Asthma morbidity in Australia: an epidemiological study

How do teens view the physical and social impact of asthma compared to other chronic diseases?

We surveyed cognitively normal teens with and without chronic illness regarding the perceived physical and social impact of various chronic diseases including asthma. The overall physical impact of asthma was perceived equivalently to diabetes and arthritis, but less than epilepsy, Down's syndrome, leukemia, and human immunodeficiency virus infection. However, asthma was rated to more commonly cause physical disability (p < 0.001) and restrict activities (p < 0.0005). The social impact of asthma was perceived equivalently to diabetes, but more favorably than the other chronic diseases surveyed. Specifically, teens with asthma were perceived as having fewer behavior problems, being more honest, popular, and fun to be around, but less adept at sports. Only 6 of 149 (4%) teens surveyed expressed any degree of reluctance to befriend peers with asthma.

Disability and breathlessness in asthmatic patients--a scoring method by repetitive inspiratory effort

Measurement of disability and breathlessness in asthma is important to guide treatment. Using an incentive spirometer, Triflo II (Tyco Healthcare, Mansfield, MA, USA), we developed a three-minute respiratory exercise test (3-MRET) to score the maximal breathing capacity (MBC) and perception of dyspnea (POD) index by means of repetitive inspiratory efforts achieved within 3 minutes. POD index was calculated based on the ratio of breathlessness on visual analogue scale over MBC score. In 175 normal healthy subjects and 158 asthmatic patients of mild (n = 26), moderate (n = 78), and severe (n = 54), severity, the mean (95% CI) MBC scores in mild, moderate, and severe asthma patients were 168 (145-192), 153 (136-169), and 125 (109-142) respectively, and 202 (191-214) in normal subjects (p < 0.001). The mean POD index in mild, moderate, and severe asthma patients was 16 (9-23), 25 (14-37), and 57 (14-100), respectively, and 6 (4-7) in normal subjects (p < 0.001). Intraclass correlation coefficients for MBC score and POD index in 17 asthmatic and 20 normal subjects were high. In 14 asthmatic patients randomized to receiving nebulized beta2-agonist or saline in a cross-over, double-blind study, % forced expiratory volume in one second (FEV1) change correlated with % change in MBC score [r(s) = 0.49, p < 0.01] and POD index [r(s)-0.46, p = 0.012]. In 21 asthmatic and 26 normal subjects, the MBC score and POD index correlated with the walking distance and walking POD index of the six-minute walking test (6MWT). We conclude that 3MRET is discriminative between asthmatic patients of varying severity and normal subjects, is reproducible, is responsive to bronchodilator effect, and is comparable with 6MWT. Taken together, it has the potential to score disability and POD in asthma simply and effectively.

Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice

The objectives of this study is to compile current knowledge about asthma control in children in relation to goals proposed in international guidelines, to elucidate the factors associated with insufficient asthma control and to address the implications for clinical practice. Review of recent worldwide large population epidemiological surveys and clinical asthma studies of more than 20,000 children are the methods used in this study. The studies report high frequencies of sleep disturbances, emergency visits, school absence and limitations of physical activity due to asthma. Only a small percentage of children with asthma reach the goals of good asthma control set out by Global Initiative for Asthma (GINA). There is evidence of underuse of inhaled corticosteroids even in children with moderate or severe persistent asthma and over-reliance on short-acting beta(2)-agonist rescue medication. Both parents and physicians generally overestimate asthma control and have low expectations about the level of achievable control. Many children with asthma are not being managed in accordance with guideline recommendations, and asthma management practices vary widely between countries. Asthma control falls short of guideline recommendations in large proportions of children with asthma worldwide. Simple methods for assessing asthma control in clinical practice are needed. Treatment goals based on raised expectations should be established in partnership with the asthmatic child and the parents. Effective anti-inflammatory treatment should be used more frequently, and patients should be reviewed regularly.

Risk factors for intensive care in children with acute asthma

OBJECTIVE

A retrospective case-control study at Monash Medical Centre (MMC), a tertiary referral hospital in Melbourne, Australia, was conducted to identify risk factors associated with very severe asthma in paediatric patients.

METHODOLOGY

Asthmatics admitted to an intensive care unit (ICU; n=52) were identified and considered to represent cases of very severe/near fatal asthma (NFA group). This group was compared to asthmatics who had been admitted on one occasion only to the emergency department at MMC (non-NFA controls, n=53). Patient files were examined and factors that may be linked to NFA were recorded. Information not on file was obtained from patients/parents during a structured telephone interview. Data for the two groups were compared, univariate and multivariate logistic regression analyses were performed, and odds ratios (OR) were calculated.

RESULTS

Univariate analysis indicated that asthmatics with NFA were more likely to be older (P=0.01) and have a longer duration of asthma (P=0.02). They were also more likely to have hay fever (P=0.002; OR, 7.6), use inhaled corticosteroids (P=0.001), long acting beta(2) agonists (P=0.02), have an asthma management plan (P=0.006), and see a respiratory specialist (P=0.001). Parental smoking habits were not different between the groups. Multivariate logistic regression analysis identified male gender (P=0.05; OR, 5.7) and use of inhaled corticosteroids (P=0.07; OR, 7.2) as factors that may be predictive of NFA.

CONCLUSIONS

This study identifies a number of factors associated with NFA; many are similar to those reported in adult patients. Asthma severity explains some findings, but the data also suggest that additional independent risk factors such as gender and duration of asthma may operate in children.

Adequacy of outpatient management of asthma patients admitted to a state hospital in Argentina

OBJECTIVE

The aim of this study was to assess chronic outpatient management of adult patients admitted with asthma.

METHODOLOGY

A cross-sectional survey was conducted of 98 consecutive asthma admissions to a specialized pulmonary State Hospital in Buenos Aires, Argentina, over a 12-month period. Patients were surveyed, within 48 h of admission, with a previously validated questionnaire which deals with chronic outpatient management and measures taken by patients or physicians to treat symptoms during asthma exacerbations.

RESULTS

FEV1% predicted was 30.2 +/- 10.7. Mean admission rate and emergency department (ED) visits in the previous year were 0.7 +/- 1.2 and 4.6 +/- 5.1, respectively. A total of 96, 65 and 9% of the patients had been treated previously in the ED, admitted to hospital or mechanically ventilated, respectively. Only 62% had been prescribed inhaled corticosteroids (IC) by their physician; 38% had been prescribed nebulized beta agonists (Nbeta2) and 68% a metered dose inhaler (MDIbeta2). Inhaled beta2-agonist usage during acute exacerbations over the 24 h prior to admission was 14.4 +/- 7.4 puffs for MDIbeta2 and 8.6 +/- 5.4 occasions for Nbeta2. Only 11% of the patients were able to perform all the steps of the MDI inhalation technique correctly. An action plan had been provided by their physicians to 43% of patients, while 58% changed their medication on their own. Only three patients had a peak flow meter (PFM) prescribed. ED was used by 26% for their routine care. No health insurance coverage was available to 75.5% of the patients.

CONCLUSIONS

Underuse of IC, poor MDI inhalation technique, and low prescription of an action plan was common and a PFM was seldom prescribed. During exacerbations, many patients changed their medication spontaneously and MDIbeta2 underuse was observed.

