Symptom perception in pediatric asthma: resistive loading and in vivo assessment compared

Understanding the effectiveness and design of parent-oriented mobile health interventions: a systematic review and narrative synthesis

BACKGROUND

Parents of children with a health condition experience high levels of distress which can have long-term impact on the child and parent. Dyadic interventions have the potential to decrease this distress, however several barriers to access including time constraints have been reported. Mobile health (mHealth) interventions can address several of these barriers.

GOAL

The goal of this systematic review was to review and synthesize the literature examining the effects of parent-oriented mHealth interventions and their content and design.

METHODS

We searched PubMed/MEDLINE, Embase, PsycINFO, CINAHL and Cochrane Central databases from January 2013 to 2023 using a search strategy based on telemedicine and parents/caregivers. Included studies were randomized controlled trials assessing the effect of parent-oriented mHealth interventions on child and parent health. The Cochrane risk-of-bias tool was used to assess for bias in studies. Trial details and design and content features of interventions were extracted. Outcomes were organized using the Van Houtven's Framework for Informal Caregiver Interventions. Results are presented narratively.

RESULTS

Fifty papers pertaining to 49 unique studies met our inclusion criteria. More than half of the studies scored high-risk for bias. Interventions targeted a wide range of pediatric conditions. Intervention type included texting (n = 17) and investigator-developed mobile applications (n = 16). Interventions significantly improved parent psychological health and child health outcomes. Key intervention features and design included the use/application of codesign and a theory-driven intervention.

CONCLUSION

Parent-oriented mHealth interventions identified in this review significantly improved both parent and child health outcomes. Therefore, these interventions have the potential to support parents outside of a clinical setting.

World Trade Center workers with asthma and post-traumatic stress disorder perceive airflow limitation more accurately

BACKGROUND

Post-traumatic stress disorder (PTSD) is a major risk factor for increased asthma morbidity among World Trade Center (WTC) workers.

OBJECTIVE

To investigate whether differences in perception of airflow limitation mediate the association of PTSD with worse asthma control in WTC workers.

METHODS

We collected data from WTC workers on asthma control (Asthma Control Questionnaire and Asthma Quality of Life Questionnaire) and daily peak expiratory flow (PEF) measures over 6 weeks. Perception of airway limitation was assessed by comparing guessed vs actual PEF values. Post-traumatic stress disorder was diagnosed using the Structured Clinical Interview. We used unadjusted and adjusted models to compare PEF and perception measures in WTC workers with PTSD with those of workers without PTSD.

RESULTS

Overall, 25% of 224 participants had PTSD. Post-traumatic stress disorder was associated with worse Asthma Control Questionnaire (2.2±0.8 vs 1.1±0.9, P < .001) and Asthma Quality of Life Questionnaire (3.9±1.1 vs 5.4±1.1, P < .001) scores. Adjusted analyses showed no significant differences in PEF between WTC workers with (351.9±143.3 L/min) and those without PTSD (364.6±131.6 L/min, P = .55). World Trade Center workers with PTSD vs those without PTSD had increased proportion of accurate perception (67.0±37.2% vs 53.5±38.1%, P = .01) and decreased underperception (23.3.0±32.1% vs 38.9±37.5%, P = .004) of airflow limitation during periods of limitation. Similar results were obtained in adjusted analyses.

CONCLUSION

This study indicates that differences in perception of airflow limitation may mediate the relationship of PTSD and increased asthma symptoms, given WTC workers with PTSD have worse self-reported asthma control, an increased proportion of accurate perception, and decreased underperception, despite no differences in daily PEF measures.

Cognition, symptom perception, and medication non-adherence in older adults with asthma

BACKGROUND

Cognitive impairment (CI) is highly prevalent in elderly asthmatics and is associated with worse asthma self-management (SM) and outcomes. CI may also explain why older adults may under-perceive asthma symptoms. We hypothesized that CI would be associated with low medication adherence and asthma symptom under-perception (ASP). We also hypothesized that ASP would mediate the relationship between CI and medication adherence.

