Asthma Exacerbations In Adults Research Articles

Personal Exposure to Black Carbon and Nitrogen Dioxide and Childhood Asthma Exacerbation in Seaport-Adjacent Communities

Introduction. Ambient and traffic-related air pollution has been linked to exacerbation of asthma in adults and children. Our community-academic partnership is evaluating the effects of diesel emissions and chronic psychosocial stress on asthma exacerbation among children in communities adjacent to the Newark-Elizabeth Seaport in New Jersey, USA. Methods. In a panel study, children with physician-diagnosed asthma, aged 9-14 years old, wear Ogawa passive samplers for NO2, and AE-51 microaethalometers (Aethlabs) to measure black carbon (BC) as a marker for exposure to diesel particulate matter for up to 30 consecutive days. Daily measurements include exhaled nitric oxide (eNO), spirometry, symptoms, medication use, and time-activity logs. We measure stress with the UCLA Chronic and Episodic Stress Interview for Children, diurnal variability in salivary cortisol, and response to an experimental acute stressor. Artifact in the BC data was cleaned using the method of Cai et al. (2013). We analyzed associations between previous 24-hr mean NO2 or BC and daily eNO among the first 6 subjects using mixed linear models. Results: Of 35 children enrolled to date, 33 completed the study. In this preliminary analysis, mean (SD) 24-hr concentrations of BC and NO2 were 1.0 (0.7) ug/m3 and 46 (18) ppb, respectively. On average, within-child increases in BC were significantly associated with acute increases in eNO (p <0.01). Within-child NO2 also increased with eNO and between-child differences in average BC and NO2 were positively associated with eNO, however these results were no statistically significant. Conclusions: Our results to date demonstrate the feasibility of measuring personal exposure to BC and NO2 among children with asthma in a participatory research project in an Environmental Justice community. Future analyses will assess interactions between chronic stress and asthma responses to traffic-related air pollutants. NIEHS ES005022 and EPA STAR R834579

Treating Adult Asthma Exacerbations With a 2-Day Course of Dexamethasone in the Emergency Department: New Protocols to Improve Compliance.

The Research to Practice column is intended to improve the research critique skills of the advanced practice registered nurse and emergency nurse (RN) and to assist with the translation of research into practice. For each column, a topic and a research study are selected. The stage is set with a case presentation. The research article is then reviewed and critiqued, and the findings are discussed in relation to the case presented. In the current column, we examine the findings of from their article, titled "Two Days of Dexamethasone Versus 5 Days of Prednisone in the Treatment of Acute Asthma: A Randomized Controlled Trial."

Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children.

