Heterogeneity of severe asthma in childhood: confirmation by cluster analysis of children in the National Institutes of Health/National Heart, Lung, and Blood Institute Severe Asthma Research Program

BACKGROUND

Asthma in children is a heterogeneous disorder with many phenotypes. Although unsupervised cluster analysis is a useful tool for identifying phenotypes, it has not been applied to school-age children with persistent asthma across a wide range of severities.

OBJECTIVES

This study determined how children with severe asthma are distributed across a cluster analysis and how well these clusters conform to current definitions of asthma severity.

METHODS

Cluster analysis was applied to 12 continuous and composite variables from 161 children at 5 centers enrolled in the Severe Asthma Research Program.

RESULTS

Four clusters of asthma were identified. Children in cluster 1 (n = 48) had relatively normal lung function and less atopy. Children in cluster 2 (n = 52) had slightly lower lung function, more atopy, and increased symptoms and medication use. Cluster 3 (n = 32) had greater comorbidity, increased bronchial responsiveness, and lower lung function. Cluster 4 (n = 29) had the lowest lung function and the greatest symptoms and medication use. Predictors of cluster assignment were asthma duration, the number of asthma controller medications, and baseline lung function. Children with severe asthma were present in all clusters, and no cluster corresponded to definitions of asthma severity provided in asthma treatment guidelines.

CONCLUSION

Severe asthma in children is highly heterogeneous. Unique phenotypic clusters previously identified in adults can also be identified in children, but with important differences. Larger validation and longitudinal studies are needed to determine the baseline and predictive validity of these phenotypic clusters in the larger clinical setting.

Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial

BACKGROUND

Preliminary evidence is equivocal about the role of exhaled nitric oxide (NO) in clinical asthma management. We aimed to assess whether measurement of exhaled NO, as a biomarker of airway inflammation, could increase the effectiveness of asthma treatment, when used as an adjunct to clinical care based on asthma guidelines for inner-city adolescents and young adults.

METHODS

We did a randomised, double-blind, parallel-group trial at ten centres in the USA. We screened 780 inner-city patients, aged 12-20 years, who had persistent asthma. All patients completed a run-in period of 3 weeks on a regimen based on standard treatment. 546 eligible participants who adhered to treatment during this run-in period were then randomly assigned to 46 weeks of either standard treatment, based on the guidelines of the National Asthma Education and Prevention Program (NAEPP), or standard treatment modified on the basis of measurements of fraction of exhaled NO. The primary outcome was the number of days with asthma symptoms. We analysed patients on an intention-to-treat basis. This trial is registered with clinicaltrials.gov, number NCT00114413.

FINDINGS

During the 46-week treatment period, the mean number of days with asthma symptoms did not differ between the treatment groups (1.93 [95% CI 1.74 to 2.11] in the NO monitoring group vs 1.89 [1.71 to 2.07] in the control group; difference 0.04 [-0.22 to 0.29], p=0.780). Other symptoms, pulmonary function, and asthma exacerbations did not differ between groups. Patients in the NO monitoring group received higher doses of inhaled corticosteroids (difference 119 mug per day, 95% CI 49 to 189, p=0.001) than controls. Adverse events did not differ between treatment groups (p>0.1 for all adverse events).

INTERPRETATION

Conventional asthma management resulted in good control of symptoms in most participants. The addition of fraction of exhaled NO as an indicator of control of asthma resulted in higher doses of inhaled corticosteroids, without clinically important improvements in symptomatic asthma control.

Inhaled corticosteroids in lung diseases

Inhaled corticosteroids (ICSs) are used extensively in the treatment of asthma and chronic obstructive pulmonary disease (COPD) due to their broad antiinflammatory effects. They improve lung function, symptoms, and quality of life and reduce exacerbations in both conditions but do not alter the progression of disease. They decrease mortality in asthma but not COPD. The available ICSs vary in their therapeutic index and potency. Although ICSs are used in all age groups, younger and smaller children may be at a greater risk for adverse systemic effects because they can receive higher mg/kg doses of ICSs compared with older children. Most of the benefit from ICSs occurs in the low to medium dose range. Minimal additional improvement is seen with higher doses, although some patients may benefit from higher doses. Although ICSs are the preferred agents for managing persistent asthma in all ages, their benefit in COPD is more controversial. When used appropriately, ICSs have few adverse events at low to medium doses, but risk increases with high-dose ICSs. Although several new drugs are being developed and evaluated, it is unlikely that any of these new medications will replace ICSs as the preferred initial long-term controller therapy for asthma, but more effective initial controller therapy could be developed for COPD.

