A comparative study was conducted on 163 asthmatic children from Kuala

Lumpur (polluted area) and 38 asthmatic children from Terengganu (less

polluted area). The objective of this study was to compare the lung functions

of the asthmatic children between the 2 sexes and study areas. Questionnaires

and diary cards were used to obtain background information and frequency of

asthma attacks. A spirometer was used to measure lung functions of the

asthmatic children. Findings showed that there was a significant difference in

the FEV,% predicted (p=0.002), FEV/FVC % predicted (p =0.001) and the

%FEV/FVC (p=0.002) between male children in the two areas. However, only

the FEV,% predicted (p=O.Oll) was significantly different between the female

children in the two areas. Significant correlation was also found between the

frequency of asthma attacks with FEV)% predicted (p=0.008), FEV/FVC %

predicted (p=O.OOI) and % FEV/FVC (p=O.OOI) among the asthmatic children

Kuala Lumpur but no significant correlation was found among the asthmatic

children in Terengganu

Hashim, Jamal H.

Hashim, Zailina

Jalaluddin, Juliana

Universiti Putra Malaysia Institutional Repository

Pertanika J. Sci. & Techno!. 12(1): II - 20 (2004)ISSN: 0128-7680© Universiti Putra Malaysia PressComparison of Lung Functions Among AsthmaticChildren in MalaysiaIZailina Hashim, IJuliana Jalaluddin & 2jamal H. HashimIEnvironmental and Occupational Health Unit,Faculty of Medicine and Health Sciences, Universiti Putra Malaysia,43400 UPM, Serdang, Selangor, Malaysia2Department of Community Health, Faculty of Medicine,Universiti Kebangsaan Malaysia Hospital, Bandar Tun Razak, Cheras56000 Kuala Lumpur, MalaysiaReceived: 24 January 2000ABSTRAKSatu kajian perbandingan telah dijalankan ke atas 163 kanak-kanak asma diKuala Lumpur (tercemar) dan 38 orang di Terengganu (kurang tercemar)telah dipilih dalam kajian. Objektif kajian adalah untuk membandingkanfungsi pam-pam kanak-kanak asma mengikut jantina dan kawasan kajian.Borang soal selidik dan kad diari digunakan untuk mengumpul maklumat latarbelakang dan kekerapan serangan asma di kalangan responden. Alat"spirometer" digunakan untuk mengukur fungsi pam-pam. Hasil kajianmendapati perbezaan yang signifikan bagi nilai FEV) % jangkaan ( p=0.002),FEV/FVC % jangkaan (p=O.OOI) dan %FEV/FVC (p=0.002) antara kanak-kanak lelaki di kedua-dua kawasan. Walau bagaimanapun, perbezaan yangsignifikan hanya terdapat antara FEV,% jangkaan di kalangan kanak-kanakperempuan di kedua-dua kawasan. KoreIasi yang signifikan juga didapatiantara kekerapan serangan asma dengan FEV,% jangkaan (p=0.008) FEV/FVC% jangkaan (p=O.OOI) dan % FEV/FVC (p=O.OOI) di kalangan kanak-kanakasma di Kuala Lumpur tetapi tiada korelasi yang signifikan didapati di kalangankanak-kanak asma di Terengganu.ABSTRACTA comparative study was conducted on 163 asthmatic children from KualaLumpur (polluted area) and 38 asthmatic children from Terengganu (lesspolluted area). The objective of this study was to compare the lung functionsof the asthmatic children between the 2 sexes and study areas. Questionnairesand diary cards were used to obtain background information and frequency ofasthma attacks. A spirometer was used to measure lung functions of theasthmatic children. Findings showed that there was a significant difference inthe FEV,% predicted (p=0.002), FEV/FVC % predicted (p =0.001) and the%FEV/FVC (p=0.002) between male children in the two areas. However, onlythe FEV,% predicted (p=O.Oll) was significantly different between the femalechildren in the two areas. Significant correlation was also found between thefrequency of asthma attacks with FEV) % predicted (p=0.008), FEV/FVC %predicted (p=O.OOI) and % FEV/FVC (p=O.OOI) among the asthmatic childrenKuala Lumpur but no significant correlation was found among the asthmaticchildren in Terengganu.Ke}"X.ords: Asthmatic children, lung functions, asthmatic attacksZailina Hashim, Juliana