Incorrect use of peak flow meters: are you observing your patients?

Can resistance prehabilitation training bring additional benefits in valvular cardiac surgery? protocol for a randomized controlled trial

INTRODUCTION

Cardiovascular diseases (CVD) are a group of illnesses that include coronary heart disease, cerebrovascular disease, congenital heart disease and deep vein thrombosis. Major surgery is often chosen as the treatment of choice for CVD. The concept of fast-track rehabilitation after surgery appeared in the 1970s. Participation in these exercise-based prehabilitation programmes may decrease postoperative complications and length of hospital stay. The primary aim of the present study is to evaluate whether the implementation of an additional resistance training (RT) prehabilitation protocol within cardiac exercises based prehabilitation can reduce intensive care unit (ICU) length of stay, postoperative complications and hospital length of stay (LOS).

METHODS

A protocol of a prospective, parallel, randomised clinical trial includes 96 adult patients diagnosed with valvular pathology and who have been scheduled for surgery. The participants will be randomly assigned to two groups of 48. Control group will be treated with ventilatory and strengthening of respiratory muscles, and aerobic exercise. Experimental group, in addition, will be treated with RT of peripheral muscles. Both hospital stay and ICU stay will be assessed as main variables. Other secondary variables such as exercise capacity, quality of life and respiratory values will also be assessed. Quantitative variables will be analysed with a T-Test or ANOVA, or Mann Witney if the distribution is non-parametric.

RESULTS AND CONCLUSION

This will be the first controlled clinical study focused on adding strength exercise as an additional treatment during prehabilitation. The results of this study will focus on helping to improve rehabilitation and prehabilitation protocols, considering that it is essential to maintain pulmonary training, as well as the inclusion of peripheral exercises that help people with heart disease to be in a better physical condition in order to increase their participation and sense of quality of life.

Attention-Deficit Hyperactivity Disorder Symptoms, Underperception of Respiratory Compromise, and Illness Representations in Black and Latino Children With Asthma

OBJECTIVE

This study examined the associations between attention-deficit/hyperactivity disorder (ADHD) symptoms, underperception of respiratory compromise, and illness representations in Black and Latino children with asthma. We hypothesized that increased child-reported ADHD symptoms, as well as parent reports for their child, would be associated with underperception of respiratory compromise, and maladaptive asthma beliefs.

METHODS

Two hundred ninety-six parent-child dyads were recruited from pediatric asthma and primary care clinics in the Bronx. Participants completed demographic questionnaires, the Conners-3 ADHD Index to measure ADHD symptoms, and the Asthma Illness Representation Scale to assess asthma beliefs. Perception of respiratory compromise was assessed by programmable electronic peak flow monitors that measured the child's subjective estimates of peak expiratory flow (PEF) and actual PEF, with underperception as the primary measure.

RESULTS

Child-reported ADHD symptoms were associated with greater underperception (β = .117, p = .049) of respiratory compromise. Parent-reported ADHD symptoms were associated with greater underperception (β = .129, p = .028) of respiratory compromise. Child-reported ADHD symptoms (β = -.188, p < .001) were associated with more maladaptive asthma beliefs, F(1, 341) = 13.135. Parent-reported ADHD symptoms (β = -.203, p ≤ .001) were associated with more maladaptive asthma beliefs, F(1, 341) = 15.644.

CONCLUSIONS

ADHD symptoms were associated with a greater underperception of respiratory compromise and more maladaptive asthma beliefs. Deficits of attentional processes and/or hyperactivity levels might be contributing factors. We emphasize the need for psychoeducation and interventions that improve perception and health beliefs in children with comorbid ADHD and asthma.

[Role of peak expiratory flow in the assessment and management of asthma in children]

Peak expiratory flow (PEF) is a portable, reliable, and inexpensive method for lung function assessment. PEF can reflect expiratory airflow limitation and its variability can document reversibility, which provides an objective basis for the diagnosis of asthma in children. Short-term PEF monitoring can be an important aid in the management of acute asthma exacerbations, identification of possible triggers, and assessment of response to treatment. Long-term PEF monitoring can assist in the assessment of asthma control and warning of acute exacerbations, and this is useful for children with severe asthma. This article reviews the measurements, influencing factors, interpretation, and application of PEF, and its role in the diagnosis and management of asthma in children, to provide references for the clinical application of PEF in children.