Cost advantages of combination asthma therapy

The addition of long-acting beta(2)-adrenoceptor agonist (LABA) therapy to 'low dose' inhaled corticosteroids improves asthma outcomes in terms of lung function, exacerbation rates, and quality of life measures in asthmatic patients who remain symptomatic on low-dose inhaled corticosteroids alone. Such treatment is now included in guidelines of asthma therapy on the basis of class A evidence from large placebo-controlled trials. Data on the cost-benefit of such treatment is less compelling, but suggests that for patients with mild asthma this clinical improvement is gained at the expense of an increase in direct costs (mostly drug costs), whereas for patients with more severe asthma there may be a cost benefit, largely from reduced costs of exacerbations. Recently, combination inhalers containing both LABA and corticosteroid in the same device have been introduced. Although it is said that a single inhaler (with some immediate symptom relief) may aid patient adherence, there are no firm data to support this, nor are there any cost-effectiveness data on this point. Overall, these devices have been priced at less than the two drugs given separately, but prospective studies evaluating costs in clinical settings are required.

Food and nutrient intakes and asthma risk in young adults

BACKGROUND

Some aspects of diet are relatively newly recognized potential risk factors for asthma, but the evidence to date is conflicting.

OBJECTIVE

The goal was to determine whether the food and nutrient intakes of adults with asthma differ from those of adults without asthma.

DESIGN

This was a community-based, cross-sectional study of 1601 young adults ( +/- SD age: 34.6 +/- 7.1 y) who were initially recruited by random selection from the federal electoral rolls in Melbourne in 1999. Subjects completed a detailed respiratory questionnaire, a validated semiquantitative food-frequency questionnaire, skin-prick testing, and lung function tests, including a methacholine challenge test for bronchial hyperreactivity (BHR). A total of 25 nutrients and 47 food groups were analyzed by using multiple logistic regression with alternate definitions of asthma and atopy as the outcomes.

RESULTS

Whole milk appeared to protect against current asthma (odds ratio: 0.66; 95% CI: 0.46, 0.97), doctor-diagnosed asthma (0.73; 0.54, 0.99), BHR (0.68; 0.48, 0.92), and atopy (0.71; 0.54, 0.94). Conversely, soy beverage was associated with an increased risk of current asthma (2.05; 1.19, 3.53), doctor-diagnosed asthma (1.69; 1.04, 2.77), and BHR (1.65; 1.00, 2.71). Apples and pears appeared to protect against current asthma (0.83; 0.71, 0.98), asthma (0.88; 0.78, 1.00), and BHR (0.88; 0.77, 1.00).

CONCLUSIONS

The consumption of dairy products, soy beverages, and apples and pears, but not of nutrients per se, was associated with a range of asthma definitions. Dietary modification after diagnosis is one possible explanation for this finding. Intervention studies using whole foods are required to ascertain whether such modifications of food intake could be beneficial in the prevention or amelioration of asthma.

Assessment of the diagnosis and prevalence of asthma in Australian indigenous children

BACKGROUND AND OBJECTIVE

Although the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire has been used in many countries and has been validated previously, it has not been used in Australian Indigenous communities. We endeavoured to assess its performance when administered in Aboriginal and Torres Strait Islander communities.

METHODS

In a cross-sectional study, we assessed the ISAAC's questionnaire when administered face-to-face in Indigenous communities in the Torres Strait region, Australia.

RESULTS

Comparing responses to the questionnaire with clinical assessment of 260 Indigenous children by a pediatric respiratory physician, sensitivity (87%) was high, but specificity (51%) and positive predictive value (33%) were low. Using a logistic regression model, we determined which questions were most useful in predicting a clinical diagnosis of asthma. Using a predictive equation, asthma was detected with 79% sensitivity and 77% specificity, and the calculated weighted estimate of asthma prevalence in the region was 16.3%.

CONCLUSION

Our findings reveal that although the ISAAC questionnaire is a reasonably sensitive tool for both epidemiologic and clinical studies of asthma in Indigenous communities, its value is enhanced when used in conjunction with a predictive model. We have also shown that asthma is prevalent in the Torres Strait region.

Asthma in children: gaps between current management and best practice

OBJECTIVES

To determine the extent to which steps three to six of the Australian six-step asthma management plan are being implemented in the community and to identify barriers to the adoption of best practice asthma management.

METHODS

A cross-sectional descriptive study was conducted at the Royal Children's Hospital and Sunshine Hospital, Melbourne. Two hundred and thirty-one 2-5-year old children who visited the emergency department for asthma were enrolled in the study. Main outcome measures were frequency of asthma management practices and barriers, as measured by parent-completed questionnaire.

RESULTS

Gaps: 51% of parents do not feel they have enough information about asthma triggers, more than 60% of children with persistent or frequent episodic asthma are not using regular preventive medication, 48% do not have a written action plan, 39% have not had their asthma reviewed in the last 6 months, and 38% of parents do not feel that they have enough information about their child's asthma. Areas where current practice was close to best practice: 83% of doctors had talked to parents about what causes or 'triggers' their child's asthma, less than 1% of children are using puffers without a spacer, 83% of parents who had an action plan used it for the current visit to the emergency department.

CONCLUSIONS

Large gaps still exist between current management and best practice in this group of emergency department attenders. Improvements in asthma management could be achieved if the child's asthma doctor requested review visits for asthma, provided an action plan and followed best practice in relation to asthma medications.

The burden of asthma in Australia

In 1997, 27% of Australian children had current wheeze, and this is increasing by 1.4% per year. The prevalence of wheeze among adults is lower and appears to be stable. The prevalence of persistent asthma (wheezing episodes with abnormal airway function between episodes) in children has increased from 5% to 9% in the past 20 years. In adults, the prevalence is 5%-6%. Up to 80% of adults with persistent asthma have abnormal lung function. Asthma deaths in Australia have fallen 28% since peaking in 1989, but the mortality rate is still twice that of England.

Understanding airway wall remodeling in asthma: a basis for improvements in therapy?

Current strategies for the management of asthma focus on suppressing airway inflammation. Other characteristic features of human asthma, such as airway hyperreactivity and the structural changes collectively referred to as airway remodeling, are largely ignored in existing guidelines for monitoring the effectiveness of treatment. Evidence is accumulating that pharmacologic therapy targeting airway wall remodeling may be valuable in treating asthma. However, development of appropriate therapeutic agents will require a better understanding of the pathogenesis of remodeling, which appears to be regulated by a variety of cytokines and growth factors produced by inflammatory, epithelial, and stromal cells. Furthermore, testing the effectiveness of novel agents that specifically target the process of remodeling will require appropriate experimental models, but most currently available animal models of asthma have major limitations. A recently described murine model of chronic human asthma offers considerable potential for dissection of the mechanisms of airway wall remodeling, as well as for investigation of the therapeutic potential of drugs that can modulate chronic inflammation and remodeling.

The rising prevalence of asthma in young Melbourne adults is associated with improvement in treatment

BACKGROUND

Asthma is a common source of morbidity and is now recognized as a national health priority in Australia. Although a number of epidemiologic studies have been conducted in Australia to determine the prevalence of asthma in adults, it is unclear whether the prevalence is changing.

OBJECTIVES

To determine the prevalence in 1998 of self-reported asthma and respiratory symptoms among young adults and changes in prevalence between 1990 and 1999.

METHODS

Cross-sectional postal survey to 4,455 young adults (aged 20 to 44 years) randomly selected from the electoral rolls of the inner southeastern suburbs of metropolitan Melbourne. The survey instrument was the validated European Community Respiratory Health Survey screening questionnaire, which gathered data on self-reported respiratory symptoms, including whether asthma had been diagnosed. Identically worded questions from similar surveys conducted in 1990, 1992, and 1999 were used to compare changes in prevalence.