Jalaluddin & Jamal H. HashimINTRODUCTIONA study on asthmatic school children was conducted in Kuala Lumpur andTerengganu. Lung function measurements such as the Forced Vital Capacity(FVC), Forced Expiratory Volume in One Second (FEV!) and %FEV/FVC areessential indicators for identifying the obstructive problems in the respiratorysystem due to diseases such as asthma, bronchitis or emphysema. If the FEV! isless than 80% of the expected percent, then the patient is categorized as havingobstructive effects. The FEV/FVC % predicted is the most important index inevaluating the severity of asthma among patients (Murray 1979). If the FEV/FVC % predicted is less than 75%, then the patients have serious asthmaproblems and need attention (Miller 1978). The objective of this study was toassess and compare lung function measurements of asthmatic children in K.Lumpur and Terengganu.METHODOLOGYFour primary schools in Kuala Lumpur and 2 schools in Terengganu wereselected. The schools in K. Lumpur are located in the city center on a mainroad where the traffic is busy. The schools in Kemaman and Setiu in Terengganuare located away from the main road.Due to the fact that the prevalence of asthmatic cases in Terengganu islower, only 38 children were selected while in Kuala Lumpur, a total of 163asthmatic children were selected. Information on the socio-economics, historyand severity of asthma attacks, type of medicine used, hospital visits andtreatment were obtained through questionnaire interviews on the children andtheir guardians.Lung functions of the children were carried out to determine their lungvolume and flow (volume per unit of time). A "Pony Cosmed Spirometer"which met the American Thoracic Society (1987) specifications was used in thisstudy. The spirometer was calibrated each day before measurements. Theprocedure was explained and demonstrated to each child in which he or shewas asked to inhale deeply in the standing position and blow rapidly andcompletely into a calibrated spirometer. Three acceptable and at least tworeproducible curves were obtained in each subject. The highest values of forcedvital capacity (FVC) and forced expiratory volume in the 1st second (FEV!)were selected. Age was recorded to the nearest year, height was measured to thenearest 0.5 cm (with the subject standing without shoes), and weight wasrecorded to the neare.st 0.5 kg. All readings were recorded at ambienttemperature and pressure saturated (ATPS). FVC and FEV! measurements wereadjusted to body temperature and pressure saturated (BTPS).For comparative purposes, only the Malay respondents from the K. Lumpurschool were studied because the asthmatic children selected in the Terengganuschools were made up of only ethnic Malays. At the same time, the predictionequations were based on sex and racial ethnicity. Therefore, other ethnicgroups had to be excluded.12 PertanikaJ. Sci. & Techno\. Vo\. 12 No. 1,2004Comparison of Lung Functions Among A~thmatic Children in MalaysiaRFSULTS AND DISCUSSIONSRespondents' Background InformationThe background and socioeconomic information of the asthmatic children areshown in Tables 1, 2 and 3. The mean age between the 2 groups of asthmaticchildren were about the same. The 163 children in Kuala Lumpur, were madeup of 143 Malays, 10 Chinese and 10 Indians. There were 98 male children and103 female children in both areas and the numbers were almost equal.The household income in Table 2 shows that the children in K. Lumpur(RMI170.40) were in the lower middle class socioeconomic group while thechildren in Terengganu (RM586.80) were in the lower class socioeconomicgroup. About half of the families in K. Lumpur had household incomes ofmore than RMI000 while in Terengganu, all of the families have householdincomes of less than RMI000. The difference in their total incomes wasstatistically significant (Table 3). In K. Lumpur, the fathers were mostlybusinessmen (34.4%), officers or office assistants (8.3%) and technicians(8.3%). In Terengganu, the majority of the fathers work as drivers (18.4%),businessmen (13.2%), labourers (13.2%) and fishermen (13.2%). The mothersin K. Lumpur (47.2%) and in Terengganu (81.6%) are mostly housewives.TABLE 1Respondents' background informationLocation Total (n) SexBoys GirlsMean age Race (n)K. LumpurTerengganu163388117822110 yrs 2 mth10 yrs 1 mthMalayChineseIndianMalay143101038TABLE 2Comparison of respondents' socioeconomic background in the study areasKuala Lumpur(mean±s.d)Household 1170.37 ± 755.44income(RM)Length of 98.34 ± 33.94residency (mth)Length of stay 48.36 ± 10.20in school (mth)s.d = standard deviationmth =monthTerengganu(mean±s.d)586.84 ± 194.41103.89 ± 32.9350.52 ± 11.31p-value(t-test)0.0010.3560.282PertanikaJ. Sci. & Technol. Vol. 12 No.1, 2004Zailina Hashim, Juliana Jalaluddin & Jamal H. HashimTABLE 3Household income of respondents in the study areasHousehold income< RM500RM500 - RMlOOORMlO01 - RM1500RM1501 - RM2000> RM2000a: n=163b: n=38Kuala Lumpur"Total (%)6 (3.7)84 (51.5)37 (22.6)23 (14.1)13 (8.1)Terengganu"Total (%)12 (31.6)26 (68.4)The children in K Lumpur have resided in the area for an average lengthof 98.34 months (-8.16 years) and have been attending the school for anaverage period of 48.36 months (-4. 03 years). The children in Terengganuhave resided and attended the school for an average period slightly longerthan the children in K Lumpur (Table 2).Only about half of the K Lumpur (49.1%) and Terengganu (44.7%)children have a family history of asthma (Table 4). They inherited the diseasefrom their parents, grandparents or siblings. However, the other half of thesechildren must have contracted the disease by other means. This type of asthmais called extrinsic asthma. It can be caused by several factors such as food,emotional stress, cigarette smoke, dust, medicine and physical exhaustion(Rahmat 1992). According to Azizi (1994), environmental pollutants in theatmosphere can trigger asthmatic attacks.The asthmatic children in K Lumpur usually get treatment from hospitalsand clinics (73.6%). Their asthmatic conditions are probably more severe thanthe Terengganu children because they were prescribed with Becotide® andVentoline® (33.2%) which are bronchodilater medications (Table 4). Asthmaticattacks are a great concern for parents in K Lumpur due to the frequency andseverity of the attacks on the children. The percentage who seek treatment atclinics or hospitals is also higher in K Lumpur (73.6%) than in Terengganu(5.8%). Table 4 also shows how parents perceive their children's asthmaticattacks. It seems that the attacks among the K Lumpur children are moresevere than those among Terengganu children.The Lung FunctionsFigs. 1 to 4 show the distribution of FEV) % predicted and %FEV/FVC amongthe asthmatic children in both areas according to their sex. The classificationwas based on Miller et at. (1978). The mean FEV) % predicted among theasthmatic children in Kuala Lumpur (87.66) was lower than the asthmaticchildren in Terengganu (100.01).14 PertanikaJ. Sci. & Technol. Vol. 12 No.1, 2004Comparison of Lung Functions Among Asthmatic Children in MalaysiaTABLE 4Comparisons of medical history, medication and severity of asthmaattacks of children in the study areasTotal (%)Family history ofasthmaMedication (Becotide3(Glaxo) & Ventoline\!l(Glaxo»Percentage who seekclinic or hospitaltreatmentSeverity of asthmaattacks-Very severe-severe-Moderate-Milda: n=163b: n=38K. Lumpur"81 (49.7)54 (33.2)120 (73.6)5 (3.1 )14 (8.6 )102 (62.6)42 (25.8)Terengganu I.17 (44.7)2 (5.79)29 (76.3)9 (23.7)p-value(Chi-square)0.7780.0010.597Table 5 shows the difference in the means of FEV, % predicted between the2 groups with regard to sex. The mean FEV! % predicted value for the males(75.19 ) and females (83.03 ) in K. Lumpur was lower than the males (91.73)and females (100.24) in Terengganu. Statistics showed that there was a significantdifference in the mean