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PubMed2003

[Asthma education and self-management: inevitable requirements to enhance disease control and achieve the goals for long-term asthma management].

The patient should be the primary manager of chronic disease guided and coached by a doctor and healthcare workers. The challenge now is to recognise that establishing patient-provider partnerships is an essential step in helping patients to learn and manage chronic illnesses like asthma. This article focuses on what is known about asthma patient education and on reducing the barriers to effectively applying what is known. Whereas traditional patient education offers information and technical skills, self-management education teaches problem-solving skills. A central concept in self-management is self-efficacy, the confidence to carry out a behavior necessary to reach a desired goal (outcome-efficacy). Effective teaching on chronic diseases must be based more closely on the findings of behavioural research. Therefore, self-management education has to become an integral part of high-quality care in asthma.

Asthma↗
PubMed1998

Asthma, rhinitis and eczema in Maltese 13-15 year-old schoolchildren -- prevalence, severity and associated factors [ISAAC]. International Study of Asthma and Allergies in Childhood.

BACKGROUND: Allergic conditions, especially asthma, seem to be increasingly common the world over. The International Study of Asthma and Allergies in Childhood [ISAAC] was the first worldwide study carried out with standardized questionnaires in order to create a reliable global map of childhood allergy. OBJECTIVES: The Maltese Islands were one of the centres participating in this study and in this paper the data obtained from 4184 13-15 year olds from 22 state and three private schools [88.7% response rate], and also data obtained from some added 'local' questions addressed to the same children, are included. in order to evaluate the problem of allergic conditions in Maltese schoolchildren. RESULTS: 27.9% of the participants were wheezers 'ever' while 16% were current wheezers. Of the latter children 15.1% were experiencing nocturnal wheezing at least once a week and 22% had a wheezing episode severe enough to limit speech. Nasal problems were present in 52.7% of these teenagers and 47.4% of all respondents persisted with these symptoms up to the year of answering the questionnaire. Hayfever had been diagnosed in 32.3% of all the children. 12.8% of respondents had a recurring itchy rash suggestive of eczema for at least 6 months of their lives and 10% had it currently. This was slightly lower than the global mean, unlike the case of wheezing, which in Malta was more common than the world average, and rhinitis, for which we had the second highest cumulative prevalence rate in the world. Multiple variables such as gender, smoking, family history of atopy, pets, soft furnishings and living in busy roads affected the prevalence and severity of the allergic conditions studied. CONCLUSIONS: Allergic conditions are very common in Maltese schoolchildren and are causing a lot of hardship to these same youngsters. The results of this study should serve as a stimulus to try and decrease this suffering through better management of these conditions, measures to control possible detrimental factors and further research on asthma, allergic rhinitis and eczema.

Adolescent↗
PubMed1999

The role of cysteinyl leukotrienes in the pathogenesis of asthma: clinical study of leukotriene antagonist pranlukast for 1 year in moderate and severe asthma.

Clinical studies have shown that pranlukast (Ono Pharmaceutical Co., Osaka, Japan) is effective for mild and moderate asthma. However, it is not well known that pranlukast is also effective on moderate and severe persistent asthma in the long term. We studied the effect of pranlukast on moderate and severe asthmatics by evaluating the change of peak expiratory flow (PEF) and therapeutic scores for 1 year before and during pranlukast therapy. We gave pranlukast 225 mg twice daily orally to 25 patients who were receiving more than 400 micrograms/day beclomethasone inhalation and beta 2 stimulant inhalation with or without oral corticosteroid. Pranlukast increased PEF more than 10 L/min in 14 patients in the first 4 weeks. In these 14 patients, 10 patients continued to monitor PEF and kept asthma diaries for 1 year. We compared the data for 1 year before and during the pranlukast therapy. During the pranlukast therapy, PEF significantly increased, puffs of beta 2 stimulant inhalation significantly decreased. The incidence of oral corticosteroid rescue therapy reduced, and the mean daily dose of oral corticosteroid decreased; however, they were not statistically significant. During treatment with pranlukast, no side effect was observed. From these results, we suggest that pranlukast is effective for more than half of the moderate and severe persistent asthmatics, and that the effectiveness continues for more than 1 year.