RESULTS

A response rate of 72% was achieved in 1998 after three mailings and telephone followup. Forty-two percent reported nasal allergies, 26% wheezed within the past 12 months, and 20% ever had asthma. The prevalence of doctor-diagnosed asthma was 18%, whereas 10% reported using asthma medications within the past 12 months. Nine percent of respondents reported an asthma attack within the past 12 months. The prevalence of having ever had asthma, doctor-diagnosed asthma, and using asthma medications had increased significantly since 1990. However, the prevalence of respiratory symptoms did not significantly change over this time.

CONCLUSIONS

The prevalence of asthma is likely to be rising, but the symptoms of asthma are being better managed in young Melbourne adults.

High prevalence of asthma in five remote indigenous communities in Australia

Data on the prevalence of asthma in children residing in remote indigenous communities in Australia are sparse, despite the many reports of high prevalence in nonindigenous children of this country. Two previous Australian studies have had poor participation rates, limiting interpretation of their results. A study of children in the Torres Strait and Northern Peninsula Area of Australia was conducted to document the prevalence of asthma symptoms. Five indigenous communities were randomly selected and trained interviewers, who were local indigenous health workers, recruited participants using a house-by-house approach. Information was collected by a structured face-to-face interview based on a standardized questionnaire constructed from the protocol International Study of Asthma and Allergy in Childhood; 1,650 children were included in the study with a 98% response rate. Overall, the prevalence of self-reported ever wheezing was 21%; 12% reported wheezing in the previous year; and 16% reported ever having asthma. There was significant variation in the prevalence of asthma symptoms between communities. It is concluded that there are significant intercommunity variations in the prevalence of asthma symptoms in remote communities and that the prevalence in these communities is as high as in nonindigenous groups.

Acute asthma

OBJECTIVE: Asthma is the most common medical emergency in children. It is associated with significant morbidity and mortality rates and poses a tremendous societal burden worldwide. Management of the acute attack involves a stepwise approach that includes beta-agonist and steroid therapy, the mainstay of emergency treatment. Most patients will respond to this regime and can be discharged from the emergency department. Failure to respond to treatment necessitates hospital admission and sometimes admission to the intensive care unit (ICU). Management in the ICU involves intensification of pharmacologic therapy, including nonstandard therapies, in an attempt to avoid intubation and ventilation. When needed, mechanical ventilatory support can be rendered fairly safe with little morbidity if the likely cardiorespiratory physiologic derangements are appreciated and if appropriate ventilatory strategies are used. In the past two decades, the availability of newer potent medications and changes in approach to monitoring and ventilatory strategies have resulted in a decrease in ICU morbidity and mortality rates. Research endeavors are presently underway to further characterize the underlying mechanisms of the disease and are likely to lead to novel therapies. This article reviews the approach to management of acute severe asthma.

Increased prevalence of asthma in Saudi Arabia

BACKGROUND

Bronchial asthma is among the most common chronic illnesses of childhood. A number of reports in the recent past suggest that the prevalence of asthma is increasing globally.

OBJECTIVE

To investigate the changing prevalence of asthma in the Kingdom of Saudi Arabia.

SUBJECTS AND METHODS

Two populations of schoolchildren between the ages of 8 and 16 years were studied using an internationally designed protocol in 1986 and 1995. The questionnaire used in these studies was very similar to the one used in the International Study of Allergy and Asthma in Childhood. A total of 2,123 school-children in 1986 (Jeddah and Riyadh) and 1,008 schoolchildren in 1995 (Hail and Gizan) were enrolled in the surveys. These cross-sectional studies of randomly selected schoolchildren were statistically analyzed using ANOVA and a Z test.

RESULTS

The comparison of data between Riyadh versus Hail (inland desert dry environment) and Jeddah versus Gizan (coastal humid environment) revealed that the prevalence of asthma in the similar populations increased significantly from 8% in 1986 to 23% in 1995 (P < .0001). Likewise, the prevalence of allergic rhinitis also increased from 20% to 25% (P < .003) since 1986. However, no significant change in the prevalence of eczema (from 12% to 13%) was noted between 1986 and 1995.

CONCLUSIONS

The study indicates that there was a significant increase in the prevalence of bronchial asthma and, to a lesser extent, in the prevalence of allergic rhinitis in the Kingdom of Saudi Arabia during this 9-year period. The study also revealed increased exposure to environmental factors such as tobacco smoke and indoor animals in Saudi houses. It seems that the continuing changes in contemporary life may well have contributed to the increased prevalence of asthma in the country.

Bone mineral density in prepubertal asthmatics receiving corticosteroid treatment

OBJECTIVE

To examine whether bone mass is reduced in prepubertal, asthmatics receiving high doses of inhaled corticosteroids.

METHODOLOGY

A cross-sectional comparison of lumbar spine-bone mineral density (LS-BMD) was undertaken in 76 subjects after stratifying them according to dosage and administration route of corticosteroid.

RESULTS

Weight was the only independent predictor of LS-BMD (r(2) = 0.38). Children receiving greater than 800 microg/day of inhaled corticosteroid plus intermittent oral corticosteroid had a significantly lower weight-adjusted LS-BMD than children treated with 400-800 microg/day of inhaled corticosteroid (mean difference: 0.06 g/cm(2), 95% confidence interval (CI): - 0.02 to - 0.10). A significant difference in weight-adjusted LS-BMD persisted when all children receiving greater than 800 microg/day of inhaled corticosteroid, irrespective of additional oral corticosteroid treatment, were compared with children receiving 400-800 microg/day of inhaled corticosteroid (mean difference: - 0.05 g/cm(2), 95%CI interval: -0.02 to - 0.09). Bone mass was similar in children not receiving any inhaled corticosteroid and those treated with 400-800 microg/day of inhaled corticosteroid.

CONCLUSIONS

A reduced bone mass in prepubertal asthmatic children receiving high doses of inhaled corticosteroids may predetermine a compromised peak bone mass and increase osteoporotic fracture risk in adulthood.

Prescribing patterns for asthma by general practitioners in six European countries

To assess the level of concordance with international consensus on asthma management, we compared primary care prescribing patterns for asthma in different European countries. A prospective study of prescription items with an associated diagnostic label of asthma in patient consultations with a total of 235 general practitioners (GPs) from Belgium, England, Ireland, Italy, Northern Ireland, Portugal, Scotland and Spain was performed. A total of 101,544 consecutive consultations were recorded in autumns 1994 and 1995 of which 3595 (3.5%) were for patients with asthma and 3243 (3.2%) were for patients receiving a prescription for asthma. Overall, asthma consultations varied from 1.8% in Italy to 5.8% in Ireland (mean 3.4%, SD 1.6). Prescribed inhaled medications for children varied from 72% of the total asthma prescriptions in Ireland and Portugal to 82% in Northern Ireland (mean 79%, SD 8.1) and for adults 55% in Italy to 85% in Spain (mean 70%, SD 10). Inhaled corticosteroid usage for adults varied from 14% in Italy to 31% in Northern Ireland (mean 24%, SD 6.4). For children, beta2-agonist use varied from 24% in Italy to 67% in Spain (mean 45%, SD 13). Despite publication of international guidelines for the management of asthma, inter-country prescribing practices vary considerably and could be improved. The frequency of use of asthma as a diagnostic label also varies markedly.

