Effect of asthma severity on symptom perception in childhood asthma

Individual ability to perceive airway obstruction varies substantially. The factors influencing the perception of asthma are probably numerous and not well established in children. The present study was designed to examine the influence of asthma severity, use of preventive medication, age and gender on the association between respiratory symptoms (RS) and peak expiratory flow (PEF) rates in asthmatic children. We followed 92 asthmatic children, aged 6 to 16 years, for five months. Symptom scores were recorded daily and PEF was measured twice a day. The correlations among variables at the within-person level over time were analyzed for each child and for the pooled data by multivariate analysis. After pooling the data, there was a significant (P<0.05) correlation between each symptom and PEF; 60% of the children were accurate perceivers (defined by a statistically significant correlation between symptoms and PEF across time) for diurnal symptoms and 37% for nocturnal symptoms. The accuracy of perception was independent of asthma severity, age, gender or the use of preventive medication. Symptom perception is inaccurate in a substantial number of asthmatic children, independently of clinical severity, age, gender or use of preventive medication. It is not clear why some asthmatic patients are capable of accurately perceiving the severity of airway obstruction while others are not.

Associations between fluctuations in lung function and asthma control in two populations with differing asthma severity

Lung function is a major criterion used to assess asthma control. Fluctuation analyses can account for lung function history over time, and may provide an additional dimension to characterise control. The relationships between mean and fluctuations in lung function with asthma control, exacerbation and quality of life were studied in two independent data sets.

Airway smooth muscle thickness in asthma is related to severity but not duration of asthma

Asthma is characterised by an increased airway smooth muscle (ASM) area (ASMarea) within the airway wall. The present study examined the relationship of factors including severity and duration of asthma to ASMarea. The perimeter of the basement membrane (PBM) and ASMarea were measured on transverse sections of large and small airways from post mortem cases of fatal (n=107) and nonfatal asthma (n=37) and from control subjects (n=69). The thickness of ASM (ASMarea/PBM) was compared between asthma groups using multivariate linear regression. When all airways were considered together, ASMarea/PBM (in millimetres) was increased in nonfatal (median 0.04; interquartile range 0.013-0.051; p=0.034) and fatal cases of asthma (0.048; 0.025-0.078; p<0.001) compared with controls (0.036; 0.024-0.042). Compared with cases of nonfatal asthma, ASMarea/PBM was greater in cases of fatal asthma in large (p<0.001) and medium (p<0.001), but not small, airways. ASMarea/PBM was not related to duration of asthma, age of onset of asthma, sex or smoking. No effect due to study centre, other than that due to sampling strategy, was found. The thickness of the ASM layer is increased in asthma and is related to the severity of asthma but not its duration.

Assessment and prediction of asthma and its severity in the pediatric community

Seventy four asthmatic children aged 7 to 11 years were examined along with controls matched by age and sex. Clinical and laboratory investigations preceded a 28-day follow-up where data about morning and evening peak expiratory flow rate (PEF), symptoms and treatment were recorded. The coefficient of variation of PEF was found to be an objective measurement of asthma severity that has statistically significant correlation with both symptoms (r s= .36) and treatment (r s= .60). Moreover, it separates mild and severe asthmatics, as confirmed by statistically significant differences (p= .008 or less) in symptoms, treatment, skin allergy and airways response to exercise. Skin allergy and airways responsiveness to exercise were found to be predictors of both disease and severity. By means of logistic regression analysis it was possible to establish the probabilities for both asthma and severe asthma when children presenting and not presenting these characteristics are compared. One single positive skin test represent a probability of 88% for the development of asthma and a probability of 70% for severe disease. A PEF reduction of 10% after an exercise test implies a probability of 73% for disease and a probability of 64% for severe disease. Increases in these variables imply geometrically increased risks and their presence together have a multiplicative effect in the final risk.

