Management Of Asthma In Adults Research Articles

Management of Chronic Asthma in Adults

Asthma is a chronic inflammatory disease of the airways. It is characterized by recurrent episodes of dyspnoea, wheeze and cough caused by reversible airways obstruction. Three factors are responsible for the airways narrowing: bronchial muscle contraction, mucosal swelling/inflammation and increased mucous production ( Fig. 1 ). About 10–15% of the UK population have asthma and the number appears to be growing although there is some difficulty understanding why. It affects 1 in 20 adults and 1 in 10 children. Approximately 5.1 million people are currently being treated for asthma in the UK.

Medical management of asthma in adults

The stepwise approach to asthma management is well established in primary care, writes Dr David Morris.

Management of life-threatening asthma in adults

Asthma is a disease of predominantly reversible airway obstruction characterized by a triad of bronchial smooth muscle contraction, airway inflammation, and increased secretions; it is a major health problem for all age groups. For the majority, control of asthma symptoms is readily achieved; however, in a small minority, asthma may cause death. Although the mortality rate for asthma in those aged less than 65 yrs is now falling, there remain around 1400 asthma deaths in the UK each year (http:// www.laia.ac.uk/kf_asthma_03.htm). Most of these occur in the pre-hospital setting and, in retrospect, the majority is considered potentially preventable. Factors associated with asthma death include disease severity, inadequate treatment, inadequate monitoring, the under use of written asthma management plans and adverse psychosocial and behavioural factors (www.sign.ac.uk/guidelines/fulltext/63/ index.html). Levels of severity of acute asthma exacerbations have been defined. The features of acute severe, life–threatening, and near fatal asthma are listed in Table 1. Of note, patients with life-threatening asthma may not appear distressed and might only display one of the features listed. Life-threatening asthma tends to occur as two sub-types. Most commonly, there is a history of progressive worsening of symptoms over several days; the majority of patients in this group report nocturnal dyspnoea in the previous three nights. As a result of greater bronchial inflammation and mucous secretion, this group (occurring more frequently in females) tends to respond more slowly to treatment. In contrast, a smaller sub-group, more frequently male, presents with a rapidly progressive condition with highly reactive airways. These patients have intense bronchospasm that often responds more rapidly to bronchodilator therapy. In February 2003, The British Thoracic Society together with the Scottish Intercollegiate Guidelines Network published guidelines on the management of asthma (http://www.britthoracic.org.uk/asthma-guideline-download.html). They were updated in November 2007. In common with other recommendations, these give guidance only up to the commencement of intensive care. Evidence for therapies in intensive care from randomized controlled trials remains sparse. Ongoing management of lifethreatening episodes (Fig. 1) is often difficult with rapid and dynamic changes in physiology. Complications of treatment are frequent.

RETRACTED ARTICLE: Inhaled corticosteroids and long-acting beta-agonists in adult asthma: a winning combination in all?

In the recent years, considerable insight has been gained in to the optimal management of adult asthma. Most adult patients with asthma have mild intermittent and persistent disease, and it is acknowledged that many patients do not reach full control of all symptoms and signs of asthma. Those with mild persistent asthma are usually not well controlled without inhaled corticosteroids (ICS). Studies have provided firm evidence that these patients can be well controlled when receiving ICS, especially when disease is of recent onset. This treatment should be given on a daily basis at a low dose and when providing a good response should be maintained to prevent severe exacerbations and disease deterioration. Intermittent ICS treatment at the time of an exacerbation has also been suggested as a strategy for mild persistent asthma, but it is less effective than low-dose regular treatment for most outcomes. Adding a long-acting beta-agonist (LABA) to ICS appears to be unnecessary in most of these patients for optimising control of their asthma. Patients with moderate persistent asthma can be regarded as those who are not ideally controlled on low-dose ICS alone. The combination of an ICS and LABA is preferred in these patients, irrespective of the brand of medicine, and this combination is better than doubling or even quadrupling the dose of ICS to achieve better asthma control and reduce exacerbation risks. An ICS/LABA combination in a single inhaler represents a safe, effective and convenient treatment option for the management of patients with asthma unstable on inhaled steroids alone. Ideally, once asthma is under full control, the dose of inhaled steroids should be reduced, which is possible in many patients. The duration of treatment before initiating this dose reduction has, however, not been fully established. One of the combinations available to treat asthma (budesonide and formoterol) has also been assessed as both maintenance and rescue therapy with a further reduction in the risk for a severe exacerbation. Clinical effectiveness in the real world now has to be established, since this approach likely improves compliance with regular maintenance therapy.

