Evaluation and determinants of asthma control among adult patients with asthma attending the Johannesburg academic respiratory clinics: A cross-sectional study

Will a nasal corticosteroid improve control for patients with step 3 or higher persistent asthma?

Background: There are insufficient data on changes in disease control after severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) infection or vaccination in patients with nonsteroidal anti-inflammatory drug exacerbated respiratory disease (N-ERD). Objective: This study aimed to investigate the history of coronavirus disease 2019 (COVID-19) in patients with N-ERD, determine whether they experienced exacerbations of asthma or rhinitis after COVID-19, and evaluate their postvaccination asthma and rhinitis control data. Methods: The demographic characteristics of patients with N-ERD and whether they had had symptoms of asthma, changes in nasal symptom scores Sino-nasal outcome test (SNOT-22), Asthma Control Test (ACT) within 1 month after SARS-CoV-2 vaccination or infection were recorded. The prevalence of COVID-19 in patients with N-ERD and in healthy controls was estimated. Results: A total of 103 patients with N-ERD and 100 healthy controls were included in the study. Thirty seven of the patients (35.9%) and 65 of the controls (65%) had a history of COVID-19. There were no significant differences in changes in the ACT and SNOT-22 scores after SARS-CoV-2 vaccination (p = 0.999). Although, the change in ACT score after infection was significant (p = 0.017; r = 0.39), there was no significant change in level of asthma control (p < 0.001). Conclusion: The history of COVID-19 was less frequent in the N-ERD group. There was no deterioration in asthma and rhinitis controls after SARS-CoV-2 vaccination. Although a significant decrease was observed in the ACT scores after COVID-19, there was no deterioration in the level of asthma control.

The present issue of Multidisciplinary Respiratory Medicine includes a paper by Bora et al. [1] investigating the relationship between the asthma control test (ACT) and airway inflammation. In a group of stable asthmatic patients admitted to a pulmonary outpatient clinic, the authors carried out the ACT, pulmonary function tests, methacholine bronchial provocation test (MBPT), fractional exhaled nitric oxide level (FeNO), and induced sputum test. All these parameters were re-evaluated the third month after adjusting patients' medications according to baseline ACT scores. In the paper there is no description of the adjustments made to the therapy. The conclusion of the authors is that, although ACT scores did not show significant correlations with the airway inflammation parameters tested in the study, a marked reduction in the percentage of patients with MBPT positivity and FeNO > 20 ppb in the follow up may underscore the importance of focusing on the control concept in the management of asthma. Today asthma treatment is based not only on assessing asthma severity, but also on achieving and maintaining asthma control [2-4]. There is general agreement that a great proportion of people with asthma are not optimally controlled [5,6]. Over a period of several years, numerous tools have been developed to determine the level of asthma control with the main aim of guiding treatment changes [7-9]. A step-up in treatment is recommended in order to achieve asthma control in uncontrolled patients and a step-down is suggested in well controlled patients [2]. ACT has been shown to be useful in the detection of poorly controlled asthma both in adults and children [9-11]. ACT is a 5-item, self-completed questionnaire. The five items evaluate: limitation of daily activities, shortness of breath, night-time waking, use of reliever medication and the patient's perception of asthma control in the 4 weeks prior [9,10]. For each question there are five possible answers, scored from 1 to 5. The total ACT score is the sum of the scores attributed to the five questions, ranging from 5 (poorest asthma control) to 25 (optimal asthma control). ACT has been validated for adult asthmatic patients and there is also a validated version for children [11]. It is accepted that a score lower than 19 indicates poorly controlled asthma. Since its validation and publication, ACT has been used extensively in clinical trials, mainly because it allows a more objective evaluation of asthma control than that performed by the physician during a spot visit [11-13]. Moreover, it has been demonstrated that patients also tend to overestimate the level of asthma control and sometimes also the extent of improvement achieved after therapy [12,13]. Finally, previous studies have also confirmed the reliability of the ACT score in guiding clinical decisions [14,15]. In Bora et al.'s study the ACT score did not significantly correlate with airway inflammation parameters and did not change from baseline visit (mean ACT score = 18.98 ± 4.59) to follow up visit (mean ACT score = 19.65 ± 4.11), and patients had good baseline respiratory function (mean FEV1 = 93.9 ± 13.7%), without significant modification follow up. Interestingly, despite the lack of respiratory function and ACT score changes, there was a statistically significant reduction in the percentage of patients with MBPT positivity (from 59% to 45% of patients, p = 0.029) and FeNO > 20 ppb (from 15 to 14, p = 0.025) the follow up visit. These findings could confirm the importance of focusing on control in the management of asthma, as the ACT is a very simple test, and more rapid to perform than a complete spirometry, obviously not burdening for patients or potentially at risk as MBPT or FeNO test. This study confirms that ACT can be widely used in clinical practice, but it does not give reliable information and does not correlate with airway inflammation.