METHODS

Participants of this longitudinal cohort study were asthmatics (N = 334) ≥60 years (51% Hispanic, 25% Black). Cognitive measures assessed general cognition, attention, processing speed, executive functioning, memory, and language. Measures of SM were self-reported and electronically measured adherence to controller medications. ASP was assessed for 6 weeks by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter, followed by PEF blows. Participants were blinded to actual PEF values. Percentage of time that participants were in the over-perception zone was calculated as an average.

RESULTS

In regression analyses, those with impairments in memory and general cognition had lower odds ratios (OR) for self-reported non-adherence (OR: 0.96, 95% CI 0.93 - 0.98 & OR: 0.90, 95% CI 0.83 - 0.96, respectively). CI was not associated with electronically measured non-adherence or ASP. In structural equation modeling, while CI was associated with adherence (β = 0.04, SE = 0.021, p = 0.04), ASP did not mediate this relationship.

CONCLUSIONS

While results confirmed the importance of cognition in asthma SM, these findings were not linked to ASP. Future analyses are needed to understand the role of confounding factors.

Using Mobile Health to Improve Asthma Self-Management in Early Adolescence: A Pilot Randomized Controlled Trial

PURPOSE

Early adolescence is an important developmental period where youth take primary responsibility for asthma self-management. Helpful caregiver support during this time is pivotal in determining whether early adolescents successfully develop asthma self-management behaviors. AIM2ACT is a dyadic mobile health intervention designed to increase helpful caregiver support as early adolescents engage in asthma self-management behaviors. We conducted a pilot randomized controlled trial to determine the feasibility and acceptability of AIM2ACT and conduct preliminary tests of efficacy.

METHODS

We randomized adolescents (12-15 years old) and a caregiver to receive AIM2ACT (n = 17) or a self-guided attention control condition (n = 16) for 20 weeks. We conducted assessment visits at baseline, postintervention, and 4-month follow-up. Outcomes included family asthma management (primary outcome), adolescent asthma control, lung function (forced expiratory volume in 1 second), asthma-related quality of life, asthma management self-efficacy, and family communication.

RESULTS

We randomized 33 dyads and had 100% retention in the trial among AIM2ACT participants. Dyads frequently engaged with AIM2ACT (M = 21 days for adolescents, 32.65 days for caregivers) and reported very high satisfaction with content, functionality, and helpfulness. Participants randomized to AIM2ACT had significant improvements in asthma control scores (p = .04) compared to control that surpassed the minimally clinically important difference threshold. Although not statistically significant, the magnitude of improvements in family asthma management, asthma-related quality of life, and family communication was larger in the AIM2ACT group.

CONCLUSIONS

AIM2ACT is a feasible and acceptable dyadic mobile health asthma self-management intervention that improves asthma control.

Depressive Symptoms and Overperception of Airflow Obstruction in Older Adults With Asthma

OBJECTIVE

Older adults are at increased risk for depression and poor asthma outcomes. We examined whether depressive symptoms are associated with overperception of airflow obstruction and a pattern of worse asthma control, but not pulmonary function.

METHODS

We recruited a cohort of adults with asthma 60 years and older in East Harlem and the Bronx, New York. Baseline measures included the Geriatric Depression Scale, Asthma Control Questionnaire, and Mini Asthma Quality of Life Questionnaire. Spirometry was conducted at baseline to assess pulmonary function. Perception of airflow obstruction was assessed for 6 weeks following baseline by participants entering estimates of peak expiratory flow (PEF) into a programmable peak flow meter followed by PEF blows. Participants were blinded to actual PEF values. The percentage of time that participants were in the overperception zone was calculated as an average.

RESULTS

Among the 334 participants (51% Hispanic, 25% Black), depressive symptoms were associated with overperception of airflow obstruction (β = 0.14, p = .029), worse self-reported asthma control (β = 0.17, p = .003), and lower asthma-related quality of life (β = -0.33, p < .001), but not with lung function (β = -0.01, p = .82). Overperception was also associated with worse self-reported asthma control (β = 0.14, p = .021), but not lung function (β = -0.05, p = .41).

CONCLUSIONS

Depressive symptoms were associated with greater perceived impairment from asthma, but not pulmonary function. Overperception of asthma symptoms may play a key role in the relationship between depression and asthma outcomes in older adults.

Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT): Development and design of a randomized controlled trial

Early adolescents have difficulties performing asthma self-management behaviors, placing them at-risk for poor asthma control and reduced quality of life. This paper describes the development and plans for testing an interactive mobile health (mHealth) tool for early adolescents, ages 12-15years, and their caregivers to help improve asthma management. Applying Interactive Mobile health to Asthma Care in Teens (AIM2ACT) is informed by the Pediatric Self-management model, which posits that helpful caregiver support is facilitated by elucidating disease management behaviors and allocating treatment responsibility in the family system, and subsequently engaging in collaborative caregiver-adolescent asthma management. The AIM2ACT intervention was developed through iterative feedback from an advisory board composed of adolescent-caregiver dyads. A pilot randomized controlled trial of AIM2ACT will be conducted with 50 early adolescents with poorly controlled asthma and a caregiver. Adolescent-caregiver dyads will be randomized to receive the AIM2ACT smartphone application (AIM2ACT app) or a self-guided asthma control condition for a 4-month period. Feasibility and acceptability data will be collected throughout the trial. Efficacy outcomes, including family asthma management, lung function, adolescent asthma control, asthma-related quality of life, and self-efficacy for asthma management, will be collected at baseline, post-treatment, and 4-month follow-up. Results from the current study will inform the utility of mHealth to foster the development of asthma self-management skills among early adolescents.

The Perception of Asthma Severity in Children

The ability to perceive the onset and severity of symptoms of worsening asthma is important, not only for initial diagnosis but also for early identification of an asthma exacerbation and prompt management. There are subjective and objective methods for identifying symptoms. Symptom perception is affected by multiple mechanisms, and not all patients can accurately perceive symptoms of airflow limitation. Hyperperceivers will report substantial discomfort in the face of minimal bronchoconstriction, and poor perceivers will report no symptoms even in the presence of severe obstruction. The use of objective measures of airflow limitation is essential for such patients. Regimens for training perception in children and adults have been studied and are available.

Association of Youth and Caregiver Anxiety and Asthma Care Among Urban Young Adolescents

OBJECTIVE

To examine the association of adolescent asthma-related anxiety, social anxiety, separation anxiety, and caregiver asthma-related anxiety with asthma care by urban adolescents.

METHODS

Participants were 386 ethnic minority adolescents (mean age 12.8 years) with persistent asthma and their caregivers. Adolescents reported what they do to prevent asthma symptoms and to manage acute symptoms, and if they or their caregiver is responsible for their asthma care. Adolescents completed the Youth Asthma-Related Anxiety Scale, and the social and separation anxiety subscales of the Screen for Child Anxiety and Emotional Disorders (SCARED); caregivers completed the Parent Asthma-Related Anxiety Scale. Linearity of the associations was assessed by generalized additive models. When there was no evidence for nonlinearity, linear mixed effects models were used to evaluate the effects of the predictors.

RESULTS

Adolescent asthma-related anxiety had a strong curvilinear relationship with symptom prevention (P < .001). Adolescents took more prevention steps as their anxiety increased, with a plateau at moderate anxiety. There was a linear relationship of adolescent asthma-related anxiety to symptom management (β = 0.03, P = .021) and to asthma responsibility (β = 0.11, P = .015), and of caregiver asthma-related anxiety to adolescent symptom prevention (β = 0.04, P = .001). Adolescent social and separation anxiety had weak to no relationship with asthma care. Results remained consistent when controlling for each of the other anxieties.

CONCLUSIONS

Asthma-related anxiety plays an important, independent role in asthma care. When low, adolescents may benefit from increased support from caregivers and awareness of the consequences of uncontrolled asthma. When elevated, health providers should ensure the adolescents are not assuming responsibility for asthma care prematurely.

Reliability and predictors of resistive load detection in children with persistent asthma: a multivariate approach

OBJECTIVE

Resistive load detection tasks enable analysis of individual differences in psychophysical outcomes. The purpose of this study was to determine both the reliability and predictors of resistive load detection in children with persistent asthma who completed multiple testing sessions.