Patient and physician evaluation of the severity of acute asthma exacerbations

We studied the ability of patients not experienced in the use of peak expiratory flow meters to assess the severity of their asthma exacerbations and compared it to the assessment of experienced clinicians. We also evaluated which data of physical examination and medical history are used by physicians to subjectively evaluate the severity of asthma attacks. Fifty-seven adult patients (15 men and 42 women, with a mean (± SD) age of 37.3 ± 14.5 years and 24.0 ± 17.9 years of asthma symptoms) with asthma exacerbations were evaluated in a University Hospital Emergency Department. Patients and physicians independently evaluated the severity of the asthma attack using a linear scale. Patient score, physician score and forced expiratory volume at the first second (FEV1) were correlated with history and physical examination variables, and were also considered as dependent variables in multiple linear regression models. FEV1 correlated significantly with the physician score (rho = 0.42, P = 0.001), but not with patient score (rho = 0.03; P = 0.77). Use of neck accessory muscles, expiratory time and wheezing intensity were the explanatory variables in the FEV1 regression model and were also present in the physician score model. We conclude that physicians evaluate asthma exacerbation severity better than patients and that physician's scoring of asthma severity correlated significantly with objective measures of airway obstruction (FEV1). Some variables (the use of neck accessory muscles, expiratory time and wheezing intensity) persisted as explanatory variables in physician score and FEV1 regression models, and should be emphasized in medical schools and emergency settings.

Asthma Polymorphic Loci genotyping in Madeira population: identification of potential genetic markers of disease susceptibility, severity and clinical relevance

Asthma is a complex disease, influenced by both environmental and genetic factors. In this study, the analysis of multiple environmental factos assessed by questionnaire and the genotyping of SNPs IL131c.144 G/A, IL41590 C/T, IL41RP2 253183, ADRB21c.16 A/G, ADAM331V4 C/G, ADAM331S1 c.710 G/A, GSDML1236 C/T and STAT6121 C/T were performed in a sample of Madeiran asthmatic patients and their families, and their association to asthma susceptibility and severity was assessed. Family, environmental, social and individual factos such as the presence of rhinitis in one of the parents,the habitation conditions, the family smoking habits, individual food habits and allergen sensitivity, were found to account for asthma severity. IL41590*T and IL41RP2*183$ alleles as well as the combined genotypes IL41590*CT/IL41590*TT and IL41 RP2*253183/IL41RP2*253183 were associated to both asthma susceptibility and severity.GSDML1236*TT was found associated only to asthma severity.Allele ADAM331 V4*C was significantly overM transmitted to asthmatic offspring being linked with the disease by TDT. These findings suggest that in addition to environmental influences, IL41 590 C/T, IL41RP2 253183, ADAM331V4 C/G and GSDML1236 C/T SNPs may constitute important genetic factos contributing to asthmasusceptibility and/or severity in Madeira population.

Health-related quality of life in Australian children with asthma: lessons for the cross-cultural use of quality of life instruments

The development of Australian forms of the Childhood Asthma Questionnaires (CAQs) is reported. Focus group methods and psychometric analyses were used to establish the conceptual, semantic and technical equivalence of these forms with the UK versions. Both versions also provide for data collection from non-asthmatic youngsters. The internal consistency was found to be acceptable (Cronbach's alpha 0.52-0.90) and the health-related quality of life (HRQoL) scores were found to vary with asthma severity (p < 0.05). Comparison with the UK data revealed that the non-asthmatic scores were higher for Australian than British children (p < 0.001) but that the scores for children with asthma did not differ between the two countries. It was only In the Australian sample that the group with asthma reported impaired HRQoL when compared to their healthy peers. These findings were interpreted in the context of cultural expectations of life quality and conclusions are presented regarding the importance of the gap between experience and expectations. The difficulties raised by the developmental and cultural issues inherent in paediatric HRQoL research were discussed. Qual. Life Res. 7:409-419 (C) 1998 Kluwer Academic Publishers

Exhaled nitric oxide as a predictor of exacerbation in children with moderate-to-severe asthma: a prospective, 5-month study