Advancing asthma care: the glass is only half full!

Over the past 20 years, there has been a concerted effort in the United States to reduce morbidity related to chronic disease, including asthma. Attention was initially directed toward asthma in response to the recognition that asthma mortality was increasing and that the burden of disease was significant. These efforts to address asthma mortality led to many new initiatives to develop clinical practice guidelines, implement the asthma guidelines into clinical practice, conduct research to fill the gaps in the guidelines, and continuously revise the asthma guidelines as more information became available. An assessment of our progress shows significant accomplishments in relation to reducing asthma mortality and hospitalizations. Consequently, we are now at a crossroads in asthma care. Although we have recognized some remarkable accomplishments in reducing asthma mortality and morbidity, the availability of new tools to monitor disease activity, including biomarkers and epigenetic markers, along with information technology systems to monitor asthma control hold some promise in identifying gaps in disease management. These advances should prompt the evolution of new strategies and new treatments to further reduce disease burden. It now becomes imperative to continue a focus on ways to further reduce the burden of asthma and prevent its onset.

Asthma across the lifespan: Time for a paradigm shift

We have a unique opportunity to significantly reduce the worldwide burden of asthma in children and affect respiratory outcomes in adults. However, this will require a paradigm shift that is directed at altering the natural history of asthma, reducing asthma exacerbations, and preventing long-term adverse outcomes of childhood asthma. Attention should continue to be directed toward minimizing risk, as well as impairment, with a goal to achieve optimal control. Based on several National Institutes of Health studies conducted over the last 10 years, we now have the tools necessary to accomplish this goal. The tools include assessment of lung function over time or defining trajectories of lung growth, the Composite Asthma Severity Index score, a panel of useful biomarkers, the Seasonal Asthma Exacerbation Prediction Index score, and rapidly advancing technology that includes adherence monitoring. Future guideline revisions should consider incorporating recommendations to follow spirometry over time and defining trajectories of lung growth to assess risk for reduced lung growth and early decline, asthma burden by using biomarkers to select and monitor therapy, assessment of social determinants of health, evaluation of risk for seasonal exacerbations, and consideration of electronic adherence monitoring for difficult-to-manage asthma. Guidelines should continue to include a core dedicated to the diagnosis and treatment of intermittent and mild and moderate persistent asthma and include additional sections dedicated to the management of severe asthma.

Assessing the risk of attack in the management of asthma: a review and proposal for revision of the current control-centred paradigm

Asthma guidelines focus on day-to-day control of symptoms. However, asthma attacks remain common. They continue to cause mortality and considerable morbidity, and are a major financial burden to the UK National Health Service (NHS) and the wider community. Asthma attacks have chronic consequences, being associated with loss of lung function and significant psychological morbidity. In this article we argue that addressing daily symptom control is only one aspect of asthma treatment, and that there should be a more explicit focus on reducing the risk of asthma attacks. Management of future risk by general practitioners is already central to other conditions such as ischaemic heart disease and chronic renal impairment. We therefore propose a revised approach that separately considers the related domains of daily control and future risk of asthma attack. We believe this approach will have advantages over the current 'stepwise' approach to asthma management. It should encourage individualised treatment, including non-pharmacological measures, and thus may lead to more efficacious and less harmful management strategies. We speculate that this type of approach has the potential to reduce morbidity and healthcare costs related to asthma attacks.

Asthma diagnosis: into the fourth dimension

Asthma is the most common chronic respiratory disease in the UK; however, the misdiagnosis rate is substantial. The lack of consistency in national guidelines and the paucity of data on the performance of diagnostic algorithms compound the challenges in asthma diagnosis. Asthma is a highly rhythmic disease, characterised by diurnal variability in clinical symptoms and pathogenesis. Asthma also varies day to day, seasonally and from year to year. As much as it is a hallmark for asthma, this variability also poses significant challenges to asthma diagnosis. Almost all established asthma diagnostic tools demonstrate diurnal variation, yet few are performed with standardised timing of measurements. The dichotomous interpretation of diagnostic outcomes using fixed cut-off values may further limit the accuracy of the tests, particularly when diurnal variability straddles cut-off values within a day, and careful interpretation beyond the 'positive' and 'negative' outcome is needed. The day-to-day and more long-term variations are less predictable and it is unclear whether performing asthma diagnostic tests during asymptomatic periods may influence diagnostic sensitivities. With the evolution of asthma diagnostic tools, home monitoring and digital apps, novel strategies are needed to bridge these gaps in knowledge, and circadian variability should be considered during the standardisation process. This review summarises the biological mechanisms of circadian rhythms in asthma and highlights novel data on the significance of time (the fourth dimension) in asthma diagnosis.

