[When are bronchodilator agents sufficient in asthma/chronic obstructive pulmonary disease?].
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Asthma↗
Biomedical subjects
H Folgering
Publications and source records attributed to H Folgering.
Bronchial responsiveness to histamine and methacholine measured with forced expirations and with the forced oscillation technique.
The objective of this study was to compare bronchial challenge tests with two substances [histamine (H) and methacholine (M)] and two methods of measuring the effect parameter FEV1 and pulmonary impedance [with the forced oscillation technique (FOT)] in order to determine which test is the shortest, and gives the least (drug) load to the patient. Furthermore, it was considered whether the result of one type of challenge test could be transferred to the result of another type of test. It was hypothesized that, since the FOT technique requires no forced manoeuvres of the subjects and therefore does not affect the airway patency, there must be differences in the provocation concentrations for reaching the conventional thresholds of 20% decrease in FEV1 (PC20 FEV1) and 40% increase in airway resistance measured at 8 Hz oscillation frequency (PC40 Rrs8). It was further hypothesized that the interindividual correlations between thresholds for both drugs will be low, because both drugs set off different mechanisms for bronchoconstriction. Bronchial challenge tests were performed in 23 stable asthmatics (15 males and 8 females; mean +/- SD age 30.3 +/- 11.6 years). Their mean control FEV1 was 85.2 +/- 12.6% predicted. For both drugs, PC40 Rrs8 was three-fold lower than PC20 FEV1. The within-drug correlation between log PC20 FEV1 (H,M) and log PC40 Rrs8 (H,M) was quite good [r(H) = 0.73, r(M) = 0.68]. The between-drug correlation of log PC20 FEV1 (H) and log PC20 FEV1 (M) was equally good. However, the 'between-drug' correlation of log PC40 Rrs8 (H) and log PC40 Rrs8 (M) was low (r = 0.36).(ABSTRACT TRUNCATED AT 250 WORDS)
Adult↗
The relationship between respiratory symptoms and bronchial hyperresponsiveness in a population-based sample of adolescents and young adults.
OBJECTIVES: to study the relationship between chronic respiratory symptoms and bronchial hyperresponsiveness (BHR) in adolescence and young adulthood and to assess the possible predictive value of these symptoms for BHR. METHODS: a cross-sectional analysis: in a population sample of 551 subjects aged 10-23 years, data collected with a standardized questionnaire on respiratory symptoms were compared with the results of a histamine challenge test. RESULTS: 43% of the subjects reported one or more chronic respiratory symptoms; of these subjects 54% did not show BHR. Forty-two per cent of the subjects had a PC20 < or = 8.0 mg ml-1 histamine, of which 53% reported no chronic respiratory symptoms. Wheezing and breathlessness were related to the level of BHR, but only 'breathless when walking on the flat' was independently related to BHR; however, its predicted value for BHR was negligible. CONCLUSIONS: in adolescents and young adults the relationship between chronic respiratory symptoms and BHR is incomplete. A standardized questionnaire on respiratory symptoms does not provide adequate information to discriminate between those with and without BHR.
Adolescent↗
The influence of an inhaled steroid on quality of life in patients with asthma or COPD.
Relatively little is known about the influence of inhaled corticosteroids on general well-being (quality of life) in patients with asthma or COPD. In a 4-year prospective controlled study, we examined the influence of beclomethasone dipropionate (BDP), 400 micrograms, two times daily, on quality of life in 56 patients with asthma or COPD in comparison with the effects of BDP on symptoms and lung function. During the first 2 years, patients received only bronchodilator therapy with salbutamol or ipratropium bromide. During the third and fourth years, additional treatment with BDP was given. Fifty-six patients (28 with asthma, 28 with COPD) with an annual decline in the forced expiratory volume in 1 s (FEV1) of at least 80 mL/yr in combination with at least two exacerbations per year during bronchodilator therapy alone participated. Quality of life was assessed at the start and after 2 and 4 years by means of the Inventory of Subjective Health (ISH) and the Nottingham Health Profile (NHP). Although BDP significantly improved the course of lung function (FEV1)(p < 0.0001), it did not improve the ISH score or the six dimensions of the NHP neither in asthma nor in COPD. Beclomethasone dipropionate temporarily decreased respiratory symptoms during months 4 to 6 of BDP treatment in patients with asthma (p < 0.01) and during months 7 to 12 in patients with COPD (p < 0.05). A weak correlation was found both cross-sectionally and longitudinally between (change in) symptoms and quality of life on the one hand, and the (change in) FEV1 on the other. It was concluded that BDP did not improve the general well-being of patients with asthma or COPD as measured by these generic health instruments. However, BDP significantly improved the course of lung function and temporarily decreased the severity of symptoms. It seems probable that changes in quality of life would have been better detected by use of a disease-specific health instrument. Such an instrument was not available at the start of the study. Another possible explanation for these observations is that patients soon get used to different levels of lung function and learn to live with their disease. It is advised that disease-specific health instruments are used in future intervention studies and that quality of life is measured frequently during the early phase of the intervention, eg, once every month.