Background: Inhaled corticosteroids (ICSs) are recommended as the first line of treatment in children with moderate-to-severe asthma. Exhaled nitric oxide (ENO) has been proposed as a clinically useful marker of control that might help identify patients in whom ICS dose may be safely reduced. Objective: To evaluate the ability of ENO to predict future asthma exacerbations in children with moderate-to-severe asthma undergoing ICS tapering. Methods: This is an observational study with no control group. ENO was measured biweekly for 14 weeks in 32 children with moderate-to-severe asthma who were undergoing ICS tapering. Clinical evaluations and spirometry were performed concomitantly, and families kept daily diaries to record symptoms between visits. We used generalized estimating equations to model the In (odds) of an asthma exacerbation in the subsequent 2-week interval as a function of ENO level at the start of the interval while adjusting for age, sex, asthma severity, and current medication use. Results: We were able to successfully lower ICS doses in 10 (56%) of the 18 children with moderate asthma and in 3 (21%) of the 14 children with severe asthma. In 83 of the 187 follow-up clinical evaluations, children were determined to have had an exacerbation during the preceding 2 weeks. ENO levels, whether expressed as a continuous variable or dichotomized, were not associated with future risk for exacerbations in either unadjusted or adjusted models. Conclusion: ENO was not a useful clinical predictor of future asthma exacerbations for children with moderate-to-severe asthma undergoing ICS tapering. Ann Allergy Asthma Immunol. 2009; 103:206-211.

Craniocervical posture and hyoid bone position in children with mild and moderate asthma and mouth breathing

Introduction The objective of the present study was to assess the craniocervical posture and the positioning of the hyoid bone in children with asthma who are mouth breathers compared to non-asthma controls. Methods The study was conducted on 56 children, 28 of them with mild (n = 15) and moderate (n = 13) asthma (14 girls aged 10 79 +/- 1 31 years and 14 boys aged 9 79 +/- 1.12 years), matched for sex, height, weight and age with 28 non-asthma children who are not mouth breathers The sample size was calculated considering a confidence interval of 95% and a prevalence of 4% of asthma in Latin America. Eighteen variables were analyzed in two radiographs (latero-lateral teleradiography and lateral cervical spine radiography), both obtained with the head in a natural position The independent t-test was used to compare means values and the chi-square test to compare percentage values (p < 0 05) Intraclass correlation coefficient (ICC) was used to verify reliability. Results. The Craniovertebral Angle (CVA) was found to be significantly smaller in asthma than in control children (106.38 +/- 766 vs. 111 21 +/- 7.40. p = 0 02) and the frequency of asthma children with an absent or inverted hyoid triangle was found to be significantly higher compared to non-asthma children (36% vs 7%, p = 0.0001). The values of the inclination angles of the superior cervical spine in relation to the horizontal plane were significantly higher in moderate than in mild asthma children (CVT/Hor 85 10 +/- 725 vs. 90 92 +/- 6.69, p = 0 04 and C1/Hor. 80 93 +/- 5.56 vs 85 00 +/- 4 20, p = 0 04) Conclusions These findings revealed that asthma children presented higher head extension and a higher frequency of changes in hyoid bone position compared to non-asthma children and that greater the asthma severity greater the extension of the upper cervical spine. (C) 2010 Elsevier Ireland Ltd. All rights reserved.

Devenir à long terme des patients intubés pour état de mal asthmatique [Late outcome after life-threatening asthma]

Pour connaître le devenir à long terme des patients intubés pour état de mal asthmatique, nous avons recontacté en 1990 les 34 patients qui avaient présenté, entre 1978 et 1988, quarante épisodes de détresse respiratoire aiguë. Deux patients sont vivants mais ont été perdus de vue, 3 sont morts dont un seul d'état de mal asthmatique 6 mois après l'épisode initial. Des 29 patients restants (7 hommes et 22 femmes, âge moyen de 48,5 ans) représentant un suivi moyen de 9,6 ans, quinze n'ont jamais été réhospitalisés; des 14 autres, seuls 5 ont requis une intubation et une ventilation mécanique lors d'un épiode ultérieur. La majorité des hospitalisations ultérieures (81%) sont survenues dans les 6 ans suivant l'épiode initial

Chronic disease management programmes for adults with asthma (intervention Review)