Community pharmacist care impact on asthma management in adults*

Community pharmacist care impact on asthma management in adults*

Management of asthma in adults: Do the patients get what they need—and want?

Suboptimal asthma control may be caused by a combination of factors, such as nonadherence to guidelines, lack of compliance, and poor asthma education. The aim was to assess patients' knowledge of asthma and different management strategies, including patients' attitudes toward involvement in treatment decisions. The participants (n=509) were recruited from all parts of Denmark through a web-based panel (Zapera Danmarkspanel). A questionnaire concerning asthma knowledge, compliance, and treatment was fulfilled through the Internet. Among the participating adult asthmatic patients, signs of uncontrolled disease with night asthma (16%), daily symptoms (18%), or exercise-induced asthma (11%) were found. Of 285 participants with persistent asthma, 70% used inhaled corticosteroids. Lung function was measured within the preceding 6 months in 24% of patients, whereas 7% had never had their lung function measured and peak flow monitoring was reported by 5%. Written action plans were provided for 12% of patients and 50% had had their inhaler technique checked. Although 59% of patients were instructed to adjust their controller therapy if needed, only 23% reported that they had done so. In conclusion, this study of adult asthmatic patients revealed an important deficit in patient education, little use of lung function measurements, and poor compliance with guidelines for asthma management. Furthermore, asthmatic patients want more education, although they do not use it when provided by their doctor, indicating that change in educational strategy is needed.

Evidence‐based implementation of adult asthma guidelines in the emergency department: A controlled trial

To determine if an evidence-based implementation (EBI) strategy could lead to the successful implementation of guidelines for the management of adult asthma in a large rural ED. This was a pre- and post-intervention trial, comparing data for seven clinical indicators from a study hospital and a control hospital. Retrospective pre-intervention audits were conducted at the study hospital for 3 months (1 April-30 June 2004) and the control hospital for 4 months (1 March-30 June 2004). The effect of an EBI to implement established guidelines for the management of asthma at the study hospital was compared with the effect of a mail-out of guideline booklets and wall charts to the control hospital. Post-intervention audits were then performed at both hospitals. Sustainability of the EBI was gauged by 12 month follow-up data at the study hospital. There were 55 presentations of adult asthma at the study hospital in the pre-intervention phase and 67 post-intervention. The corresponding numbers for the control hospital were 51 and 42, respectively. Following the EBI there were significant improvements at the study hospital for the documentation of severity (27-99%, P < 0.01), use of spirometry (38-84%, P < 0.01), medication delivery via spacer device (0-26%, P < 0.01), use of systemic steroids (66-84%P < 0.05), use of written short-term asthma plans (14-82%, P < 0.01), reduction of ipratropium use in mild asthma (43-16%, P < 0.05) and reduction in antibiotic use in afebrile asthmatics (37-6%, P < 0.01). For the control hospital there was a significant increase in spirometry use from 2% to 40% (P < 0.01). For seven clinical indicators combined, compliance with the guideline increased from 38% to 79.1% (P < 0.01) at the study hospital, whereas there was no change at the control hospital, 44.3% to 43% (P = 0.75) There were 68 presentations at 12 month follow up at the study hospital and compliance with the seven clinical indicators was 78.2%. An EBI significantly improved compliance at the study hospital with no improvement noted in the control hospital. These improvements were maintained at 12 month follow up. An EBI can lead to significant improvements in the management of asthma at a large rural referral hospital ED and might have implications for hospitals with similar roles and profiles.

Management of asthma in adults: Current trends and future directions

Bronchial asthma has witnessed a significant increase in its prevalence in the past decade. Considerable morbidity and significant mortality has been associated with it and this has been matched by increased scientific research into new methods of therapy to supplement or replace the traditionally known treatment modalities. A search for old and new literature on asthma management in adults necessitated forage in the library for old works and an internet search into relevant websites to download several works on asthma from which those relevant to this article were selected. Evidences supporting current asthma therapies including some non-pharmacological measures of intervention and alternative approaches were highlighted. Some novel interventions that may be useful in the future management of asthma were discussed. Some novel therapeutic agents acting on specific components of the inflammatory pathways in asthma are emerging. The future management of asthma may involve the use of these newer agents in combination with more established therapies. For successful management of asthma, patient's education and involvement are essential.