Measuring childhood asthma control

Introduction: Various initiatives and medications have been introduced to achieve better control of bronchial asthma. However total control according to Global Initiative for Asthma (GINA) remains elusive even at tertiary referral hospitals. Our study is to determine the level of asthma control (according to GINA 2009), Asthma Control Test (ACT) scores and the types of medications used among patients with bronchial asthma in a large tertiary hospital. Methods: A cross-sectional study of all patients with bronchial asthma who attended the Chest Clinic at Hospital Tengku Ampuan Afzan (HTAA) from 2009 to 2011. Patient demographics, self-administered ACT scores, GINA-defined level of asthma control and medications were documented. Results: 208 patients were recruited. There were 23.2%, 46.3% and 30.5% of patients with controlled, partly controlled and uncontrolled asthma respectively. The median ACT scores was 19 [inter quartile range (IQR) 6]. The most frequently used preventer therapy was inhaled long-acting β-agonist/corticosteroids (LABA/ICS) fixed-dose combination (61.7%), and 9.6% were not on preventer therapy. 75% of patients with controlled asthma were on LABA/ICS compared to 58.5% of the partly controlled and uncontrolled groups (p=0.039). Conclusion: The majority of the asthmatic patients attending the Chest Clinic at HTAA did not have GINA-defined controlled asthma. Patients with higher ACT scores had better control of asthma. There were more patients with controlled asthma who were on LABA/ ICS combination.

IntroductionA key priority in asthma management is achieving control. The Asthma Control Test (ACT) is a validated tool showing a numerical indicator which has the potential to provide a target...

One of the most important purposes of treatment of asthma is achievement and maintenance of control of the disease. The present study investigated relationship between a level of asthma control and bronchial hyperreactivity (BHR). This study involved 145 outpatients aged 18 to 34 yrs. The control of asthma was evaluated using the Asthma Control Test (ACT). The ACT score of 25 indicated the full control of asthma, the scores between 20 and 24 indicated the good control and the scores < 20 suggested the poor control. BHR was assessed in the methacholine challenge test; PD20 was the dose of methacholine causing 20 % fall in FEV 1 . PD 20 ≤ 0.046 mg suggested high BHR, PD 20 ranged 0.047 mg to 0.228 mg indicated moderate BHR, and PD 20 of 0.229–0.471 mg corresponded to low BHR. Asthma was fully controlled in 17 mild asthma patients (22 %) and was poorly controlled in 13 of them (17 %). No-one of moderate and severe asthma patients had the full control of the disease. Good control of moderate and severe asthma was found in 22 (50 %) and 2 (8 %) respectively, poor control was estimated in 22 (50 %) and 23 (92 %) patients respectively. The mean methacholine concentrations in mild, moderate and severe asthma groups were 0.304 ± 0.011 mg, 0.211 ± 0.019 mg and 0.101 ± 0.015 mg respectively (p = 0.03). BHR was low in all patients with fully controlled asthma with no regards to its severity. The patients with well controlled asthma had predominantly low and moderate BHR, and 9 % of them had high BHR. BHR was also high in 57 % of the patients with poorly controlled asthma. There was a close correlation between the ACT score and PD20 of methacholine (r = 0.78; р < 0.001). In conclusion, the results revealed insufficient quality of outpatient treatment of asthma, particularly of moderate and severe asthma. ACT is reasonable to be used in wide clinical practice, especially in primary care settings.

