The European Community Respiratory Health Survey: what are the main results so far? European Community Respiratory Health Survey II

Allergic rhinitis and asthma comorbidity in a survey of young adults in Italy

BACKGROUND

Several studies have provided evidence of a strong association between asthma and allergic or nonallergic rhinitis, leading to the hypothesis that allergic rhinitis (AR) and asthma represent a continuum of the same disease.

AIM

THE AIMS OF OUR STUDY WERE

(i) to measure the comorbidity of AR and asthma and asthma-like symptoms and (ii) to assess whether asthma, AR, and their coexistence share a common pattern of individual risk factors.

METHODS

The subjects are participants from the Italian multicentre, cross-sectional survey on respiratory symptoms in the young adult general population (Italian Study of Asthma in Young Adults, ISAYA). The relationship between individual risk factors and asthma, AR and their coexistence, was studied by means of a multinomial logistic regression.

RESULTS

About 60% of asthmatics reported AR. On the other hand, subjects with AR presented an eightfold risk of having asthma compared to subjects without AR. Age was negatively associated with asthma [OR = 0.89, 95% confidence interval (CI): 0.82-0.96], AR (OR = 0.92, 95% CI: 0.86-0.98), and asthma associated with AR (OR = 0.83, 95% CI: 0.79-0.88). The risk of AR without asthma was significantly higher in the upper social classes (OR = 1.23, 95% CI: 1.08-1.39). Active current smoking exposure was positively associated with asthma alone (OR = 1.24, 95% CI: 1.09-1.41) and negatively associated with AR with (OR = 0.69, 95% CI: 0.54-0.88) or without (OR = 0.76, 95% CI: 0.69-0.84) asthma.

CONCLUSIONS

Asthma and AR coexist in a substantial percentage of patients; bronchial asthma and AR, when associated, seem to share the same risk factors as AR alone while asthma without AR seems to be a different condition, at least with respect to some relevant risk factors.

Monitoring response to treatment in asthma management: food for thought

Asthma is a chronic inflammatory disorder of the airways that is characterized by episodic symptoms. In this regard, asthma management has classically involved periodic re-assessment by the health-care provider, during which therapy is altered mainly based on clinical and physiological parameters, such as assessment of symptoms, spirometry and peak expiratory flow monitoring. In this context, various markers of airway inflammation (e.g. eosinophils in the induced sputum, nitric oxide in the exhaled air) have been proposed to assess the severity of asthma and to adjust the therapy accordingly. The evaluation of airway hyper-responsiveness with different stimuli has also been suggested as a new tool to monitor asthma. However, the lack of definite relationships between airway inflammation and asthmatic symptoms strongly limit the use of markers of asthma severity in the clinical setting. Therefore, the need of new tools to assess the severity of asthma is raised. The ideal measurement employed to establish the proper asthmatic therapy should be safe, non-invasive, easy to perform, reproducible and accurate, and have the capability to monitor the changes induced by the therapeutic interventions. A careful review of the available techniques, and the evaluation of their sensitivity and specificity in the clinical setting is warranted.

Asthma and allergic diseases in schoolchildren: third cross-sectional survey in the same primary school in Ankara, Turkey

We investigated prevalence and determinants of asthma and allergic diseases in a cross-sectional survey of schoolchildren aged 6-14 in 2002. This was the third of a series of cross-sectional surveys, conducted in 1992 and 1997, in the same school in Ankara, Turkey. Questionnaire including information on house characteristics, dietary habits, past and current exposures and diseases were distributed to 1064 children (523 boys, 541 girls) and filled by the parents at home. Percentage of children having a pet was significantly higher (1992: 7.9, 1997: 22.9, 2002: 21), but that of passive smoking was significantly lower (1992: 74, 1997: 64, 2002: 64.1) in 1997 and 2002 when compared with 1992. Current prevalence percentage of asthma (1992: 8.3, 1997: 9.8, 2002: 6.4), wheeze (1992: 11.9, 1997: 13.3, 2002: 6.4), hay fever (1992: 15.4, 1997: 14.1, 2002: 7.2), and eczema (1992: 4, 1997: 4.3, 2002: 1.8) were significantly lower in 2002 compared with 1992. Multiple logistic regression analysis model for current wheeze included ingestion of cow's milk (no regular ingestion: reference, ORs and 95% CIs, <1 glass/day: 0.5, 0.3-1.0; at least 1 glass/day: 0.3, 0.2-0.7), ingestion of red meat (2.2, 1.2-3.8), and currently holding a dog (6.1, 1.6-23.4). Multiple logistic regression analysis model for current hay fever included ingestion of red meat (1.8, 1.1-2.9) and father's education (none of the parents finished secondary school: reference, secondary school to university: 0.5, 0.2-1.0). Our findings suggested that current prevalence of asthma and allergic diseases decreased among schoolchildren in Ankara, in the last 10 yr, and ingestion of milk and red meat could have a role in the occurrence of asthma and hay fever. Detailed assessment of dietary habits is required to test this hypothesis.

