Behavioral issues in asthma management

Despite advances in drug treatment, outcomes in asthma remain unsatisfactory. Often overlooked in developing treatment strategies are important factors that affect outcomes in asthma, namely behavioral issues such as the low rate of patient adherence to the prescribed treatment regimen, inadequate physician-patient communication, and inconsistent implementation of evidenc-based treatment guidelines. The low adherence rates among asthma patients may be improved by education programs that emphasize both the potentially serious risks of this disease and a team approach to treatment that includes patients and their families in developing a treatment plan. Interactive physician education programs have been shown to improve guideline implementation and physician communication skills. Indeed, effective physician-patient communication may be the key to improving guideline implementation and patient adherence to treatment, resulting in meaningful decreases in asthma-related morbidity and mortality. Pediatr Pulmonol. 2001; Supplement 21:26–30. © 2001 Wiley-Liss, Inc.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/35319/1/2003_ftp.pd

Bone mineral density and fracture risk with long-term use of inhaled corticosteroids in patients with asthma: systematic review and meta-analysis

Objectives: We aimed to assess the association between long-term use of inhaled corticosteroids (ICS) and bone adverse effects in patients with asthma. Design: Systematic review and meta-analysis of fracture risk and changes in bone mineral density with long-term ICS use in asthma. Methods: We initially searched MEDLINE and EMBASE in July 2013, and performed an updated PubMed search in December 2014. We selected randomised controlled trials (RCTs) and controlled observational studies of any ICS (duration at least 12 months) compared to non-ICS use in patients with asthma. We conducted meta-analysis of ORs for fractures, and mean differences in bone mineral density. Heterogeneity was assessed using the I2 statistic. Results: We included 18 studies (7 RCTs and 11 observational studies) in the systematic review. Meta-analysis of observational studies did not demonstrate any significant association between ICS and fractures in children (pooled OR 1.02, 95% CI 0.94 to 1.10, two studies), or adults (pooled OR 1.09, 95% CI 0.45 to 2.62, four studies). Three RCTs and three observational studies in children reported on bone mineral density at the lumbar spine, and our meta-analysis did not show significant reductions with ICS use. Three RCTs and four observational studies in adults reported on ICS use and bone mineral density at the lumbar spine and femur, with no significant reductions found in the meta-analysis compared to control. Conclusions ICS use for ≥12 months in adults or children with asthma was not significantly associated with harmful effects on fractures or bone mineral density

Clinical Applications of Pediatric Pulmonary Function Testing: Lung Function in Recurrent Wheezing and Asthma

Pulmonary function testing remains the gold standard for the diagnosis and management of wheezing disorders in older children and adults. Although wheezing disorders are among the most common clinical problems in pediatrics, most young children and toddlers cannot perform most of the currently clinically available pulmonary function tests. In this article, we review the different types of pulmonary function tests available and discuss the applicability and utility in the different age groups with specific reference to suitability in the diagnosis and management of wheezing disorders.Peer Reviewedhttp://deepblue.lib.umich.edu/bitstream/2027.42/90475/1/ped-2E2010-2E0060.pd

Quality of care for older adults with chronic obstructive pulmonary disease and asthma based on comparisons to practice guidelines and smoking status

<p>Abstract</p> <p>Background</p> <p>The purpose of this study was to describe the prevalence of respiratory diseases in older adults and compare the demographic, health and smoking characteristics of those with and without these diseases. Furthermore, we evaluate the association between smoking status and patterns in health care and how concordant this care is with guidelines.</p> <p>Methods</p> <p>Using a nationally representative sample of 29,902 older adults who participated in the Medicare Current Beneficiary Survey (1992–2002), we compared guideline recommendations on the treatment and prevention of chronic obstructive pulmonary disease and asthma with survey utilization data, including the use of bronchodilators, spirometry and influenza vaccine.</p> <p>Results</p> <p>26% to 30% of older adults were diagnosed with or self-reported chronic respiratory diseases; however 69% received no pharmacological treatment and 30% of patients reporting use of pharmacological treatments did not receive short-acting bronchodilator inhalers. Current smokers appeared to receive significantly less care for respiratory diseases than non-smokers or former smokers.</p> <p>Conclusion</p> <p>Disparities between recommended and actual care for older adults with chronic lung disease require further research. The needs of older adults with co-morbidities and nicotine addiction deserve special attention in care as well as guideline development and implementation.</p

Tidal breathing parameters measured using structured light plethysmography in healthy children and those with asthma before and after bronchodilator

Structured light plethysmography (SLP) is a light‐based, noncontact technique that measures tidal breathing by monitoring displacements of the thoracoabdominal (TA) wall. We used SLP to measure tidal breathing parameters and their within‐subject variability (v) in 30 children aged 7–16 years with asthma and abnormal spirometry (forced expiratory volume in 1 sec [FEV1] <80% predicted) during a routine clinic appointment. As part of standard care, the reversibility of airway obstruction was assessed by repeating spirometry after administration of an inhaled bronchodilator. In this study, SLP was performed before and after bronchodilator administration, and also once in 41 age‐matched controls. In the asthma group, there was a significant increase in spirometry‐assessed mean FEV1 after administration of bronchodilator. Of all measured tidal breathing parameters, the most informative was the inspiratory to expiratory TA displacement ratio (IE50SLP, calculated as TIF50SLP/TEF50SLP, where TIF50SLP is tidal inspiratory TA displacement rate at 50% of inspiratory displacement and TEF50SLP is tidal expiratory TA displacement rate at 50% of expiratory displacement). Median (m) IE50SLP and its variability (vIE50SLP) were both higher in children with asthma (prebronchodilator) compared with healthy children (mIE50SLP: 1.53 vs. 1.22, P < 0.001; vIE50SLP: 0.63 vs. 0.47, P < 0.001). After administration of bronchodilators to the asthma group, mIE50SLP decreased from 1.53 to 1.45 (P = 0.01) and vIE50SLP decreased from 0.63 to 0.60 (P = 0.04). SLP‐measured tidal breathing parameters could differentiate between children with and without asthma and indicate a response to bronchodilator

