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PubMed1994

Adequacy of control of asthma in a general practice. Is maximum peak expiratory flow rate a valid index of asthma severity?

OBJECTIVES: To evaluate the adequacy of control of asthma in patients attending a general practice; and to examine the validity of peak expiratory flow rate (PEFR) as an index of asthma severity in the context of general practice. DESIGN: Short-term cohort study using indices derived from two weeks of peak flow monitoring to evaluate asthma control. PARTICIPANTS: Known and newly diagnosed asthmatics aged six years or more who presented during the study period for any reason. They were enrolled if baseline forced expiratory volume in one second (FEV1) increased by 10% or more after the administration of nebulised salbutamol. Children under the age of 12 years with no initial response to bronchodilator were included if an exercise test performed on another day was positive. OUTCOME MEASURES: Peak flow criteria for "mild asthma" in the Asthma Management Plan, 1989 (Med J Aust 1989; 151: 650-653) were used as the initial definition of "adequate control". The definition of "adequate control" was modified to variability less than 20% and a minimum PEFR of 50% or more of mean predicted value. RESULTS: There was no association between variability and maximum PEFR, but variability was strongly correlated with minimum PEFR (R = -0.60; P < 0.0005). Asthma was adequately controlled in 68% of the participants. CONCLUSION: Current guidelines with respect to the peak flow indices used in the classification of the severity of asthma need to be re-evaluated and probably changed for application in general practice.

Asthma↗
PubMed1993

The National Asthma Education Program. Expert panel report guidelines for the diagnosis and management of asthma. National Heart, Lung, and Blood Institute.

The significant worldwide increase in asthma-related severity and mortality has evoked increasing concern from the medical community. To enhance early recognition and appropriate therapeutic intervention of asthma, the National Heart, Lung, and Blood Institute's National Asthma Education Program convened an expert panel to develop guidelines for the diagnosis and treatment of asthma. The guidelines discussed in this article emphasize that airway inflammation is a central characteristic of asthma. Appropriate therapy must include four components: the use of objective measures of lung function to assess the severity of asthma and to monitor the course of therapy, comprehensive pharmacologic therapy that includes medications to reverse and prevent the underlying airway inflammation and to relieve the bronchoconstriction, environmental control measures to avoid or control factors that precipitate asthma exacerbations, and patient education to foster a partnership among the patient, the patient's family, and the clinician.

Anti-Inflammatory Agents↗
PubMed1995

[Clinical significant correlation between to the onset of bronchial asthma in children and family history of allergic diseases. Part 2. The onset of allergic diseases of their parents and bronchial asthma in children].

Eighty asthmatic and 53 non-asthmatic children were evaluated in order to find out the relationship between the onset of bronchial asthma and allergic rhinitis of parents. The results are as it follows. Total serum IgE levels relate to current symptoms but not to the onset of parents' allergic diseases. Child-onset allergic diseases have more asthmatic children than adult-onset ones. Child has more asthma when either father or mother has asthma than allergic rhinitis. Child-onset asthma of parents has higher incidence of asthma in children than child-onset allergic rhinitis, adult-onset asthma and allergic rhinitis. We concluded that information on the onset of parents' allergic diseases could help us to predict bronchial asthma in their children, and both environmental and psychological factors is aggravating asthmatic attacks in children.

Adolescent↗
PubMed1996

[The epidemiology and genetics of asthma. II. Genetic aspects of the epidemiology of asthma and atopy].

Asthma is regarded as a disease with a complex interaction between genetic and environmental factors. Since the end of the 1970s and during the 80s the world has seen an increase in the prevalence, morbidity and mortality linked to asthma. The rapidity of progress of this phenomenon means that it cannot be explained only by modification of genetic factors and stresses the preponderance of exogenous factors. The purpose of this review is to examine the epidemiological knowledge of these environmental factors and of the genetic factors in asthma in order to underline how these genetic and exogenous factors interact and modulate the occurrence of the asthmatic disease. In the first part of this general review we discussed the epidemiology of asthma in terms of prevalence, incidence, mortality, cost and socio-professional and scholastic repercussions and underlined for each environmental factor its causal role and/or exacerbation in asthma as well as its contribution in the increased prevalence and severity of asthma. In the second part of this general view we touch on the epidemiological knowledge of the genetics of asthma and of atopy.

Asthma↗
PubMed1998

Medical examiner asthma death autopsies: a distinct subgroup of asthma deaths with implications for public health preventive strategies.