Administration, Inhalation↗
Continuous and on demand use of bronchodilators in patients with non-steroid dependent asthma and chronic bronchitis: four-year follow-up randomized controlled study.
BACKGROUND: A previous two-year study of continuous and on demand bronchodilator therapy in patients with moderate asthma and chronic bronchitis showed a deterioration in lung function in those on continuous therapy. AIM: A two-year follow-up study was undertaken of patients who had been shown in the previous study to have non-steroid dependent (mild) asthma and chronic bronchitis, in order to investigate the effect of continuous and on-demand treatment with bronchodilator therapy. METHOD: Patients for the study were drawn from 29 general practices in the catchment area of the University of Nijmegen, the Netherlands. A total of 83 patients (27 with asthma and 56 with chronic bronchitis) were selected from a group of 160 patients who had completed the previous two-year bronchodilator trial. During these first two years the selected subjects had been shown to be non-steroid dependent (no rapid decline in lung function and a low number of exacerbations of their condition per year), and they were followed up for another two years of treatment with bronchodilator therapy. At the start of the four-year study, patients were randomly assigned to one of two parallel treatment groups: continuous treatment (dry powder inhalations of either salbutamol 1600 micrograms or ipratropium bromide 160 micrograms daily) or treatment on demand (only during exacerbations or periods of dyspnoea). Outcome parameters were the annual decline in lung function, changes in peak flow rate, bronchial hyper-responsiveness, exacerbation rate, respiratory symptoms and reported health. RESULTS: After correction for possibly confounding variables and for regression to the mean, the decline in lung function was 49 ml year in patients taking bronchodilators continuously and 51 ml year in patients using bronchodilators on demand, irrespective of the drug use. Continuously treated patients, whether suffering from asthma or chronic bronchitis, did not differ from patients treated on demand with respect to mean morning peak flow rate, diurnal (and week to week) variation of the peak flow rate, bronchial hyper-responsiveness, exacerbation rate and reported health. There was no difference between the long-term effects of salbutamol and ipratropium. CONCLUSION: Continuous use of bronchodilators over four years in patients with non-steroid dependent asthma or chronic bronchitis does not increase the decline in lung function which had been observed previously in patients with moderate asthma or chronic bronchitis during two years of continuous treatment with bronchodilators.
Albuterol↗
Bronchodilator treatment in asthma and bronchitis.
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Albuterol↗
Exercise limitations in patients with pulmonary diseases.
An adequate analysis of the pathophysiology of the disease and of its ensuing type and degree of limitations is essential for evaluating the abilities for physical performance in patients with pulmonary diseases. Maximal exercise testing is an indispensable diagnostic tool in this respect. In light of moderate obstructive disease (FEV1 > approximately 60% pred), the exercise limitation comes from the cardio-circulatory system and/or peripheral muscle function. A rehabilitation program for these patients can be based on endurance training at high heart rate levels. Patients with a ventilatory limitation (FEV1 < 40%-60% pred.) show a failure of the respiratory pump, resulting in hypercapnia during exercise. Rehabilitation treatment will contain ergonomics, exercises for mobility and agility, breathing exercises with low-frequency breathing, relaxation exercises, and inspiratory muscle training. An oxygen-uptake limitation can be found in patients with a diffusion problem, severe ventilation-perfusion mismatch, or a reduced contact time between blood and alveolar gas. Such problems can often be seen in emphysema, and express themselves as isolated hypoxaemia during exercise. These patients benefit from a program consisting of ergonomics, exercises for mobilising the thoracic wall, low-frequency breathing, and exercising with additional oxygen. Many patients with chronic obstructive pulmonary disease (COPD) are limited for psychosocial reasons. The dyspnea is a negatively rewarding side effect of exercise in these patients. They tend to avoid all exertion, and thus get into a vicious circle of inactivity, low fitness, and unpleasant sensations during exercise. The inactivity often is also induced by the patient's family, since a 'patient-role' requires a quiet lifestyle.