People with asthma may experience exacerbations or "attacks" during which their symptoms worsen and additional treatment is required. Written action plans may advocate doubling the dose of inhaled steroids in the early stages of an asthma exacerbation to reduce the severity of the attack and to prevent the need for oral steroids or hospital admission. To compare the clinical effectiveness and safety of increased versus stable doses of inhaled corticosteroids (ICS) as part of a patient-initiated action plan for home management of exacerbations in children and adults with persistent asthma. We searched the Cochrane Airways Group Specialised Register, which is derived from searches of the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE and the Cumulative Index to Nursing and Allied Health Literature (CINAHL) to March 2016. We handsearched respiratory journals and meeting abstracts. We included randomised controlled trials (RCTs) that compared increased versus stable doses of ICS for home management of asthma exacerbations. We included studies of children or adults with persistent asthma who were receiving daily maintenance ICS. Two review authors independently selected trials, assessed quality and extracted data. We contacted authors of RCTs for additional information. This review update added three new studies including 419 participants to the review. In total, we identified eight RCTs, most of which were at low risk of bias, involving 1669 participants with mild to moderate asthma. We included three paediatric (n = 422) and five adult (n = 1247) studies; six were parallel-group trials and two had a cross-over design. All but one study followed participants for six months to one year. Allowed maintenance doses of ICS varied in adult and paediatric studies, as did use of concomitant medications and doses of ICS initiated during exacerbations. Investigators gave participants a study inhaler containing additional ICS or placebo to be started as part of an action plan for treatment of exacerbations.The odds of treatment failure, defined as the need for oral corticosteroids, were not significantly reduced among those randomised to increased ICS compared with those taking their usual stable maintenance dose (odds ratio (OR) 0.89, 95% confidence interval (CI) 0.68 to 1.18; participants = 1520; studies = 7). When we analysed only people who actually took their study inhaler for an exacerbation, we found much variation between study results but the evidence did not show a significant benefit of increasing ICS dose (OR 0.84, 95% CI 0.54 to 1.30; participants = 766; studies = 7). The odds of having an unscheduled physician visit (OR 0.96, 95% CI 0.66 to 1.41; participants = 931; studies = 3) or acute visit (Peto OR 0.98, 95% CI 0.24 to 3.98; participants = 450; studies = 3) were not significantly reduced by an increased versus stable dose of ICS, and evidence was insufficient to permit assessment of impact on the duration of exacerbation; our ability to draw conclusions from these outcomes was limited by the number of studies reporting these events and by the number of events included in the analyses. The odds of serious events (OR 1.69, 95% CI 0.77 to 3.71; participants = 394; studies = 2) and non-serious events, such as oral irritation, headaches and changes in appetite (OR 2.15, 95% CI 0.68 to 6.73; participants = 142; studies = 2), were neither increased nor decreased significantly by increased versus stable doses of ICS during an exacerbation. Too few studies are available to allow firm conclusions on the basis of subgroup analyses conducted to investigate the impact of age, time to treatment initiation, doses used, smoking history and the fold increase of ICS on the magnitude of effect; yet, effect size appears similar in children and adults. Current evidence does not support increasing the dose of ICS as part of a self initiated action plan to treat exacerbations in adults and children with mild to moderate asthma. Increased ICS dose is not associated with a statistically significant reduction in the odds of requiring rescue oral corticosteroids for the exacerbation, or of having adverse events, compared with a stable ICS dose. Wide confidence intervals for several outcomes mean we cannot rule out possible benefits of this approach.

Hot Off the Press: Do Emergency Department-based Predischarge Educational Interventions for Adult Asthma Patients Improve Outcomes?

Hot Off the Press: Do Emergency Department-based Predischarge Educational Interventions for Adult Asthma Patients Improve Outcomes?

Characteristics and Outcomes of HEDIS-Defined Asthma Patients with COPD Diagnostic Coding

Little is known of the disease burden of patients with persistent asthma (PA) who also have a chronic obstructive pulmonary disease (COPD) diagnosis code (AS-COPD). The objective of this study was to characterize and compare patients with AS-COPD with those with PA without COPD diagnosis, and determine in AS-COPD the relationship between blood eosinophil count and future asthma exacerbations. This retrospective cohort study used administrative pharmacy and health care utilization data to identify, characterize, and compare the burden and asthma exacerbations in adults with AS-COPD (N = 901) with those with PA (N = 2392). Negative binomial regression and Poisson regression models were used to evaluate the relationships between baseline blood eosinophil counts (high vs low) based on various cutoff points and asthma exacerbations in the follow-up year, adjusting for demographics, comorbidities, and asthma burden. Compared with patients with PA, those with AS-COPD were significantly (all P < .001) older, more frequently female, less well educated, more likely to be or have been a smoker, had more comorbidities, received more asthma controller medications, and had greater rates and frequencies of asthma exacerbations, but had similar blood eosinophil counts. The rate of asthma exacerbations/person-year in AS-COPD during follow-up was 1.61 (95% CI, 1.18-2.20). Patients with AS-COPD with a blood eosinophil count ≥400 cells/mm(3) had an increased rate of future asthma exacerbations compared with those whose blood eosinophil count was <400 cells/mm(3) (adjusted rate ratio, 1.44, 95% CI, 1.09-1.90). Compared with patients with PA, those with AS-COPD had more disease burden, but a similar relationship of high blood eosinophil count to more future asthma exacerbations. These findings suggest a common inflammatory component between AS-COPD and PA.