Factors associated with acute health care use in a national adult asthma management program

The use of acute health care resources for asthma is considerable. Disease severity is an established risk factor, but ethnicity and health care factors are less well studied. To investigate the independent associations of ethnicity and health care factors with acute resource use for asthma. Longitudinal data from a national adult asthma management program providing universal access to care were analyzed. Outcome measures were unscheduled physician visits with urgent nebulization, emergency department (ED) visits, and hospitalizations. In multivariate analyses, markers of disease severity were found to be significantly associated with all acute resource use. After controlling for disease severity, ethnicity was associated with increased risk of all acute resource use; Indian (vs Chinese) ethnicity was associated with increased risk of unscheduled physician visits (hazard ratio [HR], 1.32; 95% confidence interval [CI], 1.03-1.70), ED visits (HR, 1.61; 95% CI, 1.12-2.32), and hospitalizations (HR, 1.49; 95% CI, 1.03-2.16). Malay ethnicity was associated with unscheduled physician visits (HR, 1.30; 95% CI, 1.01-1.68) and ED visits (HR, 1.55; 95% CI, 1.09-2.19). Default of follow-up appointments was associated with unscheduled physician visits (HR, 1.47; 95% CI, 1.08-2.00), ED visits (HR, 2.35; 95% CI, 1.59-3.45), and hospitalizations (HR, 1.74; 95% CI, 1.09-2.76). Poor inhaler technique was associated with ED visits (HR, 1.86; 95% CI, 1.05-3.30) and smoking with unscheduled physician visits (HR, 1.38; 95% CI, 1.09-1.76). In addition to markers of asthma severity, ethnicity, smoking, discontinuity of care, and self-care behavior are risk factors for acute resource utilization and represent target groups and elements of asthma intervention for improving asthma outcomes.

Poor communication may impair optimal asthma care: a qualitative study

Despite asthma being primarily managed in general practice and primary care, there is little research into the issues and tools which may impact on managing poorly controlled asthma in this setting. To explore the views of health care professionals (HCPs) towards asthma guidelines and self-management plans (SMPs) to identify why these are not used routinely in general practice. Data from 54 HCPs [GPs and practice nurses (PNs)] in north-east Scotland were collected via qualitative interviews and focus groups. Participant views and experience of asthma guidelines and SMPs were explored. Participants had mainly positive attitudes towards guidelines and SMPs, although both were used only when deemed suitable by the individual. Suitability depended on individual patient issues (e.g. psychosocial factors, level of control) and/or professional issues (e.g. ease of use, time available, job roles). Patient issues were viewed as impacting on asthma control directly and, indirectly, as the main reason for not using guidelines or SMPs with a patient. HCPs reported lacking necessary communication skills for dealing with patient asthma control issues, particularly where these were non-medical. Professional and organizational issues such as training and communication were also perceived as impairing asthma management. Our findings indicate that guidelines are seen as providing the 'why' of helping asthma patients' self-manage but not the 'what to...' or 'how to...' communicate. Poor professional-patient communication seems largely to explain the poor uptake of SMPs and guideline use in general practice and primary care. This limitation is more obvious to professionals when they are working with patients with poorly controlled asthma. There is a need to identify key communication skills for effective professional-patient partnership in adult asthma management, and to develop robust strategies for effectively training GPs and PNs in enhancing these skills.