Limited (information only) patient education programs for adults with asthma

BACKGROUND

A key component of many asthma management guidelines is the recommendation for patient education and regular medical review. A number of controlled trials have been conducted to measure the effectiveness of asthma education programmes. These programmes improve patient knowledge, but their impact on health outcomes is less well established. At its simplest level, education is limited to the transfer of information about asthma, its causes and its treatment. This review focused on the effects of limited asthma education.

OBJECTIVES

The objective of this review was to assess the effects of limited (i.e. information only) asthma education on health outcomes in adults with asthma.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised and controlled trials of individual asthma education involving information transfer only in adults over 16 years of age.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed and data were extracted independently by two reviewers. Study authors were contacted for missing information.

MAIN RESULTS

Eleven trials were included. They were of variable quality. Limited asthma education did not reduce hospitalisation for asthma (weighted mean difference -0.03 average hospitalisations per person per year, 95% confidence interval -0.09 to 0.03). There was no effect on doctor visits, lung function and medication use. The effects on asthma symptoms were variable. There was no reduction in days lost from normal activity, but perceived asthma symptoms did improve after limited asthma education (odds ratio 0.40, 95% confidence interval 0.18 to 0.86). In one study, limited asthma education was associated with reduced emergency department visits (weighted mean difference -2.76 average visits per person per year, 95% confidence interval -4.34 to 1.18).

REVIEWER'S CONCLUSIONS

Use of limited asthma education as it has been practiced does not appear to improve health outcomes in adults with asthma. However the use of information in the emergency department may be effective, but this needs to be confirmed.

Current outpatient management of asthma shows poor compliance with International Consensus Guidelines

STUDY OBJECTIVE

This study aimed to establish whether the outpatient management of patients presenting with an asthma exacerbation to the emergency department (ED) was in compliance with the 1992 guidelines of the "International Consensus Report on the Diagnosis and Management of Asthma."

DESIGN

Prospective, observational study using a researcher-administered questionnaire.

SETTING

University tertiary referral ED.

PATIENTS

Convenience sample of asthmatics (aged 18 to 54 years) presenting for asthma treatment between July 1, 1997, and June 30, 1998.

RESULTS

Eighty-five asthmatic patients were enrolled. Of these, 34 patients (40%) smoked, 53 patients (62%) were undertreated with medication when compared to the consensus guidelines, and 74 patients (87%) had no written "plan of action." During an asthma attack, 9 patients (11%) did not use a bronchodilator as first-line action and 76 patients (89%) did not commence or increase the use of an inhaled steroid. Forty-nine patients (58%) did not know that bronchospasm occurred in asthma, and 53 patients (62%) did not know that bronchial swelling occurred. Twenty-six patients (31%) thought short-acting bronchodilator drugs were asthma preventers. Sixty-two patients (73%) could not adequately define peak expiratory flow (PF), 41 patients (48%) did not own a PF meter, and only 8 patients (9%) determined their PF daily. Fifty-three patients (62%) were reviewed by a physician once a year or less, and 18 patients (21%) noted family and friends as their only source of asthma education.

CONCLUSIONS

The outpatient management of most asthma patients presenting to the ED did not comply with the consensus guidelines, and asthma knowledge was poor.

A South Australian population survey of the ownership of asthma action plans

OBJECTIVE

To examine the relationships between ownership of written asthma action plans, asthma morbidity, use of devices, and patients' perceptions of their asthma management.

DESIGN AND SETTING

A random population survey (in 1996) of the South Australian population aged 15 years or over, using interviewers to administer a questionnaire.

PARTICIPANTS

People who reported that they had current, doctor-diagnosed asthma.

MAIN OUTCOME MEASURES

Prevalence of written asthma action plans; night-time awakenings from asthma; ownership of peak flow meters; and people's perceptions of their asthma management.

RESULTS

The ownership of asthma action plans by people with self-reported asthma was 33% and has declined since 1995 (42%; P < 0.001). Fifteen per cent were awakened weekly or more frequently by asthma symptoms. These people were more likely to have a peak flow meter and a written action plan, but less likely to consider they had been provided with enough information about their asthma, to feel comfortable managing their asthma, or to find it easy to see their doctor. Having a written asthma action plan was associated with regular corticosteroid use, understanding asthma, having enough information and owning a peak flow meter.

CONCLUSIONS

Ownership of asthma action plans in South Australia is suboptimal. Before we develop new strategies to improve asthma outcomes, we must determine whether there is a need to target people with less severe asthma and/or improve the use of guidelines by health professionals.

Outdoor air pollution and children's respiratory symptoms in the steel cities of New South Wales

OBJECTIVE

To investigate the relationship between outdoor air pollution and the respiratory health of children aged 8 to 10 years.

DESIGN

A cross-sectional survey (between October 1993 and December 1993) of children's health and home environment. Summary measures of particulate pollution (levels of particles with an aerodynamic diameter less than 10 microns [PM10] each 6th day) and SO2 (daily mean and maximum hourly values) were estimated for each area (using air quality monitoring station data from July 1993 to June 1994). SETTING AND SURVEY PARTICIPANTS: Parents of 3023 primary school children (Years 3, 4 and 5) from industrial and non-industrial areas with air quality monitoring stations in the Hunter and Illawarra regions of New South Wales.

MAIN OUTCOME MEASURES

Reported occurrence of four or more chest colds, four or more attacks of wheezing, and night-time cough without a cold for more than two weeks, all within the previous 12 months.

RESULTS

77% response rate, ranging by area from 66% to 88%. The average annual outdoor air pollution for the nine areas was 18.6-43.7 micrograms/m3 for PM10 and 0.16-0.90 parts per hundred million for SO2. The proportion of children reported to have the main outcome symptoms were: chest colds, 3.0%-9.7%; night cough, 12.3%-30.5%; and wheeze, 3.4%-11.3%. There was no significant association with SO2, but a significant increase in the odds of symptoms per 10 micrograms/m3 increase in PM10 on chest colds (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.12-1.82) and night-time cough (OR, 1.34; 95% CI, 1.19-1.53), but not wheeze. Passive smoking was significantly associated with chest colds but not with the other symptoms. Maternal allergy was associated with all three respiratory symptoms, most strongly with wheeze.

CONCLUSION

These results provide evidence of health effects at lower than expected levels of outdoor air pollution in the Australian setting. They also suggest differences in contributions of environmental and hereditary factors to cough and chest colds compared with wheeze.

Outcomes and cost benefits associated with the introduction of inhaled corticosteroid therapy in a medicaid population of asthmatic patients

A retrospective cohort study was conducted to assess the clinical and economic impact of the introduction of inhaled corticosteroid therapy in the North Carolina Medicaid population of patients with asthma. The case group consisted of 180 patients who were followed for 1 year before and 1 year after the initiation of inhaled corticosteroid therapy. The control group consisted of 233 patients whose asthma was of similar severity to that of the case group and who remained on any therapy other than corticosteroids for a continuous 2-year period. After the initiation of inhaled corticosteroid therapy, the case group had reductions of 50% in hospitalizations, 26% in outpatient visits, and 15% in physician visits. At the end of the second year, the control group had significant increases of 23% in hospitalizations and 36% in outpatient visits. All of the changes were statistically significant. However, after adjusting for potential confounding factors, there was a nearly 24% decrease in total health care costs per asthmatic patient per month as a result of the introduction of inhaled corticosteroid therapy. Overall, we found that there was a cost benefit to Medicaid in the introduction of inhaled corticosteroid therapy and that this therapy brought about dramatic decreases in health care utilization and costs.