Effect of anti-immunoglobulin E on nasal inflammation in patients with seasonal allergic rhinoconjunctivitis

BACKGROUND

Binding of allergens to IgE on mast cells and basophils causes release of inflammatory mediators in nasal secretions.

OBJECTIVE

The combined effect of specific immunotherapy (SIT) and omalizumab, a humanized monoclonal anti-IgE antibody, on release of eosinophilic cationic protein (ECP), tryptase, IL-6, and IL-8 in nasal secretion was evaluated.

METHODS

Two hundred and twenty five children (aged 6-17 years) with a history of seasonal allergic rhinoconjunctivitis induced by birch and grass pollen were randomized into four groups: either birch- or grass-pollen SIT in combination with either anti-IgE or placebo. Complete sets of nasal secretion samples before treatment Visit 1 (V1), during birch- (V2) and grass (V3)-pollen season and after the pollen season (V4) were collected from 53 patients.

RESULTS

A significant reduction in tryptase only was seen in the anti-IgE-treated group at V2 (P<0.05) and V4 (P<0.05) compared with the placebo group. During the pollen season, patients with placebo showed an increase of ECP compared with baseline (V2: +30.3 microg/L; V3: +134.2 microg/L, P< 0.005; V4: +79.0 microg/L, P< 0.05), and stable levels of tryptase, IL-6 and IL-8. Treatment with anti-IgE resulted in stable ECP values and a significant decrease of tryptase compared with V1 (baseline): V2: -80.0 microg/L (P< 0.05); V3: -56.3 microg/L, which persisted after the pollen season with V4: -71.6 microg/L (P< 0.05). After the pollen season, a decrease of IL-6 was observed in both groups (V4 placebo group: -37.5 ng/L; V4 anti-IgE group: -42.9 ng/L, P< 0.01).

CONCLUSION

The combination of SIT and anti-IgE is associated with prevention of nasal ECP increase and decreased tryptase levels in nasal secretions.

An overview of two Cochrane systematic reviews of complementary treatments for chronic asthma: acupuncture and homeopathy

BACKGROUND

Acupuncture and homeopathy are commonly used complementary treatments for chronic asthma. This review summarizes two recently updated Cochrane systematic reviews that assess the safety and efficacy of homeopathy or acupuncture in individuals with chronic stable asthma.

INCLUSION CRITERIA

Only randomized-controlled trials were considered for inclusion. Statistical aggregation of the data was undertaken where possible.

SEARCH STRATEGY

Searches for both reviews were done with the assistance of the Cochrane Airways Group, and through electronic alerts.

RESULTS

ACUPUNCTURE: 11 studies with 324 participants met the inclusion criteria. Trial reporting was poor, and the trial quality was deemed inadequate to generalize the findings. There was variation in the type of active and sham acupunctures, the outcomes assessed and the time points measured. The points used in the sham arm of some studies are used for the treatment of asthma according to traditional Chinese medicine. Two studies used individualized treatment strategies, and one study used a combination strategy of formula acupuncture with the addition of individualized points. No statistically significant or clinically relevant effects were found for acupuncture compared with sham acupuncture. When data from two small studies were pooled, no difference in lung function was observed (post-treatment FEV1): standardized mean difference 0.12, 95% confidence interval 0.31 to 0.55).

CONCLUSION

ACUPUNCTURE: There is not enough evidence to recommend the use of acupuncture in the treatment of asthma. Further research needs to be undertaken, and this should take into account the different types of acupuncture practiced.

RESULTS

HOMEOPATHY: Six trials with a total of 556 people were included in the review. These trials were all placebo-controlled and double-blind, but were of variable quality. Standardized treatments in these trials are unlikely to represent common homeopathic practice where treatment tends to be individualized. The results of the studies are conflicting in terms of effects on lung function. There has been only a limited attempt to measure a "package of care" effect (i.e. the effect of the medication as well as the consultation, which is considered a vital part of individualized homeopathic practice).

CONCLUSION

HOMEOPATHY: There is not enough evidence to reliably assess the possible role of homeopathy in the treatment of asthma. Further studies could assess whether individuals respond to a "package of care" rather than the homeopathic intervention alone.

Non-linear short-term effects of airborne pollen levels with allergenic capacity on asthma emergency room admissions in Madrid, Spain

BACKGROUND

Several time-series studies have shown positive associations between pollen levels and asthma morbidity. However, few studies have included air pollution as a potential confounder when examining this relationship, and they have only done so on a linear basis.