Cost Effectiveness of Leukotriene Modifiers in Adults with Asthma

Asthma is the most common chronic disorder in industrialised nations, with over 100 million people worldwide affected. Leukotrienes are chemical mediators released from mast cells, eosinophils and basophils. They cause bronchoconstriction, an increase in mucous secretions and activation of inflammatory cells. Leukotriene modifiers are a long-term controller medication used to treat asthma. They function by selectively competing for the leukotriene receptor sites, thereby blocking their action, or by inhibiting 5-lipoxygenase and thus preventing leukotriene formation. Both current US and Global Initiative for Asthma treatment guidelines have clarified the role of leukotriene modifiers in the management of asthma in adults and children. Leukotriene modifiers have two distinct roles: to replace inhaled corticosteroids in milder asthma and as an add-on therapy to inhaled corticosteroids in more severe asthma. While efficacy is certainly an important issue, economic considerations are also important in a disease such as asthma where there are a variety of treatment options and the severity of the disease varies widely. This review examined published studies to better understand the cost effectiveness of leukotriene modifiers in adults with asthma. Fifteen articles were found that analysed the cost effectiveness of leukotriene modifiers, with almost all performed in the US. The vast majority of the studies were retrospective claims analyses, but three randomised controlled trials incorporating economic outcomes have been reported. The majority of the articles found that for both monotherapy in mild persistent asthma and add-on therapy in moderate persistent asthma, leukotriene modifiers were less cost effective than inhaled corticosteroids with or without a long-acting beta2-adrenoceptor agonist. However, these results must be viewed cautiously as in several studies there were methodological issues such as comparisons of unequal treatment groups or inappropriate use of leukotriene modifiers in stepwise treatment.

Does Home Use of Peak Flow Meters Improve Asthma Management in Adults

According to guidelines from the National Asthma Education and Prevention Program, peak flow monitoring “should be considered” for patients with moderate or severe persistent asthma. In this randomized trial, researchers assessed the value of peak flow monitoring in …

Asthma Management Issues in Infancy and Childhood

The prevalence of asthma has been increasing worldwide over the past 2 decades, especially the prevalence of childhood asthma. Currently, the prevalence of childhood asthma is around 3-20% in different countries based on the report from the International Study of Asthma and Allergies in Children (ISAAC). Asthma in childhood is predominantly an extrinsic asthma. In general, countries in the coastal, temperate, and subtropical zones have the highest prevalence of mite- and cockroach-sensitive asthma. Countries in the sub-arctic or semi-arid areas have a lower prevalence of childhood asthma, mostly associated with sensitization to pet dander, moulds, and pollens. Many genes have been linked to asthma in different ethnic populations. A global consensus for the management of asthma in adults and children >5 years of age has been made possible in the Global Initiative for Asthma (GINA) guidelines, where a step-wise management program using inhaled medication with and without oral anti-inflammatory drugs is recommended. The management of asthma in children <5 years of age remains inconclusive. Recent studies suggest that inherited susceptibility associated with risk factors from the prenatal and postnatal environment is likely to promote allergic sensitization and development of asthma. Consequently, early prevention of prenatal sensitization in utero and environmental control of early life exposure to various allergens may decrease the incidence of childhood asthma. In the management of moderate persistent asthma in infants and young children <5 years of age, airway resistance tests (FEV(1) or PEF) are not of significance, but assessment of respiratory rate and skin pulse oximeter measurements of arterial oxygen saturation are helpful. Moreover, recent advances in pharmacogenetics and pharmacogenomics may provide better individualized care for early pharmacological prevention of childhood asthma via selective modulation of airway remodeling.

Compliance with guidelines for emergency management of asthma in adults: experience at a tertiary care teaching hospital

Despite evidence-based clinical practice guidelines for the emergency management of asthma, substantial treatment variation exists. Our objective was to assess compliance with the Canadian Association of Emergency Physicians (CAEP) / Canadian Thoracic Society (CTS) Asthma Advisory Committee's "Guidelines for the emergency management of asthma in adults" in the emergency department (ED) of a university-affiliated tertiary care teaching hospital. This retrospective study was conducted in a Canadian inner city adult ED. Investigators reviewed all ED records for the period from Jan. 1, 2001, to Dec. 31, 2001, and identified adult patients (i.e., >18 years of age) with a primary ED diagnosis of asthma. Hospital records were then reviewed to document compliance with the CAEP/CTS asthma guidelines. Descriptive statistics, including means, standard deviations and frequencies were used to summarize information. Overall compliance with the guidelines was 69.6%, (95% confidence interval, 64.7%-74.5%), but compliance ranged from 41.4% for severe asthma, 67.1% for moderate asthma, and 88.6% for mild asthma. Interobserver reliability for compliance assessment was excellent. Despite publication and dissemination of evidence-based guidelines for the management of acute asthma in adults, guideline compliance at a university-affiliated, inner city, tertiary care teaching hospital ED is suboptimal.

