A randomized clinical trial of peak flow versus symptom monitoring in older adults with asthma

Between-Visit Asthma Symptom Monitoring With a Scalable Digital Intervention: A Randomized Clinical Trial

Importance

Asthma affects an estimated 7.7% of the US population and 262 million people worldwide. Symptom monitoring has demonstrated benefits but has not achieved widespread use.

Objective

To assess the effect of a scalable asthma symptom monitoring intervention on asthma outcomes.

Design, Setting, and Participants

This randomized clinical trial was conducted between July 2020 and March 2023 at 7 primary care clinics affiliated with an academic medical center (Brigham and Women's Hospital in Boston, Massachusetts). Candidate patients with a diagnosis of asthma over a 20-month recruitment period (July 2020 to March 2022) were identified and categorized into tiers of varying disease activity based on electronic health record data. Eligible patients were adults (aged ≥18 years) and had a primary care practitioner in 1 of the 7 participating clinics.

Intervention

Intervention group patients were asked to use a mobile health app to complete weekly symptom questionnaires; track notes, peak flows, and triggers; and view educational information. Patients who reported worsening or severe symptoms were offered clinical callback requests. App data were available in the electronic health record. Usual care group patients received general asthma guidance.

Main Outcomes and Measures

The primary outcome was the mean change in Mini Asthma Quality of Life Questionnaire (MiniAQLQ) score for the intended 12-month study period. A change of 0.5 on a scale of 1 to 7 was considered a minimally important change. The secondary outcome was the mean number of asthma-related health care utilization events (urgent care visits, emergency department visits, or hospitalizations). Mean differences for all outcomes between groups were compared using robust linear regression models (generalized estimating equations) with treatment group as the only covariate.

Results

Baseline questionnaires were completed by 413 patients (mean [SD] age, 52.2 [15.4] years; 321 women [77.7%]). Of these, 366 patients completed final questionnaires and were included in the primary analysis. MiniAQLQ scores increased 0.34 (95% CI, 0.19-0.49) in the intervention group and 0.11 (95% CI, -0.11 to 0.33) in the usual care group from baseline to final questionnaire completion (adjusted difference-in-difference, 0.23 [95% CI, 0.06-0.40]; P = .01); although the difference was statistically significant, it did not reach the threshold for a minimally important change. Intervention subgroups showed positive differences in MiniAQLQ scores relative to the usual care group, with noteworthy increases among individuals aged 18 to 44 years (adjusted difference-in-difference, 0.40 [95% CI, 0.13-0.66]), those with low baseline patient activation (adjusted difference-in-difference, 0.77 [95% CI, 0.30-1.24]), those with a low baseline MiniAQLQ score (adjusted difference-in-difference, 0.33 [95% CI, 0.07-0.59]), and those with uncontrolled asthma at baseline (adjusted difference-in-difference, 0.30 [95% CI, 0.05-0.54]). The intervention group had a mean of 0.59 (95% CI, 0.42-0.77) nonroutine asthma-related utilization events compared with 0.76 (95% CI, 0.55-0.96) in the usual care group (adjusted effect size, -0.16 [95% CI, -0.42 to 0.17]; P = .23).

Conclusions and Relevance

In this randomized clinical trial of a scalable symptom monitoring intervention, the increase in asthma-related quality of life did not reach the threshold for a minimally important change. Exploratory analyses suggest possible benefits for patients with low levels of activation.

Trial Registration

ClinicalTrials.gov Identifier: NCT04401332.

Evaluation of a Primary Care-Integrated Mobile Health Intervention to Monitor between-Visit Asthma Symptoms

OBJECTIVES

 This study aimed to evaluate implementation of a digital remote symptom monitoring intervention that delivered weekly symptom questionnaires and included the option to receive nurse callbacks via a mobile app for asthma patients in primary care.

METHODS

 Research questions were structured by the NASSS (Nonadoption, Abandonment, Scale-up Spread, and Sustainability) framework. Quantitative and qualitative methods assessed scalability of the electronic health record (EHR)-integrated app intervention implemented in a 12-month randomized controlled trial. Data sources included patient asthma control questionnaires; app usage logs; EHRs; and interviews and discussions with patients, primary care providers (PCPs), and nurses.

RESULTS

 We included app usage data from 190 patients and interview data from 21 patients and several clinician participants. Among 190 patients, average questionnaire completion rate was 72.3% and retention was 78.9% (i.e., 150 patients continued to use the app at the end of the trial period). App use was lower among Hispanic and younger patients and those with fewer years of education. Of 1,185 nurse callback requests offered to patients. Thirty-three (2.8%) were requested. Of 84 PCP participants, 14 (16.7%) accessed the patient-reported data in the EHR. Analyses showed that the intervention was appropriate for all levels of asthma control; had no major technical barriers; was desirable and useful for patient treatment; involved achievable tasks for patients; required modest role changes for clinicians; and was a minimal burden on the organization.

CONCLUSION

 A clinically integrated symptom monitoring intervention has strong potential for sustained adoption. Inequitable adoption remains a concern. PCP use of patient-reported data during visits could improve intervention adoption but may not be required for patient benefits.

Domiciliary Fractional Exhaled Nitric Oxide and Spirometry in Monitoring Asthma Control and Exacerbations

BACKGROUND

Domiciliary measurements of airflow obstruction and inflammation may assist healthcare teams and patients in determining asthma control and facilitate self-management.

OBJECTIVE

To evaluate parameters derived from domiciliary spirometry and fractional exhaled nitric oxide (Feno) in monitoring asthma exacerbations and control.

METHODS

Patients with asthma were provided with hand-held spirometry and Feno devices in addition to their usual asthma care. Patients were instructed to perform twice-daily measurements for 1 month. Daily symptoms and medication change were reported through a mobile health system. The Asthma Control Questionnaire was completed at the end of the monitoring period.

RESULTS

One hundred patients had spirometry, of which 60 were given additional Feno devices. Compliance rates for twice-daily measurements were poor (median [interquartile range], 43% [25%-62%] for spirometry; 30% [3%-48%] for Feno); at least 15% of patients took little or no spirometry measurements and 40% rarely measured Feno. The coefficient of variation (CV) values in FEV1 and Feno were higher, and the mean % personal best FEV1 lower in those who had major exacerbations compared with those without (P < .05). Feno CV and FEV1 CV were associated with asthma exacerbation during the monitoring period (area under the receiver-operating characteristic curve, 0.79 and 0.74, respectively). Higher Feno CV also predicted poorer asthma control (area under the receiver-operating characteristic curve, 0.71) at the end of the monitoring period.

CONCLUSIONS

Compliance with domiciliary spirometry and Feno varied widely among patients even in the setting of a research study. However, despite significant missing data, Feno and FEV1 were associated with asthma exacerbations and control, making these measurements potentially clinically valuable if used.