METHODS

Both University of North Carolina (UNC) Charlotte and Ohio University institutional review boards approved the research protocol. The detection of inspiratory resistive loads was evaluated in 75 children with asthma between 8 and 15 years of age. Each child participated in four experimental sessions that occurred approximately once every 2 weeks. Multivariate analyses were used to delineate predictors of task performance.

RESULTS

Reliability of resistive load detection was determined for each child, and predictors of load detection outcomes were investigated in two groups of children: those who performed reliably in all four sessions (n = 31) and those who performed reliably in three or fewer sessions (n = 44). Three factors (development, symptoms, and compliance) accounted for 66.3% of the variance among variables that predicted 38.7% of the variance in load detection outcomes (Multiple R = 0.62, p = 0.004) and correctly classified performance as reliable or less reliable in 80.6% of the children, χ(2)(12) = 28.88, p = 0.004.

CONCLUSIONS

Cognitive and physical development, appraisal of symptom experiences, and adherence-related behaviors (1) account for a significant proportion of the interrelationships among variables that affect perception of airflow obstruction in children with asthma and (2) differentiate between children who perform more or less reliably in a resistive load detection task.

Asthma management self-efficacy in parents of primary school-age children

The aim of this study was to investigate asthma management self-efficacy in parents of primary school-age children with asthma and to explore possible associations between parent asthma management self-efficacy, parent and child characteristics, asthma task difficulty and asthma management responsibility. A cross-sectional descriptive survey of 113 parents was conducted to assess the level of parent asthma management self-efficacy, asthma task difficulty and confidence, asthma responsibility and socio-demographic characteristics. The findings indicate that parents had higher self-efficacy for attack prevention than attack management. Parents had higher self-efficacy for asthma management tasks that are simple, skills based and performed frequently such as medication administration and less confidence and greater difficulty with tasks associated with judgement and decision-making. Multivariate linear regression analysis identified English language, child asthma responsibility and parent education as predictors of higher asthma management self-efficacy, while an older child was associated with lower parent asthma management self-efficacy. The implications of these results for planning and targeting health education and self-management interventions for parents and children are discussed.

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.

Asthma knowledge, subjective assessment of severity and symptom perception in parents of children with asthma

OBJECTIVES

This study aimed to confirm the tendency for parents to underestimate the severity of symptoms and the poor consistency between parents' reports of symptoms and the physicians' evaluation of asthma control. Additionally, the relationship between parents' asthma knowledge and their report of symptoms and estimation of asthma severity was explored.

METHODS

Fifty children (M = 10.5 years) and their caregivers were recruited from two Portuguese hospitals. A measure of asthma symptoms report (Severity of Chronic Asthma, SCA) and a subjective evaluation of asthma severity were collected and compared with physicians' ratings of asthma control, as well as parents' knowledge about asthma (Asthma Knowledge Questionnaire, AKQ) and emotional disturbance (Brief Symptom Inventory, BSI).

RESULTS

Although parents' evaluation of perceived asthma severity was moderately correlated to symptoms reported, results confirm an inconsistency between parents' reports of symptoms, their subjective rating of asthma severity and the physician's rating of clinical control, revealing a tendency for parents to underestimate disease severity and to underreport asthma symptoms. Asthma knowledge was not significantly correlated to SCA or to parents' subjective evaluation of asthma severity. Parents with poorer knowledge reported fewer symptoms.

CONCLUSIONS

Portuguese parents revealed a tendency to overestimate their child's level of asthma control and a low level of asthma knowledge. Parents' education, psychological disturbance and time since diagnosis were associated with asthma knowledge. Parents' knowledge was not related to the child's asthma outcomes or to their subjective evaluation of asthma severity or symptoms reports. Parents' asthma knowledge deficits, underreporting of symptoms and underestimation of asthma severity, may affect parent-provider communication and impede asthma control.

Perception of pulmonary function and asthma control: the differential role of child versus caregiver anxiety and depression

OBJECTIVE

To examine child and caregiver anxiety and depression as predictors of children's perception of pulmonary function, quick-relief medication use, and pulmonary function.