Clinical efficacy and safety of anticholinergic therapies in pediatric patients

The burden of uncontrolled asthma in children and adolescents is high. Treatment options for pediatric patients (aged under 18 years) with asthma are largely influenced by the Global Initiative for Asthma recommendations. Algorithms for adolescents (12-18 years) and adults are identical, but recommendations for children aged under 6 years and 6-11 years differ. Although the goals of treatment for pediatric patients with asthma are similar to those for adults, relatively few new therapies have been approved for this patient population within the last decade. Designing clinical trials involving children presents several challenges, notably that children are often less able to perform lung function tests, and traditional endpoints used in clinical trials with adults, such as forced expiratory volume in 1 second, asthma exacerbations and questionnaires, have limitations associated with their use in children. There are also ethical considerations related to the performance of longer placebo-controlled exacerbation trials. This review considers additional clinical endpoints to those traditionally reported, including forced expiratory flow at 25%-75% of forced vital capacity, which may help shed light on which treatments are most effective for use in pediatric patients with asthma. The pros and cons of specific and potentially clinically relevant endpoints are considered, along with device considerations and patient preferences that may enhance adherence and quality of life. Recent advances in the management of children and adolescents, including the US Food and Drug Administration and European Medicines Agency approval of tiotropium in patients with asthma aged 6 years and over, are also discussed.

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.

Taming Asthma in School-Aged Children: A Comprehensive Review

Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. Multiple factors play a role in the development, treatment and prevention of childhood asthma including racial/ethnic and socioeconomic disparities, both the home and school environments, and medication use. The goals of this review are to summarize these aspects of asthma in school-aged children and to present an updated review of medications as it relates to treatment strategies that will help in the care of these children. We conclude that phenotypic heterogeneity and appropriate environmental assessments and interventions are important considerations in the management of childhood asthma.

Randomized Trial of Interventions to Improve Childhood Asthma in Homes with Wood-burning Stoves

BACKGROUND

Household air pollution due to biomass combustion for residential heating adversely affects vulnerable populations. Randomized controlled trials to improve indoor air quality in homes of children with asthma are limited, and no such studies have been conducted in homes using wood for heating.

OBJECTIVES

Our aims were to test the hypothesis that household-level interventions, specifically improved-technology wood-burning appliances or air-filtration devices, would improve health measures, in particular Pediatric Asthma Quality of Life Questionnaire (PAQLQ) scores, relative to placebo, among children living with asthma in homes with wood-burning stoves.

METHODS

A three-arm placebo-controlled randomized trial was conducted in homes with wood-burning stoves among children with asthma. Multiple preintervention and postintervention data included PAQLQ (primary outcome), peak expiratory flow (PEF) monitoring, diurnal peak flow variability (dPFV, an indicator of airway hyperreactivity) and indoor particulate matter (PM) PM2.5.

RESULTS

Relative to placebo, neither the air filter nor the woodstove intervention showed improvement in quality-of-life measures. Among the secondary outcomes, dPFV showed a 4.1 percentage point decrease in variability [95% confidence interval (CI)=-7.8 to -0.4] for air-filtration use in comparison with placebo. The air-filter intervention showed a 67% (95% CI: 50% to 77%) reduction in indoor PM2.5, but no change was observed with the improved-technology woodstove intervention.

CONCLUSIONS

Among children with asthma and chronic exposure to woodsmoke, an air-filter intervention that improved indoor air quality did not affect quality-of-life measures. Intent-to-treat analysis did show an improvement in the secondary measure of dPFV.

TRIAL REGISTRATION

ClincialTrials.gov NCT00807183. https://doi.org/10.1289/EHP849.

Special considerations--asthma in children

BACKGROUND

Asthma is among the most common chronic diseases of childhood. Management of pediatric asthma requires an understanding of the issues that uniquely effect children. This review provides the reader with the current state and future directions of pediatric asthma.

METHODS

Review of the pediatric asthma literature was undertaken with emphasis on randomized controlled trials and systematic reviews.

RESULTS

The prevalence of pediatric asthma remains elevated and is increasingly being appreciated in select global regions. Effective treatment in any setting begins with a focused medical history that queries key asthma features that inform both diagnostic and monitoring strategies. A thorough medical history may yield comorbid upper airway disorders and allergic triggers that could potentially exacerbate airway inflammation. Pre-bronchodilator and post-bronchodilator lung function testing is a preferable diagnostic strategy to quantitatively assess obstructive pulmonary disease among children capable of performing the testing maneuvers. Pediatric asthmatics who continue to have poor disease control require monitoring of medication adherence and drug delivery techniques, because both are often linked with disease outcomes. Therapeutic strategies in children are notably distinct from adults due to the possible effects of inhaled corticosteroids on reduced bone mineral density and growth. Adolescents may also require more time to address the psychosocial complexities that may complicate the required daily usage of asthma medicines.

CONCLUSION

Asthmatic children are distinct from their adult counterparts due to limitations inherent in the pediatric age group. A unified and evidence-based approach to pediatric asthma may improve clinical outcomes.