OBJECTIVE: Asthma deaths have been increasing in the United States and worldwide. We studied medical examiner asthma death autopsy (MEADA) records for the state of Maryland, compared selected characteristics with state and national total asthma deaths (TADs), and comprehensively reviewed relevant literature to define characteristics of asthma deaths and to provide insight for the design of future preventive strategies directed at this subgroup. DESIGN: Protocols for autopsy and clinical data. SETTING: The Office of the Chief Medical Examiner of the State of Maryland. SUBJECTS: All MEADAs in the state of Maryland from 1988 through 1992. MAIN OUTCOME MEASURES: Descriptive analysis. RESULTS: Maryland MEADAs (63 cases) represented 16.62% of Maryland TADs (379 cases). Most common characteristics of individuals on whom autopsies were performed: inner-city residence; single; black male; 15 to 54 years old; history of asthma; no other significant medical condition; fatal episode more likely to begin at home; pronounced dead at hospital; time of death between midnight and 6 AM; no particular seasonality; and typical gross and/or microscopic pathology. Analysis also revealed that 17.46% of deceased asthma patients had a history of drug abuse; 12.69% had positive toxicology for drugs of abuse; 9.52% were infants and young children up to 4 years old, all of whom were found, unresponsive, at home; and white females comprised the highest number of TADs but the lowest number of MEADAs. CONCLUSION: Asthma education programs focused on asthmatic inner-city black males, especially those with a history of drug abuse, and on parents of inner-city asthmatic infants and children may be a useful preventive strategy. International, national, and regional MEADA databases may also be of use in the design and monitoring of preventive strategies directed at this subgroup.

Adolescent↗
PubMed1998

[Reduction in the number of hospitalizations for asthma. Quality assurance program for the management of asthma crises in a district hospital].

OBJECTIVE: The purpose of this study was to analyze the impact of a quality assurance program intended to improve the care of children with acute asthma in the emergency ward of a first level hospital. PATIENTS AND METHODS: New guidelines for acute asthma management in children were developed and applied beginning 1-1-1997. The ways to deal with an asthma crisis in 1996 and 1997 were compared. The quality guarantee cycle was the method for application of the guidelines, health workers being aware of the starting point (1996) and which areas could be improved. The quality of the clinical assessment of the asthma crisis, the adequacy of treatment, and the final destination of the patients (discharge or admission) were evaluated. RESULTS: Seventy-seven and 68 asthma crises were attended to during 1996 and 1997, respectively. We noticed significant improvements in the clinical assessment of the crisis (p < 0.001), in the correct usage of the term "asthma crisis" (p < 0.001) and in the description of the crisis severity (p < 0.001). The number of improper therapeutic procedures was reduced (p < 0.0001). Children with a mild crisis, except for those associated with risk factors (14% in 1996 and 6% in 1997), were discharged from the hospital. All children with severe crises were admitted to the hospital. Of the children with moderate crises, 75% need hospitalization in 1996, while only 45.1% did during 1997 (p = 0.05). CONCLUSIONS: Following appropriate guidelines during acute asthma attacks implies better care of the asthmatic child and reduces the number of hospital admissions. The quality guarantee cycle is a proper way to achieve these goals.

Acute Disease↗
PubMed2000

Speleotherapy for asthma.

BACKGROUND: Speleotherapy, the use of subterranean environments, is a therapeutic measure in the treatment of chronic obstructive airways diseases. It is virtually unknown in the UK or the US, but has considerable widespread use in some Central and Eastern European countries. OBJECTIVES: To review evidence for the efficacy of speleotherapy in the treatment of asthma. SEARCH STRATEGY: We searched electronic databases (Medline, Embase, Cochrane Airways group database), contacted speleotherapy centres and experts in the field, hand searched proceedings, and checked bibliographies of articles obtained to identify possible relevant publications. SELECTION CRITERIA: We included controlled clinical trials (i.e., both randomized and those not reporting the method of allocation) that compared clinical effects of speleotherapy with another intervention or no intervention in patients with chronic asthma. DATA COLLECTION AND ANALYSIS: Information concerning patients, interventions, results, and methodology were extracted in standardized manner by two independent reviewers and summarized descriptively. MAIN RESULTS: Three trials including a total of 124 asthmatic children met the inclusion criteria, but only one trial had reasonable methodological quality. Two trials reported that speleotherapy had a beneficial short-term effect on lung function. Other outcomes could not be assessed in a reliable manner. REVIEWER'S CONCLUSIONS: The available evidence does not permit a reliable conclusion as to whether speleo-therapeutic interventions are effective for the treatment of chronic asthma. Randomized controlled trials with long-term follow-up are necessary.

Air Ionization↗
PubMed1980

The behavioral management of asthma and asthma-related problems in children: a critical review of the literature.