Epinephrine (adrenaline) compared to selective beta-2-agonist in adults or children with acute asthma: a systematic review and meta-analysis

BACKGROUND

International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β₂-agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β₂-agonist in acute asthma.

METHODS

We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β₂-agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death.

RESULTS

Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I²=56%. The pooled Peto's OR for treatment failure with epinephrine versus selective β₂-agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β₂-agonist improved outcomes.

CONCLUSION

The low-quality evidence available suggests that epinephrine and selective β₂-agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β₂-agonist improves outcome.

PROSPERO REGISTRATION NUMBER

CRD42017079472.

Reducing carbon footprint of inhalers: analysis of climate and clinical implications of different scenarios in five European countries

BACKGROUND

Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications.

METHODS

We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO2e) emissions reductions over a 10-year period (2020-2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting β2-agonist (SABA) use; and inhaler recycling.

RESULTS

Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO2e emissions by 68%-84% and 64%-71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%-89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO2e emissions by 17%-48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%-87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions.

CONCLUSIONS

While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies.

Development of a patient passport in asthma management

This article outlines the development, testing and evaluation of an asthma patient passport (APP). The APP was designed specifically for patients with severe and difficult-to-manage asthma. This patient group tends not to access emergency services when needed, potentially putting life at risk. These individuals prefer to self-manage rather than expose themselves to feelings of vulnerability in the emergency department (ED). The aims of the project were to save lives by ensuring these patients attend the ED, to improve patient experience in the ED and to assist healthcare professionals in their clinical decision making, enabling them to deliver appropriate and individualised emergency treatment.

Treat to target approach for asthma

Recognition that about half of asthma deaths might be preventable if recommended guidelines are followed suggests that better implementation of established management strategies is needed. However, to achieve a further substantive reduction in asthma mortality, novel strategies will also be required. It is well established that asthma is a disease of chronic inflammation, with episodes of worsening inflammation associated with increased symptoms and/or exacerbations; however, current guidelines paradoxically recommend that initial treatment is only symptomatic, rather than directed at the underlying inflammatory mechanism. The "Treat to target" (TTT) approach has become a popular concept in the medical management of several common chronic conditions, including rheumatoid arthritis (RA), diabetes, hypertension and hyperlipidemia. For example, as part of a TTT approach, rheumatologists recommend methotrexate for RA with onset within 6 months. Applying the TTT approach to asthma, the primary target could be clinical remission and the primary goals as follows: eliminate symptoms and exacerbation risk; prevent airway remodeling; and normalize lung function. To construct a TTT algorithm for chronic asthma, the proposal is to eradicate short-acting β2-agonists (SABA) at all asthma severity levels and replace SABA with "Anti-Inflammatory Reliever Therapy" (AIR), using inhaled corticosteroids (ICS)/SABA or ICS/formoterol. For individuals with equal to or less than 12 months' history of symptoms, fewer than two symptoms per month, no exacerbations in the last 12 months and normal lung function, the recommendation is early initiation of ICS/SABA or ICS/formoterol as AIR.

Update on the NAEPPCC Asthma Guidelines: The wait is over, or is it?

As an asthma specialist, one is often asked to discuss the asthma guidelines. The challenge that one faces is deciding which guidelines to use as a resource for discussion or presentation. It often comes down to the following questions: What is the question? What message does one want to deliver? Where is the most current information? and Who is the target audience? This commentary will help answer those questions as it guides the reader through the new update of the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program guidelines and then outlines differences between 2 widely used strategies for the management of asthma: the Global Initiative for Asthma and the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma.

Asthma Patient Education: Partnership in Care

BACKGROUND

Asthma education is a necessary and critical component of asthma management.

METHODS

A review of the most-to-date global and national (US) guidelines and standards provides the basis for this concise asthma education primer.

RESULTS

Effective asthma education that yields enhanced long-term health outcomes is accomplished by the proper patient-specific knowledge and behavior change tools. Communication technique (quality) as well as asthma education content (quantity) should receive recurrent assessment by all healthcare team members.

CONCLUSION

Asthma education delivery can be easily planned for and routinely delivered, keeping the shared goals of patient and healthcare team in mind.