METHOD

97 children with asthma, ages 7 to 11 years old, reported their anxiety and depressive symptoms and completed spirometry. Caregivers completed a psychiatric interview. Children's predictions of their peak expiratory flow were compared with actual values across 6 weeks. Quick-relief medication use was assessed by Dosers.

RESULTS

Children's anxiety symptoms were associated with over-perception of respiratory compromise and greater quick-relief medication use. Children's depressive symptoms were associated with greater quick-relief medication use, but not perception of pulmonary function. Children of caregivers with an anxiety or depressive disorder had lower pulmonary function than children of caregivers without anxiety or depression.

CONCLUSIONS

Child anxiety was associated with a subjective pattern of over-perception. Caregiver anxiety and depression were risk factors for lower lung function assessed by objective measurement.

Psychosocial factors and behavioral medicine interventions in asthma

OBJECTIVE

This review examines the evidence for psychosocial influences in asthma and behavioral medicine approaches to its treatment.

METHOD

We conducted a systematic review of the literature on psychosocial influences and the evidence for behavioral interventions in asthma with a focus on research in the past 10 years and clinical trials. Additional attention was directed at promising new developments in the field.

RESULTS

Psychosocial factors can influence the pathogenesis and pathophysiology of asthma, either directly through autonomic, endocrine, immunological, and central nervous system mechanisms or indirectly through lifestyle factors, health behaviors, illness cognitions, and disease management, including medication adherence and trigger avoidance. The recent decade has witnessed surging interest in behavioral interventions that target the various pathways of influence. Among these, self-management training, breathing training, and exercise or physical activation programs have proved particularly useful, whereas other essential or promising interventions, such as smoking cessation, dietary programs, perception and biofeedback training, and suggestive or expressive psychotherapy, require further, more rigorous evaluation. Given the high comorbidity with anxiety and mood disorders, further evaluation of illness-specific cognitive behavior therapy is of particular importance. Progress has also been made in devising community-based and culturally tailored intervention programs.

CONCLUSION

In concert with an essential medication treatment, behavioral medicine treatment of asthma is moving closer toward an integrated biopsychosocial approach to disease management.

Dose effect of once-daily fluticasone furoate in persistent asthma: a randomized trial

BACKGROUND

This randomized, double-blind, multicenter study was designed to evaluate the efficacy of inhaled once-daily fluticasone furoate (FF) administered in the evening in patients with persistent asthma not controlled by short-acting beta(2) agonists, and to determine the dose(s) suitable for further development.

METHODS

Of 1459 patients screened, 598 received one of six treatments: placebo, FF (25 μg, 50 μg, 100 μg or 200 μg) once daily each evening, or fluticasone propionate (FP) 100 μg twice daily for 8 weeks. The primary endpoint was change from baseline in pre-dose evening forced expiratory volume in 1 s (FEV(1)).

RESULTS

A dose-response effect was observed for once-daily FF 25-200 μg including (p < 0.001) and excluding placebo (p = 0.03). FF 50-200 μg once daily significantly increased FEV(1) from baseline (p < 0.05 vs placebo), by >200 mL for FF 100 μg and 200 μg. Significant improvements were also achieved for peak expiratory flow, and percentage symptom-free and rescue-free 24 h periods. The magnitude of effect was at least as good as twice-daily FP. Overall, once-daily FF was well tolerated with no systemic corticosteroid effects.

CONCLUSION

FF 50-200 μg/day once daily in the evening demonstrated dose-related efficacy in asthma with 100-200 μg appearing to be the optimal doses for further evaluation. ClinicalTrials.gov: NCT00603382.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Analysis of the concentration-respiratory response among asthmatics following controlled short-term exposures to sulfur dioxide