FEV! % predicted value between both groups. Asthmaticchildren in Terengganu have better expiratory air flow from the lungs comparedto the K. Lumpur children.The measurements of %FEV/FVC, were also carried out according to sexas shown in Table 6. The mean %FEV/FVC for the males (75.70) and females(84.81) in K. Lumpur was lower than that of the males (94.91) and females(92.21) in Terengganu. However, the difference was only significant for themales (p = 0.002).As for the mean FEV/FVC% predicted, the mean for male children (82.76)and female (91.41) in K. Lumpur was also lower than the Terengganu male(102.67) and female (l00.39) respectively (Table 6). However, similar to the%FEV/FVC, a significant difference in FEV/FVC% predicted was found onlyamong the male children. This implies that the lung obstructiveness in themale K. Lumpur children was more severe than that of Terengganu.PertanikaJ. Sci. & Technol. Vol. 12 No. 1,2004 1579-65 MILD 64-45 44-20MODERATE SEVEREFEV1 value9018070~ 60II 50gI~ 40IIl:!II 3011.//20100>80NORMALZailina Hashim, Juliana Jalaluddin & Jamal H. Hashim,--'--J..-~-L.-..IO!O---.-...L.-.lC-----.-~ /<20 VERYSEVEREFig. 1: Distribution of FEV, % predicted among asthmatic boys in the study areas1009080/70~ 60IIgI• 50-CII40u"-II11. 3020100>80NORMAL79-65 MILD 64-45MODERATEFEV1Value44-20SEVERE-,-'?#,--,,"----(,/<20 VERYSEVERE [D~~I16Fig. 2: Distribution of FEV, % predicted among asthmatic girls in the study areasPertanikaJ. Sci. & Techno\. Vol. 12 No. 1,2004Comparison of Lung Functions Among Asthmatic Children in Malaysia,------- --- - -1009080~ 70"6001• 501:" 40~:. 3020100~~ ~~,,:::E" 0Z~"'Wrole:;Yv>~W>FEV1/FVC valueFig. 3: Distribution of FEV,IFVC% predicted among asthmatic bays in the study areas100908070605040302010o/-L:4/ L/_.- - -/ >-- -/ I-----~-/ --- - -v' -V - -- - --- - -/ ---- -- -- -/"-((I B'--JL ~T ~r , ..-I 00 W W We( <fi>-1 ~ IOrr rrIO:!: v- oe( NW w1'0:: f':!: v 0:: en> IO>"0 'w MW~o N WZ C/) yC/)0 >-:!: 0::W>FEV11FVC valueFig. 4: Distribution of FEV,IFVC% predicted among asthmatic girls in the study areasPertanikaJ. Sci. & Technol. Vol. 12 o. 1,2004 17Zailina Hashim, Juliana Jalaluddin & Jamal H. HashimTABLE 5Comparison of means for FEV. % predicted betweenasthmatic children in the study areasVariablesFEV, % Predicted(Male)FEV, % Predicted(Female)Total (n)a=68 b=17c=75 d=21K. LumpurMean ± s.d75.19" ± 24.3883.03' ± 28.31TerengganuMean ± s.d91.73" ± 14.82100.24 d ± 18.34p value(t- test)0.0020.011TABLE 6Comparison of means for FEV, /FVC between asthmatic children in the study areasVariables%FEV/FVC (male)%FEV/FVC (female)FEV/FVC %Predicted (male)FEV/FVC %Predicted (female)Total (n)a=68 b =17c=75 d=21K.L Mean ± s.d75.70" ± 23.2784.81' ± 22.5082.76" ± 23.9791.41' ± 24.55TR Mean ±s.d94.91" ± 7.1992.21 d ± 5.51102.67b ± 8.05100.39d ± 10.28p (t-test)0.0020.1260.0010.092The results showed that there was an inverse correlation between thefrequency of asthma attacks and all of the lung function measurements amongthe children in K Lumpur (Table 7). This suggests that children who experiencemore frequent asthma attacks have deficient lungs. However, in Terengganu,the correlation between the frequency of the asthma attacks and the lungfunction was not statistically significant. Terengganu children have milderasthma attacks than the Kuala Lumpur children. Lung function deficiency wasdue to the severity of the asthma attack experienced by these children.Results by others (Marko 1980; Forestiere et aL 1994; Schmitzberger et aL1993) also found that children who lived in polluted areas had lower lungfunction measurements than those in less polluted areas. Boys are usually moreactive than girls and are more exposed to polluted outdoor environments.Therefore, their lung function capabilities would be more affected (Paumels1986).The Multiple Regression "enter" method conducted on the individualasthmatic attacks for all the children have a statistically significant relationship18 