Clinical management of severe therapy-resistant asthma

INTRODUCTION

Severe therapy-resistant asthma is an area where there has been recent advances in understanding that is percolating into improvements in management. Areas covered: This review covers the recent definition and approach to the diagnosis of severe asthma and its differentiation from difficult-to-treat asthma. The recent advances in phenotyping severe asthma and in ensuing changes in management approaches together with the introduction of new therapies are covered from a review of the recent literature. Expert commentary: After ascertaining the diagnosis of severe asthma, patients need to be treated adequately with existing therapies. The management approach to severe asthma now comprises of a phenotyping step for the definition of either an allergic or eosinophilic severe asthma for which targeted therapies are currently available. This will lead to a precision medicine approach to the management of severe asthma.

Association of asthma severity and educational attainment at age 6-7 years in a birth cohort: population-based record-linkage study

Background

There is conflicting research about the association between asthma and poor educational attainment that may be due to asthma definitions. Our study creates seven categories of current chronic and acute asthma to investigate if there is an association for poorer educational attainment at age 6–7 years, and the role of respiratory infections and school absence.

Methods

This study used a population-based electronic cross-sectional birth cohort 1998–2005, in Wales, UK, using health and education administrative datasets. Current asthma or wheeze categories were developed using clinical management guidelines in general practice (GP) data, acute asthma was inpatient hospital admissions and respiratory infections were the count of GP visits, from birth to age 6–7 years. We used multilevel logistic regression grouped by schools to ascertain if asthma or wheeze was associated with not attaining the expected level in teacher assessment at Key Stage 1 (KS1) adjusting for sociodemographics, perinatal, other respiratory illness and school characteristics. We tested if absence from school was a mediator in this relationship using the difference method.

Results

There were 85 906 children in this population representative cohort with 7-year follow-up. In adjusted multilevel logistic regression, only asthma inpatient hospital admission was associated with increased risk for not attaining the expected level at KS1 (adjusted OR 1.14 95% CI (1.02 to 1.27)). Lower respiratory tract infection (LRTI) GP contacts remained an independent predictor for not attaining the expected level of education. Absence from school was a potential mediator of the association between hospital admission and educational attainment.

Conclusions

Clinicians and educators need to be aware that children who have inpatient hospital admissions for asthma or wheeze, or repeated LRTI, may require additional educational support for their educational outcomes.

Inconsistent calculation methodology for the eucapnic voluntary hyperpnoea test affects the diagnosis of exercise-induced bronchoconstriction

Introduction

The eucapnic voluntary hyperpnoea (EVH) challenge is used to screen for exercise-induced bronchoconstriction. Several criteria have been proposed to determine the decrease in lung function (fall index, FI) following EVH. We compared three published FI calculation methods to determine if they affect the diagnostic classification.

Methods

The three FIs were calculated for 126 EVH tests. Spirometry was performed in duplicate at baseline and repeated 3, 5, 10, 15 and 20 min following 6 min of EVH. The higher of the two forced expiratory volume in 1 s (FEV₁) measures at all time-points post-hyperpnoea was selected for the calculation of the FIs. The FI_A was determined as the single lowest of the five postchallenge values, and a test was considered positive if FEV₁ decreased ≥10 %. In FI_B, a test was considered positive if FEV₁ decreased ≥10% at two consecutive post-challenge time-points. The FI_C was calculated identically to FI_A, but was normalised to the achieved minute ventilation during the EVH challenge.

Results

Calculation method affected the raw FIs with FI_B generating the smallest and FI_C generating the highest values (p<0.001) and a within-subject range of 7%±10%. The number of positive tests differed between the calculation criteria: FI_A: 62, FI_B: 48 and FI_C: 70, p<0.001. Nineteen participants (15%) tested positive in one or two FI methods only, indicating that the FI method used determined whether the test was positive or negative.

Discussion

Inconsistency in methodology of calculating the FI leads to differences in the diagnostic rate of the EVH test, with potential implications in both treatment and research outcomes.

Fractional Exhaled Nitric Oxide-Assisted Management of Uncontrolled Persistent Asthma: A Real-World Prospective Observational Study

CONTEXT

The utility of fractional exhaled nitric oxide (FeNO) measurement in real-world asthma management requires investigation.

OBJECTIVE

To determine whether FeNO-assisted care added to standard asthma management improves asthma control in a managed care organization.