Background Asthma is a common clinical Condition, its inflammatory disorder of air passage in which many cell and elements play a role, its non-communicable, non-curable, reversible obstructive airway disease. Most of the patients with asthma are not well controlled according to guidelines. The best way for management bronchial asthma is to control the disease, once asthma is controlled, it allows patients to do everything just like a normal healthy person, this might be achieved by good knowledge about the disease, because asthma may affect anyone regardless age, education level, and location. Objectives The goal of the study is to identify how asthma knowledge differs among groups of people and find out the relationship between the patient's knowledge and their level of asthma control in Sulaimani. Patients and Methods A cross-sectional study with randomized sample was collected from one hundred asthmatic patients in Sulaimani, using questionnaires filled in via a direct interview which consisted of three parts: 1- sociodemographic, 2- asthma knowledge, and 3- asthma control test. The relationship between asthma knowledge and demographic factors and asthma control levels was determined. The collected data were reviewed and analyzed using the Statistical Package for Social sciences (SPSS version 22). P value was obtained for the continuous variable using chi square, and considered significant if it was less than 0.05. Results The asthma knowledge was adequate, only 0.9% of these patients had a good knowledge, 58% had adequate knowledge, and 33% had poor knowledge. Most participants (62%) had poor asthma control, 35% had partial control, and only 3% had complete control. The higher the patient’s level of control, the better the asthma knowledge scores, Conversely, patients with better knowledge of asthma had better asthma control based on the Asthma Control Test score (p= 0.001). Also, a higher education level was associated with more asthma control level (p=0.001). Conclusion In these patients, the level of asthma control was low and significantly correlated with the level of asthma knowledge. There is a clear need to improve knowledge in order to improve asthma control in Sulaimani.

Modified School-Based Asthma Therapy Targeting Poorly Controlled Asthma

BackgroundMost asthma patients in Vietnam have poorly controlled asthma. Besides reasons related to the health care system and health care providers, knowledge on the self-management of patients has also contributed to this situation.PurposeTo assess knowledge on asthma self-management among adult asthma patients in Ho Chi Minh City.Patients and methodsA cross-sectional study with convenience sampling was conducted among 322 ambulatory patients using questionnaires filled in via a face-to-face interview. The questionnaires enquired about: 1) sociodemographic details, 2) the Global Initiative for Asthma 2017 criteria of asthma control, 3) the Asthma Control Test, and 4) the Asthma Self-Management Questionnaire (ASMQ). Knowledge on asthma self-management was determined by the ASMQ score. The relationship between this knowledge and demographic factors and asthma control levels was determined.ResultsThe knowledge on asthma self-management was low, with a mean raw ASMQ score of 4.3 (maximum 14); this is equivalent to 30 in a transformed score (maximum 100). Only 0.3% of these patients had good knowledge, 16.2% had adequate knowledge, and 83.5% had poor knowledge. Of all participants, 52% stated erroneously that asthma can be cured, 30% were confused about control and rescue medications, 68% failed to correctly describe the inhalation technique, and only 15.5% could answer correctly about the management of an exacerbation. Although most participants had poor asthma control, the higher the patient’s level of control, the better the ASMQ score. Conversely, patients with better knowledge of asthma self-management (ASMQ score ≥50) had better asthma control based on the Asthma Control Test score. Also, a higher education level was associated with more knowledge on asthma self-management.ConclusionIn these patients, the level of knowledge on asthma self-management was low and significantly correlated with the level of asthma control. There is a clear need to improve knowledge in order to improve asthma control in Vietnam.