OBJECTIVE

To investigate the potential non-linear short-term effects of the types of pollen with allergenic capacity across the whole range of exposure on the daily number of asthma-related hospital emergencies in Madrid for the period 1995-1998.

METHODS

Data were collected on the daily number of asthma emergency room admissions and daily average levels of major types of pollen with allergenic capacity: Olea, Plantago, Poaceae and Urticaceae. We used Poisson regression with generalized additive models, controlling for trend and seasonality, meteorological variables, acute respiratory infections and air pollutants. To study the non-linear effect of pollen levels on asthma emergency room admissions, pollens were categorized into five groups defined on the basis of their respective distributions.

RESULTS

The strongest associations were registered in respect of a lag of 1 day for Urticaceae, a lag of 2 days for Plantago, and a day lag of 3 days for Poaceae. Adjustment for the different types of pollen failed to result in major changes. Non-linearities were evident for pollen levels. The greatest increase in risk vs. the reference category (minimum value - 50th percentile) was observed for the categories between the 95th and 99th percentiles, with increases of 32.0% for Plantago, 32.2% for Poaceae and 24.6% for Urticaceae, and between the 99th percentile and the maximum value, with increases of 31.3%, 78.7% and 49.8%, respectively. Olea was not related with asthma emergency room admissions.

CONCLUSIONS

Pollens with allergenic capacity in Madrid are positively associated with asthma-related hospital emergencies. These associations remain stable when simultaneous adjustment is made for the four types of pollen and for air pollutants and meteorological variables. In terms of non-linear effects, Poaceae register the strongest association with asthma emergency room admissions.

ImmunoCAP Specific IgE test: an objective tool for research and routine allergy diagnosis

Immunoglobulin (Ig) E-mediated allergic diseases are increasing rapidly, affecting the quality of life of millions of people and causing enormous costs for society. Accurately identifying the sensitizing allergen and its sources is one of the cornerstones in the clinical management of allergic patients. The original ImmunoCAP Specific IgE test (Pharmacia Diagnostics) is the only test for IgE antibodies sufficiently documented and recommended in research for advanced diagnosis and risk assessment. It is a reliable diagnostic tool and particularly useful in primary care where the use of in vivo tests cannot be recommended if the personnel have insufficient opportunities to get the appropriate experience.

Socioeconomic status and asthma prevalence in young adults: the European Community Respiratory Health Survey

The authors assessed the association between asthma prevalence and socioeconomic status at both the individual and center levels simultaneously.by using data from 32 centers in 15 countries. Included were 10,971 subjects aged 20-44 years selected from the general population and interviewed in 1991-1992. Socioeconomic status at both the individual and aggregated levels was measured on the basis of occupation and educational level. Associations were assessed by using multilevel models adjusted for age, sex, body mass index, parental asthma, childhood respiratory infections, presence of immunoglobulin E to common allergens, rhinitis, smoking, and occupational exposure to irritants. Asthma prevalence was higher in lower socioeconomic groups, whether defined by educational level (odds ratio for finishing full-time studies-<16 vs. >19 years = 1.28, 95% confidence interval: 1.00, 1.64) or social class (odds ratio for semiskilled and unskilled manual workers vs. professional/managerial = 1.51, 95% confidence interval: 1.20, 1.90), regardless of atopic status. The relation was consistent between centers. Irrespective of individual socioeconomic status, subjects living in areas in which educational levels were lower had a higher risk of asthma (p < 0.05). This center-level association partially explained geographic differences in asthma prevalence, but considerable heterogeneity still remained. The authors concluded that community influences of living in a low-educational area are associated with asthma, independently of subjects' own educational level and social class.

The Stockholm Indoor Environment Questionnaire: a sociologically based tool for the assessment of indoor environment and health in dwellings

The aim was to develop and validate a standardized questionnaire - the Stockholm Indoor Environment Questionnaire (SIEQ). The validation procedure was based on sociological principles and test procedures for validation. The indicators of indoor environment are air quality, thermal climate, noise, and illumination. The indicators of health are symptoms comprised in the sick building syndrome (SBS). The questionnaire also contains questions about the apartment, individual behavior, and personal factors. The everyday language describing the building and its function was first obtained by qualitative personal interviews, then by standardized questions. The interview questionnaire was transformed into a postal self-administered questionnaire. The reduction of the questionnaire was based on correlation analysis. It was found that to obtain a good validity, general questions are not sufficient, but specific question on perceptions and observations are needed. Good test-retest agreement was found both on an area level, building level, and individually. For each indicator, a set of questions are constructed and validated. SIEQ has been used in several studies, and the results are presented in graphic problem profiles. Reference data has been calculated for the Stockholm area.