Exercise Therapy↗
Asthma in adolescents and young adults: screening outcome versus diagnosis in general practice.
The objectives of this study were to investigate underdiagnosis of asthma in adolescents and young adults in general practice and to examine the influence of patient characteristics. The results of screening on asthma (questionnaire, spirometry) were compared with the diagnosis made in general practice. Screening results served as the reference standard. Four general practices forming the Continuous Morbidity Registration, Nijmegen were used. Five-hundred and fifty-one subjects aged 10-23, registered since their birth till the year of the study (1989) on the practice lists of these practices were involved in the study. The data collected included: (i) all episodes of respiratory morbidity in their life presented in general practice; (ii) socioeconomic level and family history of asthma; and (iii) current respiratory status, allergy to inhalant allergens and smoking behaviour (questionnaire, spirometry, histamine-challenge test and Phadiatop-test). The screening identified asthma in 19% of the study subjects, of whom 56% not had been recognized in general practice. Of the asthmatics recognized in general practice, significantly more were boys, had presented acute bronchitis in the last 5 years preceding this study and had a family history of asthma than those not recognized. Of the latter, 30% had not presented any respiratory disease in the last 5 years to their general practitioner (GP). This study suggests underdiagnosis of asthma in adolescents and young adults. Asthmatics are more likely to be recognized by their GPs in case of male sex, previous diagnosis of acute bronchitis and a family history of asthma. Reluctance of some patients to consult their doctor and low perception of symptoms may play a role in underdiagnosis.
Adolescent↗
Pulmonary function before surgery for pectus excavatum and at long-term follow-up.
Pulmonary function tests were performed before surgery on 152 patients who were operated on for pectus excavatum between 1970 and 1987 and at long-term follow-up to assess the degree of impairment and to investigate any changes caused by surgical correction. The mean age at surgery was 15.3 +/- 5.5 years. Pulmonary function was found to be restricted preoperatively. Multivariate analysis showed that preoperative pulmonary function was not related to age, the severity of the deformity at physical examination, or to pulmonary complaints. Only the patients with obstructive disease showed significantly more pulmonary complaints (p = 0.042). The total lung capacity (TLC) and inspiratory vital capacity (IVC) were significantly related to the age-corrected (delta) anteroposterior diameter of the chest (lower vertebral index [LVI]) (p = 0.0001). At follow-up (mean, 8.1 +/- 3.6 years), the restriction of pulmonary function was increased despite improvement in the symptoms of most patients and despite a significant increase in the anteroposterior diameter of the chest (p = 0.0001): the TLC was decreased from 83.7 percent predicted (pred) preoperatively to 73.8 percent pred (p = 0.0001) and the IVC from 78.3 percent pred to 70.7 percent pred (p = 0.0001). The surgical results were satisfactory in 83.6 percent. No relation was found between the changes in pulmonary function measured at follow-up and the surgical results. Only the age at surgery and the changes in the TLC and IVC at follow-up were significantly related (p = 0.0036, 0.0043, respectively), although the correlation coefficients were low (r = 27 percent and 28 percent, respectively). The reduction in lung function at follow-up was most pronounced in the patients who had the least functional impairment (TLC > 75 percent pred) preoperatively. No correlation was found between the changes in the pulmonary function test results at follow-up and follow-up interval, preoperative delta LVI, and the change in delta LVI at follow-up.
Adolescent↗
Does bronchial hyperresponsiveness precede or follow airway obstruction in asthma or COPD?