Global Initiative for Asthma (GINA) reports emphasize the use of validated and simple tools in order to assess the level of asthma control, as the Asthma Control Test (ACT). However, an ACT does not include assessment of airway inflammation, which is better reflected when measuring nonspecific bronchial hyperresponsiveness (BHR). The authors aimed to find out if the level of asthma control quantified by an ACT correlates with BHR and pulmonary function tests. 118 asthmatics participated in the study. All patients completed an ACT. The scores of the ACTs were compared with pulmonary function tests and BHR assessed with the methacholine challenge test and expressed as a provocative concentration of methacholine, inducing a 20% decline in the FEV1 (PC20 M in mg/ml). Patients with controlled asthma amounted to 52 (44%) while those with uncontrolled asthma amounted to 66 (56%). In patients with controlled asthma (ACT score ≥ 20) the mean geometric value of PC20M was 2.72 mg/ml (range from 0.25 to > 8.0), whereas 0.94 mg/ml (range from 0.28 to 8.0) (p = 0.02) was observed in patients with uncontrolled asthma (ACT score < 20). Almost 64% (21/33) of uncontrolled asthmatics achieved normal lung function (FEV1 > 80% pred. value) while 19% (5/26) patients with controlled asthma presented an FEV1 < 80% predicted value. Asthma duration in years in controlled asthmatics was significantly shorter than in uncontrolled patients (6.2 ± 8.9 vs. 12.0 ± 11.4, p = 0.005) CONCLUSION: In determining the most accurate level of asthma control it is reasonable to use an ACT in conjunction with BHR, which provides more accurate assessment of bronchial inflammation than ventilatory parameters alone.

Poor asthma control can lead to exercise-induced bronchoconstriction (EIB), but the relationship between subjective disease control and EIB is unclear. No studies have compared asthma control test (ACT) scores of children with those of their parents regarding EIB. We assessed whether ACT scores predict the occurrence of EIB in two age groups. We also evaluated ACT scores and objective measures as explanatory variables for airway response to exercise. Patients (71, aged <12 years; 93, aged ≥12 years) and their parents completed an ACT questionnaire separately. Current therapy, skin prick testing, and spirometry at baseline and after exercise were assessed. EIB was defined as a fall in forced expiratory volume in 1 s (FEV1) of at least 12% from baseline. Sensitivity and specificity for cut-off values of ACT scores predictive of EIB were plotted, and the area under curve (AUC) was described. Atopy and current therapy were similarly frequent. EIB was observed in 23.9% of children aged <12 years and in 33.3% of children aged ≥12 years. EIB occurrence in subjects previously scored as having full control (25), partial control (20-24), and no control (<20) varied according to the age group and responders. Percentages of EIB cases increased as ACT scores decreased in children aged ≥12 years alone (child ACT scores, 25: 21.9%, 20-24: 31.1%, <20: 62.5%, p = 0.017). Plots for ACT scores as predictors of EIB yielded low non-significant AUC values in children aged <12 years; in contrast, moderate AUC values emerged in children aged ≥12 years (child: 0.67, p = 0.007; parent: 0.69, p = 0.002). Sensitivity of ACT scores below 20 as a predictor of EIB was low in older children (child: 32.3%, parent: 22.6%), whereas specificity was high (child: 90.3%, parent: 93.5%). Multiple regression analysis with percent fall in FEV1 as dependent variable included FEV1/FVC%, ACT child score, and gender in the prediction model (r = 0.42, p = 0.000). ACT scores are a more effective means of excluding than confirming EIB in asthmatic patients aged ≥12 years; their predictive value decreases in younger patients. ACT scores together with lung function may help to predict airway response to exercise. New tools for pediatric asthma assessment may optimize this association.