A comparison of indoor air pollutants in Japan and Sweden: formaldehyde, nitrogen dioxide, and chlorinated volatile organic compounds

Indoor and outdoor concentrations of formaldehyde (HCHO), nitrogen dioxide (NO2), and selected chlorinated volatile organic compounds (chlorinated VOC) were measured in 37 urban dwellings in Nagoya, Japan, and 27 urban dwellings in Uppsala, Sweden, using the same sampling procedures and analytical methods. Indoor as well as outdoor air concentrations of HCHO, NO2, and chlorinated VOC were significantly higher in Nagoya than in Uppsala (P<0.01), with the exception of tetrachlorocarbon in outdoor air. In Nagoya, HCHO and NO2 concentrations were significantly higher in modern concrete houses than in wooden houses and higher in newer (less than 10 years) than in older dwellings (P<0.01), possibly due to less natural ventilation and more emission sources in modern buildings. Dwellings heated with unvented combustion sources had significantly higher indoor concentrations of NO2 than those with clean heating (P<0.05). Moreover, dwellings with moth repellents containing p-dichlorobenzene had significantly higher indoor concentrations of p-dichlorobenzene (P<0.01). In conclusion, there appear to be differences between Nagoya and Uppsala with respect to both indoor and outdoor pollution levels of the measured pollutants. More indoor pollution sources could be identified in Nagoya than in Uppsala, including construction and interior materials emitting VOC, use of unvented combustion space heaters, and moth repellents containing p-dichlorobenzene.

Short term effects of airborne pollen concentrations on asthma epidemic

BACKGROUND

Few studies have used time series to investigate the relationship between asthma attacks and aeroallergen levels on a daily basis.

METHODS

This study, based on time series analysis adjusting for meteorological factors and air pollution variables, assessed the short term effects of different types of allergenic pollen on asthma hospital emergencies in the metropolitan area of Madrid (Spain) for the period 1995-8.

RESULTS

Statistically significant associations were found for Poaceae pollen (lag of 3 days) and Plantago pollen (lag of 2 days), representing an increase in the range between the 99th and 95th percentiles of 17.1% (95% confidence interval (CI) 3.2 to 32.8) and 15.9% (95% CI 6.5 to 26.2) for Poaceae and Plantago, respectively. A positive association was also observed for Urticaceae (lag of 1 day) with an 8.4% increase (95% CI 2.8 to 14.4).

CONCLUSIONS

There is an association between pollen levels and asthma related emergencies, independent of the effect of air pollutants. The marked relationship observed for Poaceae and Plantago pollens suggests their implication in the epidemic distribution of asthma during the period coinciding with their abrupt release into the environment.

Onset of allergy and asthma symptoms in extra-European immigrants to Milan, Italy: possible role of environmental factors

BACKGROUND

Allergy and asthma are typical disorders of the affluent societies. Migrants from developing to industrialized countries seem to be at increased risk of allergy and asthma development.

OBJECTIVE

To evaluate time of onset, spectrum of sensitization and clinical features in a population of extra-European immigrants to Milan, Italy, complaining of allergy and asthma symptoms.

METHODS

Data regarding 243 extra-European immigrants checked at an allergy clinic from 1994 to 2000 were collected retrospectively. The demographic data were compared with those of the extra-European immigrants living in Milan at the end of 1999.

RESULTS

The patients were complaining of asthma (63.7%), rhinoconjunctivitis (56.7%), rhinitis alone (21%) or urticaria (3%). One hundred and eighty-seven out of 222 patients (84.3%) declared they were healthy before migrating and allergy/asthma symptoms started to appear after their arrival in Italy, namely after an average period of 4 years and 7 months. The proportion of male patients was lower than the proportion of men in the extra-European immigrant population (48% vs. 55%), suggesting that in adult immigrants allergy and asthma are more common in women than in men. Furthermore, there was an over-representation of Central-South Americans attending the clinic, which seemed to be due to a genetic predisposition to allergy/asthma development. When data were analysed for single countries, a trend towards an increased risk of allergy and asthma was found in immigrants from all Central-South American countries. A skin test positivity for at least one inhalant allergen was found in 196 out of 232 patients (81%), and the spectrum of allergic sensitization was similar to that of the Italian population living in the North of Italy.

CONCLUSION

Most extra-European immigrants declared that they were healthy at home and that allergy and asthma symptoms had appeared after immigration to Milan; lifestyle and environmental factors in a western industrialized city seem indeed to facilitate allergy/asthma onset in immigrants from developing countries. Allergy/asthma risk seems to be different in different ethnic groups.