Preventable factors in hospital admissions for asthma

Asthma remains the second most common cause for admissions to a paediatric hospital bed. The aim of this study was to describe the characteristics of children admitted to hospital with an acute asthma attack and to identify factors that may prevent future hospital admissions. Parents of all children aged 3 to 15 years admitted to hospital for acute asthma were interviewed and the child's case record reviewed. Children were recruited consecutively in two groups: 141 summer/autumn and 125 winter/spring 1996. According to the pattern of symptoms in the previous 12 months, 61% of the children had infrequent episodic asthma, 26% had frequent episodic asthma, and 13% persistent asthma. Only 8% of children aged 8 years or less had persistent asthma, in contrast to 22% of those aged > 8 years. There was evidence of both inadequate prescription of preventive treatment and poor compliance in the frequent episodic and persistent asthma groups. Of the whole group, 44% had previously been given an acute asthma management plan, but only 9% of them used it before the current hospital admission. There was a delay in seeking medical advice (> 24 hours after the onset of symptoms) in 27% of all admissions. This study has identified potential areas where intervention may reduce the number of future admissions.

Western Australian primary school teachers' knowledge about childhood asthma and its management

A total of 164 primary school teachers from Perth, Western Australia anonymously completed a survey of their knowledge and attitudes about asthma. These teachers were active in assisting children with asthma management but most (91.5%) felt that they did not know enough about asthma. Attitudes toward children with asthma were positive; 97% agreed that such children should be encouraged to participate in sporting activities. Specific knowledge about asthma management and medications was, however, poor. This large sample of Western Australian teachers knew more than their European counterparts but asthma training is needed and should be targeted at improving knowledge of both regular and emergency treatments for asthma.

Asthma prevalence, morbidity and management practices in South Australia, 1992-1995

BACKGROUND

The Spring South Australian Health Omnibus Survey (SSAHOS) has been used to monitor trends in asthma prevalence, asthma morbidity and asthma management practices between 1992 and 1995.

AIMS

To determine if self-reported asthma prevalence and availability of asthma action plans were increasing. To identify deficiencies in asthma management and opportunities for intervention.

METHODS

Representative population survey by trained interviewers using a multistage, systematic, clustered area sample of 4200 households in South Australia where people aged 15 years or more are living.

RESULTS

Over 3000 interviews were conducted each year. Between 1992 and 1995 the self-reported prevalence of asthma in those aged 15 years or more increased significantly from 15.7% to 20.3% (p < 0.0005), and the prevalence of current asthma increased from 9.3% to 11.4% (p < 0.05). The self-reported availability of individual asthma action plans increased from 21.9% in 1992 to 42.2% in 1995 (p < 0.0005). In 1992, 21% had a nebuliser at home, and 10.5% had a peak flow meter. In 1993, 61.4% were using preventive medications, and 35% thought bronchodilators were 'preventer' medications. In 1994 and 1995, between 12.5% and 15.6% had nocturnal awakening weekly or more often, and 31.4% had morning asthma symptoms weekly or more often. Between 20.1% and 20.8% had lost days from usual activities during the last year. Those on incomes below $20,000 had more symptoms, had more admissions to hospital, and required more medication than those on higher incomes.

CONCLUSIONS

Self-reported asthma prevalence has increased. There remains a gap between current asthma management and that recommended by the National Asthma Campaign.

Gas chromatographic-mass spectrometric determination of beta 2-agonists in postmortem blood: application in forensic medicine

A solid-phase extraction procedure is described for the simultaneous determination of terbutaline, salbutamol and fenoterol in human postmortem whole blood, using gas chromatography-electron impact mass spectrometry. The limit of quantitation in 1 ml of blood was 1 ng/ml for all analytes. A linear response was observed over the concentration ranges tested, covering both low and high concentrations of each drug. The recoveries in postmortem blood were: terbutaline, 88%; salbutamol, 86%; fenoterol, 92%; orciprenaline (internal standard), 86%. Coefficients of variations for both intra-assay precision and inter-assay reproducibility ranged between 2.2 and 13.0% for all analytes. This method is sensitive and selective, and has been applied successfully to over 60 postmortem blood specimens.

Metered-dose inhaler technique and quality of life with airways disease: assessing the value of the Vitalograph in educational intervention

The efficacy of delivering medicines by metered-dose inhaler (MDI) is well established, and the patient's technique with MDIs is related directly to achieving the desired clinical outcome. The present study was designed to assess and improve MDI technique by using a Vitalograph Aerosol Inhalation Monitor (VAIM) in an airways disease education programme. Baseline measurements were made immediately prior to educational intervention incorporating feedback from a VAIM unit. At 6 weeks' follow-up, MDI technique was found to have regressed to the sub-optimal measures recorded at baseline prior to educational intervention. However, patients reported a significant improvement in physical function between baseline and follow-up as measured by the Rand 36-Item Health Survey (SF-36), Version 1.0. The results reinforce the need for a longitudinal educational programme for patients prescribed medications delivered by MDI. The VAIM unit provided health educators and patients with both a visual and a quantitative assessment of patients' MDI technique, and was thus of positive value as part of the intervention process.

Asthma management in eastern Australia, 1990 and 1993

OBJECTIVE

To compare the prevalence and management of asthma before and after institution of the National Asthma Campaign.

DESIGN

Repeat population-based cross-sectional analytic surveys.

SETTING

Eastern Australia (Sydney, Brisbane, Melbourne, and the Hunter Valley, New South Wales) in September 1990 and 1993.

SUBJECTS

Primary school children and their parents from 33 schools (8746 children) in 1990 and 40 schools (10 106 children) in 1993.

OUTCOME MEASURES

Frequency of respiratory symptoms; diagnoses of asthma; medications; lung function measurements; possession of a peak flow meter and a written action plan.

RESULTS

Age and sex distribution of the subjects and the reported prevalence of asthma were similar in 1990 and 1993. The frequency of reported episodes of wheezing and troublesome cough increased significantly in children between 1990 and 1993. Asthma management improved in accordance with current recommendations, with significantly decreased use of regular inhaled bronchodilator medication in children and increased use of preventive medication, monitoring of lung function by doctors and use of peak flow meters and written action plans in both children and adults.

CONCLUSION

There is evidence that the National Asthma Campaign may have contributed to increased awareness and improved management of asthma in children and adults in eastern Australia.

Assessment of the severity of asthma in a family practice

The objective of this study was to evaluate clinical history and self-perception of severity as predictors of asthma severity. A short-term longitudinal study was conducted in a family practice in Melbourne, Australia, utilizing peak flow monitoring, medication diary, and self-administered asthma severity questionnaire. Seventy-two asthmatic subjects with a positive bronchodilator or exercise test, aged between 6 and 79 years, were studied. Symptom and treatment items were correlated with peak flow variability and minimal peak expiratory flow rate (PEFR). An asthma severity scale was generated using the partial credit version of Item Response Theory and the participants' severity scores were validated against lung function tests and medication usage. Quantitative modeling procedures were used to investigate the interrelationships of factors associated with peak flow variability. Severity scores demonstrated significant relationships with peak flow variability (partial r = 0.34) and treatment items. Self-perceived severity of asthma in the preceding 2 weeks showed significant association with peak flow variability (partial rho = 0.46) and minimal PEFR (rho = -0.41). The severity module of the Monash Respiratory Questionnaire is a valid and reliable instrument. The most important symptoms appear to be the frequency of use of bronchodilator and frequency of nocturnal attacks. A carefully structured clinical history in conjunction with the peak flow criteria of variability and minimal peak flow rate would be appropriate in the evaluation of asthma severity. Patients' self-perception of the severity of their asthma needs further evaluation.