Objective. Evaluate the relationship between Asthma Control Test™ (ACT) and exercise-induced bronchospasm (EIB) in 81 asthmatic children. Methods. EIB was assessed in every patient by Balke protocol and asthma control was evaluated by ACT. Patients were divided into three groups: Group A (30 patients) with complete asthma control (ACT score = 25), Group B (37 patients) with partial asthma control (ACT score = 21–24), and Group C (14 patients) with poor asthma control (ACT score < 20). Results. About 36% (11/30) of patients in Group A (with complete asthma control) tested positive for EIB, whereas 21% (8/37) in Group B (with partial asthma control) and 28% (4/14) in Group C (with poor asthma control) exhibited EIB. The percentage of positive EIB was very similar between the three groups with no differences between controlled, partially controlled, and uncontrolled asthma. Statistical evaluation by χ2-test between complete (ACT score = 25) and not complete asthma control (ACT score < 24) confirmed a statistically significant difference (p < .01) between the obtained data. Conclusions. It must be stated that ACT alone is not sufficient to evaluate asthma control in children correctly because it fails to detect EIB in a significant percentage of subjects.

To examine how asthma control is related to the association between the division of responsibility for asthma management and asthma-related quality of life among early adolescents. Forty-nine youth aged 10-15 years (Mage = 12.25, 57.1% female) with a physician-verified asthma diagnosis completed the Standardized Pediatric Asthma Quality of Life Questionnaire (PAQLQ) and Asthma Control Test (ACT). Youth and their caregivers also completed the Asthma Responsibility Questionnaire (ARQ). Higher ACT scores indicate better asthma control. There was a significant difference in ARQ scores between youth and caregivers (p < .001, d = .94). Youth reported sharing equal responsibility for asthma management with caregivers, while caregivers reported having more responsibility relative to youth. Greater youth-reported ARQ (p = .004) and greater ACT scores (p < .001) were associated with higher PAQLQ scores. ACT scores moderated the effect of youth-reported ARQ on PAQLQ scores (p = .043). For youth with lower ACT scores, higher youth-reported responsibility was associated with higher PAQLQ scores; while for youth with higher ACT scores, PAQLQ scores were high regardless of perceived responsibility. The interaction between caregiver ARQ scores and ACT scores was not significant. This study suggests youth and caregivers report discrepant ARQ for asthma management tasks. Responsibility and level of asthma control are important factors for PAQLQ, with results indicating that fostering responsibility is an important factor, even among youth with poorly controlled asthma. Findings suggest that healthcare providers should assess family responsibility and help caregivers support adolescents in developing asthma management skills.

Background Asthma is a chronic inflammatory disease of airways. Gastroesophageal reflux disease (GERD) is known to be associated with worsening asthma. We hypothesized that treatment of GERD in asthmatics will improve asthma control and quality of life. We reviewed our experience of treatment of GERD in asthmatics in Thailand. Objectives To study the effects of omeprazole for treatment of GERD in patients with poorly controlled asthma on pulmonary function tests and asthma control test (ACT) scores. Methods This study was conducted at King Chulalongkorn Memorial Hospital between August 2009 and December 2010. Patients with partly controlled and uncontrolled asthma who were found to have GERD by 24 hour esophageal pH monitoring were administered omeprazole 40 mg per day for 8 weeks. Pulmonary function tests and ACT scores before and after treatment were compared at 4-weeks and 8-weeks follow up. Results Twenty four patients were included in this study. None of them had asthmatic attacks during the study. After 4 and 8 weeks of omeprazole treatment, the mean FEV1 (2.20 ± 0.64 L, 2.36 ± 0.58 L, respectively) and the mean ACT score (20.82 ± 3.30, 23.00 ± 1.69, respectively) were significantly higher than the pretreatment values (mean FEV1 1.99 ± 0.56 L and ACT score 16.36 ± 3.97) (P &lt; 0.05). Conclusion High-dose omeprazole may improve pulmonary function and the level of asthma control in Thai patients with partly controlled or uncontrolled asthma and coexisting GERD.