A retrospective study on drug utilization in patients with acute exacerbation of bronchial asthma in adults at a tertiary teaching hospital in Bengaluru

BackgroundDrug utilization plays a role in helping the health care system to understand, interpret and improve the drug use and continuous quality improvement. It plays an essential part of pharmaco-epidemiological studies. The purpose of this study was to evaluate the drug utilization trends in patients with acute exacerbation of bronchial asthma in a tertiary teaching hospital in Bengaluru. Materials and methods100 prescriptions from patients with established diagnosis of acute exacerbation of bronchial asthma were assessed from the Department of Pulmonary Medicine and the data gathered was analysed using MS Excel. ResultsMajority of the prescriptions irrespective of severity received inhalation β2 agonist (formoterol) as a bronchodilator. Nebulization route was given for managing the acute exacerbations followed by inhalation route. Hydrocortisone was prescribed to all patients for managing acute exacerbations. Montelukast was used an adjuvant therapy. Most of them were prescribed combination therapy. Doxophylline was prescribed among all the methylxanthines.

The importance of bacterial and viral infections associated with adult asthma exacerbations in clinical practice.

BackgroundViral infection is one of the risk factors for asthma exacerbation. However, which pathogens are related to asthma exacerbation in adults remains unclear.ObjectiveThe relation between various infections and adult asthma exacerbations was investigated in clinical practice.MethodsThe study subjects included 50 adult inpatients due to asthma exacerbations and 20 stable outpatients for comparison. The pathogens from a nasopharyngeal swab were measured by multiplex PCR analysis.ResultsAsthma exacerbations occurred after a common cold in 48 inpatients. The numbers of patients with viral, bacterial, or both infections were 16, 9, and 9, respectively. The dominant viruses were rhinoviruses, respiratory syncytial virus, influenza virus, and metapneumovirus. The major bacteria were S. pneumoniae and H. influenzae. Compared to pathogen-free patients, the patients with pathogens were older and non-atopic and had later onset of disease, lower FeNO levels, lower IgE titers, and a higher incidence of comorbid sinusitis, COPD, or pneumonia. Compared to stable outpatients, asthma exacerbation inpatients had a higher incidence of smoking and comorbid sinusitis, COPD, or pneumonia. Viruses were detected in 50% of stable outpatients, but a higher incidence of rhinovirus, respiratory syncytial virus, and metapneumovirus infections was observed in asthma exacerbation inpatients. H. influenzae was observed in stable asthmatic patients. Other bacteria, especially S. pneumoniae, were important in asthma exacerbation inpatients.ConclusionViral or bacterial infections were observed in 70% of inpatients with an asthma exacerbation in clinical practice. Infection with S. pneumoniae was related to adult asthma exacerbation.

Benralizumab, an anti-interleukin 5 receptor α monoclonal antibody, versus placebo for uncontrolled eosinophilic asthma: a phase 2b randomised dose-ranging study