Acute Effects of Asian Dust Events on Respiratory Symptoms and Peak Expiratory Flow in Children with Mild Asthma

The aim of this study was to investigate the possible adverse effects of Asian dust events on respiratory health in asthmatic children. Fifty-two children with mild asthma were studied for eight consecutive weeks in the spring of 2004 (March 8 to May 2). During the study period, five Asian dust days were identified; we included a lag period of two days following each of the events. Subjects recorded their respiratory symptom diaries and peak expiratory flow (PEF) twice daily during the study period; and they underwent methacholine bronchial challenge tests. The subjects reported a significantly higher frequency of respiratory symptoms during the Asian dust days than during the control days. They showed significantly more reduced morning and evening PEF values, and more increased PEF variability (10.1%±3.5% vs. 5.5%±2.2%) during the Asian dust days than during the control days. Methacholine PC20 was not significantly different between before and after the study period (geometric mean: 2.82 mg/mL vs. 3.16 mg/mL). These results suggest that the short-term Asian dust events might be associated with increased acute respiratory symptoms and changes in PEF outcomes. However, there might be little long-term influence on airway hyperresponsiveness in children with mild asthma

Assessing the Quality and Contents of Asthma-Related Information on the Korean Internet as an Educational Material for Patients

Despite the substantial amount of asthma-related information available on the internet, little is known about the quality of such information. We assessed asthma-related information on the Korean internet intended as an educational material for asthma patients. By entering the key word, 'asthma', into 4 popular search engines, 32 web sites were identified and categorized with respect to authorship. The core asthma educational concepts and Health On the Net Code of Conduct principles were used to evaluate informational value and justifiability of unreliable information. Eight of 32 web sites were categorized as western physician, seventeen as oriental physician, four as commercial, and three as others. The mean number of core asthma educational concepts on the whole web sites was 2.7 out of 8. By type of authorship, 1.7 on the commercial sites, 2.1 on the oriental physician sites, 3.5 on the western physician sites, and 5.0 on the others sites in decreasing order. One of the western physician sites, two of the commercial sites, and all of the oriental physician and others sites contained unreliable information. However all of them except one site failed to satisfy our criteria of justifiability. Asthma-related information currently available on the Korean internet is highly variable in quality and lacks core asthma educational concepts and justifiability

Weekly self-monitoring and treatment adjustment benefit patients with partly controlled and uncontrolled asthma: an analysis of the SMASHING study

<p>Abstract</p> <p>Background</p> <p>Internet-based self-management has shown to improve asthma control and asthma related quality of life, but the improvements were only marginally clinically relevant for the group as a whole. We hypothesized that self-management guided by weekly monitoring of asthma control tailors pharmacological therapy to individual needs and improves asthma control for patients with partly controlled or uncontrolled asthma.</p> <p>Methods</p> <p>In a 1-year randomised controlled trial involving 200 adults (18-50 years) with mild to moderate persistent asthma we evaluated the adherence with weekly monitoring and effect on asthma control and pharmacological treatment of a self-management algorithm based on the Asthma Control Questionnaire (ACQ). Participants were assigned either to the Internet group (n = 101) that monitored asthma control weekly with the ACQ on the Internet and adjusted treatment using a self-management algorithm supervised by an asthma nurse specialist or to the usual care group (UC) (n = 99). We analysed 3 subgroups: patients with well controlled (ACQ ≤ 0.75), partly controlled (0.75>ACQ ≤ 1.5) or uncontrolled (ACQ>1.5) asthma at baseline.</p> <p>Results</p> <p>Overall monitoring adherence was 67% (95% CI, 60% to 74%). Improvements in ACQ score after 12 months were -0.14 (p = 0.23), -0.52 (p < 0.001) and -0.82 (p < 0.001) in the Internet group compared to usual care for patients with well, partly and uncontrolled asthma at baseline, respectively. Daily inhaled corticosteroid dose significantly increased in the Internet group compared to usual care in the first 3 months in patients with uncontrolled asthma (+278 μg, p = 0.001), but not in patients with well or partly controlled asthma. After one year there were no differences in daily inhaled corticosteroid use or long-acting β₂-agonists between the Internet group and usual care.</p> <p>Conclusions</p> <p>Weekly self-monitoring and subsequent treatment adjustment leads to improved asthma control in patients with partly and uncontrolled asthma at baseline and tailors asthma medication to individual patients' needs.</p> <p>Trial registration</p> <p>Current Controlled Trials ISRCTN79864465</p

Family-school connections and internalizing problems among children living with asthma in urban, low-income neighborhoods

Children with asthma living in urban environments are at risk for experiencing internalizing problems and difficulties at school due to social context and health-related stressors. Parent confidence and participation in the school and children’s attitudes about school were explored in association with children’s depressed mood and school anxiety. Forty-five parent—child dyads were recruited from urban community health centers. Most participants were members of ethnic minority groups. Hierarchical multiple regression analyses revealed that higher levels of parent confidence in the school were associated with fewer symptoms of school anxiety in children. Children’s attitudes toward school moderated the relation between parent participation in the school and children’s depressed mood. Specifically, lower levels of parent participation were associated with higher levels of depressed mood only for children with the least positive school attitudes. Although preliminary, these results suggest the importance of attending to family—school connections to optimize the school-related psychological functioning of children living with asthma in urban environments