National survey on the management of rhinopathies in asthma patients by French pulmonologists in everyday practice

BACKGROUND

Epidemiological and pathophysiologic studies have shown that allergic rhinitis and asthma often occur in combination. The internationally developed ARIA position paper (Allergic Rhinitis and its Impact on Asthma) recently offered recommendations on allergic rhinitis. As part of this new report and prior to its diffusion, we investigated the management of rhinopathies in asthma patients by pulmonologists in their everyday practice.

METHODS

From March to June 2000, 477 (48%) French pulmonologists in office-based practice participated in the survey. They were asked to include their first five asthmatic adult patients. In addition to descriptive statistics, univariate and multivariate analyzes were performed.

RESULTS

We studied 1623 patients with varying severity of asthma (sex ratio 0.9; median age 35 years). The pulmonologists reported rhinopathy in 76.6% of these, with a chronic course in 91%. Among the patients, 67.1% reported rhinopathy. The diagnosis was allergic rhinitis in 66.2% of participants and nasal polyposis in 10.1%. Examination of the nasal cavities was performed by the pulmonologists themselves in 56.2% of patients. Imaging of the sinuses was performed radiographically in 55.3% of enrolled patients and/or by computed tomography in 17.2%. Referral to an ENT specialist occurred for 21.6% of patients, being more common for patients with rhinitis that failed to respond to medical therapy (although some pulmonologists referred their patients routinely).

CONCLUSIONS

The high prevalence of rhinopathies in asthma patients requires that these conditions are recognized and managed by pulmonologists. Thus, our findings support one of the central messages contained in the new ARIA guidelines-asthma patients should be investigated routinely for rhinitis and other rhinopathies.

Rhinitis is associated with increased systolic blood pressure in men: a population-based study

An association between impaired lower respiratory function and cardiovascular risk factors, such as hypertension, is often reported but it is unknown whether there is a relationship between upper airway disorders and cardiovascular risk factors, despite evidence that upper and lower respiratory tract disorders are closely linked. Our objective was to assess whether rhinitis is associated with arterial blood pressure and hypertension. In a population-based study of 330 adults aged 28-56 years, as part of the European Community Respiratory Health Survey, rhinitis was assessed by means of a questionnaire, and cardiovascular data were obtained using a questionnaire and by measuring blood pressure. Systolic blood pressure (SBP) was higher in men with rhinitis than in men without rhinitis (130.6 +/- 12.7 mm Hg versus 123.5 +/- 13.9 mm Hg; p = 0.002), and it was still the case after adjustment for cardiovascular and respiratory confounding factors. Hypertension was more frequent in men with rhinitis than in men without rhinitis, even after multivariate adjustment (odds ratio = 2.6, 95% confidence interval = [1.14-5.91]). The observation of SBP levels according to whether men have no rhinitis, seasonal rhinitis, or perennial rhinitis was compatible with a dose-response relationship (p for trend = 0.02). In conclusion, rhinitis is strongly associated with SBP and hypertension in men. Blood pressure should be regularly checked in men with rhinitis.

The relationships between atopy, rhinitis and asthma: pathophysiological considerations

PURPOSE OF REVIEW

A close relationship has been described between atopy, allergic rhinitis and asthma. The purpose of this work was to review recent data that have become available on the interactions between these conditions and the ways in which they influence one another.

RECENT FINDINGS

Recent findings support previous observations suggesting that atopic dermatitis and rhinitis often accompany or precede the development of asthma. Further data support the notion that early-life exposure to domestic animals, a farming environment, passive smoking, and being raised in a large family, may be protective against the development of atopy and/or allergic diseases, although this seems modulated by genetic factors. Furthermore, the appearance of house-dust-mite-specific immunoglobulin E antibodies in early childhood has been identified as a major risk factor for the development of asthma in children with atopic dermatitis; and the association between sensitization to specific allergens and airway hyperresponsiveness was reported to be the strongest for indoor allergens such as house-dust-mite and cat. Allergen exposure can increase airway responsiveness in non-asthmatic subjects with allergic rhinitis and is associated with an increase in markers of lower airway inflammation, particularly with indoor allergens. Furthermore, nasal allergen provocation can induce bronchial inflammation and vice versa, suggesting close interrelations between upper and lower airways.

SUMMARY

In summary, the recent observations on the relationships between atopy, rhinitis and asthma support the hypothesis of a unique systemic condition with variable manifestations, which may develop following an imbalance between T helper cell types 1 and 2 lymphocyte populations. The latter may be influenced by environmental exposure in early life. Upper- and lower-airway inflammatory events influence each other, supporting the concept of 'united airways'. Further studies should look at the relationships between these conditions to identify individuals at high-risk of developing them and develop strategies to possibly prevent their onset.