Persistent eosinophilic airway inflammation in asthma increases the risk of exacerbations. In a phase 2b dose-ranging study, we aimed to assess the efficacy and safety of benralizumab, an anti-interleukin 5 receptor α monoclonal antibody that depletes blood and airway eosinophils, in adults with uncontrolled eosinophilic asthma. We did a randomised, controlled, double-blind, dose-ranging phase 2b study. Eligible participants were adults aged 18-75 years with uncontrolled asthma using medium-dose or high-dose inhaled corticosteroids and longacting β agonists, with two to six exacerbations in the past year. Current or former smokers were excluded. We used the ELEN index (an algorithm to predict elevated sputum eosinophils) or baseline fraction of exhaled nitric oxide to stratify patients by eosinophilic status, and with an interactive web-voice response system randomly assigned eosinophilic individuals in a 1:1:1:1 ratio to receive placebo, 2 mg benralizumab, 20 mg benralizumab, or 100 mg benralizumab, and non-eosinophilic individuals in a 1:1 ratio to receive placebo or 100 mg benralizumab. Study drugs were given as two subcutaneous injections every 4 weeks for the first three doses, then every 8 weeks, for 1 year. Patients, treating physicians, and study investigators were masked to treatment allocation. The primary endpoint was annual exacerbation rate in eosinophilic individuals after 1 year of follow-up. Analysis was by modified intention to treat. This study was designed with a two-sided α of 0·2 and powered at 78% for the primary outcome in the eosinophilic population. This study is registered with ClinicalTrials.gov, number NCT01238861. Between Jan 3, 2011, and March 6, 2012, we randomly assigned 324 eosinophilic individuals to placebo (n=80) or benralizumab 2 mg dose (n=81), 20 mg dose, (n=81), or 100 mg dose (n=82), and 285 non-eosinophilic individuals to 100 mg benralizumab (n=142, 140 included in analysis) or placebo (n=143, 142 included in analysis). In eosinophilic individuals, benralizumab reduced exacerbation rates compared with placebo in the 100 mg group (0·34 vs 0·57, reduction 41%, 80% CI 11 to 60, p=0·096) but not in the 2 mg group (0·65 vs 0·57, difference -9%, 80% CI -59 to 26, p=0·781) or the 20 mg group (0·37 vs 0·57, reduction 36%, 80% CI 3 to 58, p=0·173). In patients with a baseline blood eosinophil cutoff of at least 300 cells per μL, exacerbation rates in the benralizumab 20 mg group (n=70) and 100 mg group (n=97) were lower than in the placebo group (n=83; 0·30 vs 0·68, reduction 57%, 80% CI 33 to 72, p=0·015 for 20 mg dose; 0·38 vs 0·68, difference 43%, 80% CI 18 to 60, p=0·049 for 100 mg dose). Our findings suggested that benralizumab 20 mg and 100 mg resided at the dose-response plateau. Treatment-emergent adverse events occurred in 277 (72%) of 385 participants receiving any benralizumab dose compared with 143 (65%) of 221 receiving placebo. Nasopharyngitis (44 [11%] patients receiving benralizumab vs 13 [6%] patients receiving placebo) and injection site reactions (60 [16%] vs eight [4%]) occurred more frequently with benralizumab than with placebo. Benralizumab at 20 mg and 100 mg doses seemed to reduce asthma exacerbations in adults with uncontrolled eosinophilic asthma and baseline blood eosinophils of at least 300 cells per μL, possibly due to targeting of the interleukin 5 receptor rather than interleukin 5 ligand. Further investigation of benralizumab treatment in phase 3 studies is warranted. MedImmune.

Montelukast for prevention and treatment of asthma exacerbations in adults: Systematic review and meta-analysis.

It has proven efficacy in reducing asthma exacerbations, but the effect size of montelukast (a leukotriene receptor antagonist) for varied severity of asthma exacerbations is not systematically assessed. This study was designed to systematically explore the evidence for montelukast, as first-line or add-on therapy, in preventing and treating asthma exacerbations in adult patients with asthma. Randomized controlled trials were searched in PubMed, CENTRAL, Web of Science, Embase, and OVID up to March 2013, where montelukast prevented or treated asthma exacerbations in adults. Primary outcomes were the number of patients experiencing exacerbations in chronic asthma and hospitalizations in acute asthma. Odds ratio (OR) with 95% confidence intervals (CI), risk difference, and number needed to treat (NNT) were calculated and pooled. Adverse events were also assessed in chronic asthma. Twenty trials for chronic asthma and six for acute asthma were identified. In comparison with placebo, adults with chronic asthma receiving montelukast had significantly reduced number of exacerbations (OR = 0.60 and 95% CI, 0.49, 0.74; NNT = 17 and 95% CI, 12, 29). However, montelukast was inferior to inhaled corticosteroids (ICSs) (OR = 1.63; 95% CI, 1.29, 2.0) and ICS plus long-acting beta2-agonist (LABA; OR = 3.94; 95% CI, 1.64, 9.48) as the first-line therapies and LABA (OR = 1.22; 95% CI, 1.05, 1.42) as the add-on therapies in reducing asthma exacerbations. In acute asthma, montelukast could statistically improve peak expiratory flow percent predicted (p = 0.008) and reduce systemic corticosteroid intake (p = 0.005). Montelukast had low risk in hoarseness and insomnia. Our meta-analysis suggests that montelukast significantly reduces mild, moderate, and part of severe exacerbations in chronic mild to moderate asthma, but it has inferior efficacy to ICS or ICS plus LABA.