Acceptance and Dropout Rates of Individuals with Asthma Approached in Self-management Interventions: A Systematic Review and Meta-analysis

Objective

The objectives of this systematic review were to assess the acceptability of self-management interventions for people with asthma and identify contributing factors.

Methods

A systematic literature search was conducted using PubMed, MEDLINE, EMBASE (OVIDWEB), CINAHL and Cochrane databases. Clinical trials design was included if they met specified criteria. A random-effect meta-regression analysis was conducted to estimate the overall acceptance and drop-out rates and to assess the potential factors that may influence the outcomes.

Results

A total of 64 studies were included and 8,092 participants were recruited and participated in the trials. The estimated acceptance rate was 51.1%, while the estimated drop-out rates in the intervention and control groups were 18.2% and 15.6%, respectively. Lack of interest was the main reported reason for refusing to participate and dropping out from the program. Study-related and program-related factors influenced the acceptance and drop-out rates statistically and clinically.

Conclusion

The acceptance rate of self-management programs among asthmatic people was not high and the dropout rate was somewhat low. The review suggests optimizing the design of self-management studies and modifying the implemented self-management programs to increase the acceptance rate and decrease the dropout rate.

Toward an asthma patient-reported outcome measure for use in digital remote monitoring

OBJECTIVE

To develop and test a patient-reported outcome measure (PROM) for suitability in digital remote asthma symptom monitoring to identify uncontrolled asthma.

METHODS

We modified a 5-item PROM that does not require a license, the asthma control measure (ACM), from a one-month to one-week lookback period, and evaluated it using the 5-item asthma control questionnaire (ACQ-5). We recruited subjects with asthma through MTurk, an online platform.

RESULTS

In a sample of 498 subjects, the ACM identified uncontrolled asthma with sensitivity 0.99 and specificity 0.65. The two measures correlated with r = 0.81.

CONCLUSION

The ACM modified to a weekly lookback period can differentiate patients with well-controlled asthma from those with uncontrolled asthma. This PROM does not require a license and can be used in digital remote monitoring interventions.

Usefulness of diurnal variation of fractional exhaled nitric oxide for predicting early therapeutic response to asthma treatment

OBJECTIVE

Fractional exhaled nitric oxide (FeNO) is considered to be an adjunct for asthma management, although its usefulness remains controversial. Therefore, it may be necessary for new approaches to use FeNO for asthma management. We evaluated whether diurnal variations of FeNO can predict response to asthma treatment.

METHODS

This pilot study consisted of 22 uncontrolled asthmatics and 16 healthy subjects. FeNO and peak expiratory flow (PEF) were measured by themselves twice daily at home for three weeks (asthmatics) or two weeks (healthy subjects), and daily mean and diurnal variations of FeNO and PEF levels were calculated. In uncontrolled asthmatics, treatment was intensified a week after study entry, and then control status was reevaluated after three to four weeks. Asthmatics were then divided into two groups; good or poor responders.

RESULTS

Diurnal variations of FeNO levels, as well as daily mean FeNO and PEF levels, in uncontrolled asthmatics before intensive treatment were significantly higher than those in healthy subjects, regardless of treatment response (p < 0.01). Furthermore, in the good responders, diurnal variations of FeNO levels were significantly decreased in the 1^st week (p < 0.05) of intensive treatment, whereas the daily mean FeNO levels significantly dropped in the 2^nd week (p < 0.05). In the poor responders, no such changes were observed in FeNO levels. In terms of PEF, only the daily mean levels were significantly elevated after the initiation of intensive treatment, regardless of treatment response.

CONCLUSIONS

Diurnal variations of FeNO may contribute to predicting early therapeutic response to asthma treatment.

Impact of pharmacist-led educational interventions on asthma control and adherence: single-blind, randomised clinical trial

Background Asthma is an important cause of morbidity and mortality worldwide. Education is a critical component in the management of asthma. Objective This study sought to assess the impact of pharmacist-led educational interventions on asthma control and adherence. Setting Tertiary Hospitals in Nigeria Method This was a single-blind, three-arm, prospective, randomised, controlled, parallel-group study conducted in the Respiratory Units of the University of Nigeria Teaching Hospital, Enugu State and the Lagos University Teaching Hospital, Lagos State between March 2016 and September 2017. The three arms were: Usual Care, Individual Intervention, Caregiver-assisted Intervention (1:1:1 ratio). The Intervention arms received education for 6 months while the Usual Care arm received no education. The Asthma Control Test and the 8-item Morisky Medication Adherence Scale were filled at baseline, 3 months, and 6 months after baseline. Data were analyzed using the IBM SPSS Version 25.0 with statistical significance set as P < 0.05. Main outcome measure Asthma control and adherence. Results Seventy-eight (78) asthma patients participated; thirty-nine (39) per hospital; thirteen (13) in each arm. The Individual Intervention arm possessed significantly better asthma control compared to Usual Care at 3 months (21.42 Vs. 18.85; P = 0.004, t = 3.124, df = 25, 95% confidence interval = 0.88 - 4.28) and 6 months (21.81 Vs. 19.58; P = 0.003, t = 3.259, df = 25, 95% confidence interval = 0.82 - 3.64). The Individual Intervention arm also possessed significantly better adherence compared to Usual Care at 3 months (6.81 Vs. 4.94; P = 0.001, t = 3.706, df = 25, 95% confidence interval = 0.83 - 2.90) and 6 months (7.28 Vs. 5.13; P < 0.001, t = 4.094, df = 25, 95% confidence interval = 1.07 -3.24). The Caregiver-assisted Interventions had no significant improvement in asthma control and adherence. Conclusion The individualized educational interventions produced better improvements in asthma control and adherence.

Retrospective analysis of the effect of inhaler education on improvements in inhaler usage

INTRODUCTION

Various types of inhalation devices have been released, and it is necessary to acquire the skills for using each of them. The factors that have been previously associated with poor inhalator usage include gender, duration of disease, age, and the type of device. However, it is unclear whether these factors also apply to the Japanese population. The number of education sessions needed to acquire inhaler usage skills is also not established.

PATIENTS AND METHODS

We performed a retrospective review of the medical records of selected patients and their subjective assessments of their inhaler usage skills between January 2016 and March 2018. The primary outcome was the effect of inhaler education for each inhaler device. The secondary outcomes were the factors affecting the effectiveness of inhaler education, the effects of inhalation education stratified by age, and the number of inhaler education sessions needed to improve inhaler usage skills.

RESULTS

Data from 399 patients were analyzed. Age and the type of delivery device affected the mastery of inhaler usage skills. Approximately half of the patients had acquired inhaler usage skills during baseline evaluation. Approximately 90% of patients acquired inhalation usage skills after two education sessions, regardless of the type of inhalation device. Among the older patients, 35.0% had acquired inhaler usage skills during the baseline evaluation, and 86.8% acquired them after two education sessions.