This review focuses upon the behavioral approach to childhood asthma. Asthma is defined as intermittent, variable, and reversible airways obstruction with a complex multidimensional etiology. The major measures of asthma include physiological, symptomatic, and collateral measures. The behavioral management of childhood asthma has been restricted to relaxation training, systematic desensitization, assertive training, biofeedback, and deconditioning of exercise-induced asthma. The efficacy of such intervention strategies for asthmatic children is in doubt, although the management of asthma-related problems in children appears to be a more promising area of research. The author suggests that the power of intervention programs for asthmatic children may be strengthened by the development of multifaceted treatment programs contingent upon the antecedents and consequences of the individual case. Also, behavior therapy may be of assistance to mild asthmatic children.

Adolescent↗
PubMed2004

[The German guideline clearing-project on bronchial asthma - part 2: recommendations and key topics for a national guideline on bronchial asthma].

BACKGROUND: In order to promote the quality of asthma management in Germany, a national asthma guidelines clearing project was initiated in 2000 by the German Guidelines Clearinghouse (Sponsors: German Medical Association (GMA), National Association of the Statutory Health Insurance Physicians (NASHIP), German Hospital Federation, Federal Association of the Statutory Sickness Funds. This Part shows the key topics which should be dealt with in a German guideline on bronchial asthma. SUMMARY POINTS: For quality promotion of bronchial asthma management in Germany, the development of a national evidence-based guideline, using the internationally accepted quality criteria for clinical practice guidelines, was recommended by an expert group of the German Guideline Clearinghouse. The experts identified and peer-reviewed 16 out of 54 guidelines, which might be useful as benchmarks and examples for a German asthma guideline. From the peer review results, the expert group identified 18 key topics for a national asthma guideline.

Asthma↗
PubMed2000

Mouse allergen. II. The relationship of mouse allergen exposure to mouse sensitization and asthma morbidity in inner-city children with asthma.

BACKGROUND: Although mouse allergen is known to cause occupational asthma in laboratory workers, its potential significance in home environments has never been studied. OBJECTIVE: This study was designed to define the prevalence of mouse sensitivity and its relationship to mouse allergen exposure and disease activity in inner-city children with asthma. METHODS: A subset of 499 subjects from the National Cooperative Inner-City Asthma Study had dust samples adequate for mouse allergen analysis, as well as valid puncture skin test (PST) results. Data were analyzed to relate mouse allergen exposure and other risk factors to mouse sensitization and asthma morbidity. RESULTS: Eighty-nine (18%) of the 499 children had a positive mouse skin test response. Children whose homes had mouse allergen levels above the median (1.60 microg/g) in the kitchen had a significantly higher rate of mouse sensitization (23% vs 11%, P =. 007). Atopy was also significantly related to mouse sensitization, with 40% of those with more than 4 positive PST responses having mouse sensitivity compared with 4% of those with no other positive PST responses (P <.0001). When atopy and exposure were considered together, 53% of those with more than 4 positive PST responses and allergen levels above the median had a positive PST response to mouse allergen compared with 22% of those with more than 4 positive PST responses and allergen levels below the median (P <.0001). The relationship among mouse allergen exposure, sensitization, and any measures of asthma morbidity was not statistically significant. CONCLUSIONS: Mouse allergen may be an important indoor allergen in inner-city children with asthma, with exposure and atopy contributing to mouse sensitization.

Allergens↗
PubMed2005

Underrecognition of the severity of asthma and undertreatment of asthma in a rural area of Japan.

BACKGROUND AND AIM: Revised guidelines were released in Japan in 2003 for the assessment, treatment, and management of adult asthmatics, and similar guidelines for child asthmatics were released in 2002. We reassessed the severity and possible undertreatment of asthma according to these guidelines in stable asthmatics. METHODS: We reviewed medical records of 861 well-controlled asthmatic patients who, in April through June 2004 were cared for by 47 pulmonologists at 29 medical centers and 13 asthma clinics in a rural community in the San-in area of Japan. The physician obtained completed medical records about their symptoms and current treatment of the subjects, 726 adult and 135 children (aged 6 years or older) who were in stable condition and had had no exacerbations in the previous 3 months. The severity of asthma and current treatment for each patient were assessed according to the newly revised Japanese guidelines for the assessment, treatment, and management of adult and child asthmatics. RESULTS: In adult and child asthmatics, the percentage of predicted forced expiratory volume at 1 second (FEV1.0) was smaller and has a narrower distribution range than the percentage of predicted peak expiratory flow (PEF). When the severity of asthma was classified according to symptoms alone, 50% and 35% of those classified as mildly asthmatics patients with adults and children, respectively, had moderate to severe airflow limitation. Inhaled corticosteroids were prescribed to 90.6% of adult and 14.9% of child patients. When we compared the treatments that patients were actually receiving against the optimal treatments indexed according to a combined symptoms-FEV1.0 classification, we found that 49% of adult asthmatics were overtreated, 21% were properly treated, and 30% were undertreated. Among children, the respective percentages were 35%, 25%, and 40%. CONCLUSION: In well-controlled adult and child asthmatics, the severity of asthma is poorly judged when symptoms alone are considered. We suggest that the severity of asthma should be assessed through a combination of symptoms and the measurement of FEV1.0 during office visits. We also suggest that the proper dose of inhaled steroid needed to maintain stable conditions should be judged according to this combined symptoms-FEV1.0 classification.

