the effectiveness and usefulness of vaccines require regular revision. As part of the Saudi Thoracic Society (STS) commitment to promote the best practices in the field of respiratory diseases, we conducted a review of S. pneumoniae infections and the best evidence base available in the literature. The aim of the present study is to develop the STS pneumococcal vaccination guidelines for healthcare workers in Saudi Arabia. We recommend vaccination against pneumococcal infections for all children <5 years old, adults ≥50 years old, and people ≥6 years old with certain risk factors. These recommendations are based on the presence of a large number of comorbidities in Saudi Arabia population <50 years of age, many of whom have risk factors for contracting pneumococcal infections. A section for pneumococcal vaccination before the Umrah and Hajj pilgrimages is included as well.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

The Saudi Thoracic Society guidelines for influenza vaccinations

Influenza viruses are responsible for the influenza outbreaks that lead to significant burden and cause significant morbidity and mortality worldwide. Based on the core proteins, influenza viruses are classified into three types, A, B, and C, of which only A and B cause significant human disease and so the vaccine is directed against these two subtypes only. The effectiveness of the vaccine depends on boosting the immune system against the serotypes included within it. As influenza viruses undergo periodic changes in their antigen, the vaccine is modified annually to ensure susceptibility. In contrast to other countries, Saudi Arabia faces a unique and challenging situation due to Hajj and Umrah seasons, when millions of people gather at the holy places in Mecca and Madinah, during which influenza outbreaks are commonly found. Such challenges making the adoption of strict vaccination strategy in Saudi Arabia is of great importance. All efforts were made to develop this guideline in an easy-to-read form, making it very handy and easy to use by health care workers. The guideline was designed to provide recommendations for problems frequently encountered in real life, with special consideration for special situations such as Hajj and Umrah seasons and pregnancy.

Prevalence of asthma in Saudi adults: findings from a national household survey, 2013

BACKGROUND

There are not enough data on the epidemiology of asthma in the Kingdom of Saudi Arabia (KSA). We analyzed data from a national household survey conducted in KSA in 2013 to estimate prevalence, associated risk factors and control measurements of asthma.

METHODS

The Saudi Health Interview Survey was a cross-sectional national multistage survey of 10,735 individuals aged 15 years or older. The survey included a detailed household questionnaire and a physical exam. We used self-reported clinical diagnosis of asthma to assess prevalence of asthma.

RESULTS

The prevalence of asthma in KSA was 4.05 % (95 % confidence interval [CI]: 3.54-4.62 %). Asthma was less frequent in individuals with higher education but higher in former smokers and obese individuals. Around 76.7 % of asthma patients (95 % CI: 70.6-82.0 %) experienced an asthmatic attack, and 61.6 % (95 % CI: 54.4-68.4 %) visited a hospital/emergency room because of asthma during the past year. Asthma attack was less frequent in older patients (odds ratio [OR] = 0.78, 95 %CI: 0.59-0.96 for each decade of life). Current use of medication for asthma was highly associated with asthma attacks (OR = 9.14, 95 % CI: 3.29-25.38). Asthma attack was also more frequent in individuals who were exposed to secondhand smoking (OR = 2.17, 95 %CI: 1.05-4.45) and those who were obese (OR = 3.01, 95 %CI: 1.34-6.78).

CONCLUSION

Saudi Arabia has a relatively low prevalence of diagnosed asthma; however, many of the patients with known asthma do not have it under good control. Our study calls for programs to inform patients about the importance and proper means of controlling their condition. Implementing and monitoring of clinical guidelines can also help to improve asthma control among patients as well as identify undiagnosed cases.

Poor asthma education and medication compliance are associated with increased emergency department visits by asthmatic children

BACKGROUND:

Acute exacerbations of bronchial asthma remain a major cause of frequent Emergency Department (ED) visits by pediatric patients. However, other factors including psychosocial, behavioural and educational, are also reportedly associated with repetitive ED visits. Therefore, it is necessary to determine whether such visits are justifiable.

OBJECTIVE:

The objective of this cross-sectional study was to identify risk factors associated with visits to ED by asthmatic children.

METHODS:

Asthmatic children (n = 297) between 1-17 years old were recruited and information collected at the time of visiting an ED facility at two major hospitals.