CONCLUSIONS

Inhaler usage skills significantly improved, regardless of the device, after inhalation education, and this was also observed in elderly patients after two education sessions.

Living well with severe asthma

Living well with severe asthma can be challenging. People with severe asthma can be refractory to treatment, can experience poor symptom control and are at a heightened risk of death. Patients experience symptoms of shortness of breath, chest tightness, cough and wheeze. These symptoms influence many aspects of an individual's life, resulting in emotional, financial, functional and medication-related burdens that negatively impact quality of life. Quality of life is known to be influenced by individual levels of satisfaction that stem from real-life treatment experiences. This experience is portrayed through the lens of the patient, which is commonly referred to as the patient perspective. The patient perspective is only one element of the patient experience. It influences health status, which, in severe asthma, is commonly assessed using validated health-related quality of life measures. A positive patient perspective may be achieved with implementation of management strategies tailored to individual needs. Management strategies developed in partnership between the patient, the severe asthma multidisciplinary team and the general practitioner may minimise disease-related impairment, allowing patients to live well with severe asthma.

Key points

Despite advances in treatment over the past decade, the experience of living with severe asthma has not significantly improved, with high levels of burden influencing the patient perspective.The impact of severe disease is not only restricted to asthma symptoms and acute attacks. It causes significant emotional, financial, functional and medication-related burdens, leading to impaired health-related quality of life.Clinical outcomes should not be stand-alone measures in severe asthma. Nonclinical measures should also be considered when evaluating health-related quality of life.Disease burden may be minimised and quality of life improved via self-management strategies, including education sessions, written asthma action plans, symptom monitoring, breathing exercises, physical activity and psychotherapeutic interventions.

Educational aims

To demonstrate the importance of the patient perspective in severe asthma.To identify the significant levels of disease burden associated with severe asthma.To discuss quality of life in severe asthma.To outline strategies that increase well-being in severe asthma.

Asthma in the older adult

Objective: The older adult population is increasing worldwide, and a significant percentage has asthma. This review will discuss the challenges to diagnosis and management of asthma in older adults. Data Sources: PubMed was searched for multiple terms in various combinations, including asthma, older adult, elderly, comorbid conditions, asthma diagnosis, asthma treatment, biologics and medication side effects, and adverse events. From the search, the data sources that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Study Selections: Study selections that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Results: Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital. Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting β-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Conclusions: The diagnosis and management of asthma in older adults has certain challenges, but if the clinician is aware of them, the morbidity and mortality of this condition can be improved in this growing population.

Inhaler Technique Education and Exacerbation Risk in Older Adults with Asthma or Chronic Obstructive Pulmonary Disease: A Meta-Analysis

OBJECTIVES

To evaluate the effect of inhaler education programs on clinical outcomes and exacerbation rates in older adults with asthma or chronic obstructive pulmonary disease (COPD).

DESIGN

Systematic review and meta-analysis.

SETTING AND PARTICIPANTS

Older adults with asthma or COPD, either in primary or secondary health care and pharmacy setting.

MEASUREMENTS

We searched the Medline, Embase, and Central databases according to the main eligibility criteria for inclusion: systematic reviews, meta-analysis, clinical trials and quasi-experimental studies; participants aged 65 and older; education on inhaler technique and reporting of disease control and exacerbation rates. We used the Grading of Recommendations, Assessment, Development and Evaluations scale for quality assessment and used a random-effect model with Mantel-Haenszel adjustment to perform a meta-analysis.

RESULTS

We included 8 studies (4 randomized, 4 quasi-experimental) with a total of 1,812 participants. The most frequent type of intervention was physical demonstration of inhaler technique, training with placebo devices. Five studies showed significant reduction in exacerbation rates (pooled risk ratio=0.71, 95% confidence interval=0.59-0.86; p < .001), although effect on disease control and quality of life showed high discrepancy in the reported results, and all randomized studies revealed uncertainty in their risk of bias assessment.

CONCLUSION

All interventions seemed to improve inhaler performance and clinically relevant outcomes, but a placebo device could be the most effective. There is evidence that interventions reduce exacerbation risk in older adults, although to an overall moderate degree. J Am Geriatr Soc 67:57-66, 2019.

Peak expiratory flow in obese subjects in different positions

Objective: To analyze the peak expiratory flow (PEF) in obese subjects in standing (ST), seated (SE), supine (SU), prone (PR), and right and left lateral decubitus (RL and LL) positions. Methods: 36 obese volunteers, aged between 18 and 54 years, and nonsmokers, were evaluated by anthropometric data; spirometry; international physical activity questionnaire (IPAQ); and PEF in ST, SE, SU, PR, RL, and LL positions, randomly. Results: The mean age was 27.3 ± 7.4 years and BMI of 38.7 ± 3.2 kg/m²; IPAQ results: active (50%), irregularly active (25%), very active (16.7%), and sedentary (08.3%); spirometry results: FVC = 100.33%, FEV₁ = 92.83%, FEV₁/FVC ratio = 0.95, FEF_25-75% = 85.55%. The PEF (L/min) were within the normal range and there was no difference between the ST and SE (428.6 ± 100.9 and 430.0 ± 100.1). Comparing ST and SE to the other positions, in absolute and percent of predicted values (L/min and %), there was a decrease in the SU (85.4 ± 14.9), PR (401.1 ± 92.4 and 84.1 ± 14.4), RL (398.6 ± 94.7 and 83.3 ± 14.9) (p < 0.05), and there was no difference to SU (409.4 ± 102.8) and LL (410.3 ± 93.9 and 85.8 ± 14.5). Conclusion: The PEF of healthy obese are similar in the standing and seated positions. The PEF decreases in the lying positions, except for the LL, that could be used as an alternative for measurements.

Risk factors and clinical outcomes associated with fixed airflow obstruction in older adults with asthma

BACKGROUND

Asthma in older adults is associated with increased morbidity and mortality compared with asthma in younger patients. Fixed airflow obstruction (FAO) is associated with decreased survival in younger patients, but its significance remains unclear in older adults with asthma.

OBJECTIVE

To identify risk factors and outcomes related to FAO in older adults with asthma.

METHODS

Subjects older than 55 years with a physician diagnosis of persistent asthma were evaluated. Collected data included participant demographic information, medications, asthma exacerbations, Asthma Control Test (ACT) score, Asthma Quality of Life (AQLQ) score, comorbidities, spirometry, atopic status, and fractional exhaled nitric oxide. Clinical characteristics and outcomes associated with FAO (defined as post-bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity ≤70%) were assessed.