Vitamin D deficiency and adult asthma exacerbations

Objectives: There is growing evidence indicating a connection between vitamin D deficiency and the severity of asthma exacerbations. This study seeks to assess the relationship between vitamin D deficiency and the number and severity of asthma exacerbation in adults. Methods: A retrospective analysis was conducted in 92 patients being treated for asthma at the University of New Mexico Adult Asthma Clinic. Serum 25-hydroxyvitamin D3 levels were analyzed in adults with mild to severe persistent asthma. Using multi-variant modeling, the relationship was examined between serum vitamin D levels and the odds of asthma exacerbations ranging in severity from moderate to severe over the span of five years. Results: This study demonstrates that vitamin D sufficiency was significantly associated with a decreased total number of asthma exacerbations (incidence rate ratio [IRR]: 0.61, 95% confidence interval [CI]: 0.44–0.84, p = 0.002), decreased total severe asthma exacerbations (IRR: 0.41, 95% CI: 0.24–0.72, p = 0.002) and decreased emergency room visits (IRR: 0.42, 95% CI: 0.20–0.88, p = 0.023). Conclusion: Vitamin D deficiency may be linked to the risk of severe asthma exacerbations in adults.

Treatment of asthma exacerbations with the human-powered nebuliser: a randomised parallel-group clinical trial.

Background:Nebulisers aid the treatment of respiratory diseases, including asthma, but they require electricity and are often cost-prohibitive for low- and middle-income countries.Aims:The aim of this study was to compare a low-cost, human-powered nebuliser compressor with an electric nebuliser compressor for the treatment of mild to moderate asthma exacerbations in adults and children.Methods:This was a non-blinded, parallel-group, equivalence study, with 110 subjects between 6 and 65 years of age, conducted in the emergency department of a district hospital in Ilopango, El Salvador. Participants were assigned by random allocation to receive a 2.5-mg dose of salbutamol from the experimental human-powered nebuliser or the electric nebuliser control. All assigned participants completed treatment and were included in analysis. The study was not blinded as this was clinically unfeasible; however, data analysis was blinded.Results:The mean improvement in peak flow of the experimental and control groups was 37.5 (95% confidence interval (CI) 26.7–48.2) l/min and 38.7 (95% CI, 26.1–51.3) l/min, respectively, with a mean difference of 1.3 (95% CI, −15.1 to 17.7) l/min. The mean improvement in percent-expected peak flow for the experimental and control groups was 12.3% (95% CI, 9.1–15.5%) and 13.8% (95% CI, 9.8–17.9%), respectively, with a mean difference of 1.5% (95% CI, −3.6 to 6.6%).Conclusions:The human-powered nebuliser compressor is equivalent to a standard nebuliser compressor for the treatment of mild-to-moderate asthma. (Funded by the Opus Dean’s Fund, Marquette University College of Engineering; ClinicalTrials.gov NCT01795742.)

Does zafirlukast reduce future risk of asthma exacerbations in adults? Systematic review and meta-analysis

&#x0D; &#x0D; &#x0D; &#x0D; Background and objective: The purpose of asthma management is to achieve a total asthma control that involves current control and future risk. It has proven efficacy in reducing asthma exacerbations, but the effect size of zafirlukast for asthma exacerbations of various severity is not systematically explored.&#x0D; Methods: Randomized controlled trials were searched in PubMed Central, Web of Science, and Embase, where zafirlukast prevented asthma exacerbations in adults. The primary outcome was asthma exacerbations, the secondary outcomes were asthma exacerbations requiring systemic corticosteroids and emergency visits, respectively. Odds ratio (OR) with 95% confidence intervals (CI) were pooled.&#x0D; Results: Twelve trials were identified. As first-line therapy, compared to those having placebo, the patients with chronic asthma receiving zafirlukast experienced statistically lower asthma exacerbations (OR = 0.68, 95% CI = [0.45, 1.00]), but it was not found that zafirlukast was superior to placebo in asthma exacerbations requiring systemic corticosteroids (OR = 0.76, 95% CI = [0.45, 1.29]). Furthermore, zafirlukast was inferior to ICs in asthma exacerbations (OR = 2.11, 95% CI = [1.35, 3.30]) and requiring systemic corticosteroids (OR = 3.71, 95% CI = [1.82, 7.59]). As add-on therapy, zafirlukast was not superior to placebo in asthma exacerbations (OR =0.99, 95% CI = [0.54, 1.81] and requiring emergency visits (OR = 0.72, 95% CI = [0.18, 2.99]). Intriguingly, there was not a significant difference in asthma exacerbations between zafirlukast and ICs (OR = 1.12, 95% CI = [0.53, 2.34]).&#x0D; Conclusions: Our study suggests that zafirlukast, as the first-line therapy, significantly reduces mild to moderate but not severe asthma exacerbations. In the add-on regimen, zafirlukast could not reduce asthma exacerbations, which would perhaps result from small sample size and needs to be further studied.&#x0D; &#x0D; &#x0D; &#x0D;