RESULTS:

Asthmatic patients visited the ED 3.9 ΁ 3.2 times-per-year, on average. Inadequately controlled asthma was perceived in 60.3% of patients. The majority of patients (56.4%) reported not receiving education about asthma. Patients reflected misconceptions about the ED department, including the belief that more effective treatments are available (40.9%), or that the ED staff is better qualified (27.8%). About half of patients (48.2%) visited the ED because of the convenience of being open 24 hours, or because they are received immediately (38.4%). Uncontrolled asthma was associated with poor education about asthma and/or medication use. Patients educated about asthma, were less likely to stop corticosteroid therapy when their symptoms get better (OR:0.55; 95% CI:0.3-0.9; P = 0.04).

CONCLUSION:

This study reports that most patients had poor knowledge about asthma and were using medications improperly, thus suggesting inefficient application of management action plan. Unnecessary and frequent visits to the ED for asthma care was associated with poor education about asthma and medication use. Potential deficiencies of the health system at directing patients to the proper medical facility were uncovered and underline the necessity to improve education about the disease and medication compliance of patients and their parents/guardians.

Status of respiratory care profession in Saudi Arabia: A national survey

BACKGROUND:

Respiratory care (RC) is an allied health profession that involves assessing and treating patients who have pulmonary diseases. Research indicates that respiratory therapists’ (RT's) involvement in caring for patients with respiratory disorders improves important outcome measures. In Kingdome of Saudi Arabia (KSA), RC has been practiced by RTs for more than 30 years.

OBJECTIVE:

We sought to investigate the status of the RC workforce in Saudi Arabia in terms of demographic distribution, number, education, and RC service coverage.

METHODS:

We used a specially designed survey to collect data. A list of 411 working hospitals in KSA was obtained. All hospitals were contacted to inquire if RC is practiced by RTs. Data were collected from hospitals that employ RTs.

RESULTS:

Only 88 hospitals, 21.4% of total hospitals in the country, have RTs. Out of the 244 Ministry of Health (MOH) hospitals, only 31 hospitals (12.7%) employ RTs. There are 1,477 active RTs in KSA. Twenty-five percent of them, or 371, are Saudis. The majority of the RT workforce (60%) work for non-MOH government hospitals, and almost half the total RTs work in Riyadh province. About 60% of RTs work in critical care settings. RC coverage of critical care was 44.5% of ideal. The overall RT-to-ICU bed ratio was 1:11. The ratio was 1:9 for non-MOH government hospitals, and 1:20 for MOH hospitals.

CONCLUSIONS:

We report the first insightful data on RC workforce in KSA. These data should be used by educational institutions and health policy makers to plan better RC coverage in the country.

Replacing nebulizers by MDI-spacers for bronchodilator and inhaled corticosteroid administration: Impact on the utilization of hospital resources

Background and objectives

Metered-dose inhalers plus spacers (MDI-spacer) are as effective as, or better than, nebulizers in aerosol delivery. The selection of aerosol delivery system for hospitalized children can have a significant impact on the utilization of healthcare resources.

Design and setting

A quality improvement project to evaluate the impact of conversion to MDI-spacer to administer bronchodilators (BDs) and inhaled corticosteroids (ICSs) to hospitalized children on the utilization of hospital resources. The project was conducted in a tertiary pediatric ward from April to May 2013.

Materials and methods

The project was conducted over a six-week period. In the first two weeks, data were gathered from all hospitalized children receiving BDs and/or ICSs by nebulizers. This data collection was followed by a two-week washout period during which training of healthcare providers and operational changes were implemented to enhance the conversion to MDI-spacer. In the last two weeks, data were gathered from hospitalized children after conversion to MDI-spacer. The primary outcomes included the mean time (in minutes) of medication preparation and delivery. Secondary outcomes included the following: need for respiratory therapy assistance, estimated cost of treatment sessions, and patient/caregiver satisfaction.