PertanikaJ. Sci. & Technol. Vol. 12 No. 1,2004Comparison of Lung Functions Among Asthmatic Children in MalaysiaTABLE 7Correlation between individual asthma attacks with lung functions in the study areasKuala Lumpur(n=163)Terengganu(n=38)r value p value r value p valueFEV, % predictedFEV/FVC % predicted% FEV/FVC-0.206-0.317-0.3430.0080.0010.0010.0480.139-0.2460.7750.4050.136with only %FEV/FVC when all other confounding factors are controlled(Table 8), even though the R2• value is only 12.4%. Atmospheric pollutants suchas respirable particulate (PMIO) and gases are foreign materials that canpromote or increase the overall bronchiole hyperactivity, thus obstructing orrestricting bronchioles repetitively by causing mucuosal edema. This can causeabnormal air flow in the lungs and as a result, cause lung function inefficiency.TABLE 8Relationship between individual asthma attacks with selected variablesRegression t value p valueCoefficient3.856 0.969 0.3341.902 1.693 0.0921.541 1.396 0.1644.191E-o.2 1.463 0.1454. 146E-0.2 0.704 0.482-0.193 -2.728 0.007'enter' method'Multiple Regression' forF statistics = 5.698P value = 0.01R value = 0.387adjusted R2 value 0.124Independent variableConstantSexFood tabulationFEV) % PredictedFEV/FVC % Predicted% FEV/FVCCONCLUSIONSOn the whole, the results of FEV,% predicted showed that the asthmaticchildren in Terengganu have better lung function capacity compared to theircounterparts in Kuala Lumpur. Statistical results showed that the difference inthe obstructiveness as indicated by the FEV) values was significant between boththe males and females in both study areas. The degree of severity of the asthmaattacks as shown by the %FEV/FVC also differ significantly among the malechildren in both areas. The K. Lumpur asthmatic children have poorer lungPertanikaJ. Sci. & Techno!. Vo!. 12 No. 1,2004 19Zailina Hashim, juliana jalaluddin & jamal H. Hashimcapacity and functions and experience more severe asthma attacks thanTerengganu children as indicated by the %FEV/FVC .Atmospheric pollutants influence the lung function efficiency of thesechildren. Even though the medical facilities are better in Kuala Lumpur, thechildren are more exposed to these pollutants. The children in Kuala Lumpurare experiencing more serious asthmatic problems than in Terengganu due tothe high industrial and traffic activities in these urban areas which contributeto air pollution.REFERENCESAmerican Thoracic Society. 1978. Health Effects oj Air Pollution. p.I-25. American LungAssociation, 1740 Broadway, New York.AzIZI B.H.O. and R. L. HENRY. 1994. Ethnic differerences in normal spirometric lungfunction of Malaysian children. Respiratory Medicine 88: 349-356.FORESTIERE F., M. G. CORBO, R. PISTEI.I., M. PAOlA, N. AGABATI, B. CIAPPI and A. G. PERUCCL1994. Bronchial responsiveness pollution levels. Archives of Environmental Health63(5): 113-120. Washington, D.C.MARKO, S., F. MIRRA and H. OMER. 1980. Effect of urban air pollution on school agechildren. Achives of Environmental Health 36(3): 101-107.MILLER, W. F., R. SCACCI and L. R. GAST. 1978. Laboratory Evaluation Pulmonary Function.Phidade1phia: J.B. Uppincott. Company.MURRAY, A. D. 1979. The physiological basis of pulmonary function testing. ClinicalSymposia 31(2): 1-30.PAUMEIS R., P. D. S AI SHALl. and C. H. BOWKER. 1986. A Practical Approach to Asthma. CBAPublishing Services on Behalf of Fison Pic. 2-30.RAHMAT, H. 1992. Asma. p.15-20. Petaling Jaya: Fajar Bakti Sdn. Bhd.SCHMIIlBERGER R., B. K. RHOMBERG, R. PUCHEGGER, N. D. SCHMIIlBERGER, G. KEMMLER andN. PA OSH. 1993. Effects of air pollution on the respiratory tract of children. PediatricPulmonology 1592: 68-74.20 PertanikaJ. Sci. & Technol. Vol. 12 o. 1,2004

Comparison of Lung Functions Among Asthmatic

Children in Malaysia

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Comparison of Lung Functions Among Asthmatic Children in Malaysia

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