Association of airborne Aspergillus with asthma exacerbation in Southern Pakistan.

BackgroundExposure to airborne fungi has been related with exacerbation of asthma in adults and children leading to increased outpatient, emergency room visits, and hospitalizations. Hypersensitivity to these airborne fungi may be an important initial predisposing factor in the development and exacerbation of asthma.ObjectiveThis study was conducted to determine an association between fungal types and spore concentrations with the risk of asthma exacerbation in adults.MethodsThis cross-sectional study was conducted from May 2008 to August 2009 at the Aga Khan University Hospital Karachi, Pakistan. All adult (age≥16 years) patients presenting to the hospital with acute asthma exacerbation were enrolled after informed consent. A home survey was conducted for each patient to assess their environmental characteristics. Indoor air samples were also obtained from the patient's home to determine the type and spore concentration of fungi within the week of their enrollment in the study.ResultsThree hundred and ninety-one patients with an acute asthma exacerbation were enrolled during the study period. The mean age of participants was 46 years (standard deviation, ±18 years) and 247 (63.2%) were females. A trend of higher asthma enrollment associated with higher Aspergillus concentrations was found in two consecutive summers. A total of nineteen types of fungi were found in air samples. Aspergillus spp. was the most frequently isolated fungus with acute asthma exacerbation.ConclusionAn association of higher concentration of indoor Aspergillus spp. with asthma exacerbation in adults was observed in this study.

Improving asthma care

The RCN Learning Zone is a FREE online service to help RCN members with their continuing professional development and professional portfolio management. The RCN Learning Zone can be found at www.rcn.org.uk/members/learningzone.php This practice profile is based on NS689 Hazeldine V (2013) Pharmacological management of acute asthma exacerbations in adults. Nursing Standard. 27, 33, 43-49. I care for many people with coexisting conditions, including asthma, in a nursing and residential care home. The CPD article helped me to change practice in this setting. Although the prevalence of asthma is slowly declining, it affects an estimated 3.8 million people in the UK. There have been advances in diagnosing and managing asthma, but exacerbations remain a problem, and early recognition of such exacerbations can save lives. Where I work, several service users experience asthma and other respiratory pathologies. All service users are monitored regularly using the National Early Warning Score (NEWS) observation chart, which includes temperature, pulse, blood pressure, respiratory rate, peripheral oxygen level and consciousness measurements. These parameters are measured routinely in the nursing and residential care home and recorded on clinical charts. It was interesting to read that the signs and symptoms of an acute asthma exacerbation can include cough, wheeze, dyspnoea, chest tightness and variable airflow obstruction. Patients with asthma and other respiratory conditions could be monitored more effectively using a peak expiratory flow (PEF) meter. PEF meters are low cost, portable, and easy to use. Using this meter, along with the NEWS observations, allows for greater monitoring of asthma and other respiratory conditions. Individuals with asthma ideally require a recorded PEF from within the last two years for comparison purposes. This would help nurses to determine if a service user was experiencing an acute asthma exacerbation. A series of PEF readings were taken for service users, initially only for those with asthma, to record baseline levels. PEF can be used with a traffic light system, and this is how it is used at the care home: Red (danger) – PEF less than 50% of the individual’s personal best indicates a medical alert. Advice should be obtained as soon as possible. At the care home, the service user’s GP or nurse practitioner responds as appropriate. Yellow (caution) – PEF 50-79% of the individual’s personal best indicates that the asthma is worsening. Medical review of the service user should be obtained. At the care home, the GP or nurse practitioner responds as appropriate. Green (safe) – PEF 80-100% of the individual’s personal best indicates that the asthma is under control and that the person should continue to be monitored. The rapid assessment of a service user during an asthma exacerbation is important. At the care home, individuals with asthma usually only develop exacerbations when they have an acute illness, such as a chest infection or pneumonia. Monitoring PEF and using the NEWS observation chart will help to improve the care I give NS