The use of the self-management plan system of care in adult asthma

The development of self-management plans arose as clinicians tried to design better methods by which they could deliver asthma care and reduce the significant mortality and morbidity associated with this disease. The basic principles that resulted have been widely endorsed, and self-management plans are now recommended in the long-term management of adult asthma. Self-management plans essentially focus on the early recognition of unstable or deteriorating asthma, by monitoring peak flow or symptoms. Through the use of written guidelines, patients are then able to determine when it is necessary to adjust therapy or obtain medical assistance. There is now convincing evidence that the use of self-management plans by patients with asthma leads to a marked reduction in morbidity and a reduced requirement for acute medical treatment including hospital admissions. Recent research has also clarified many of the different issues concerning their structure and implementation. In some respects the skill in the use of the asthma self-management plan system of care is the ability to modify the standard plans to meet the particular needs of the individual asthmatic patient, including their preferences.

Diagnosis and management of adult asthma

Clinical diagnosis of asthma is usually based on an accurate history, supported by physical examination and confirmed by the demonstration reversible airflow obstruction on repeated measures of lung function.

The management of acute severe asthma in adults

Asthma is a common condition, which can develop into a severe, life-threatening form in any sufferer. Generally, those at risk of an acute attack are women from minority ethnic groups, who have a poor compliance history. Most patients that die of asthma do so in the community. Those who attend the emergency room generally respond to conventional treatments and hospital admission. However, a small proportion of patients will require ITU admission and mechanical ventilation, and, if the admission is not secondary to cardiorespiratory arrest, generally survive. Ventilation techniques that prevent dynamic hyperinflation and the consequent complications of hypotension and barotrauma, are now generally adopted. This includes a pressure-limited mode of ventilation associated with low tidal volumes, high flows and low respiratory rate. Follow up of these patients is essential as they form a very poor prognostic group. Detailed self-management planning, PEFR monitoring and physician review should be therefore encouraged.

Prevalence, morbidity and management of adult asthma in South Australia.

This paper reviews asthma-related data obtained between 1987 and 1997 from self-report population surveys of adults in South Australia. A multistage, systematic, clustered area sample of adults (>15 years) was selected from a random sample of Australian Bureau of Statistics collector districts, and interviewed at home by trained health interviewers. The self-report prevalence of doctor-diagnosed asthma increased from 5.6% in 1987 to 12.2% in 1997. Morbidity measured as days lost from usual activities and nights awakened by asthma remained high, but hospitalization rates are trending down. The ownership of asthma action plans peaked in 1995 and has declined. The ownership of peak flow meters increased between 1992 and 1997, and the ownership of nebulisers remained constant. Evidence-based interventions are required to improve asthma management.

Survey of recognition and utilization of guidelines for the diagnosis and management of bronchial asthma in Japan.

In Japan in 1993, the Japanese Society of Allergology (JSA) developed guidelines for diagnosis and management of asthma (JGL), which were based on the concept that asthma is a chronic inflammatory disorder of the airway. This survey study was intended to investigate the recognition and utilization of JGL among physicians who had treated asthma. The survey comprised two methods: a quantitative mail survey and a qualitative door-to-door survey conducted by trained interviewers. In the mail survey, a total of 1028 physicians responded; 552 members of the JSA and 476 nonmembers. Ninety-four percent of JSA members were aware of adult asthma management guidelines, while 53% of nonmembers were aware of them. Although approximately half of the physicians, both members and nonmembers, found differences between the asthma management policies in JGL and their previous policies, most of them utilized JGL once they read it. In the qualitative door-to-door survey, 80-90% of physicians evaluated JGL as good after they read it. JGL was recognized and utilized by most JSA members, but only half of nonmember physicians were aware of JGL, although they utilized JGL after they read it. Further action to implement JGL among nonspecialist physicians is needed to improve management of asthma.

Changing clinical practice: views about the management of adult asthma.

A case study of clinical practice in adult asthma is presented. The case is part of a larger project, funded by the North Thames NHS Executive Research and Development Programme,...