Teacher initiated improvement of asthma policy in schools

OBJECTIVE

To assess whether information about asthma acquired by individual teachers, following attendance at an inservice seminar, would be communicated to other school staff, and whether policies about asthma management would be subsequently developed in schools.

METHODOLOGY

A telephone interview was conducted of 50 primary school teachers in the Hunter Region who were selected randomly from those who had represented their school at an inservice seminar about asthma.

RESULTS

All 48 respondents had provided feedback to their colleagues, mostly at a staff meeting. After the seminar the number of schools with a written policy about the management of asthma had increased from 1 to 20. Initially the school's first aid kits contained a bronchodilator inhaler in 25 schools (increasing to 43 after the seminar), a spacer device in six schools (increasing to 47) and written guidelines for management of an asthma attack in seven schools (increasing to 32). Teachers from four schools indicated that all school staff knew how to recognize an acute attack prior to the seminar compared with 22 schools afterwards. Before the seminar 18 schools asked parents to supply written instructions for the management of their children at school but this increased to 44 after the seminar.

CONCLUSIONS

A programme of one-off seminars attended by one teacher from each primary school resulted in large increases in the proportion of schools with appropriate policies for the management of asthma in the school environment.

Asthma management and morbidity in Australian general practice: the relationship between patient and doctor estimates

The aims of this study were to describe asthma management and morbidity in patients attending general practitioners in Australia, and to assess the relationship between patient reports and those of their general practitioner (GP). The sample comprised consecutive patients attending 46 general practitioners chosen at random in five regions of New South Wales, Australia. A total of 4538 patients were screened, 607 (13.4%) reported ever having diagnosed asthma, and the 501 who reported asthma in the previous 12 months completed a detailed questionnaire. Three hundred and thirty-four patients also had information about their asthma management recorded by their GP. The patient questionnaire asked about asthma symptoms, therapy, lung function measurement, and asthma-related morbidity. The GP questionnaire asked the doctor to record similar information about the patients. Two-thirds of the patients used regular inhaled beta 2-agonist medication, and one-half reported using preventive therapy. Only 24% owned a peak flow meter and 9% had a written plan of action for asthma attacks. Although preventive therapy and airway function assessment were more common in those with frequent symptoms (> 2-3 times per week), this group were still sub-optimally managed. In the matched sample (n = 334), doctors reported prescribing bronchodilator and preventive medication, measuring airway function and recommending peak flow meter use more often than suggested by patient-reported data. The study concludes that many patients do not attend for regular review, and that management remains sub-optimal, particularly in young adults. Data from patient surveys may underestimate clinical practice, as assessed from doctors' records. This should lead to patient-derived estimates of management being interpreted with caution in epidemiological studies. Further attention to patient understanding and compliance with prescribed asthma management advice is needed in order to better manage asthma in the community.

Asthma management and mode of acquisition of inhaled bronchodilators

BACKGROUND

Controversy has existed about the benefits and disadvantages associated with the availability of inhaled bronchodilators over the counter (OTC).

AIMS

To compare sociodemographic features, use of preventive medications, use of medical services and control of asthma in adults who purchased inhaled bronchodilators OTC with those who purchased on prescription (script).

METHODS

A cross-sectional telephone survey of 772 adults 18 years and over who used inhaled bronchodilators for their asthma. Symptoms, asthma medications, and management practices were determined by a structured questionnaire administered by trained telephone interviewers.

RESULTS

Two hundred and thirty adults purchased their bronchodilator OTC and 542 on script. OTC purchasers were more likely to be male (OR: 1.5), have had tertiary education (1.5) and be in paid employment (2.8); they were less likely to report frequent symptoms (wheeze, nocturnal symptoms or EIA more than once a week) (0.71); were less likely to use preventive medications more than twice a day (0.57) and were less likely to have consulted a general practitioner in the previous year (0.38). However, poor control of asthma symptoms was evident in both OTC and script groups. Forty per cent of the OTC group who had symptoms more than two to three times a week and 34% of the script group were not using preventive medication.

CONCLUSIONS

Undertreatment and suboptimal management of asthma were apparent in both OTC and script groups.

Towards a better understanding of childhood asthma

OBJECTIVE

To explore the ways asthma may be defined in childhood and consider the current evidence to support these possible definitions.

METHODOLOGY

The relationship of symptoms, atopy, bronchial hyperresponsiveness (BHR) and airway inflammation in defining childhood asthma is reviewed.

RESULTS

While none of the four proposed methods of defining asthma can stand alone as the 'gold standard', in childhood asthma, all four, namely clinical symptoms, atopy, BHR and airway inflammation, are intimately related. The degree of atopy and BHR, and the presence of airway inflammation, should be viewed as significant risk factors for persistent wheezing in childhood.

CONCLUSION

At present the clinical diagnosis of asthma in childhood remains largely based on symptoms but it is likely that, with further research, the group of children who are now labelled as having asthma will be subdivided into different subgroups with implications for both treatment and outcome.

Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management

We evaluated hospital readmission as an indicator of the quality of management of asthma patients, between July 1989 and June 1990. Using hospital separation data, we constructed a matched data set to identify early (within two weeks of discharge) readmissions. Of over 14,000 admissions for asthma in the 1-to-44-year age group, 2.8 per cent were classified as early readmissions. Admissions and readmissions were more common in rural than metropolitan areas. Admissions were most common during autumn, but early readmissions occurred most often during spring. Patients staying more than one day were 0.5 times (95 per cent confidence interval (CI) 0.37 to 0.68) as likely to have an early readmission than patients staying less than one day. Using the same data set, we identified patients who had the potential for readmission within a six-month period. Of the 5052 patients, 17.8 per cent were readmitted at least once during the period; 3.7 per cent had at least one early readmission, and 15.8 per cent had at least one late readmission (more than two weeks following discharge). A length of stay of more than one day was associated with 0.41 times (CI 0.24 to 0.70) the risk of early readmission in this cohort. A length of stay of more than one day was associated with a higher risk of late readmission (1.52, CI 1.09 to 2.12), which was less likely to occur in rural than metropolitan areas (0.45, CI 0.37 to 0.55).(ABSTRACT TRUNCATED AT 250 WORDS)

Prevalence and severity of childhood asthma and allergic sensitisation in seven climatic regions of New South Wales

OBJECTIVE

To compare the prevalence and severity of asthma and of allergic sensitisation in children in different regions. We hypothesised that regions with different standardised hospital admission rates would have different prevalences of childhood asthma and that diverse climates would result in a range of sensitisations to different allergens.

DESIGN AND SETTING

We studied large random population samples of children in seven regions in New South Wales (NSW) in 1991-1993. Hospitalisation rates were obtained from NSW Department of Health data.

PARTICIPANTS

6394 children aged 8-11 years.

OUTCOME MEASURES

History of respiratory symptoms by self-administered questionnaire; airway hyperresponsiveness by histamine inhalation test; and sensitisation to allergens by skin-prick tests.

RESULTS

Children in all regions had a high prevalence of recent wheeze (22%-27%), of diagnosed asthma (24%-38%) and of use of asthma medications (22%-30%), but no region was consistently higher or lower for all measurements. The prevalence of current asthma in children living in three coastal regions (where sensitisation to house-dust mites was high) and in the far west (where sensitisation to alternaria was high) was 12%-13%, which was significantly higher than the prevalence of 7%-10% in children living in three inland regions (where sensitisation to these allergens was lower) (P < 0.01).