Does zafirlukast reduce future risk of asthma exacerbations in adults? Systematic review and meta-analysis.

Background and objectiveThe purpose of asthma management is to achieve a total asthma control that involves current control and future risk. It has proven efficacy in reducing asthma exacerbations, but the effect size of zafirlukast for asthma exacerbations of various severity is not systematically explored.MethodsRandomized controlled trials were searched in PubMed Central, Web of Science, and Embase, where zafirlukast prevented asthma exacerbations in adults. The primary outcome was asthma exacerbations, the secondary outcomes were asthma exacerbations requiring systemic corticosteroids and emergency visits, respectively. Odds ratio (OR) with 95% confidence intervals (CI) were pooled.ResultsTwelve trials were identified. As first-line therapy, compared to those having placebo, the patients with chronic asthma receiving zafirlukast experienced statistically lower asthma exacerbations (OR = 0.68, 95% CI = [0.45, 1.00]), but it was not found that zafirlukast was superior to placebo in asthma exacerbations requiring systemic corticosteroids (OR = 0.76, 95% CI = [0.45, 1.29]). Furthermore, zafirlukast was inferior to ICs in asthma exacerbations (OR = 2.11, 95% CI = [1.35, 3.30]) and requiring systemic corticosteroids (OR = 3.71, 95% CI = [1.82, 7.59]). As add-on therapy, zafirlukast was not superior to placebo in asthma exacerbations (OR =0.99, 95% CI = [0.54, 1.81] and requiring emergency visits (OR = 0.72, 95% CI = [0.18, 2.99]). Intriguingly, there was not a significant difference in asthma exacerbations between zafirlukast and ICs (OR = 1.12, 95% CI = [0.53, 2.34]).ConclusionsOur study suggests that zafirlukast, as the first-line therapy, significantly reduces mild to moderate but not severe asthma exacerbations. In the add-on regimen, zafirlukast could not reduce asthma exacerbations, which would perhaps result from small sample size and needs to be further studied.

Overweight/Obesity and Risk of Seasonal Asthma Exacerbations

Obesity is associated with an increased risk for asthma exacerbations, but whether this risk is related to the season of exacerbation is not known. To determine the relationship of increased body mass index (BMI) to the season of asthma exacerbation. Study subjects were adult (aged 18-65 years) and children (aged 5-17 years) health plan members with persistent asthma in 2008 for whom a BMI measurement was available. BMI categories were normal (<25 kg/m(2)), overweight (25-29.9 kg/m(2)), and obese (≥30 kg/m(2)). Exacerbations were defined as oral corticosteroid dispensings linked to an asthma encounter in the spring, summer, fall, or winter of 2009. The cohort included 17,316 adults and 10,700 children. There was a significant (P < .05) linear increase with BMI category in the proportion of adults with exacerbations in every season and in the proportion of children with exacerbations during fall and winter. Relationships of overweight or obesity (vs normal weight) to fall and winter exacerbations remained significant in both adults and children after adjustment for sex and education. In a generalized estimating equation model, both BMI status and season (spring, fall, and winter) were related to exacerbations. Moreover, we noted a significant interaction in adults (P = .03) but not children (P = .97) of the BMI-exacerbation association by season (fall-winter vs spring-summer). Higher BMI values increased the risk for asthma exacerbations in adults and children with persistent asthma, particularly for fall-winter exacerbations in adults. Potential mechanisms for these findings, including vitamin D status, viral infections, and corticosteroid responsiveness, merit further study.