Adult↗
PubMed2001

Improved safety with equivalent asthma control in adults with chronic severe asthma on high-dose fluticasone propionate.

OBJECTIVE: High-dose inhaled corticosteroids (ICS) have been associated with the same side-effects as oral corticosteroids. Beclomethasone dipropionate (BDP) and budesonide (BUD) in doses greater than 2000 microg/day are used regularly in severe asthma, despite the fact that safety and efficacy data at such high doses are limited. Fluticasone propionate (FP) has been promoted as being twice as potent clinically as BDP or BUD at doses of 2000 microg/day or less with a similar safety profile. The aim of this study was to compare the efficacy and safety of FP with BDP and BUD in 133 symptomatic adult asthmatics requiring at least 1750 microg/day of BDP or BUD. METHODOLOGY: Patients fulfilling the entry criteria were randomized to receive either their regular ICS medication or FP at approximately half the microgram dose for 6 months in an open, parallel group study. The primary efficacy measure was based on morning peak expiratory flow measurements recorded by patients on daily record cards, while determination of safety was based on a number of endpoints including changes in bone turnover indices, the incidence of topical side-effects and assessments of quality of life. RESULTS: It was shown that patients who were switched to FP, but not those continuing with BDP or BUD, had significant increases in levels of morning serum cortisol and the urine cortisol:creatinine ratio while maintaining asthma control. Serum osteocalcin and the pyridinoline:creatinine ratio, as well as the deoxypyridinoline:creatinine ratio, were also shown to increase only in the FP group. Subjective assessments such as quality of life score, the incidence and ease of bruising, and reports of hoarseness also favoured the FP group. CONCLUSIONS: It is concluded that, at the doses studied and with the delivery devices used clinically, FP is at least as effective as BDP/BUD in the management of severe asthma and may offer clinical advantages with respect to steroid-related adverse effects.

Adult↗
PubMed2006

Exhaled nitric oxide in asthma: variability, relation to asthma severity, and peripheral blood lymphocyte cytokine expression.

Exhaled nitric oxide has been used as a means of indirectly measuring the underlying inflammation in asthma. The objectives of the study were to measure exhaled nitric oxide levels in asthma patients and healthy volunteers, to study peripheral blood lymphocyte cytokine expression, and to study the relationship between exhaled nitric oxide and intracellular cytokine expression. Exhaled nitric oxide was elevated in patients with moderate to severe asthma and with treatment decreased in the first week reaching to a near normal level by 4 weeks. Elevated exhaled nitric oxide was associated with decreased IL-4 and IL-13 cytokine expression by CD8 lymphocytes.

Adult↗
PubMed2006

Quantifying preventive asthma care delivered at office visits: the Preventive Asthma Care-Composite Index (PAC-CI).

Our objective was to develop a composite index to measure and quantify preventive asthma care delivered in the primary care office. We documented preventive actions used for children with asthma at the time of an office visit and weighted actions based on their intensity to create a composite index. The usefulness of the index was supported by significant correlations with several measures of symptom severity. The composite index also varied by visit type, with the highest scores noted for asthma-related visits, compared to well-child and other illness visits. This composite index has potential use for research and quality improvement efforts.

Administration, Inhalation↗
PubMed2000

Quality of life in childhood asthma: use of the Paediatric Asthma Quality of Life Questionnaire in a Swedish sample of children 7 to 9 years old.