CONCLUSIONS

We found significant variations in the prevalence and severity of childhood asthma in NSW. The prevalence of hospitalisations, diagnosed asthma, recent symptoms and medication use may relate to different regional diagnostic patterns, whereas current asthma prevalence may relate to different levels of allergic sensitisation.

Parental asthma knowledge: its association with readmission of children to hospital

OBJECTIVE

To assess whether poor parental knowledge about asthma was a risk factor for readmission of their children to hospital.

METHODOLOGY

Parents of children who were admitted to the paediatric facility at Newcastle Mater and John Hunter Hospitals were administered a previously validated asthma knowledge questionnaire with a maximum possible score of 31.

RESULTS

The mean parental knowledge scores for three groups of children were determined: those with a previous diagnosis of asthma being readmitted to hospital (170 children, mean score 18.3); those with a previous diagnosis of asthma being admitted for the first time (114 children, mean score 17.2); and children being admitted with their first attack of asthma (65 children, mean score 15.6). There was a significant difference in parental asthma knowledge between the first and third group (P < 0.001) but not between the first and second group. A linear regression model with knowledge score as an outcome found that increased knowledge was associated with previously diagnosed asthma, higher parental occupation and no smoker in the home.

CONCLUSIONS

Knowledge was poor in all groups. Readmission rate was related to the severity of the child's asthma.

The prevalence of respiratory symptoms in South Australian preschool children. I. Geographic location

OBJECTIVE

This study was designed to ascertain the prevalence of respiratory symptoms in South Australian preschool children and to investigate the relationship between prevalence rates and geographic location.

METHODOLOGY

Data were collected from 14,124 families with a child aged 4 years 3 months to 5 years of age. This sample represents 73% of the State preschool population of that age. At the time of a routine preschool health check, parents completed a questionnaire regarding their child's respiratory health and place of residence (postcode).

RESULTS

Results showed that the prevalence rates were as follows: (i) ever having chest wheezing 38.6%; (ii) chest wheezing within the preceding 12 months 25.2%; (iii) ever having asthma 22.5%; (iv) ever having a dry cough at night 33.7%; (v) ever having bronchitis or cough with sputum 55.3%; (vi) ever having hay fever 29.7%; (vii) prone to excessive head colds 32.6%; and (viii) ever having eczema 18.8%. Over 38% of parents claimed that winter was the season for the most frequent or severe attacks of wheezing and 31.7% claimed no seasonal difference. Winter was the season most associated with episodes of bronchitis (50.9%), with no seasonal difference in episodes for 29.8% of children. Prevalence rates differed by geographic location within South Australia and within the Adelaide metropolitan region.

CONCLUSION

This population-based survey shows that over 22% of South Australian 4 to 5 year old preschool children have had (or continue to have) asthma. The study also documented the geographic distribution of respiratory symptom prevalence within South Australia.

Improving asthma documentation in a paediatric emergency department

OBJECTIVE

To improve documentation for children presenting to the Emergency Department (ED) of The Children's Hospital with acute asthma.

METHODOLOGY

In phase I, the documentation process was analysed using a standard total quality management (TQM) approach to identify specific problems leading to poor documentation. Fifty-two medical records of children presenting over a 3 week period were reviewed for nursing and medical documentation. A set of minimum criteria, consistent with the Paediatric Asthma Management Plan, were established for documentation by both medical and nursing staff. Following dissemination and education, compliance with documentation was evaluated and compared to an asthma survey performed in the ED in 1991. In phase II, a specific proforma for medical assessment was developed and 80 medical records of children presenting over a 3 week period were reviewed. Fifty-two (65%) with completed proformas were evaluated. The outcome measure was the documentation rate for minimum criteria established by TQM process.

RESULTS

In phase I, nursing compliance with documentation ranged from 46% for signs of respiratory distress to 83% for a past history of asthma and 100% for pulse rate. Doctors were similarly poor at documenting essential elements such as severity (31%), palpable pulsus paradoxus (29%), the child's usual doctor (46%) and follow-up arrangements (21-56%). In phase II, the documentation of the severity of acute asthma (42%) and of the child's usual doctor (42%) remained poor but there were statistically significant improvements in documentation of interval medications, palpable pulsus paradoxus, respiratory rate, pre-treatment oximetry, education, follow-up arrangements and communication letters.

CONCLUSION

The process of TQM has proved valuable in improving some aspects of documentation of children presenting to ED with acute asthma. It remains to be shown whether improved documentation will result in improved outcome.

Self-management, autonomy, and quality of life in asthma. Population Medicine Group 91C

STUDY OBJECTIVE

Asthma management guidelines emphasize increased autonomy for asthmatics through patient education and patient-initiated action plans. The aim of this study was to examine autonomy, as reflected in the preferences of asthmatic subjects for decision making and their preferences for information seeking. The results were related to quality of life in asthma.

SUBJECTS

One hundred twenty-three adults with asthma.

DESIGN

Questionnaire-based cross-sectional analytic survey.

SETTING

Eighty-five subjects were recruited from community pharmacies at the point of sale of albuterol inhalers for asthma and compared with 38 subjects recently hospitalized for acute severe asthma.

MEASUREMENTS

Asthma-related quality of life, autonomy preferences questionnaire.

RESULTS

The subjects in both groups had a mild-to-moderate quality of life impairment in all domains that was greater in the posthospitalization group (p < 0.05). Both groups expressed strong preferences for information concerning their condition (92se 0.8, 91se 1.1, out of a possible 100). Subjects did not prefer to make decisions alone about the management of asthma exacerbations (51.0se 1.2, 52.5 se2.0, out of a possible 100). As the severity of the asthma exacerbation increased, the desire to make decisions decreased (p < 0.05). Older subjects expressed less desire for decision making than younger subjects. Self-management autonomy was not correlated with quality of life in asthma.

CONCLUSIONS

We conclude that while asthmatics have strong desires to be informed about their illness, they do not wish to be the prime decision makers during an exacerbation. These findings have implications for the success of self-management programs and action plans.

An evaluation of the action plans of children with asthma

OBJECTIVE

To assess the provision and use of action plans in children attending hospital because of asthma.

METHODOLOGY

An interviewer administered a structured questionnaire to the parents of 279 children attending the Casualty Department, Outpatient clinics or admitted to hospital because of asthma, at two Level 3 teaching hospitals.

RESULTS

Only 82 (29%) of the children attending hospital had a written action plan. The majority (57%) were devised by paediatricians and covered the salient aspects of care. However, indications for steroid use were included in only 28% of plans and only 37% of the action plans in children over 5 years incorporated the use of peak flow meters.

CONCLUSIONS

Action plans are still under-utilized in children with asthma. General practitioners should be encouraged to consider the use of action plans for the group of children not already covered.

Integrated health and education input in the development of educational resources about asthma for schools

The development of educational packages on health-related topics has become common in school curricula. This paper describes an integrated health and education input in the development of an educational package about asthma for Year 8 high school students. Ownership and educational relevance of the package (ensuring its appropriateness for inclusion within the Personal Development/Health/Physical Education curriculum) was achieved by collaboration between teachers with an understanding of the principles of curriculum design and health professionals with content knowledge about asthma. The model used for the production of the package about asthma could be extended to other health topics.