BACKGROUND: The burden of asthma on patients and healthcare systems is substantial. Interventions have been developed to overcome difficulties in asthma management. These include chronic disease management programmes, which are more than simple patient education, encompassing a set of coherent interventions that centre on the patients' needs, encouraging the co-ordination and integration of health services provided by a variety of healthcare professionals, and emphasising patient self-management as well as patient education. OBJECTIVES: To evaluate the effectiveness of chronic disease management programmes for adults with asthma. SEARCH METHODS: Cochrane Central Register of Controlled Trials (CENTRAL), Cochrane Effective Practice and Organisation of Care (EPOC) Group Specialised Register, MEDLINE (MEDLINE In-Process and Other Non-Indexed Citations), EMBASE, CINAHL, and PsycINFO were searched up to June 2014. We also handsearched selected journals from 2000 to 2012 and scanned reference lists of relevant reviews. SELECTION CRITERIA: We included individual or cluster-randomised controlled trials, non-randomised controlled trials, and controlled before-after studies comparing chronic disease management programmes with usual care in adults over 16 years of age with a diagnosis of asthma. The chronic disease management programmes had to satisfy at least the following five criteria: an organisational component targeting patients; an organisational component targeting healthcare professionals or the healthcare system, or both; patient education or self-management support, or both; active involvement of two or more healthcare professionals in patient care; a minimum duration of three months. DATA COLLECTION AND ANALYSIS: After an initial screen of the titles, two review authors working independently assessed the studies for eligibility and study quality; they also extracted the data. We contacted authors to obtain missing information and additional data, where necessary. We pooled results using the random-effects model and reported the pooled mean or standardised mean differences (SMDs). MAIN RESULTS: A total of 20 studies including 81,746 patients (median 129.5) were included in this review, with a follow-up ranging from 3 to more than 12 months. Patients' mean age was 42.5 years, 60% were female, and their asthma was mostly rated as moderate to severe. Overall the studies were of moderate to low methodological quality, because of limitations in their design and the wide confidence intervals for certain results.Compared with usual care, chronic disease management programmes resulted in improvements in asthma-specific quality of life (SMD 0.22, 95% confidence interval (CI) 0.08 to 0.37), asthma severity scores (SMD 0.18, 95% CI 0.05 to 0.30), and lung function tests (SMD 0.19, 95% CI 0.09 to 0.30). The data for improvement in self-efficacy scores were inconclusive (SMD 0.51, 95% CI -0.08 to 1.11). Results on hospitalisations and emergency department or unscheduled visits could not be combined in a meta-analysis because the data were too heterogeneous; results from the individual studies were inconclusive overall. Only a few studies reported results on asthma exacerbations, days off work or school, use of an action plan, and patient satisfaction. Meta-analyses could not be performed for these outcomes. AUTHORS' CONCLUSIONS: There is moderate to low quality evidence that chronic disease management programmes for adults with asthma can improve asthma-specific quality of life, asthma severity, and lung function tests. Overall, these results provide encouraging evidence of the potential effectiveness of these programmes in adults with asthma when compared with usual care. However, the optimal composition of asthma chronic disease management programmes and their added value, compared with education or self-management alone that is usually offered to patients with asthma, need further investigation.

Factors associated with uncontrolled asthma in Porto Alegre, Brazil

The prevalence of uncontrolled and controlled asthma, and the factors associated with uncontrolled asthma were investigated in a cross-sectional study. Patients aged 11 years with confirmed asthma diagnosis were recruited from the outpatient asthma clinic of Hospital de Clínicas de Porto Alegre, Brazil. Patients were excluded if they had other chronic pulmonary disease. They underwent an evaluation by a general questionnaire, an asthma control questionnaire (based on the 2006 Global Initiative for Asthma guidelines), assessment of inhaled device technique and pulmonary function tests. Asthma was controlled in 48 of 275 patients (17.5%), partly controlled in 74 (26.9%) and uncontrolled in 153 (55.6%). In the univariate analysis, asthma severity was associated with asthma control (P < 0.001). Availability of asthma medications was associated with asthma control (P = 0.01), so that most patients who could purchase medications had controlled asthma, while patients who depend on the public health system for access to medications had lower rates of controlled asthma. The use of inhaled corticosteroid was lower in the uncontrolled group (P < 0.001). Logistic regression analysis identified three factors associated with uncontrolled asthma: severity of asthma (OR = 5.33, P < 0.0001), access to medications (OR = 1.97, P = 0.025) and use of inhaled corticosteroids (OR = 0.17, P = 0.030). This study showed a high rate of uncontrolled asthma in patients who attended an outpatient asthma clinic. Severity of asthma, access to medications and adequate use of inhaled corticosteroids were associated with the degree of asthma control.