Results

Five hundred seventy-five treatment sessions were enrolled (288 on nebulizers, 287 on MDI-spacer). The nebulizer group had more male predominance and were slightly older compared to the MDI-spacer group (male: 59% vs. 53% and mean age: 52 vs. 40 months respectively). The duration of treatment preparation and delivery was significantly lower in the MDI-spacer group (2 min reduction in preparation time and 5 min reduction in delivery time; p < 0.01). Caregivers mastered MDI-spacer use after an average of two observed sessions, eliminating the need for respiratory therapy assistance during the hospital stay. Medication cost analysis showed savings in favor of MDI-spacer (cost reduction per 100 doses: 50% for albuterol, 30% for ipratropium bromide, and 87% for ICSs). The patient satisfaction survey showed “very good” to “excellent” levels in both groups.

Conclusions

Conversion to MDI-spacer for BDs and ICSs administration in hospitalized children improve hospital resource utilization.

Bronchial asthma and chronic obstructive pulmonary disease: research activity in Arab countries

BACKGROUND

Chronic respiratory diseases, like bronchial asthma and chronic obstructive pulmonary disease (COPD), are a worldwide health problem. Quantitative and qualitative assessment of asthma and COPD-related research from Arab countries has not been explored and there are few internationally published reports on such field. The main objectives of this study were to analyze research output originating from Arab countries in the field of bronchial asthma and COPD.

METHODS

Original scientific articles or reviews published from the 22 Arab countries were screened using specific words pertaining to asthma and COPD using Scopus database and search engine. Research productivity was evaluated based on: (a) total and trends of contribution of each Arab country to asthma and COPD research and (b) journals in which researchers from Arab countries published their research.

RESULTS

The total number of original research and review articles published globally about bronchial asthma and COPD was 163,964. The leading country in bronchial asthma and COPD research was United States of America (38,632; 23.56%). Worldwide, Turkey ranked 19th while Israel and Iran ranked 25th and 29th respectively. Among Arab countries, Egypt and Kingdom of Saudi Arabia came on positions 39th and 43rd, respectively. A total of 1,304 documents about bronchial asthma and COPD were published from Arab countries which represents 0.8% of the global research output. Research in bronchial asthma was almost double that in COPD. Research from Arab countries was low and showed a significant increase after 2000. Approximately 12% of research activity in asthma and COPD from Arab countries was published in Saudi Medical Journal, Annals of Saudi Medicine, Eastern Mediterranean Health Journal and Tunisie Medicale. Kingdom of Saudi Arabia, with a total publication of 353 (27.07%) ranked first among the Arab countries while University of Kuwait was the most productive institution with a total of 123 (9.43%) documents.

CONCLUSIONS

The present data showed relatively low research productivity about bronchial asthma and COPD in Arab countries. Research output can be improved by investing more in international and national collaborative research projects in the field of asthma and COPD.

The Saudi Guidelines for the Diagnosis and Management of COPD

The Saudi Thoracic Society (STS) launched the Saudi Initiative for Chronic Airway Diseases (SICAD) to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease (COPD). This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test (CAT) and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation (<2 in the past year) can be classified as either Class I when they have less symptoms (CAT < 10) or Class II when they have more symptoms (CAT ≥ 10). High-risk COPD patients, as manifested with ≥2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score ≥10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

Biomarkers of oxidative stress in acute and chronic bronchial asthma

OBJECTIVE

Oxidative stress plays an important role in inflammatory diseases of the airways, such as bronchial asthma. This study highlights the effects of the imbalance of oxidant/antioxidant parameters and their roles in the severity of asthma, in order to target the deficiency of antioxidants when treating asthmatic patients.

METHODS

The study included 45 male and 45 female subjects, aged 18-48 years, with and without asthma. They were classified into 3 groups: G1 was healthy volunteers (CT, n = 15), G2 included patients with stable (chronic) conditions of asthma from the outpatients department (OP, n = 15), and G3 included patients admitted emergency room (ER, n = 15) with acute asthma attacks. For all subjects, the levels of total antioxidant capacity (TAC), reduced glutathione (GSH), malondialdehyde (MDA), and uric acid were colorimetrically estimated. The correlations between the studied parameters were statistically analyzed.

RESULTS

The levels of TAC and GSH in asthmatic patients, either male or female, were significantly decreased in the ER more than in the OP group as compared to the control (p < 0.001). MDA increased significantly in the ER group and over the OP group when compared with healthy subjects. Significant positive correlations (p < 0.001) were observed between MDA and other studied parameters TAC (r = -0.74), GSH (r = -0.69), and uric acid (r = -0.35).