Recognition and crisis management of asthma in schools

Under-reporting of asthma and inappropriate management at school can hamper a child's academic progress. The aim of this study was to assess asthma reporting and crisis management, following implementation of a Primary School Asthma Programme. The intervention covered 12 primary schools with 5093 students in an area of high unemployment with a large proportion of the community from a non-English background. The programme included School Asthma First Aid Kits, training workshops for school staff and individual Crisis Management Plans for students with asthma. Registration of students with asthma at school increased from 6.2% before the intervention in 1989 to 12.7% in 1992. School Asthma Crisis Plans were completed appropriately by the child's doctor and parents and returned by 68% of the students with asthma. Teachers' asthma knowledge and confidence with the management of acute asthma at school improved following asthma education workshops. It was concluded that asthma reporting and acute crisis management of asthma at school can be achieved by a programme undertaken by school medical services.

Changing prevalence of asthma in Australian children

OBJECTIVE

To investigate whether prevalence of asthma in children increased in 10 years.

DESIGN

Serial cross sectional studies of two populations of children by means of standard protocol.

SETTING

Two towns in New South Wales: Belmont (coastal and humid) and Wagga Wagga (inland and dry).

SUBJECTS

Children aged 8-10 years: 718 in Belmont and 769 in Wagga Wagga in 1982; 873 in Belmont and 795 in Wagga Wagga in 1992.

MAIN OUTCOME MEASURES

History of respiratory illness recorded by parents in self administered questionnaire; airway hyperresponsiveness by histamine inhalation test; atopy by skin prick tests; counts of house dust mites in domestic dust.

RESULTS

Prevalence of wheeze in previous 12 months increased in Belmont, from 10.4% (75/718) in 1982 to 27.6% (240/873) in 1992 (P < 0.001), and in Wagga Wagga, from 15.5% (119/769) to 23.1% (183/795) (P < 0.001). The prevalence of airway hyperresponsiveness increased twofold in Belmont to 19.8% (173/873) (P < 0.001) and 1.4-fold in Wagga Wagga to 18.1% (P < 0.05). The prevalence of airway hyperresponsiveness increased mainly in atopic children only, but the prevalence of atopy was unchanged (about 28.5% in Belmont and about 32.5% in Wagga Wagga). Numbers of house dust mites increased 5.5-fold in Belmont and 4.5-fold in Wagga Wagga.

CONCLUSIONS

We suggest that exposure to higher allergen levels has increased airway abnormalities in atopic children or that mechanisms that protected airways of earlier generations of children have been altered by new environmental factors.

Asthma severity and morbidity in a population sample of Sydney schoolchildren: Part II--Importance of house dust mite allergens

BACKGROUND

Despite an increasing prevalence of childhood asthma, few studies have quantified the strength of associations between asthma and its aetiological factors.

AIMS

To quantify the risk factors associated with childhood asthma and to investigate the characteristics of children most at risk.

METHODS

We studied a population sample of 1339 schoolchildren aged eight-11 years living in Sydney, NSW. Questionnaires were used to measure respiratory illness, histamine inhalation test to measure airway hyperresponsiveness (AHR), skin prick tests to measure atopy and ELISA assay to measure house dust mite allergen (Der p I) levels. 'Current asthma' was defined as the presence of wheeze in the previous year and AHR.

RESULTS

The mean Der p I level in 72 homes was 22.5 micrograms/gm dust which is high compared to suggested thresholds of 2 microgram/gm for sensitisation and 10 micrograms/gm for exacerbation of symptoms. Sensitisation to house dust mites was the most important risk factor for current asthma (odds ratio 7.0, 95% CI 9.4, 22.2). Sensitisation to ryegrass was of minor importance (odds ratio 2.0, 95% CI 1.4, 3.1). The presence of AHR was strongly related to the degree of sensitisation to house dust mite allergen and children with skin wheals greater than 4 mm had frequent morbidity caused by asthma.

CONCLUSIONS

To reduce the high prevalence of childhood asthma in NSW, it is imperative that we design interventions which recognise that house dust mite allergens are a dominant risk factor and that children with large skin wheal reactions to this allergen are most at risk for severe illness including disturbed sleep, days missed from school and urgent medical attention.

Headache and asthma

The aim of this study was to investigate the association between headache and asthma, bronchodilators and atopy in school children. A cross-sectional survey of all primary school children was conducted in two towns near Newcastle, New South Wales, Australia; one in the vicinity of two coal-fired power stations, the other free of outdoor industrial air pollution. The main outcome measures were frequent headache, wheezing, bronchial reactivity, use of bronchodilators and atopy. Eight hundred and fifty-one primary school children aged 5-12 years participated (92% response rate). Twenty-three per cent of the children were reported to have had a history of frequent headache. Crude odds ratios indicated that the odds of frequent headache was significantly higher in children with asthma and atopy and where there was a smoker in the home, but that there was no association between frequent headache and use of bronchodilators or the sex of the child or socio-economic status measured as father's occupation. Stepwise logistic regression with frequent headache as the outcome of interest showed that, after adjusting for age and smoking in the home, the odds ratio for asthma (defined as current wheeze) was 3.24 (95% confidence interval [CI] 2.19-4.77). The similarly adjusted odds ratio for asthma defined as bronchial hyperreactivity (BHR) was 1.60 (95% CI 1.09-2.37). Atopy was not statistically significantly associated with headache for either model. Asthma (defined as wheeze or BHR) is an independent risk factor for frequent headache. The relationship between headache and asthma is an association with bronchial hyperresponsiveness rather than atopy.

Prevalence of asthma and risk factors among Chinese, Malay, and Indian adults in Singapore

BACKGROUND

The prevalence and morbidity of asthma vary greatly among different ethnic communities and geographical locations, but the roles of environmental and genetic factors are not fully understood. The differences in prevalence of adult asthma among Chinese, Malay, and Indian ethnic groups in Singapore were examined, and the extent to which these could be explained by personal and environmental factors were investigated.

METHODS

A stratified disproportionate random sample (n = 2868) of Chinese (n = 1018), Malays (n = 967), and Indians (n = 883) of both sexes was drawn from households in five public housing estates, and an interviewer administered questionnaire was used to determine cumulative and current prevalence of "physician diagnosed asthma" (symptoms with a physician diagnosis of asthma).

RESULTS

Lifetime cumulative prevalence (standardised to the general population) of "physician diagnosed asthma" was 4.7% in men and 4.3% in women; 12 month period prevalences were 2.4% and 2.0%, respectively. Cumulative prevalence of asthma was significantly higher in Indians (6.6%) and Malays (6.0%) than in Chinese (3.0%); period prevalences of asthma were 4.5% in Indians, 3.3% in Malays, and 0.9% in Chinese. Ownership of cats or dogs was more frequent in Malays (15.4%) and Indians (11.2%) than in Chinese (8.8%). Rugs and carpets were also more frequently used by Malays (52.2%) and Indians (40.7%) than by Chinese (8.9%). Current smoking prevalences were higher in Malays (27.3%) than in Indians (19.4%) and Chinese (23.0%). Malays and Indians did not have higher rates of atopy (11.1% and 15.2%, respectively) than Chinese (15.4%). Adjustment for these factors in multivariate analyses reduced the greater odds of asthma in Malays and Indians, but not to a significant extent.

CONCLUSIONS

There are ethnic differences in the prevalence of asthma in Singapore which are not entirely explained by differences in smoking, atopy, or other risk factors. Other unmeasured environmental factors or genetic influences are likely to account for residual differences in the prevalence of asthma.