DESIGN

Prospective observational study in patients aged 12 years and older with uncontrolled persistent asthma identified during a scheduled visit to an Allergy Department that routinely used FeNO (FeNO-assisted care, n = 426) vs visits to 4 Allergy Departments that did not, but followed routine guideline-based care (standard care, n = 925). The FeNO-assisted care was based on FeNO level, asthma control status, and step-care level.

MAIN OUTCOME MEASURES

Composite primary outcome was 1 or more asthma exacerbations or 7 or more dispensed canisters containing short-acting β2-agonists in the follow-up year. Inverse probability of treatment weighting propensity scoring balanced covariates, and multivariable regression analyses compared outcomes between groups.

RESULTS

Compared with standard care, FeNO-assisted care was not associated with reducing the primary composite outcome (adjusted risk ratio = 0.94, 95% confidence interval = 0.69-1.29, p = 0.71), nor with a reduction in asthma exacerbations or dispensing of 7 or more short-acting β2-agonist canisters as separate outcomes. In an atopic subgroup with aeroallergen sensitization, the composite outcome was similar between groups, but the rate of asthma exacerbations was lower with FeNO-assisted treatment (adjusted rate ratio = 0.67, 95% confidence interval = 0.49-0.91, p = 0.01).

CONCLUSION

These findings suggest future studies of FeNO-assisted care should be directed at the atopic phenotype.

Thai pediatricians' current practice toward childhood asthma

BACKGROUND

Childhood asthma is a substantial health burden in Thailand. Due to a lack of pediatric respiratory specialists (pediatric pulmonologists and allergists; RS), most Thai children are cared for by general pediatricians (pediatric primary care providers (PCP)).

OBJECTIVES

We investigated whether current practices of Thai pediatricians complied with asthma guidelines and compared practices (diagnosis and treatments) provided by PCP and RS.

METHODS

A cross-sectional study was conducted using electronic surveys including four case scenarios of different asthma phenotypes distributed to Thai pediatricians. Asthma diagnosis and management were evaluated for compliance with standard guidelines. The practices of PCP and RS were compared.

RESULTS

From 800 surveys distributed, there were 405 respondents (51%). Most respondents (81%) were PCP, who preferred to use clinical diagnosis rather than laboratory investigations to diagnose asthma. For acute asthmatic attacks, 58% of the pediatricians prescribed a systemic corticosteroid. For uncontrolled asthma, 89% of the pediatricians prescribed at least one controller. For exercise-induced bronchospasm, 55% of the pediatricians chose an inhaled bronchodilator, while 38% chose a leukotriene receptor antagonist (LTRA). For virus-induced wheeze, 40% of the respondents chose an LTRA, while 15% chose inhaled corticosteroids (ICS). PCP prescribed more oral bronchodilators (31% vs. 18%, p = 0.02), antibiotics (20% vs. 6%, p < 0.001), and antihistamines (13% vs. 0%, p = 0.02) than RS for the management of an acute asthmatic attack.

CONCLUSIONS

Most of the Thai pediatricians' practices toward diagnosis and treatment of acute asthmatic attack and uncontrolled asthma conform to the guidelines. PCP prescribed more oral bronchodilators, antibiotics, and antihistamines than RS.

How should treatment approaches differ depending on the severity of asthma?

INTRODUCTION

Asthma is nowadays regarded as a syndrome of various overlapping phenotypes with defined clinical characteristics, different underlying inflammatory mechanisms, identifiable genetic background, environmental risk factors and possible biomarkers. There are no doubts that due to the diversity of asthma, a 'one size fits all' management of the disease is no longer valid. Areas covered: Nowadays asthma management is based on the control of the disease, and the goals of asthma treatment are defined as good symptom control, decreased future risk of exacerbations, fixed airflow limitation, and side-effects of treatment. Alternative strategies for adjusting asthma treatment such as sputum or exhaled nitric oxide guided protocols have been evaluated and despite some effectiveness, are regarded as impractical in every-day clinical conditions. Further studies in the field of asthma phenotypes/endotypes and biomarkers are warranted with the main goal to define which of those possible subgroups will be useful in clinical practice in regards to the potential allocation of successful treatment. Expert commentary: Despite the availability of guidelines on the diagnosis and management of asthma, it seems that the disease is still not optimally controlled. Addressing unmet needs in every day care, improving education, adherence/compliance and inhalation technique may significantly improve asthma control across all severities of the disease.

The impact of some demographic factors on the severity of asthma in children

OBJECTIVE

To investigate the association between some demographic factors and the levels of severity among asthmatic children.