To validate a Swedish translation of the Paediatric Asthma Quality of Life Questionnaire (PAQLQ) and to study determinants of asthmatic children's quality of life, seventy-one 7-9-y-old children and their families were approached. Sixty-one children (86%) participated, 36 boys and 25 girls: 11 children with mild, 40 with moderate and 10 with severe asthma. The mean age was 8.7 y. Most commonly restricted activities during the week preceding the investigation were running (74%), gymnastics (30%), walking uphill (26%), playing football (20%) and shouting (13%). Parental rating of symptoms (Spearman's rho = -0.40, p = 0.001), percentage of expected peak flow rate (PEFR) (rho = 0.30, p = 0.009) and physicians' grading (mild, moderate and severe asthma, p = 0.047) all correlated significantly with PAQLQ scores. Younger children reported more impairment of QoL, as did children of parents not sharing household. Sex or presence of eczema or rhinoconjunctivitis did not significantly affect the scores. Children suffering from food allergy scored less impairment of QoL. The instrument was easy to administer, was well accepted by the children and had acceptable internal consistency.

Asthma↗
PubMed1995

Pickled onion-induced asthma: a model of sulfite-sensitive asthma?

BACKGROUND: Asthma elicited by sulfite ingestion has been mainly described in steroid-dependent and in non-atopic asthmatics. We have studied a group of 18 young extrinsic asthmatics who presented with asthma attacks immediately after eating pickled onions. OBJECTIVE: The aim of this study is to ascertain if these asthma attacks are elicited by sulfites contained in pickled onions and the influence of the dose and pH of onions. METHODS: The bronchial hyperreactivity of the patients was assessed by a methacholine challenge test. Oral challenge tests were performed with sodium metabisulfite (MSB) diluted in lemon juice at pH 4.2 and at pH 3.3 (only in patients who did not react with pH 4.2). Two types of pickled onions, Spanish and Dutch pickled onions, were used for oral challenge in seven of the patients. The Monier-Williams method was used to measure the SO2 concentration in pickled onions. RESULTS: The oral provocation test with MBS, pH 4.2, elicited a positive response in six patients (33.3%) and the test at pH 3.3 was positive in three out of 12. No significant difference in PD20 values was found between these groups. Three of the seven patients challenged with Spanish pickled onions had a positive reaction but had no reaction with Dutch pickled onions. The SO2 concentration in Spanish pickled onions varied between 765 and 1182 ppm while in Dutch pickled onions were 200 ppm; this exceeded the permitted level (100 ppm). SO2 release in Spanish pickled onion samples was nearly 2.5 times higher when the pH of the sample decreased from 4.2 to 3.3. CONCLUSION: High levels of SO2 in Spanish pickled onions, and their low pH (3.3) would be the responsible factors of the asthmatic outbreaks after ingestion of Spanish pickled onions by these patients.

Adolescent↗
PubMed1991

Passive smoking and childhood asthma. Urinary cotinine levels in children with asthma and in referents.

Passive exposure to tobacco smoke was assessed in children with asthma (age 3-15) and in referents. There was statistically significantly (P less than 0.0005) higher excretion of the nicotine metabolite, cotinine, in the urine of 49 children with asthma (geometric mean 10 ng/ml) compared with 77 referents (4.8 ng/ml). Maternal smoking was statistically significantly more prevalent among the asthmatics than among the referents (relative risk = RR = 2.6, 95% C1 = 1.2-5.3). In conclusion, the exposure to environmental tobacco smoke in asthmatic children was higher than among healthy children, indicating that passive smoking may be a predisposing and/or aggravating factor for childhood asthma.

Adolescent↗
PubMed1979

Panic-fear research in asthma and the nuclear conflict theory of asthma; similarities, differences and clinical implications.

Recent research with the MMPI panic-fear scale has identified personality traits implicated in the psychological maintenance of the medical intractability of asthma. Intensity of prescribed medication, length of hospitalization, and rates of rehospitalization have been found to relate to MMPI panic-fear scores independent of the objective medical severity of the illness as indexed by longitudinal pulmonary functions. In the present study, MMPI panic-fear scores are related to separation and protection conflicts arising in childhood. While the nuclear conflict theory of asthma maintains that such conflicts occur in nearly all asthmatics and form a genetic component of the asthma, the present study finds that childhood separation and protection conflicts occur in a minority of patients, but may be instrumental in maintaining the medical intractability of the illness.