Responses to bronchial challenge submitted for approval to use inhaled beta2-agonists before an event at the 2002 Winter Olympics

BACKGROUND

There has been an increase in the number and percentage of athletes competing in Olympic Games notifying use of beta2-agonists, from 1.7% at Los Angeles (1984) to 5.5% at Sydney (2000). For Salt Lake City (2002), the International Olympic Committee requested objective evidence to use beta2-agonists for asthma or exercise-induced asthma (EIA).

OBJECTIVE

The objective of this study was to evaluate the evidence submitted for approval to use a beta2-agonist.

METHODS

Objective evidence for asthma or EIA included (1) an increase of 12% or more of the predicted FEV1 in response to bronchodilator, (2) a reduction in FEV1 of 10% or greater from baseline in response to exercise or eucapnic voluntary hyperpnea, (3) a PD20 FEV1 to methacholine or histamine at a dose of less than 200 microg (2 mg/mL) or less than 1320 microg (13.2 mg/mL) for those taking inhaled corticosteroids for 3 months.

RESULTS

There were 165 applications. Of these, 147 (89%) included evidence of a challenge, bronchodilator response, or both, and 163 test results were submitted. One hundred thirty (5.2%) applications were approved. For those with positive responses, the median value (1) was 16.2% of predicted FEV1 for response to a bronchodilator (n = 13), (2) was a 15.9% decrease in FEV1 for response to a physical challenge (n = 36), and, (3) for PD20 FEV1, was 173 microg for response to a pharmacologic challenge (n = 45).

CONCLUSION

The analysis demonstrated that it is feasible to request objective evidence to justify use of beta2-agonists on the medical grounds of asthma or EIA.

Inhaled long acting beta agonists for stable chronic asthma

BACKGROUND

Asthma is a common respiratory disease among both adults and children and short acting inhaled beta-2 agonists are used widely for 'reliever' bronchodilator therapy. Long acting beta-2 agonists were introduced as prospective 'symptom controllers' in addition to inhaled corticosteroid 'preventer' therapy (ICS).

OBJECTIVES

This review aimed to determine the benefit or detriment on the primary outcome of asthma control with the regular use of long acting inhaled beta-2 agonists compared with placebo.

SEARCH STRATEGY

We carried out searches using the Cochrane Airways Group trial register, most recently in October 2002. We searched bibliographies of identified RCTs for additional relevant RCTs and contacted authors of identified RCTs for other published and unpublished studies.

SELECTION CRITERIA

All randomised studies of at least two weeks duration, comparing a long acting inhaled beta-agonist given twice daily with a placebo, in chronic asthma.

DATA COLLECTION AND ANALYSIS

Two reviewers performed data extraction and study quality assessment independently. We contacted authors of studies for missing data.

MAIN RESULTS

Eighty five studies met the inclusion criteria, 56 parallel group and 29 cross over design. Salmeterol xinafoate was used as long acting agent in 60 studies and formoterol fumarate in 25. The treatment period was two to four weeks in 32 studies, and 12 to 52 weeks in 53 studies. 34 study groups used concurrent inhaled corticosteroid treatment, 21 studies did not permit their use and 35 permitted either inhaled corticosteroid or cromones. There were significant advantages to long acting beta-2 agonist treatment compared to placebo for a variety of measurements of airway calibre including morning peak expiratory flow (PEF) (weighted mean difference (WMD) 26.78 L/min 95%CI 20.36 to 33.20), evening PEF (WMD 19.17 L/min 95%CI 11.63 to 26.73). They were associated with significantly fewer symptoms, less use of rescue medication and higher quality of life scores. The risk of exacerbation was lower in adults using regular inhaled corticosteroids.

REVIEWER'S CONCLUSIONS

Long acting beta-2 agonists are effective in the control of chronic asthma, and the evidence supports their use in addition to inhaled corticosteroids, as emphasised in current guidelines. Further research is needed on their use in children under 12 and in mild asthmatics not taking ICS.

Allergic rhinitis and asthma: the link further unraveled

Allergic asthma and rhinitis are manifestations of the atopic syndrome. Although the diseases commonly occur together, it is still unclear why some allergic patients develop only asthma and others only rhinitis. The reason for the variety in clinical expression of allergic airway disease is not known. Besides a genetic predisposition, environmental factors contribute to the development of the allergic phenotype. Local and systemic inflammatory processes also seem to be involved, however, their exact contribution to the clinical picture of airway allergy still remains to be elucidated. Although it is clear that the condition of the upper airways has an impact on lower airway physiology, the mechanisms underlying this relation are far from being resolved. To date, most data point towards a systemic link between upper and lower airways, involving bloodstream and bone marrow. In this article, the latest developments with regard to nasobronchial interaction in allergic airway disease will be reviewed. Epidemiologic, experimental and clinical data underline the importance of a global approach in allergic rhinitis and asthma.