RESULTS

A total of 186 participants were analyzed (48 men and 138 women, mean age 66 years). FAO was demonstrated in 30% of participants. Using regression analysis, predictors of FAO included advanced age, African American race, male sex, and longer duration of asthma. In outcomes analysis, FAO was associated with worsened ACT and AQLQ scores; however, after controlling for confounding factors, logistic regression showed no association. No significant association was found between FAO and exacerbations, fractional exhaled nitric oxide, atopy, rhinitis, education level, depression, smoking, or body mass index.

CONCLUSION

Risk factors associated with FAO in older adults with asthma include advanced age, African American race, increased asthma duration, and male sex. Unlike younger patients, FAO is not independently associated with worsened asthma control, quality of life, or exacerbations in older patients with asthma.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT01979055.

An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

Asthma in the Elderly

The older population has seen the greatest increase in the prevalence of current asthma in recent years. Asthma may begin at any age and when it occurs at an advanced as opposed to a young age, it is often nonatopic, severe, and unremitting. Unfortunately, geriatric-specific guidelines are not available for the diagnosis and treatment of asthma. However, with objective monitoring, avoidance of asthma triggers, appropriate pharmacotherapy, and patient education, the disease can be managed successfully.

The current state and provisions for elderly patients with asthma

Demographic statistics of Japan indicate that it is moving toward a super‐aging society and, accordingly, the ratio of elderly patients with asthma is also increasing. An important point in diagnosing elderly patients with asthma is that the onset of asthma in old age, along with a history of smoking, differentiation, and complications of chronic obstructive pulmonary disease must be considered. Primary care physicians must understand the characteristics of elderly patients when treating them. When conducting inhalation therapy in any asthmatic patient, especially elderly asthmatic patients, it is important to teach the patients proper technique and sustain medication adherence. We believe this effort will lead to an improvement in controlling asthma as well as a decrease in the number of asthma deaths.

The Saudi Initiative for Asthma - 2016 update: Guidelines for the diagnosis and management of asthma in adults and children

This is an updated guideline for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have guidelines that are up to date, simple to understand and easy to use by nonasthma specialists, including primary care and general practice physicians. SINA approach is mainly based on symptom control and assessment of risk as it is the ultimate goal of treatment. The new SINA guidelines include updates of acute and chronic asthma management, with more emphasis on the use of asthma control in the management of asthma in adults and children, inclusion of a new medication appendix, and keeping consistency on the management at different age groups. The section on asthma in children is rewritten and expanded where the approach is stratified based on the age. The guidelines are constructed based on the available evidence, local literature, and the current situation in Saudi Arabia. There is also an emphasis on patient-doctor partnership in the management that also includes a self-management plan.

Rationale and design of a comparative effectiveness trial of home- and clinic-based self-management support coaching for older adults with asthma

Older adults with asthma face numerous barriers to effective self-management and asthma control, and experience worse outcomes than younger asthmatics. Yet, there have been no controlled trials of interventions specifically designed to improve their care and outcomes. Through a multi-stakeholder collaboration (patients, academia, community-based organizations, a state department of health, and an advocacy organization) we developed a multi-component asthma self-management support intervention to address the myriad psychosocial, functional, health status, and cognitive barriers to effective asthma self-management in adults ages 60 and older. We are recruiting 425 New Yorkers in Manhattan and the Bronx for a pragmatic randomized controlled trial with 3 arms: the intervention delivered in primary care settings or in their home, or usual care. In the intervention, care coaches use a novel screening tool to identify the specific barriers to asthma control and self-management they experience. Once identified, the coach and patient choose from a menu of actions to address it. The intervention emphasizes efficiency, flexibility, shared decision making and goal setting, communication strategies appropriate for individuals with limited cognition and literacy skills, and ongoing reinforcement and support. Additionally, we introduced asthma-specific enhancements to the electronic health records of all participating clinical practices, including an asthma severity assessment, clinical decision support, and a patient-tailored asthma action plan. Patients will be followed for 12months and interviewed at baseline, 3, 6, and 12months and data on emergency department visits and hospitalizations will be obtained through the New York State Statewide Planning and Research Cooperative System.

Current clinical diagnostic tests for asthma

Asthma involves variable airflow obstruction in both large and small airways. The physiological consequences of obstruction include increased airway resistance and decreased expiratory flow rates, which lead to air trapping and dynamic hyperinflation. This chapter reviews current methods for pulmonary function testing to detect these physiological changes for both diagnosis and monitoring.

Educational intervention for older people with asthma: a randomised controlled trial

OBJECTIVES

To improve the asthma control and adherence to asthma preventer medication of older people using the Patient Asthma Concerns Tool (PACT) to identify and address unmet needs and patient concerns.

METHODS

Community dwelling adults over 55 years, living in Victoria or New South Wales were recruited into a single-blind, parallel design, randomised-controlled trial comparing person-centred education including device technique, versus written information-only education. Fifty-eight participants randomised to the intervention group and 56 to the control completed participation.

OUTCOME MEASURES

asthma control, adherence to preventer medication, asthma related quality of life, asthma exacerbations and written action plan ownership were assessed at baseline, and 3 and 12 months post intervention.

RESULTS

Intervention participants experienced improvements in asthma control, adherence to asthma preventer medication, reduced exacerbations, improved quality of life and an increase in asthma action plan ownership at 3 and 12 months.

CONCLUSION

Asthma outcomes in older people can be significantly improved by delivering tailored education that identifies specific patient concerns and unmet needs.

PRACTICAL IMPLICATIONS

Use of the PACT to identify patient concerns and unmet needs will assist health professionals to improve the health literacy of patients by addressing gaps in their knowledge and perceptions of asthma control.

Effects of feedback on the perception of inspiratory resistance in children with persistent asthma: a signal detection approach

OBJECTIVE

Accurate perception of asthma episodes increases the likelihood that they will be managed effectively. The purpose of the study was to examine the effect of feedback in a signal detection task on perception of increased airflow obstruction in children with persistent asthma.

METHODS

The effect of feedback training on the perception of resistive loads was evaluated in 155 children with persistent asthma between 8 and 15 years of age. Each child participated in four experimental sessions that occurred approximately once every 2 weeks, an initial session followed by three training sessions. During the initial session, the threshold resistance to breathing was determined for each child. Subsequently, each child was randomly assigned to one of two resistive load training conditions in a signal detection paradigm: training with immediate performance feedback or training with no performance feedback.

RESULTS

The threshold resistance to breathing, determined in the initial session, was equivalent between groups. Children in the feedback condition discriminated more accurately between both the presence and the absence of increases in the resistance to breathing (206 [48] versus 180 [39] correct responses, p < .001), and differences over time between groups increased reliably as a function of training (165 [40] versus 145 [32] correct responses, p < .001). Response times and confidence ratings were equivalent between groups, and no differences in breathing patterns were observed between conditions.