Adolescent↗
PubMed1993

National asthma attack audit 1991-2. General Practitioners in Asthma Group.

OBJECTIVE: To describe the frequency and characteristics of asthma attacks in the United Kingdom and to compare actual management with recommended guidelines for the management of attacks. DESIGN: Correspondence survey. SETTING: 218 general practices in the United Kingdom. SUBJECTS: 1775 patients of all ages who had a total of 1805 asthma attacks over three months. MAIN OUTCOME MEASURES: Patient characteristics, place of management of attacks, comparison of actual management with recommended guidelines. RESULTS: Of the 1805 attacks, 300 occurred in boys aged 0-9, 144 in girls aged 0-9, and 118 in women aged 20-29. The estimated frequency of attacks in the community was 14.3 per 1000 patients per year. 1546 (86%) patients with attacks were managed within general practice, 225 (12%) were admitted to hospital, and 34 (2%) were discharged from an accident and emergency department. Two patients died. On initial presentation, 248 (14%) patients were "not breathless," 900 (50%) were "moderately breathless," 535 (30%) were "breathless and distressed," 68 (4%) were "too breathless to talk," and 2 were "moribund." Recording of clinical data was variable. Underuse of nebulised bronchodilators and systemic steroid was apparent in all grades of clinical severity. Contrary to current guidelines for asthma management, "step up" in maintenance therapy after an attack was often not practised. CONCLUSION: Reported management was at variance with recommended guidelines. This has major implications for the design and distribution of future guidelines.

Acute Disease↗
PubMed1988

The relationship between age and duration of asthma and the presence of persistent obstruction in asthma.

Persistent obstruction was assessed in 630 asthmatic subjects by measurement after bronchodilator of the maximum potential peak flow rate and forced vital capacity. Persistent obstruction was directly related to duration of asthma. The fit was slightly better after logarithmic transformation, suggesting that the early stages of asthma may be as important as the later ones in the development of persistent obstruction. On multivariate analysis age was an additional factor in males, but made no significant difference to females. Atopy did not prove relevant. Measurements of peak flow suggested a more rapid deterioration in males of social classes III, IV and V than classes I and II. Although current smokers had lower peak flow rate and vital capacity than non-smokers, there was no evidence of a steeper decline in smokers than non-smokers suggesting that the effect of cigarette smoking was at most additive to that of duration of asthma.

Adolescent↗
PubMed2005

Exhaled nitric oxide predicts asthma relapse in children with clinical asthma remission.

BACKGROUND: Nitric oxide in exhaled air (FE(NO)) is a marker of eosinophilic airway inflammation. A study was undertaken to determine whether FE(NO) predicts asthma relapse in asymptomatic asthmatic children in whom inhaled corticosteroids are discontinued. METHODS: Forty children (21 boys) of mean age 12.2 years on a median dose of 400 mug budesonide or equivalent (range 100-400) were included. FE(NO) was measured before and 2, 4, 12, and 24 weeks after withdrawal of steroids. A relapse was defined as more than one exacerbation per month, or need for beta agonist treatment on 4 days per week for at least 2 weeks, or diurnal peak flow variability of >20%. FE(NO) measurements were performed online with an expiratory flow of 50 ml/s. RESULTS: Nine patients relapsed. Two and 4 weeks after withdrawal of steroids geometric mean FE(NO) in children who were about to relapse was higher than in those who did not relapse: 35.3 ppb v 15.7 ppb at 2 weeks (ratio 2.3; 95% CI 1.2 to 4.1; p = 0.01) and 40.8 ppb v 15.9 ppb at 4 weeks (ratio 2.6; 95% CI 1.3 to 5.1). An FE(NO) value of 49 ppb at 4 weeks after discontinuation of steroids had the best combination of sensitivity (71%) and specificity (93%) for asthma relapse. CONCLUSION: FE(NO) 2 and 4 weeks after discontinuation of steroids in asymptomatic asthmatic children may be an objective predictor of asthma relapse.