METHOD

One hundred and twenty five asthmatic children aged between 6 months and 15 years were studied in pediatric and asthma clinics at King AbdulAziz University Hospital (KAUH). The assessment of clinical severity was based on the global strategy guidelines for asthma assessment and management. Subjects were grouped by age: infants (≤1 year), toddlers (1-3 years), preschool or kindergarten (3-6 years), school (6-12 years), and adolescents (12-15 years). Demographic data (age and sex) were analyzed for any statistical significance.

RESULTS

Boys were 80 (64%) and predominated in all age groups except in infants. 10(8%) were infants, 22(17.6%) toddlers, 26 (20.8%) preschool or kindergarten, 49 (39.2%) school, and 18 (14.4%) adolescent. The levels of severity of asthma were intermittent 11 (8.8%), mild persistent 74 (59.2%), moderate persistent 33 (26.4%), and severe persistent 7 (5.6%). Frequency and severity of asthma were significantly higher in boys than girls (P<0.05) and at school age compared to other age groups (P<0.05). CONCLUSION #ENTITYSTARTX00026;

RECOMMENDATION

This study demonstrated an increase in the frequency and severity of bronchial asthma in boys, particularly, those at school age. As stated in the literature, correlating demographic factors and clinical status can help in the prediction of the severity of asthma and possibly its outcome. This demands greater vigilance in the care of this group of asthmatics more than any others.

Understanding how sleep disorders are managed in people with asthma: a scoping review of the literature

OBJECTIVE

People with asthma may experience sleep disturbances due to uncontrolled asthma symptoms and/or co-occurring sleep disorders. Asthma shares pathophysiological pathways with sleep disorders including insomnia and obstructive sleep apnea and the interrelationship between asthma and sleep disorders is bi-directional. Insufficient sleep in general and in people with asthma leads to worsened mental and physical health. How this is managed in people with asthma is less known.

DATA SOURCES

This scoping review examines current literature around sleep health management employed by people with asthma and their care providers. Peer reviewed journal articles on sleep health interventions/management in adults with comorbid asthma were searched for in 4 databases, across 10 years, in a search strategy developed with medical librarians.

STUDY SELECTION

The search led to the inclusion of 13 studies that met the review criteria, which reported sleep management interventions tested in people with sleep disorders comorbid with asthma.

RESULTS

For people with obstructive sleep apnea and asthma, continuous positive pressure devices, oral appliances and bariatric surgery improved sleep and asthma outcomes. Improvements in other sleep disorders and asthma were shown with behavioral interventions and digital interventions including fitness tracker use.

CONCLUSION

The limited studies retrievable on this topic suggest management of sleep disorders in people with asthma is an under-researched area. Future research directed at how and when to assess sleep management in people with asthma will better inform specific guidelines and achieve improved sleep health in this population.

Barriers to identifying occupational asthma among primary healthcare professionals: a qualitative study

INTRODUCTION

Occupational asthma (OA) accounts for one in six cases of adult-onset asthma and is associated with a large societal cost. Many cases of OA are missed or delayed, leading to ongoing exposure to the causative agent and avoidable lung function loss and poor employment-related outcomes. Enquiry about work-related symptoms and the nature of work by healthcare professionals (HCPs) is limited, evident in primary and secondary care. Potential reasons cited for this are time pressure, lack of expertise and poor access to specialists.

AIM

To understand organisational factors and beliefs and behaviours among primary HCPs that may present barriers to identifying OA.

METHODS

We employed a qualitative phenomenological methodology and undertook 20-45 min interviews with primary HCPs in West Midlands, UK. We used purposive and snowball sampling to include general practitioners (GPs) and practice nurses with a range of experience, from urban and rural settings. Interviews were recorded digitally and transcribed professionally for analysis. Data were coded by hand, and thematic analysis was undertaken and determined theoretically until themes were saturated.

RESULTS

Eleven HCPs participated (eight GPs, three nurses). Four themes were identified that were considered to impact on identification of OA: (1) training and experience, (2) perceptions and beliefs, (3) systems constraints, and (4) variation in individual practice. OA-specific education had been inadequate at every stage of training and practice, and clinical exposure to OA had been generally limited. OA-specific beliefs varied, as did clinical behaviour with working-age individuals with asthma. There was a focus on diagnosis and treatment rather than attributing causation. Identified issues regarding organisation of asthma care were time constraints, lack of continuity, referral pressure, use of guidelines and templates, and external targets.

CONCLUSION

Organisation and delivery of primary asthma care, negative OA-related beliefs, lack of formal education, and exposure to OA may all currently inhibit its identification.