Relation of bronchial responsiveness to body mass index in the ECRHS. European Community Respiratory Health Survey

BACKGROUND

There is substantial evidence for an association between symptoms of asthma and overweight or obesity. However, a study that reported no association between bronchial responsiveness (BHR) and body mass index (BMI) suggested that the relation of symptoms to obesity was due to increased diagnosis of asthma. The relation of BHR to BMI was therefore investigated in a large multicentre study.

METHODS

Data were obtained for 11,277 participants in stage II of the European Community Respiratory Health Survey (ECRHS). BHR to methacholine was analysed in relation to BMI adjusted for a number of factors known to be associated with BHR, including baseline lung function and allergen sensitisation, and combined across 34 centres using random effects meta-analysis.

RESULTS

BHR increased with increasing BMI in men (ECRHS slope changed by -0.027 for each unit increase in BMI, 95% confidence interval -0.044 to -0.010, p=0.002), but the relation in women was weak (-0.014, 95% CI -0.033 to 0.005, p=0.14). There was no evidence for an interaction of sex with BMI (p=0.41).

CONCLUSIONS

BHR is related to BMI in the ECRHS. This suggests that the association is not due to greater diagnosis or perception of symptoms in obese people compared with those of normal weight. The data do not support the finding by some studies of a relation between asthma and obesity in women but not in men.

Relationship between total and allergen-specific IgE serum levels and presence of symptoms in farm workers sensitized to Tetranychus urticae

BACKGROUND

Clinical complaints in atopic subjects with asthma and rhinitis occur more frequently in the presence of high total and allergen-specific IgE serum levels. Here we report on the relationship between total and allergen-specific IgE serum levels and presence of symptoms in an unselected farmer population sensitized to Tetranychus urticae (TU).

METHODS

Farmers were recruited as previously described. Total IgE and allergen-specific IgE were measured by immunoassay in TU-positive skin prick test (SPT) farmers (n = 58) and two control groups including Dermatophagoides pteronyssinus (Dp)-positive SPT subjects (n = 40) and non-atopic, TU-negative SPT healthy farmers (n = 25).

RESULTS

Both TU+ and Dp+ subjects had significantly higher total IgE values (P < 0.001) than healthy non-atopic subjects. TU-specific IgE levels were significantly more elevated in symptomatic than non-symptomatic TU+ subjects (P = 0.028). Dp-specific IgE levels were higher in symptomatic than non-symptomatic Dp+ subjects (P = 0.003). Finally, total IgE levels were significantly higher in the symptomatic than non-symptomatic subgroups in both TU+ and Dp+ subjects (P < 0.0001 and P = 0.007, respectively). Logistic regression analysis showed that only total IgE concentrations were significant predictors of current symptoms in TU+ subjects.

CONCLUSIONS

High total IgE and allergen-specific IgE levels are associated with symptoms in TU+ subjects. Definition of their predictive value requires further studies.

Sensitisation to airborne moulds and severity of asthma: cross sectional study from European Community respiratory health survey

OBJECTIVE

To assess whether the severity of asthma is associated with sensitisation to airborne moulds rather than to other seasonal or perennial allergens.

DESIGN

Multicentre epidemiological survey in 30 centres.

SETTING

European Community respiratory health survey.

PARTICIPANTS

1132 adults aged 20-44 years with current asthma and with skin prick test results.

MAIN OUTCOME MEASURES

Severity of asthma according to score based on forced expiratory volume in one second, number of asthma attacks, hospital admissions for breathing problems, and use of corticosteroids in past 12 months.

RESULTS

The frequency of sensitisation to moulds (Alternaria alternata or Cladosporium herbarum, or both) increased significantly with increasing asthma severity (odds ratio 2.34 (95% confidence interval 1.56 to 3.52) for either for severe v mild asthma). This association existed in all of the study areas (gathered into regions), although there were differences in the frequency of sensitisation. There was no association between asthma severity and sensitisation to pollens or cats. Sensitisation to Dermatophagoides pteronyssinus was also positively associated with severity. In multivariable logistic regressions including sensitisation to moulds, pollens, D pteronyssinus, and cats simultaneously, the odds ratios for sensitisation to moulds were 1.48 (0.97 to 2.26) for moderate v mild asthma and 2.16 (1.37 to 3.35) for severe v mild asthma (P<0.001 for trend).

CONCLUSIONS

Sensitisation to moulds is a powerful risk factor for severe asthma in adults. This should be taken into account in primary prevention, management, and patients' education.

Housing characteristics, reported mold exposure, and asthma in the European Community Respiratory Health Survey

BACKGROUND

The effects of home dampness and mold exposure on adult asthma are not clear.