Administration, Inhalation↗
PubMed1997

One year treatment with salmeterol compared with beclomethasone in children with asthma. The Dutch Paediatric Asthma Study Group.

The aim of this study was to compare the effects of salmeterol and beclomethasone on lung function and symptoms in children with mild to moderate asthma. Sixty-seven children not treated with inhaled corticosteroids were randomized in a double-blind parallel study either to salmeterol 50 micrograms b.i.d. or beclomethasone 200 micrograms b.i.d. After one year, FEV1 significantly increased in the beclomethasone group, whereas in the salmeterol group there was a small reduction. Differences between groups were 14.2% predicted (p < 0.0001) and 7.0% predicted (p = 0.007) for pre- and postbronchodilator FEV1 values, respectively. PD20 methacholine decreased by 0.73 DD (p = 0.05) in the salmeterol group and increased by 2.02 DD (p < 0.0001) in the beclomethasone group. Morning and evening PEF and symptom scores improved in both groups, although more in the beclomethasone group. Asthma exacerbations, for which prednisolone was needed, were more frequent in the salmeterol group (17 versus two), as were the number of withdrawals due to exacerbations (six versus one). However, growth was significantly slower in the beclomethasone group (-0.28 SDS) compared with that in the salmeterol group (-0.03 SDS) (p = 0.001). We conclude that treatment with a moderate dose of beclomethasone is superior to salmeterol in children with mild to moderate asthma and recommend that salmeterol should not be used as monotherapy.

Adolescent↗
PubMed1999

Airway inflammation, exhaled nitric oxide, and severity of asthma in patients with western red cedar asthma.

Examination of induced sputum and measurement of exhaled NO have been advocated as noninvasive methods of assessing the degree of airway inflammation. In this study, we performed follow-up evaluation on 71 subjects with asthma caused by exposure to Western red cedar; 50 subjects had left exposure, whereas the rest continued to work in the same job. Spirometry, methacholine challenge tests, exhaled nitric oxide, and sputum induction were carried out. Of the 50 subjects who left exposure, 12 had no respiratory impairment according to the American Throacic Society guidelines for assessing respiratory impairment in patients with asthma, 17 belonged to Class 1, 12 to Class 2, five to Class 3, and four to Class 4. The percentage of eosinophils in induced sputum showed a significant inverse relationship with FEV1 (r = -0.46, p < 0.001), and a significant positive correlation with levels of exhaled NO (r = 0.42, p < 0.001) and with the class of respiratory impairment (r = 0.52, p < 0.001). Mean percent eosinophils were 1.5 for impairment Class 0, 2.2 for Class 1, 1.7 for Class 2, 6.8 for Class 3, and 16.3 for Class 4. No relationship was found between the levels of exhaled NO and the functional parameters as well as the impairment class. NO levels in ppb were 21 for impairment Class 0, 30 for Class 1, 22 for Class 2, 26 for Class 3, and 49 for Class 4. This study also provides objective evidence that airway inflammation, as indicated by induced sputum, corroborates the rating of respiratory impairment in patients with asthma.

Adult↗
PubMed1988

Persistent asthma due to isocyanates. A follow-up study of subjects with occupational asthma due to toluene diisocyanate (TDI).