CONCLUSIONS

Feedback training results in improved perception of respiratory sensations in children with asthma, a finding with implications for strategies of asthma self-management.

Management of asthma in the elderly patient

A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.

A randomized controlled trial of a self-regulation intervention for older adults with asthma

OBJECTIVES

To evaluate a self-regulation intervention for asthma for older adults.

DESIGN

A blinded randomized controlled trial.

SETTING

Single-center tertiary care academic center.

PARTICIPANTS

Seventy older adults aged 65 and older with persistent asthma randomized to an intervention or control group.

INTERVENTION

Participants participate in a six-session program conducted over the telephone and in group sessions. Participants selected an asthma-specific goal, identified problems, and addressed potential barriers.

MEASUREMENTS

Outcomes were assessed at 1, 6, and 12 months and included the mini-Asthma Quality of Life Questionnaire (mAQLQ), Asthma Control Questionnaire (ACQ), healthcare utilization, exhaled nitric oxide (FENO), and percentage of predicted forced expiratory volume in 1 second (FEV1%).

RESULTS

The mAQLQ score was significantly higher in the intervention group at 1, 6, and 12 months, even after controlling for confounding factors. The between-group difference decreased over time, although at 12 months, it remained greater than 0.5 points. The ACQ was better in the intervention group than in the control group at 1, 6, and 12 months. At 12 months, those in the intervention group were 4.2 times as likely as those in the control group to have an ACQ score in the controlled range. Healthcare utilization was lower in the intervention group, although no difference was observed in FENO or predicted FEV1%.

CONCLUSION

A self-regulation intervention can improve asthma control, quality of life, and healthcare utilization in older adults.

Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults

BACKGROUND

Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. However, often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations.

OBJECTIVES

The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov web site up to October 2012.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1. Quality of the evidence was assessed using GRADE.

MAIN RESULTS

Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32; the large confidence interval translates into a risk of exacerbations in the intermittent ICS group varying between 17% and 25%, assuming a 19% risk with daily ICS). Age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β2-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV1), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment.

AUTHORS' CONCLUSIONS

In children and adults with persistent asthma and in preschool children suspected of persistent asthma, there was low quality evidence that intermittent and daily ICS strategies were similarly effective in the use of rescue oral corticosteroids and the rate of severe adverse health events. The strength of the evidence means that we cannot currently assume equivalence between the two options.. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. Clinicians should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.

Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults

BACKGROUND

Daily inhaled corticosteroids (ICS) are the recommended mainstay of treatment in children and adults with persistent asthma. Yet often, ICS are used intermittently by patients or recommended by physicians to be used only at the onset of exacerbations.

OBJECTIVES

The aim of this review was to compare the efficacy and safety of intermittent versus daily ICS in the management of children and adults with persistent asthma and preschool-aged children suspected of persistent asthma.

SEARCH METHODS

We searched the Cochrane Airways Group Specialised Register of trials (CAGR) and the ClinicalTrials.gov website up to December 2011.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) that compared intermittent ICS versus daily ICS in children and adults with persistent asthma. No co-interventions were permitted other than rescue relievers and oral corticosteroids used during exacerbations.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trials for inclusion, methodological quality and extracted data. The primary efficacy outcome was the number of patients with one or more exacerbations requiring oral corticosteroids and the primary safety outcome was the number of patients with serious adverse health events. Secondary outcomes included exacerbations, lung function tests, asthma control, adverse effects, withdrawal rates and inflammatory markers. Equivalence was assumed if the risk ratio (RR) estimate and its 95% confidence interval (CI) were between 0.9 and 1.1.

MAIN RESULTS

Six trials (including one trial testing two relevant protocols) met the inclusion criteria for a total of seven group comparisons. The four paediatric trials (two involving preschool children and two school-aged children) and two adult parallel-group trials, lasting 12 to 52 weeks, were of high methodological quality. A total of 1211 patients with confirmed, or suspected, persistent asthma contributed to the meta-analyses. There was no statistically significant group difference in the risk of patients experiencing one or more exacerbations requiring oral corticosteroids (1204 patients; RR 1.07; 95% CI 0.87 to 1.32). The patients' age, severity of airway obstruction, step-up protocol used during exacerbations and trial duration did not significantly influence the primary efficacy outcome. No group difference was observed in the risk of patients with serious adverse health events (1055 patients; RR 0.82; 95% CI 0.33 to 2.03). Compared to the daily ICS group, the intermittent ICS group displayed a smaller improvement in change from baseline peak expiratory flow rate (PEFR) by 2.56% (95% CI -4.49% to -0.63%), fewer symptom-free days (standardised mean difference (SMD) -0.15 (95% CI -0.28 to -0.03), fewer asthma control days -9% (95% CI -14% to -4%), more use of rescue β(2)-agonists by 0.12 puffs/day (95% CI 0 to 0.23) and a greater increase from baseline in exhaled nitric oxide of 16.80 parts per billion (95% CI 11.95 to 21.64). There was no significant group difference in forced expiratory volume in one second (FEV(1)), quality of life, airway hyper-reactivity, adverse effects, hospitalisations, emergency department visits or withdrawals. In paediatric trials, intermittent ICS (budesonide and beclomethasone) were associated with greater growth by 0.41 cm change from baseline (532 children; 95% CI 0.13 to 0.69) compared to daily treatment.

AUTHORS' CONCLUSIONS

In children and adults with persistent asthma and in preschool children suspected of persistent asthma, intermittent and daily ICS strategies did not significantly differ in the use of rescue oral corticosteroids and the rate of severe adverse health events, neither did they reach equivalence. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. The clinician should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.

The Saudi initiative for asthma - 2012 update: Guidelines for the diagnosis and management of asthma in adults and children

This an updated guidelines for the diagnosis and management of asthma, developed by the Saudi Initiative for Asthma (SINA) group, a subsidiary of the Saudi Thoracic Society. The main objective of SINA is to have updated guidelines, which are simple to understand and easy to use by non-asthma specialists, including primary care and general practice physicians. This new version includes updates of acute and chronic asthma management, with more emphasis on the use of Asthma Control Test in the management of asthma, and a new section on "difficult-to-treat asthma." Further, the section on asthma in children was re-written to cover different aspects in this age group. The SINA panel is a group of Saudi experts with well-respected academic backgrounds and experience in the field of asthma. The guidelines are formatted based on the available evidence, local literature, and the current situation in Saudi Arabia. There was an emphasis on patient-doctor partnership in the management that also includes a self-management plan. The approach adopted by the SINA group is mainly based on disease control as it is the ultimate goal of treatment.

Modifiable factors associated with severe asthma exacerbations in urban patients

BACKGROUND

Rates of asthma morbidity, mortality, and resource use are highest among African American individuals residing in inner-city locations, yet factors associated with adverse outcomes are not well established.