Administration, Inhalation↗
PubMed2001

Genomewide screen and identification of gene-gene interactions for asthma-susceptibility loci in three U.S. populations: collaborative study on the genetics of asthma.

The genomewide screen to search for asthma-susceptibility loci, in the Collaborative Study on the Genetics of Asthma (CSGA), has been conducted in two stages and includes 266 families (199 nuclear and 67 extended pedigrees) from three U.S. populations: African American, European American, and Hispanic. Evidence for linkage with the asthma phenotype was observed for multiple chromosomal regions, through use of several analytical approaches that facilitated the identification of multiple disease loci. Ethnicity-specific analyses, which allowed for different frequencies of asthma-susceptibility genes in each ethnic population, provided the strongest evidence for linkage at 6p21 in the European American population, at 11q21 in the African American population, and at 1p32 in the Hispanic population. Both the conditional analysis and the affected-sib-pair two-locus analysis provided further evidence for linkage, at 5q31, 8p23, 12q22, and 15q13. Several of these regions have been observed in other genomewide screens and linkage or association studies, for asthma and related phenotypes. These results were used to develop a conceptual model to delineate asthma-susceptibility loci and their genetic interactions, which provides a promising basis for initiation of fine-mapping studies and, ultimately, for gene identification.

Adolescent↗
PubMed2000

Risk factors for pediatric asthma emergency visits. Milwaukee Childhood Asthma Project Team.

The purpose of this study was to identify risk factors for pediatric asthma emergency department (ED) visits. A cross-sectional sample of 307 families (24%) responded to a mailed survey. Respondents were similar to the target population of 2487 children with asthma. Thirty-seven percent of respondents had two or more asthma ED visits in the past year. Asthma ED use was associated with persistent asthma symptoms, parents without high school diplomas, age under 4 years, African-American race/ethnicity, use of written care plans, and use of spacers at school. The latter two variables were associated with severe asthma. High-risk children can be targeted for office-based medical care.

Adolescent↗
PubMed2002

Fatal asthma from powdering shark cartilage and review of fatal occupational asthma literature.

BACKGROUND: Work-related asthma (WRA) is the most common work-associated respiratory disease in developed countries. METHOD: We report shark cartilage dust as a new potential cause of occupational asthma (OA) in the context of other fatal OA case reports. RESULTS: A 38-year-old white male worked for 8 years in a facility which primarily granulated and powdered various plastics. Sixteen months prior to his death, the plant began grinding shark cartilage. After 10 months of exposure, he reported chest symptoms at work in association with exposure to shark cartilage dust and a physician diagnosed asthma. Six months later, he complained of shortness of breath at work and died from autopsy-confirmed asthma. The latency from onset of exposure to symptoms and from symptom onset to death was shorter than 10 previously reported OA fatalities. CONCLUSION: Recognition of occupational causes and triggers of asthma and removal of affected individuals from these exposures is critical and can prevent progression to irreversible or even fatal asthma.

Adult↗
PubMed2002

Evaluation of an asthma management program for Chinese children with mild-to-moderate asthma in Hong Kong.

There is inconclusive evidence on the efficacy of outpatient clinic-based asthma management programs (AMP) in children. We hypothesized that an AMP based on key symptoms could improve outcome measures of asthma in Chinese children in Hong Kong. This study involved an outpatient clinic-based prospective cohort of Chinese children with asthma. Each patient received one 2-hr session of AMP which was conducted by a pediatric nurse specialist. Asthma outcomes were measured at baseline and at 6 and 12 months after completion of AMP. Demographic data, family history of allergic diseases, and changes in inhaled steroid therapy were also recorded. A total of 106 asthmatic children were enrolled, and they showed a significant decrease in nocturnal cough, wheezing attacks, and subjective assessment of severity at 6 and 12 months following participation in AMP, compared with their baseline status. Acute asthmatic attacks, unscheduled outpatient attendance, emergency room visits, school absenteeism, and number and duration of hospitalizations were also reduced during the follow-up period. Significantly more (21%) children were reported to use inhaled beclomethasone at the end of the study. Nocturnal cough, wheeze, and symptoms due to rhinitis improved significantly after AMP. In conclusion, our cohort of Chinese children with mild-to-moderate asthma used significantly more inhaled corticosteroids and practiced more measures to control house dust mites at the end of the 1-year treatment period. The main reason for better asthma control appeared to be related to the increased use of inhaled steroids, although some additional decrease in nocturnal cough, wheeze, and allergic rhinitis was found after adjusting for the use of inhaled corticosteroids.