OBJECTIVE

We aimed to investigate the associations between housing characteristics related to dampness, mold exposure, and house dust mite levels and adult asthma in 38 study centers from the European Community Respiratory Health Survey.

METHODS

Data about the present home, heating and ventilation systems, double glazing, floor covers, recent water damage, and mold exposure were obtained by means of an interviewer-led questionnaire. The associations between these factors and asthma, as defined on the basis of symptoms in the last year, and of bronchial responsiveness, as determined with methacholine challenge, were evaluated. Odds ratios (ORs) were obtained by using random-effects meta-analyses adjusted within study centers for sex, age group, and smoking status.

RESULTS

Fitted carpets and rugs in the bedroom were related to fewer asthma symptoms and bronchial responsiveness (OR range, 0.69-0.91). This effect was consistent across centers and more pronounced among house dust mite-sensitized individuals. Reported mold exposure in the last year was associated with asthma symptoms and bronchial responsiveness (OR range, 1.14-1.44). This effect was homogeneous among centers and stronger in subjects sensitized to Cladosporium species. In centers with a higher prevalence of asthma, the prevalence of reported indoor mold exposure was also high. This association was observed for reported mold exposure by asthmatic subjects (Spearman r (s) = 0.46), as well as reported mold exposure by nonasthmatic subjects (r (s) = 0.54). Reported mold exposure was highest in older houses with recent water damage.

CONCLUSION

We conclude that indoor mold growth has an adverse effect on adult asthma.

Serum eosinophil cationic protein (S-ECP) in a population with low prevalence of atopy

The study is a part of the European Community Respiratory Health Survey. A random sample (n = 351) of 20-44-year olds and persons of the same age with asthma-like symptoms or current asthma medication according to a postal questionnaire (n = 95) were studied. Interview was taken, methacholine challenge was done and ECP, total and specific IgE were measured from serum. The median S-ECP value was 8.0 micrograms/l in the random sample. The geometric mean of S-ECP was higher in subjects with, than without atopy (10.2 vs 8.9 micrograms/l, P < 0.01) and in subjects with bronchial hyperresponsiveness (BHR) than in subjects without BHR (9.9 vs 8.0 micrograms/l, P < 0.01). The levels correlated weakly to forced expiratory volume in one second (FEV1) (r = 0.13, P < 0.01) and were not independently correlated with respiratory symptoms, asthma or FEV1 after adjusting for BHR, IgE, sensitisation and smoking. Our results indicate that the level of eosinophil activation is low in a population with a low prevalence of atopy, even when BHR is common.

Regular treatment with long acting beta agonists versus daily regular treatment with short acting beta agonists in adults and children with stable asthma

BACKGROUND

Selective beta-adrenergic agonists for use in asthma are: short acting (2-6 hours) and long acting (>12 hours). There has been little controversy about using short acting beta-agonists intermittently, but long acting beta-agonists are used regularly, and their regular use has been controversial.

OBJECTIVES

To determine the benefit or detriment of treatment with regular short- or long acting inhaled beta-agonists in chronic asthma.

SEARCH STRATEGY

A search was carried out using the Cochrane Airways Group register. Bibliographies of identified RCTs were searched for additional relevant RCTs. Authors of identified RCTs were contacted for other published and unpublished studies.

SELECTION CRITERIA

All randomised studies of at least two weeks duration, comparing a long acting inhaled beta-agonist given twice daily with any short acting inhaled beta-agonist of equivalent bronchodilator effectiveness given regularly in chronic asthma.

DATA COLLECTION AND ANALYSIS

Two reviewers performed data extraction and study quality assessment independently. Authors of studies were contacted for missing data.

MAIN RESULTS

31 studies met the inclusion criteria, 24 of parallel group and 7 cross over design. Salmeterol xinafoate was used as long acting agent in 22 studies and formoterol fumarate in 9. Salbutamol was the short acting agent used in 27 studies and terbutaline in 5. The treatment period was over 2 weeks in 29 studies, and at least 12 weeks in 20. 25 studies permitted a variety of co-intervention treatments, usually inhaled corticosteroid or cromones. One study did not permit inhaled corticosteroid. Long acting beta-agonists were significantly better than short acting for a variety of lung function measurements including morning PEF (Weighted Mean Difference (WMD) 33 l/min 95% CI 25, 42) or evening PEF (WMD 26 l/min 95% CI 18, 33); and had significantly lower scores for day and night time asthma symptom scores and percentage of days and nights without symptoms. They were also associated with a significantly lower use of rescue medication both during the day and night. Risk of exacerbations was not different between the two types of agent, but most studies were of short duration which limits the power to test for such differences.

REVIEWER'S CONCLUSIONS

Long acting inhaled beta-agonists have advantages across a wide range of physiological and clinical outcomes for regular treatment.