OBJECTIVE

To identify modifiable factors associated with asthma exacerbations.

METHODS

A total of 104 adult patients who presented to an inner-city hospital or emergency department (ED) with an asthma exacerbation from October 1, 2009, through June 31, 2010, completed surveys of clinical status, acute events, sociodemographic characteristics, current asthma knowledge, self-efficacy, attitudes toward asthma self-management, and perceived barriers to asthma care questionnaires. Associations with asthma hospitalizations and ED visits were assessed.

RESULTS

The mean age of the patients was 42 years, 91% were African American, 33% were insured, 57% were taking a controller medication, and 63% had an income level below the federal poverty line. On bivariate analysis, males, years of asthma, history of smoking, self-classification of asthma severity, history of admission to intensive care unit or intubation, use of peak flow meter or asthma action plan, controller medication use, and history of oral corticosteroid bursts were positively associated, whereas self-efficacy was negatively associated with number of ED visits or hospitalizations. No association was found for asthma knowledge, perceived barriers to care, or attitudes toward asthma management. On multivariate analysis, low self-efficacy remained associated with both asthma hospitalizations and ED visits.

CONCLUSION

Short-term use of health services for asthma is negatively associated with asthma self-efficacy. Self-management programs that enhance self-efficacy, rather than those that focus on knowledge or attitudes, may be effective in reducing adverse asthma outcomes for inner-city, predominantly African American populations.

Accuracy of the piko-1 pocket spirometer

BACKGROUND

Good asthma control is the main goal of long-term asthma treatment. According to the Global Initiative for Asthma (GINA) guidelines (www.ginasthma.com), medical professionals assess asthma control based on specific questions regarding asthma symptoms and by spirometry measuring forced expiratory volume in 1 second (FEV(1)). Patients trained in early self-detection of asthma exacerbations use a symptom-based questionnaire, such as the Asthma Control Test (ACT) [Nathan RA, Sorkness CA, Kosinski M, et al. Development of the Asthma Control Test. A survey for assessing asthma control. J Allergy Clin Immunol 2004; 113:59-64]. However, some patients may prefer harder indicators, like peak flow values, when considering how to act within their regular asthma self-management plan.

OBJECTIVES

Monitoring of FEV(1) at home could be an even more valuable alternative to recording peak flow values. The inexpensive handheld pocket spirometer "Piko-1®" offers the opportunity to monitor and store consecutive FEV(1) values. This study assesses the accuracy of the Piko-1 device.

METHODS

Twenty volunteers tested 20 Piko-1 devices over five consecutive days. All results were compared to daily FEV(1) values, as measured by a calibrated reference spirometer.

RESULTS

Overall, the accuracy was acceptable, although Piko-1 tended to underestimate FEV(1) in the lower range. Moreover, there was no evidence of major heterogeneity between Piko-1 devices.

CONCLUSION

The Piko-1 FEV(1) measurements are sufficiently accurate to start a clinical trial to compare the detection of asthma exacerbations with this device and based on asthma symptoms alone.

Asthma in the elderly: Current understanding and future research needs--a report of a National Institute on Aging (NIA) workshop

Asthma in the elderly is underdiagnosed and undertreated, and there is a paucity of knowledge on the subject. The National Institute on Aging convened this workshop to identify what is known and what gaps in knowledge remain and suggest research directions needed to improve the understanding and care of asthma in the elderly. Asthma presenting at an advanced age often has similar clinical and physiologic consequences as seen with younger patients, but comorbid illnesses and the psychosocial effects of aging might affect the diagnosis, clinical presentation, and care of asthma in this population. At least 2 phenotypes exist among elderly patients with asthma; those with longstanding asthma have more severe airflow limitation and less complete reversibility than those with late-onset asthma. Many challenges exist in the recognition and treatment of asthma in the elderly. Furthermore, the pathophysiologic mechanisms of asthma in the elderly are likely to be different from those seen in young asthmatic patients, and these differences might influence the clinical course and outcomes of asthma in this population.

Ten-year follow-up of early intensive self-management guidance in newly diagnosed patients with asthma

OBJECTIVE

We assessed the 10-year effectiveness of self-management guidance in a prospective follow-up study of patients with asthma when inhaled corticosteroids were used from the beginning in the treatment.

METHODS

Consecutive newly diagnosed asthmatics (n = 162) were randomized: 80 to an intervention group (IG) and 82 to a control group (CG). Lung function (LF), airway hyperresponsiveness (AHR), and health-related quality of life (HRQoL) were examined at 10 years.

RESULTS

The advantages of intensive education with regards to LF measured by forced expiratory volume in 1 second and forced vital capacity were seen only after the first year. Later, there were no statistically significant differences in any parameters between the groups. However, during 10-year follow-up, peak expiratory flow, AHR, and HRQoL improved significantly in both groups (no differences as regards gender, smoking, or atopy). At 10 years, 68% of the IG and 75% of the CG patients still showed AHR after histamine challenge. Generic HRQoL scores in both groups equaled that of the age-standardized group a general population but only 50% in the IG and 55% in the CG had normal disease-specific HRQoL scores. According to Global Initiative for Asthma (GINA) criteria 23% of patients in the IG and 25% in the CG had asthma under control.

CONCLUSIONS

The effectiveness of intensive self-management education could be shown only in the short term. The groups did not differ significantly in any of the parameters investigated, and showed nearly normal LF and HRQoL. AHR improved only partly and only a minority of the patients had asthma under good control according to GINA criteria. This study showed that evaluation of asthma using LF alone does not show the whole truth about asthma treatment results. HRQoL should be used in conjunction with GINA criteria, to assess asthma treatment outcomes. The value and importance of AHR for the evaluation of treatment remains obscure.

Asthma education for older adults: results from the National Asthma Survey

RATIONALE

Although asthma education is effective in younger population, it is unknown whether it is effective in older adults.

METHODS

Using the Four-State National Asthma Survey (NAS) data, asthma control was compared between older adults (≥65 years) who had been taught to use a peak flow meter (PFM) and asthma action plan (AAP) with those who had not. We also compared older adults who had taken an asthma course with those who had not. Both short-term (symptoms within last 1 week, day and night symptoms in last 30 days, and the use of steroid in last 3 months) and long-term (asthma attack, emergency department visit, hospitalizations, and activity limitations in the prior year) outcomes were compared.

RESULTS

Three hundred and ninety-eight older adults with asthma were identified. There were no differences in the short- and long-term asthma outcomes between the older adults who had or had not received instruction on PFM or AAP use. In preliminary analysis, those who took AC were more likely to have at least one poorly controlled long-term outcome measure (81 vs. 65%, p = 0.034). However, this difference did not remain significant in a logistic regression analysis.