OBJECTIVE: The following hypothesis was tested: The degree of bronchial hyperresponsiveness (BHR) is a risk factor for the progression of airway obstruction in asthma, while in chronic obstructive pulmonary disease (COPD) it reflects the existing airway obstruction. METHODS: The relationships between the (annual change in) PC20 histamine and the (annual change in) FEV1 were investigated in a 2-year prospective controlled study. The FEV1 and the PC20 histamine were assessed at 6-month intervals. 183 patients (74 asthma, 109 COPD) participated. The investigated relationships were assessed by means of multiple analysis of variance (ANOVA). Patients used bronchodilator therapy alone. No steroids were permitted during the study. RESULTS: The results demonstrated that the PC20 at the start of the study was related to the subsequent annual decline of FEV1 in asthma (r = 0.32, p < 0.05) but not in COPD (r = -0.10, p = 0.89). Asthmatic patients with a PC20 value < or = 2 mg/ml had an average decline of 118 ml/yr, those with a PC20 value > 2 mg/ml of 27 ml/yr. The change in PC20 histamine during the 2-year study period was related to the annual change in FEV1 in COPD (r = 0.45, p < 0.05), but not in asthma (r = 0.06, p = 0.90). The disturbing influence of possible confounders was investigated and if necessary controlled for. CONCLUSIONS: It was concluded that BHR, assessed with PC20 histamine, is probably involved in the progression of airway obstruction in asthma. In COPD, however, the degree of BHR probably only reflects the degree of existing airway obstruction. This conclusion may contribute to the ongoing debate whether it is useful to combine the diagnosis of asthma, COPD and emphysema under the umbrella-term CARA (or CNSLD = chronic non-specific lung disease). The so-called "Dutch hypothesis" which laid the foundation for this term, suggested that bronchial hyperresponsiveness plays a central role in the pathogenesis of CNSLD. The present study supports evidence that at least BHR does not seem to play the same role in the pathogenesis of asthma and COPD.
Adult↗
Education and cost/benefit ratios in pulmonary patients.
The need for education of pulmonary patients stems from bad symptom perception, problems in using instruments for assessment of the severity of obstruction, problems in understanding and using (inhaled) medications, and lack in insight in the process of the underlying disease. Education of asthma patients usually leads to better management of the disease, less visits to doctors, less hospital admissions, and less days lost at school or at work. The use of medication often increases. Quality of life improves after an education program. The cost-benefit balance usually is favourable. The effects of education in COPD patients is equivocal. The costs usually are high; the benefits are substantially less than in the asthma group.
Asthma↗
Asthma in adolescents and young adults: relationship with early childhood respiratory morbidity.
AIM: This study was undertaken to examine the relationship between respiratory illness in early childhood and asthma in adolescence and young adulthood (age group 10-23 years). METHOD: The study population comprised 277 boys and 274 girls, born between 1967 and 1978 and registered from their birth to the year of study (1989) on the practice lists of the four general practices taking part in the continuous morbidity registration project (CMR) at the University of Nijmegen in the Netherlands. Details of all episodes of respiratory morbidity presented in the first five years of life and registered in the project were collected together with data on current respiratory status determined by means of a questionnaire on respiratory symptoms, spirometry and a histamine-challenge test. RESULTS: Sixteen per cent of the study group were diagnosed as having asthma. Only asthma and acute bronchitis in early childhood were significantly associated with asthma at age 10-23 years. CONCLUSION: Asthma in adolescence and young adulthood is related to asthma and acute bronchitis in early childhood. This study supports the view that this could be a causal relationship although an alternative explanation could be misclassification. The results provide no indication that upper respiratory tract infections are associated with the development of asthma in adolescence or young adulthood.
Adolescent↗
[Hyperventilation: not a cause of panic attacks].
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Blood Gas Analysis↗
Slowing the deterioration of asthma and chronic obstructive pulmonary disease observed during bronchodilator therapy by adding inhaled corticosteroids. A 4-year prospective study.
OBJECTIVE: To determine if deterioration in patients with asthma or chronic obstructive pulmonary disease (COPD) during bronchodilator therapy could be slowed by additional treatment with an inhaled corticosteroid. DESIGN: A 4-year prospective study. SETTING: Twenty-nine general practices in the catchment area of the University of Nijmegen, Nijmegen, the Netherlands. PATIENTS: The study included 56 patients (28 with asthma and 28 with COPD) who showed an annual decrease in the forced expiratory volume in 1 second (FEV1) of at least 80 mL in combination with at least two exacerbations per year during bronchodilator therapy alone. Forty-eight patients completed the study. INTERVENTION: During the first 2 years of treatment, patients received only bronchodilator therapy (salbutamol, 400 micrograms, or ipratropium bromide, 40 micrograms). During years 3 and 4, they received additional treatment with beclomethasone dipropionate, 400 micrograms two times daily. RESULTS: Prebronchodilator FEV1 increased 458 mL/y (95% CI, 233 to 683 mL/y) during the first 6 months of beclomethasone treatment; FEV1 then decreased 102 mL/y (CI, 57 to 147 mL/y) during months 7 to 24. The annual decline in FEV1 during beclomethasone treatment was less than the decline of 160 mL/y seen before beclomethasone therapy (difference, 58 mL/y; 95% CI, 2 to 87 mL/y). Only in patients with asthma did beclomethasone treatment improve bronchial hyperresponsiveness (assessed by determining the concentration of histamine that provoked a 20% decrease in FEV1 [PC20]) by 3.0 doubling doses per year (95% CI, 0.8 to 5.2 doses per year). Beclomethasone treatment was associated with improvement in peak expiratory flow rate, alleviation of symptoms, and a decrease in the number of exacerbations in both patient groups. CONCLUSIONS: Adding beclomethasone, 800 micrograms daily, slowed the unfavorable course of asthma or COPD seen with bronchodilator therapy alone. This effect was most evident in asthmatic patients.