Asthma during Pregnancy

L’asthme est connu comme l’une des maladies chroniques les plus fréquentes chez la femme enceinte avec une prévalence de 4 à 8%. La prévalence élevée de l’asthme fait en sorte qu’on se préoccupe de l’impact de la grossesse sur l’asthme et de l’impact de l’asthme sur les issus de la grossesse. La littérature présente des résultats conflictuels concernant l’impact de l’asthme maternel sur les issus périnatales comme les naissances prématurées, les bébés de petit poids et les bébés de petit poids pour l’âge gestationnel (PPGA). De plus, les données scientifiques sont rares concernant l’impact de la sévérité et de la maîtrise de l’asthme durant la grossesse sur les issus périnatales. Donc, nous avons mené cinq études pour réaliser les objectifs suivants: 1. Le développement et la validation de deux indexes pour mesurer la sévérité et la maîtrise de l’asthme. 2. L’évaluation de l’impact du sexe du fœtus sur le risque d’exacerbation de l’asthme maternel et l’utilisation de médicaments antiasthmatiques durant la grossesse; 3. L’évaluation de l’impact de l’asthme maternel sur les issus périnatales; 4. L’évaluation de l’impact de la sévérité de l’asthme maternel durant la grossesse sur les issus périnatales; 5. L’évaluation de l’impact de la maîtrise de l’asthme maternel durant la grossesse sur les issus périnatales. Pour réaliser ces projets de recherche, nous avons travaillé avec une large cohorte de grossesse reconstruite à partir du croisement de trois banques de données administratives du Québec recouvrant la période entre 1990 et 2002. Pour les trois dernières études, nous avons utilisé un devis de cohorte à deux phases d’échantillonnage pour obtenir, à l’aide d’un questionnaire postal, des informations complémentaires qui ne se trouvaient pas dans les banques de données, comme la consommation de cigarettes et d’alcool pendant la grossesse. Nous n’avons trouvé aucune différence significative entre les mères de fétus féminins et de fétus masculins pour les exacerbations de l’asthme pendant la grossesse (aRR=1.02; IC 95%: 0.92 to 1.14). Par contre, nous avons trouvé que le risque de bébé PPGA (OR: 1.27, IC 95%: 1.14-1.41), de bébé de petit poids (OR: 1.41, IC 95%:1.22-1.63) et de naissance prématurée (OR: 1.64, IC 95%:1.46-1.83) était significativement plus élevés chez les femmes asthmatiques que chez les femmes non asthmatiques. De plus, nous avons démontré que le risque d’un bébé PPAG était significativement plus élevé chez les femmes avec un asthme sévère (OR:1.48, IC 95%: 1.15-1.91) et modéré (OR: 1.30, IC 95%:1.10-1.55) que chez les femmes qui avaient un asthme léger. Nous avons aussi observé que les femmes qui avaient un asthme bien maîtrisé durant la grossesse étaient significativement plus à risque d’avoir un bébé PPAG (OR:1.28, IC 95%: 1.15-1.43), un bébé de petit poids (OR: 1.42, IC 95%:1.22-1.66), et un bébé prématuré (OR: 1.63, IC 95%:1.46-1.83) que les femmes non asthmatiques. D’après nos résultats, toutes les femmes asthmatiques même celles qui ont un asthme bien maîtrisé doivent être suivies de près durant la grossesse car elles courent un risque plus élevé d’avoir des issus de grossesses défavorables pour leur nouveau-né.

Complexity of chronic asthma and chronic obstructive pulmonary disease: implications for risk assessment, and disease progression and control

Although assessment of asthma control is important to guide treatment, it is difficult since the temporal pattern and risk of exacerbations are often unpredictable. In this Review, we summarise the classic methods to assess control with unidimensional and multidimensional approaches. Next, we show how ideas from the science of complexity can explain the seemingly unpredictable nature of bronchial asthma and emphysema, with implications for chronic obstructive pulmonary disease. We show that fluctuation analysis, a method used in statistical physics, can be used to gain insight into asthma as a dynamic disease of the respiratory system, viewed as a set of interacting subsystems (eg, inflammatory, immunological, and mechanical). The basis of the fluctuation analysis methods is the quantification of the long-term temporal history of lung function parameters. We summarise how this analysis can be used to assess the risk of future asthma episodes, with implications for asthma severity and control both in children and adults.