CONCLUSIONS

Engagement in asthma education course, instruction on action plans, and instruction on PFM use does not appear to affect asthma outcomes in older adults. Education specifically tailored toward older adults is required for better asthma control.

Clinical pharmacist counseling improves outcomes for Taiwanese asthma patients

OBJECTIVE

To assess the impact of an asthma educational program provided by a nurse combined with asthma counseling provided by a pharmacist on asthma knowledge, quality of life and clinical outcomes in Taiwanese patients with asthma.

SETTING

All patients were recruited from Pulmonary Medicine outpatient clinic, the Tri-Service General Hospital, Taipei, Taiwan. Asthma education was given in three one-hour sessions offered during monthly clinic visits.

METHOD

A total of 91 asthma patients were randomly assigned to a nurse-administered education program (Group 1), the education program with additional pharmacist counseling (Group 2), or a control group receiving routine care only (control). Three questionnaires were used for assessment at months 0, 3 and 6. Outcomes were compared between groups to determine efficacy.

MAIN OUTCOME MEASURE

Asthma knowledge, health-related quality of life, and medication adherence were measured at baseline and 3 and 6 months after enrollment.

RESULTS

A total of 104 patients were enrolled; 91 completed the study. Knowledge scores of patients in Groups 1 and 2 increased significantly compared to control group. Both intervention groups showed significant increases in knowledge scores with longer follow-up. Group 2 showed a significant improvement in clinical symptoms between baseline (month 0) and month 6 (4.99 vs. 4.21, P=0.008). No significant differences in medication adherence were seen among groups.

CONCLUSION

Regular nurse-administered asthma education with additional pharmacist counseling improves asthma knowledge and clinical symptoms in asthma patients.

[Adult asthma exacerbations in questions]

In this article a French working party critically review the international literature to revise the definition, pathophysiology, treatment and cost of exacerbations of adult asthma. The various guidelines do not always provide a consistent definition of exacerbations of asthma. An exacerbation can be defined as deterioration of clinical and/or functional parameters lasting more than 24 hours, without return to baseline, requiring a change of treatment. No single clinical or functional criterion can be used as an early marker of an exacerbation. Innate and acquired immune mechanisms, modified by contact with infectious, irritant or allergenic agents, participate in the pathogenesis of exacerbations, which are accompanied by bronchial inflammation. In 2010, mortality is related to progression of exacerbations, often occurring before the patient seeks medical attention. The objective of treatment is to control asthma and prevent exacerbations. However, many factors can trigger exacerbations and often cannot be controlled. The efficacy of inhaled corticosteroids has been demonstrated on reduction of the number of exacerbations and the number of asthma-related deaths. This treatment is cost-effective, especially in terms of reduction of exacerbations.

Asthma in older adults

Asthma in older people is common and is characterised by underdiagnosis and undertreatment. Ageing is associated with unique issues that modify expression, recognition, and treatment of the disease. In particular, asthma and chronic obstructive pulmonary disease (COPD) both overlap and converge in older people. This concurrence, together with absence of precise diagnostic methods, makes diagnosis complex. A multidimensional assessment that addresses airway problems, comorbidities, risk factors, and management skills will draw attention to key needs for intervention. Increased attention to the complications of asthma and obstructive airway disease in older people is needed, specifically to develop effective systems of care, appropriate clinical practice guidelines, and a research agenda that delivers improved health outcomes.

Is the maintenance and reliever approach the answer?

OBJECTIVE

To examine the efficacy of the maintenance and reliever (M+R) approach in the treatment of asthma exacerbations.

DATA SOURCES

PubMed, MEDLINE, and Cochrane database searches using the key words formoterol and budesonide, dynamic dosing, adjustable dosing, and M+R therapy.

STUDY SELECTION

Articles were selected based on their relevance to the topic of this review.

RESULTS

Several studies have examined dynamic dosing of the long-acting beta-agonist formoterol combined with budesonide in the treatment of asthma. Most of these studies have shown reductions in asthma exacerbations. Although obvious concern arises regarding increase in dose of the long-acting beta-agonist component, no significant signal of morbidity or mortality has been seen. Potential concerns regarding the studies performed thus far include the fact that all have been sponsored by the pharmaceutical industry and have required beta-agonist response as an inclusion criterion.

CONCLUSIONS

Although many of the data regarding this approach are positive, not all the studies have demonstrated efficacy. It is hoped that future non-pharmaceutical company-sponsored research will clarify this issue and, should efficacy be confirmed, shed light on the mechanism of action.

Shared treatment decision making improves adherence and outcomes in poorly controlled asthma

RATIONALE

Poor adherence to asthma controller medications results in poor treatment outcomes.

OBJECTIVES

To compare controller medication adherence and clinical outcomes in 612 adults with poorly controlled asthma randomized to one of two different treatment decision-making models or to usual care.

METHODS

In shared decision making (SDM), nonphysician clinicians and patients negotiated a treatment regimen that accommodated patient goals and preferences. In clinician decision making, treatment was prescribed without specifically eliciting patient goals/preferences. The otherwise identical intervention protocols both provided asthma education and involved two in-person and three brief phone encounters.

MEASUREMENTS AND MAIN RESULTS

Refill adherence was measured using continuous medication acquisition (CMA) indices-the total days' supply acquired per year divided by 365 days. Cumulative controller medication dose was measured in beclomethasone canister equivalents. In follow-up Year 1, compared with usual care, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.46; P < 0.0001) and long-acting beta-agonist adherence (CMA, 0.51 vs. 0.40; P = 0.0225); higher cumulative controller medication dose (canister equivalent, 10.9 vs. 5.2; P < 0.0001); significantly better clinical outcomes (asthma-related quality of life, health care use, rescue medication use, asthma control, and lung function). In Year 2, compared with usual care, SDM resulted in significantly lower rescue medication use, the sole clinical outcome available for that year. Compared with clinician decision making, SDM resulted in: significantly better controller adherence (CMA, 0.67 vs. 0.59; P = 0.03) and long-acting beta-agonist adherence (CMA, 0.51 vs. 0.41; P = 0.0143); higher cumulative controller dose (CMA, 10.9 vs. 9.1; P = 0.005); and quantitatively, but not significantly, better outcomes on all clinical measures.

CONCLUSIONS

Negotiating patients' treatment decisions significantly improves adherence to asthma pharmacotherapy and clinical outcomes. Clinical trials registered with www.clinicaltrials.gov (NCT00217945 and NCT00149526).