CONCLUSIONS

The levels of total antioxidants were inversely related to the severity of asthma as observed in asthmatic patients visiting outpatient clinics and patients with acute asthmatic attacks admitted to emergency rooms. Meanwhile, those patients with acute attacks showed increased oxidative stress as reflected in the raised MDA levels.

Risk factors, management and outcomes of patients admitted with near fatal asthma to a tertiary care hospital in Riyadh

RATIONALE:

Near-fatal asthma (NFA) has not been well studied in Saudi Arabia. We evaluated NFA risk factors in asthmatics admitted to a tertiary-care hospital and described NFA management and outcomes.

MATERIALS AND METHODS:

This was a retrospective study of NFA patients admitted to an ICU in Riyadh (2006-2010). NFA was defined as a severe asthma attack requiring intubation. To evaluate NFA risk factors, randomly selected patients admitted to the ward for asthma exacerbation were used as controls. Collected data included demographics, information on prior asthma control and various NFA treatments and outcomes.

RESULTS:

Thirty NFA cases were admitted to the ICU in the five-year period. Compared to controls (N = 120), NFA patients were younger (37.5 ± 19.9 vs. 50.3 ± 23.1 years, P = 0.004) and predominantly males (70.0% vs. 41.7%, P = 0.005) and used less inhaled steroids/long-acting ß2-agonists combination (13.6% vs. 38.7% P = 0.024. Most (73.3%) NFA cases presented in the cool months (October-March). On multivariate analysis, age (odds ratio [OR] 0.96; 95% confidence interval [CI], 0.92-0.99, P = 0.015) and the number of ED visits in the preceding year (OR, 1.25; 95% CI, 1.00-1.55) were associated with NFA. Rescue NFA management included ketamine (50%) and theophylline (19%) infusions. NFA outcomes included: neuromyopathy (23%), mechanical ventilation duration = 6.4 ± 4.7 days, tracheostomy (13%) and mortality (0%). Neuromuscular blockade duration was associated with neuromyopathy (OR, 3.16 per one day increment; 95% CI, 1.27-7.83).

CONCLUSIONS:

In our study, NFA risk factors were younger age and higher number of ED visits. NFA had significant morbidity. Reducing neuromuscular blockade duration during ventilator management may decrease neuromyopathy risk.

Increased IL-4 mRNA expression and poly-aromatic hydrocarbon concentrations from children with asthma

Background

Asthma is the most common chronic childhood disease. Imbalance of cytokines released from T helper cells and environmental factors, such as exposure to poly-aromatic hydrocarbon (PAH), play pivotal roles in the pathogenesis of asthma. The aim of this study was to compare the mRNA expression patterns of Interleukin (IL)-4, interferon (IFN)-γ and Acyl Co A long chain 3 (ACSL3) in peripheral blood leukocytes of children with and without asthma. To correlate the obtained mRNA data with serum IL-4, IFN-γ and PAH levels. Further, to determine the effect of in vivo exposure to PAH on mRNA expression of IL-4, IFN-γ and ACSL3 genes in a rat model.

Methods

A total of 170 children below 16 years (85 pediatric asthma patients and 85 matched healthy controls) were randomly selected from the Riyadh Cohort, Saudi Arabia. Gene expression analysis was performed using qRTPCR. Serum IL-4, IFN-γ and PAH were measured using LINCOplex (human multiplex immunoassay kit) and HPLC respectively.

Results

IL-4 mRNA expression was significantly increased (P < 0.05) in children with asthma compared to healthy control group whereas no differences were observed for either IFN-γ or ACSL3 mRNA. Similarly, serum IL- 4 and PAHs concentration was significantly higher as well in children with asthma in whom IFN-γ was also significantly lower. Results obtained in rats showed that exposure to the benzopyrene prototype PAH resulted in a 2.6 fold (P < 0.001) increased IL-4 mRNA expression in blood.

Conclusion

Peripheral blood IL-4 mRNA levels, serum concentration of this cytokine are elevated in children with asthma. Also, elevated levels of PAH were observed in children with asthma. Additionally, PAH administration in rodents resulted in an increased IL-4 mRNA which is supposed to partly mediate the inflammatory response noted in asthma.