Ambulatory Care Facilities↗
PubMed1993

Occupational asthma--a model to study the natural history and pathogenic mechanisms in asthma.

Occupational agents can give rise to asthma either through producing specific IgE antibodies or through some as yet unidentified immunological mechanism. Study of pathogenic mechanisms of occupational asthma can generate very useful information on the pathogenesis of nonoccupational asthma. Occupational asthma also provides an ideal model to study the natural history of asthma. As the agent responsible for asthma is known, it is possible to design a study to investigate predisposing host factors and level of exposure and their interaction in determining the onset, the severity, and the outcome of the disease.

Asthma↗
PubMed2005

Effect of gender, age, and severity of asthma attack on patterns of emergency department visits due to asthma by month and day of the week.

OBJECTIVE: To examine the pattern and strength of seasonal fluctuations in emergency department (ED) visits due to asthma, by month and day of the week, by the patient's age, gender, and severity of asthma attack. METHODS: Time series analysis of ED visits was conducted among patients with asthma aged from 18 to 55 years who visited Ontario EDs between April 1, 2001 and March 31, 2004. Autoregressive regression models with months and days of the week as predictors were fitted for (1) all patients; (2) females and males separately; (3) each combination of gender and age group, and (4) each combination of gender and level of severity. The strength of seasonality in each group of patients was estimated from the R2-statistic derived from autoregression models. RESULTS: For all patient groups, the highest number of ED visits occurred in October and December, and on Sundays and Mondays. Month of January and Fridays were associated with a decreased number of visits. The strength of seasonality was similar in men and women (R2 = 0.52), was the highest in young patients and decreased with age, in men more rapidly than in women. Severe cases of asthma attacks exhibited weaker seasonality (R2 = 0.30) compared to mild (R2 = 0.45) or moderate (R2 = 0.53) cases. CONCLUSION: The strength of seasonal patterns of asthma ED visits is influenced by age and the severity of attack, and to a lesser extent, gender. Understanding the significance of seasonal precipitants of asthma in different patients subgroups could lead to better management strategies.

Acute Disease↗
PubMed1994

Fluticasone propionate aerosol for the treatment of adults with mild to moderate asthma. The Fluticasone Propionate Asthma Study Group.

BACKGROUND: Recent emphasis on the control of airway inflammation in asthma highlights the need for safe and effective antiinflammatory agents. Fluticasone propionate is one of the most potent antiinflammatory corticosteroids developed to date. OBJECTIVE: This study assessed the safety and efficacy of fluticasone propionate aerosol in the treatment of mild to moderate asthma. METHODS: Fluticasone propionate aerosol (25, 100, or 500 micrograms twice daily) or placebo was given for as long as 8 weeks to adults with mild to moderate asthma in a randomized, double-blind, parallel-group study. Patients were removed from the study if they showed predefined signs of worsening asthma. RESULTS: Sixty-three percent of placebo-treated patients and 23%, 13%, and 4% of patients treated with fluticasone propionate 25, 100, and 500 micrograms twice daily, respectively, were removed from the study. Mean forced expiratory volume in 1 second, forced vital capacity, and forced expiratory flow at midexpiratory phase at weekly visits throughout the study demonstrated that fluticasone propionate was more efficacious than placebo in maintaining asthma control. Measurements of peak expiratory flow and symptom scores significantly improved and nighttime awakenings and albuterol use to treat symptoms significantly declined in fluticasone propionate-treated groups relative to the placebo-treated group. Differences among fluticasone propionate groups for these variables were not statistically significant. Incidence and severity of adverse events were similar across groups. Fluticasone propionate did not affect morning or stimulated plasma cortisol concentrations, although slight, transient reductions in urinary free cortisol and urinary 17-hydroxy steroids occurred in the group receiving 500 micrograms fluticasone propionate twice daily. CONCLUSION: These data indicate that fluticasone propionate provides safe and effective treatment for mild to moderate asthma.

Administration, Topical↗