Administration, Inhalation↗
[Differences between family physicians and pulmonary specialists in the treatment of COPD patients].
This cross-sectional study comprised 223 patients with moderate asthma or chronic bronchitis (FEV1 > 50% of the predicted value) from 29 general practices in the catchment area of Nijmegen University. Fifty-six patients were treated by 19 chest physicians, the remaining 167 by 29 general practitioners, without specialist care. In the study population no relevant differences in sex, age, smoking behaviour or severity of the disease (symptoms, lung function, and bronchial hyperreactivity) could be observed between the two groups of patients, except for allergy. Chest physicians prescribed on average almost three times as much medication as general practitioners. We could identify only a weak relationship between the severity of the disease (symptoms and pulmonary function combined) and the prescribed pharmacotherapy: with rising degrees of severity the general practitioner prescribes more bronchodilators, the specialist more inhaled corticosteroids. No relationship could be observed between bronchial hyperreactivity and the prescribed pharmacotherapy. No response to prescribed bronchodilators was found in 16% of the patients treated by the general practitioner and in 20% of the patients treated by the specialist. On the basis of this cross-sectional study no well-defined treatment policy of patients with moderate asthma or chronic bronchitis either by the general practitioner or by the lung specialist could be found.
Administration, Inhalation↗
Pulmonary rehabilitation in asthma and COPD, physiological basics.
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Asthma↗
Treatment with inhaled steroids in asthma and chronic bronchitis: long-term compliance and inhaler technique.
We investigated compliance and inhaler technique in 50 patients with airway obstruction (26 asthma, 24 chronic bronchitis) being treated with inhaled steroid (beclomethasone dipropionate, BDP) via a dry powder inhaler (Rotahaler omega). Patients had already participated for one year in a 2-year trial of BDP in general practice. They were treated daily with two dry powder inhalations of 400 micrograms BDP in combination with a bronchodilator. Compliance with BDP was measured by counting capsules (single-blind) at the end of a 4-month period and through a questionnaire. Counting capsules revealed non-compliance in 46% of the patients. Compliance was not related to age, sex, diagnosis or side-effects of BDP. In chronic bronchitis, but not in asthma, compliance was related to the outcome parameters of steroid treatment (pulmonary symptoms, change in lung function and non-specific bronchial responsiveness). The inhaler technique was judged insufficient in 27% of the patients. This study stresses the importance of regular instruction in inhaler technique and proper information about prophylactic steroid treatment by the general practitioner during the treatment of asthma and chronic bronchitis.
Administration, Inhalation↗
Does the continuous use of bronchodilators mask the progression of asthma or chronic bronchitis?
Recently, we published data of a 2 year randomized controlled study in which the effects of continuous versus symptomatic bronchodilator treatment in patients with moderate asthma or chronic bronchitis were investigated. The results showed that FEV1 decline in the continuously treated group was significantly larger than in the symptomatically treated group (72 versus 20 ml/year, P < 0.05). We reanalysed these data in order to investigate the hypothesis that the continuous use of bronchodilators may mask a rapid decline in lung function. Lung function decline was assessed by regression analysis of seven FEV1 measurements. Respiratory symptoms were assessed by means of the MRC questionnaire every 12 months, and they were also recorded by the patients in a weekly report. Of the participating patients 144 completed the study. Increased lung function decline in the continuously treated group was not reflected in a significant deterioration of the symptoms. Moreover, the decline in FEV1 showed no correlation at all with changes in respiratory symptoms in continuously treated patients (r = -0.03, P = 0.80), whereas in the symptomatically treated group, there was a better relation (r = -0.32, P = 0.003) to changes in respiratory symptoms. These results show that continuous bronchodilation may indeed mask the worsening of the disease. This lack of awareness of deterioration of the disease is probably caused by the continuous symptom relief of bronchodilators. It may be misleading to both patients and physicians.
Adult↗