Some of the most compelling evidence of sulfur dioxide (SO(2))-induced respiratory morbidity is derived from a large body of studies involving controlled short-term exposures among groups of asthmatic volunteers. These studies were extensively cited in the recently completed review of the primary National Ambient Air Quality Standards for SO(2). Although it is clear from these investigations that exposure to SO(2) may result in a significant increase in bronchoconstriction, there is uncertainty regarding the range of concentrations over which this respiratory response occurs. The objective of this study was to better characterize the concentration-response relationship between SO(2) and measures of bronchoconstriction using individual subject lung function response data. In reviewing studies of asthmatics exposed to SO(2) during 5- to 10-min periods of elevated ventilation, we observed clear and consistent evidence of an increase in the bronchoconstrictive response to SO(2) with increasing exposure concentrations between 0.2 and 1.0 ppm. In a subsequent analysis of individual subject data, it was found that those asthmatics experiencing SO(2)-induced respiratory effects at relatively high exposure concentrations are also more likely than nonresponders to experience similar effects after exposure to lower SO(2) concentrations (≤0.4 ppm). Although the clinical significance of these effects is unsettled, the findings provide additional support to epidemiologic evidence of an association between ambient SO(2) concentration and various measures of respiratory morbidity in the general population.

Adolescents' perception of asthma symptoms and health care utilization

INTRODUCTION

Pediatric asthma is accountable for a substantial use of health care services. The purpose of this study was to systemically examine the extent to which inaccurate perception of asthma symptoms is associated with the use of health care services.

METHODS

This exploratory study included 126 adolescents with asthma who were between 13 and 20 years of age. Subjects were classified as having inaccurate symptom perception (IG); well-controlled accurate symptom perception (WCA); and poorly controlled accurate symptom perception (PCA). These groups were compared with respect to health care utilization, including emergency department (ED) visits, hospitalization, and office visits and school absenteeism in the past 3 months.

RESULTS

More adolescents in the IG group had at least one hospitalization compared with adolescents in the PCA or WCA groups (23.1% vs. 11.1% vs. 2.6%, respectively). A similar trend was seen for ED visits. Compared with the WCA group, adolescents in the IG group were nearly nine times more likely to have been hospitalized, 3.4 times more likely to have visited an ED, and four times more likely to have missed school days.

DISCUSSION

Adolescents with inaccurate symptom perception are more likely to have hospitalizations, ED visits, and missed days from school compared with those who have accurate perceptions. The findings underscore the importance of screening for perceptual accuracy of asthma symptoms and call for interventions promoting accurate symptom assessment in adolescents with asthma to ensure appropriate care.

Physical activity, lung function, and shortness of breath in the daily life of individuals with asthma

BACKGROUND

The effects of physical activity on asthma have been explored extensively. Exercise can trigger later bronchoconstriction in many patients, and deconditioning due to a sedentary lifestyle may be the consequence. However, the immediate effect of physical activity in asthma and health is bronchodilation. To date, little is known about the association between physical activity and lung function in the daily life of asthma patients.

METHODS

We studied 20 individuals with asthma and 20 control subjects using an electronic diary of activities and spirometry (peak expiratory flow [PEF], FEV(1)). Participants rated their shortness of breath and their intensity of physical and social activity for the preceding 30 min. Assessments were made over the course of 3 weeks, tid (morning, afternoon, evening/night).

RESULTS

Stronger physical activity was concurrently associated with significantly higher lung function. In contrast, it also showed a positive concurrent association with shortness of breath. In prospective cross-lag analyses, lower PEF and FEV(1) earlier in the day predicted lower physical and social activity levels later in the day, but shortness of breath did not.

CONCLUSION

The findings show that detrimental effects observed in exercise-induced bronchoconstriction cannot be generalized to physical activity in daily lives of individuals with asthma. Nevertheless, people with asthma still feel more shortness of breath when being more physically active. They adjust their activity levels throughout the day according to their earlier lung function, but this does not fully explain the concurrent positive association of physical activity and lung function.

Psychological considerations of the child with asthma

Asthma, the most common chronic disease in children and adolescents in industrialized countries, is typified by airway inflammation and obstruction leading to wheezing, dyspnea, and cough. However, the effect of asthma does not end with pulmonary changes. Research has shown a direct link between asthma and stress and psychiatric illness, which if untreated results in heightened morbidity and effects on society. The link between asthma and psychiatric illness, however, is often underappreciated by many pediatric and child mental health professionals. This article reviews the diagnosis and treatment of asthma as well as the correlation between asthma and psychiatric illness in children in an effort to improve management and treatment strategies for this prevalent disease.