The Saudi Initiative for Asthma

The Saudi Initiative for Asthma (SINA) provides up-to-date guidelines for healthcare workers managing patients with asthma. SINA was developed by a panel of Saudi experts with respectable academic backgrounds and long-standing experience in the field. SINA is founded on the latest available evidence, local literature, and knowledge of the current setting in Saudi Arabia. Emphasis is placed on understanding the epidemiology, pathophysiology, medications, and clinical presentation. SINA elaborates on the development of patient-doctor partnership, self-management, and control of precipitating factors. Approaches to asthma treatment in SINA are based on disease control by the utilization of Asthma Control Test for the initiation and adjustment of asthma treatment. This guideline is established for the treatment of asthma in both children and adults, with special attention to children 5 years and younger. It is expected that the implementation of these guidelines for treating asthma will lead to better asthma control and decrease patient utilization of the health care system.

Factors associated with asthma exacerbations during a long-term clinical trial of controller medications in children

BACKGROUND

Asthma exacerbations are a common cause of critical illness in children.

OBJECTIVE

To determine factors associated with exacerbations in children with persistent asthma.

METHODS

Regression modeling was used to identify historical, phenotypic, treatment, and time-dependent factors associated with the occurrence of exacerbations, defined by need for oral corticosteroids or emergency or hospital care in the 48-week Pediatric Asthma Controller Trial study. Children age 6 to 14 years with mild-to-moderate persistent asthma were randomized to receive either fluticasone propionate 100 microg twice daily (FP monotherapy), combination fluticasone 100 microg AM and salmeterol twice daily, or montelukast 5 mg once daily.

RESULTS

Of the 285 participants randomized, 48% had 231 exacerbations. Using a multivariate analysis, which included numerous demographic, pulmonary, and inflammatory parameters, only a history of an asthma exacerbation requiring a systemic corticosteroid in the past year (odds ratio [OR], 2.10; P < .001) was associated with a subsequent exacerbation during the trial. During the trial, treatment with montelukast versus FP monotherapy (OR, 2.00; P = .005), season (spring, fall, or winter vs summer; P < or = .001), and average seasonal 5% reduction in AM peak expiratory flow (OR, 1.21; P = .01) were each associated with exacerbations. Changes in worsening of symptoms, beta-agonist use, and low peak expiratory flow track together before an exacerbation, but have poor positive predictive value of exacerbation.

CONCLUSION

Children with mild-to-moderate persistent asthma with previous exacerbations are more likely to have a repeat exacerbation despite controller treatment. Inhaled corticosteroids are superior to montelukast at modifying the exacerbation risk. Available physiologic measures and biomarkers and diary card tracking are not reliable predictors of asthma exacerbations.

The effectiveness of nurse-led telemonitoring of asthma: results of a randomized controlled trial

RATIONALE, AIMS AND OBJECTIVES

The aim of the study was to evaluate the effects on, and the relationship between, asthma symptoms, asthma-specific quality of life and medical consumption of a nurse-led telemonitoring intervention compared with regular care in asthma in the Netherlands.

METHODS

One hundred and nine asthmatic outpatients (56 children; 53 adults) were randomly assigned to the treatment arms (12-month follow-up). The control group received regular outpatient care, while the intervention group used an asthma monitor with modem at home with an asthma nurse as the main caregiver. Clinical asthma symptoms and medical consumption were measured by using diaries. Asthma-specific quality of life was measured by the (Paediatric) Asthma Quality of Life Questionnaire.

RESULTS

The study population generally represented mild to moderate asthmatics. The results show improvement in follow-up, but no statistically significant difference between the groups was observed. Moderate to high correlations were found within the outcome parameters, but the most remarkable was the low and statistically significant correlation between asthma-specific quality of life (daily functioning) and the self-reported beta-2 agonists.

CONCLUSION

Overall, the telemonitoring programme evaluated in this study did not significantly decrease asthma symptoms or medical consumption, or improve asthma-specific quality of life. The results showed that a telemonitoring programme on its own is not a guarantee of success. The patients' perception of asthma-specific quality of life (daily functioning) should be a key element in asthma telemonitoring programmes.

Outcomes of a home-based environmental remediation for urban children with asthma

CONTEXT

Increasing urban asthma prevalence and severity is found among minority, underserved populations. Improving asthma self-management includes home management of complex medical protocols as well as environmental trigger removal.

OBJECTIVE

To study the effectiveness of a low-cost approach to improve control of asthma symptoms in an urban population through lay educators who promote a generalized approach to asthma trigger avoidance in the bedrooms of children with asthma.

DESIGN AND PATIENTS

Prospective, randomized controlled trial with two arms: historical controls and matched controls for each subject.

SUBJECTS

Two-hundred-eighty-one patients living in an urban environment, randomized to receive home visits only (n = 128) or home visits with environmental remediation (n = 153). One-hundred-fifteen controls matched according to age, gender and ethnicity did not receive any intervention.

INTERVENTIONS

In-home education visits covered asthma physiology, asthma trigger avoidance and asthma management. Environmental remediation was conducted together with the caregiver.

OUTCOMES

Primary outcomes include length of hospital stay, number of emergency visits and number of sick visits. Secondary outcomes are symptom frequency, medication management and trigger reduction.

RESULTS

Both intervention groups experienced reduction of hospitalizations, emergency room visits, sick visits and asthma symptoms. Both groups showed outcomes significantly superior to the matched control group. Intervention effectively reduced the presence of rodents and carpet in home and increased the use of mattress and pillow covers.

CONCLUSIONS

This study shows that low-cost in-home education and environmental remediation improve outcomes for children with asthma. Lay educators can deliver effective asthma-specific education that results in improved asthma control.

Asthma in older adults

Asthma is underdiagnosed and undertreated in older adults. The classic symptoms, including episodic wheezing, shortness of breath, and chest tightness, are nonspecific in this age group. Older patients may underrate symptoms, and other diseases, such as chronic obstructive pulmonary disease, congestive heart failure, and angina, may have similar presentations. Objective measurements of lung function always should complement the history taking and physical examination. Management of asthma in older adults should include careful monitoring, controlling triggers, optimizing and monitoring pharmacotherapy, and providing appropriate asthma education. Adverse effects to commonly used asthma medications are more common in older adults, and careful monitoring of their use and adverse effects is important.

[Lung function tests in refractory asthma]

Obstructive airway disorders and bronchial hyperreactivity are part of the definition of asthma. Lung function tests (LFT) are therefore essential in the diagnosis and follow-up of patients with asthma. Maximum forced expiratory volume in one second (FEV1) is the essential functional indicator of severity and reversibility, according to the Global Initiative for Asthma (Gina). FEV1 has some limitations: it is poorly correlated with dyspnea, symptom control, and lung distention. In severe asthma, FEV1 is the only functional indicator included in the diagnostic criteria. It is one minor criterion among 2 major and 7 minor criteria. Other indicators measured during standard LFT and new functional indicators not yet sufficiently validated should provide important supplementary information to help to characterize the different clinical phenotypes and the pathophysiologic mechanisms involved in refractory asthma.