Thirty-five subjects with occupational asthma due to toluene diisocyanate (TDI) exposure were examined. All the subjects were studied with inhalation challenges with TDI and with methacholine. TDI asthma was documented by a positive inhalation challenge to low levels of TDI. Airway responsiveness to methacholine was in the range of asthmatic patients at the time of diagnosis. After an average follow-up interval of 10 months, all the subjects were re-examined. Of the 35 subjects examined, 30 subjects (85.7%) left the workplace, and 5 remained in the same job. Twenty-seven subjects (77.1%) continued to have asthmatic attacks requiring medication for relief of symptoms. At follow-up examination, TDI asthma was documented by a positive inhalation challenge to TDI in 27 subjects. Of these 27 TDI reactors, 22 subjects were removed from occupational exposure to TDI. The TDI reactors had persistent respiratory symptoms and airway hyperresponsiveness to methacholine. At follow-up visit, 8 subjects (22.9%) lost sensitization to TDI; 5 subjects (62.5%) in this group had also normal airway responsiveness to methacholine after removal from exposure. Only 1 subject among the TDI nonreactors complained of mild respiratory symptoms. At diagnosis, there were no significant differences between subjects who recovered and those who did not with regard to age, smoking habits, atopy, duration of exposure to isocyanates, duration of symptoms, baseline FEV1 (% pred), and baseline airway responsiveness to methacholine.(ABSTRACT TRUNCATED AT 250 WORDS)

Asthma↗
PubMed1992

Bronchial clearance of DTPA is increased in acute asthma but not in chronic asthma.

To investigate bronchial permeability in asthma, we measured the bronchial clearance of 113mIn-DTPA in seven asthmatics during and after an acute attack of asthma, seven asthmatics with chronic airflow limitation, and seven asthmatics without airflow limitation but with bronchial hyperresponsiveness to methacholine. We compared these results with those from seven normal subjects, seven patients with chronic bronchitis and bronchial infection, and seven patients with emphysema. An aerosol of 113mIn-DTPA was produced with a spinning disc to ensure a predominantly bronchial deposition of inhaled particles (6.3 microns MMAD). Radioactivity over the chest was recorded with a gamma-camera for 10 min after the subject inhaled the aerosol. Central regions of interest were selected, and the logarithm of the radioactivity was plotted against time; bronchial clearance of 113mIn-DTPA was calculated as the negative slope of the regression line. Clearance was substantially higher in asthmatics during their acute attacks than in all other groups (p less than 0.0001), and it decreased toward normal levels after recovery from the acute episode. The bronchial clearance of 113mIn-DTPA in all other groups did not differ from normal. We conclude that the bronchial clearance of 113mIn-DTPA is increased in asthmatics during attacks of asthma but in the stable state is not related either to bronchial hyperresponsiveness or to airflow limitation. Our findings are best explained by an increase in permeability of the bronchial mucosa of asthmatics during acute attacks.

Acute Disease↗
PubMed1992

Long-term prognosis of near-fatal asthma. A 6-year follow-up study of 145 asthmatic patients who underwent mechanical ventilation for a near-fatal attack of asthma.

The objective of the present study was to investigate the long-term prognosis of near-fatal asthma. A retrospective cohort study design was used. Cases were defined as any asthmatic individual requiring mechanical ventilation for the first time for an asthma exacerbation between January 1, 1983 and December 31, 1988. The consecutive sample of patients was drawn from four study sites, specifically four intensive care units (ICU), based in a large urban area (1 million inhabitants). These four ICU total approximately 5,000 admissions per year and are the referral centers for more than 95% of patients requiring respiratory intensive care in the area. Data collection was obtained by questionnaires addressed to the patients and to their attending physicians and was completed by telephone calls if necessary. A total of 147 patients entered the study. The long-term outcome could be evaluated in all but two patients. The follow-up period ranged from 1 to 75 months. In-hospital mortality was 16.5%. Among the 121 patients discharged from the ICU, 18 subsequently died, 17 of whom died from a new attack of asthma. Post-hospitalization mortality was 10.1% (95% CI, 5.9 to 16.8%) after 1 yr, 14.4% (CI, 9 to 22.3%) after 3 yr, and 22.6% (CI, 12.7 to 36.8%) after 6 yr. Nearly two-thirds (61.5%) of these secondary deaths occurred within the year following discharge from the ICU. Smoking was associated with a higher in-hospital mortality, as well as with a higher posthospitalization mortality. Age was also independently associated with a higher posthospitalization mortality. It is noteworthy that the secondary deaths were mostly observed in patients over 40 yr of age.(ABSTRACT TRUNCATED AT 250 WORDS)

Acute Disease↗