Perception of multiple-breath inspiratory resistive loads in males and females

Resistive load magnitude estimation (ME) was measured over multiple breaths in male and female subjects. It was hypothesized that multiple breaths against a range of resistive loads would result in a change in the perceived load magnitude as a function of load magnitude and the number of inspiratory efforts. It was further hypothesized that males and females would differ in their perceptual response to sustained breathing against inspiratory resistive loads. The subjects were tested in a sound isolated room and respired through a non-rebreathing valve, the inspiratory port connected to the loading manifold. The subject inspired to a peak airflow target for each breath. Each R load was presented for 10 continuous breaths. The load was estimated at breath 1, 5, and 10 using a modified Borg scale. Each 10-breath load presentation was presented in a randomized block. There was no significant group difference between the ME for breath 1 and 10 for small R loads, but a significant group difference for large R loads. The ME for males did not change between breath 1 and 10 for the small load magnitudes, but decreased with large loads. The ME for the 10th breath of the large R load was greater than the 1st breath for females. Males estimated the large R load on the 1st breath the same as females but the ME on the 10th breath was significantly less for males compared to females. These results demonstrate that magnitude estimation of large resistive loads with a sustained 10-breath trial elicits significant increases in females, but significantly decreased in males. The increase in ME may represent increased respiratory discomfort for females and the decrease habituation in males.

Ethnic differences in perception of lung function: a factor in pediatric asthma disparities?

RATIONALE

Disparities in pediatric asthma exist in that Latino children have higher prevalence and greater morbidity from asthma than non-Latino white children. The factors behind these disparities are poorly understood, but ethnic-related variations in children's ability to accurately recognize and report their pulmonary functioning may be a contributing process.

OBJECTIVES

To determine (1) if differences exist between Latino and non-Latino white children's perceptual accuracy and (2) whether these differences are related to asthma outcomes.

METHODS

Five hundred and twelve children, aged 7-16 years (290 island Puerto Ricans, 115 Rhode Island Latinos, and 107 Rhode Island non-Latino white children) participated in a 5-week home-based protocol in which twice daily they entered subjective estimates of their peak expiratory flow rate into a hand-held, programmable spirometer and then performed spirometry. Their accuracy was summarized as three perceptual accuracy scores. Demographic data, asthma severity, intelligence, emotional expression, and general symptom-reporting tendencies were assessed and covaried in analyses of the relationship of perceptual accuracy to asthma morbidity and health care use.

MEASUREMENTS AND MAIN RESULTS

Younger age, female sex, lower intelligence, and poverty were associated with lower pulmonary function perception scores. Island Puerto Rican children had the lowest accuracy and highest magnification scores, followed by Rhode Island Latinos; both differed significantly from non-Latino white children. Perceptual accuracy scores were associated with most indices of asthma morbidity.

CONCLUSIONS

Controlling for other predictive variables, ethnicity was related to pulmonary function perception ability, as Latino children were less accurate than non-Latino white children. This difference in perceptual ability may contribute to recognized asthma disparities.

The impact of emotion on respiratory-related evoked potentials

Emotion influences the perception of respiratory sensations, although the specific mechanism underlying this modulation is not yet clear. We examined the impact of viewing pleasant, neutral, and unpleasant affective pictures on the respiratory-related evoked potential (RREP) elicited by a short inspiratory occlusion in healthy volunteers. Reduced P3 amplitude of the RREP was found for respiratory probes presented when viewing pleasant or unpleasant series, when compared to those presented during the neutral series. Earlier RREP components, such as Nf, P1, N1, and P2, showed no modulation by emotion. The results suggest that emotion impacts the perception of respiratory sensations by reducing the attentional resources available for processing afferent respiratory sensory signals.

Issues and methods in disparities research: the Rhode Island-Puerto Rico asthma center

BACKGROUND

Epidemiologic studies have documented higher rates of asthma prevalence and morbidity in minority children compared to non-Latino white (NLW) children. Few studies focus on the mechanisms involved in explaining this disparity, and fewer still on the methodological challenges involved in rigorous disparities research.

OBJECTIVES AND METHODS

This article provides an overview of challenges and potential solutions to research design for studies of health disparities. The methodological issues described in this article were framed on an empirical model of asthma health disparities that views disparities as resulting from several factors related to the healthcare system and the individual/community system. The methods used in the Rhode Island-Puerto Rico Asthma Center are provided as examples, illustrating the challenges in executing disparities research.

RESULTS

Several methods are described: distinguishing ethnic/racial differences from methodological artifacts, identifying and adapting culturally sensitive measures to explain disparities, and addressing the challenges involved in determining asthma and its severity in Latino and other minority children. The measures employed are framed within each of the components of the conceptual model presented.

CONCLUSIONS

Understanding ethnic and/or cultural disparities in asthma morbidity is a complicated process. Methodologic approaches to studying the problem must reflect this complexity, allowing us to move from documenting disparities to understanding them, and ultimately to reducing them.

Perception of airflow obstruction in patients hospitalized for acute asthma

BACKGROUND

Little is known about the perception of airflow obstruction in patients hospitalized for acute asthma.

OBJECTIVES

To evaluate patient perception of airflow obstruction at hospital discharge and at a 2-week follow-up visit and to determine whether symptom control and/or severity of airflow obstruction identified patients at risk for acute asthma after discharge.

METHODS

In a prospective cohort study of inner-city adults hospitalized for acute asthma from April 1, 2001, through October 31, 2002, symptom control (Asthma Control Questionnaire) and airflow obstruction (forced expiratory volume in 1 second [FEV1] percentage predicted) were evaluated at discharge and 2 weeks after discharge. We evaluated perception of airflow obstruction (symptom control vs FEV1 percentage predicted) and perception of change in airflow obstruction (change in symptom control vs percentage change in FEV1) between the 2 visits. Acute asthma after discharge was defined as an emergency department visit or hospitalization for asthma within 90 days of discharge.

RESULTS

In fifty-one participants, symptom control was not significantly associated with airflow obstruction at hospital discharge (P = .30), indicating poor perception of airflow obstruction. Among the 41 participants (80.4% of those enrolled) who completed the follow-up visit, change in symptom control was not significantly associated with change in airflow obstruction (P = .20), indicating poor perception of change in airflow obstruction. Greater airflow obstruction at follow-up (P = .02) and a smaller improvement in airflow obstruction (P = .03), but not symptom control, were associated with a higher risk of acute asthma after discharge.

CONCLUSIONS

Patients hospitalized for acute asthma have poor perception of airflow obstruction and change in airflow obstruction. Objective measurements of lung function should guide treatment decisions after discharge in this population.

Inaccurate perception of asthma symptoms: a cognitive-affective framework and implications for asthma treatment

Inaccurate perception of respiratory symptoms is often found in asthma patients. Typically, patients who inaccurately perceive asthma symptoms are divided into underperceivers and overperceivers. In this paper we point out that this division is problematic. We argue that little evidence exists for a trait-like stability of under- and overperception and that accuracy of respiratory symptom perception is highly variable within persons and strongly influenced by contextual information. Particularly, expectancy and affective cues appear to have a powerful influence on symptom accuracy. Based on these findings and incorporating recent work on associative learning, attention and mental representations in anxiety and symptom perception, we propose a cognitive-affective model of symptom perception in asthma. The model can act as a framework to understand both normal perception as well as under- and overperception of asthma symptoms and can guide the development of affect-related interventions to improve perceptual accuracy, asthma control and quality of life in asthma patients.

Differing reports of asthma symptoms in African Americans and Caucasians

OBJECTIVE

This pilot study explores the reported symptoms in African Americans and Caucasians with asthma.

METHODS

Asthma patients in an inner-city pulmonary clinic were given a brief questionnaire of asthma symptoms and the BORG scale, followed by spirometry.

RESULTS

African Americans were less likely to report nocturnal awakenings (67% vs. 100%; p = 0.037), complain of dyspnea (33% vs. 75%; p = 0.038), or experience chest pain (13% vs. 75%; p = 0.002) than Caucasians.

CONCLUSIONS

This is the first study to demonstrate that there are clinically significant differences in the reporting of asthma symptoms between African Americans and Caucasians.