Pharmacological management of acute asthma exacerbations in adults

Acute exacerbations of asthma can be life threatening. This article provides an overview of the pathophysiology, diagnosis and management of acute severe asthma in adults. An understanding of the signs and symptoms of the disorder, and treatment options will ensure rapid decision making when time is crucial during an exacerbation. A proactive approach to managing acute severe asthma may substantially improve patient outcomes and reduce the need for readmission to hospital.

Retrospective Cohort Study of Leukotriene Receptor Antagonist Therapy for Preventing Upper Respiratory Infection-Induced Acute Asthma Exacerbations

Upper respiratory tract infections (URIs) represent the most frequent cause of acute asthma exacerbations. It has yet to be determined whether leukotriene receptor antagonist (LTRA) treatment prevents URI-induced acute asthma exacerbations in adults. The objective of the present study was to evaluate the preventive effects of LTRA treatment on URI-induced acute asthma exacerbations. The incidences of URI alone, acute asthma exacerbation without URI, and URI-induced acute asthma exacerbation were determined retrospectively by analyzing diary and medical records of 321 adult asthmatic patients (mean age, 56.3 ± 17.2 years; male/female ratio, 117:204) over 1 year. Results were compared between patients who had been taking an LTRA (n = 137) and those who had never taken any LTRA (n = 184) during the study periods. Significantly fewer URIs alone and acute asthma exacerbations without URI occurred in patients with than in those without prophylactic daily use of LTRA. LTRA treatment significantly reduced the durations of URIs alone and of total acute asthma exacerbations, as well as the incidence of mild exacerbations of asthma. In contrast, in patients with URI-induced acute asthma exacerbations, LTRA treatment failed to significantly reduce the interval between URI onset and acute asthma exacerbation, as well as the duration and severity of both URIs and acute asthma exacerbations. Use of an LTRA for adult asthmatic patients appears to reduce the incidences of URIs alone and acute asthma exacerbations without URI, but it failed to prevent URI-induced acute asthma exacerbations once a URI occurred.

P273 Asthma: Is It as Predictable as the Seasons?

BackgroundCurrent literature shows a distinct peak in asthma exacerbations in September among children, attributing it in part to their return to school and the spread of viral agents accompanying this....

Emergency department treatment of adults with acute asthma exacerbations: Effect on exhaled nitric oxide levels

Measurement of exhaled nitric oxide levels (eNO) from asthmatic patients is a noninvasive marker of airway inflammation in both adults and children and has been used as an outpatient measure of asthma control. We examined eNO in acute asthma exacerbations and how it is affected by treatment in the emergency department (ED) setting. Both eNO and peak expiratory flow (PEF) rate were measured at arrival and before discharge for adult asthmatic subjects (n = 28) treated for acute exacerbations in the ED at Kings County Hospital Center during spring and fall pollen seasons. Total serum Immunoglobulin E (IgE), peripheral blood leukocyte numbers, and tobacco smoking history were determined. Routine ED treatment included oral prednisone at 60 mg and inhalation of nebulized albuterol and ipratropium. Both PEF (p = 0.0005) and eNO (p < 0.0001) increased after treatment of subjects. Initial eNO was associated with age (p = 0.0004), absolute eosinophil count (p = 0.003), Asthma Control Test (p = 0.004), and Asthma Quality of Life Questionnaire (p = 0.04). Change in pre- versus posttreatment eNO (ΔeNO) was associated with change in PEF (ΔPEF; p < 0.0001). Initial PEF was associated with oxygen saturation (p < 0.0001). ΔPEF was associated with serum IgE levels. ED visit duration was associated with initial PEF (p = 0.0004), ΔeNO (p = 0.004), and number of albuterol treatments (p = 0.001). These associations remained significant in multivariate models that controlled for demographic factors, asthma control, smoking, and measures of inflammation and ventilation. eNO levels increase after ED treatment of acute asthma exacerbations in adults. Improved ventilation may allow for more accurate measurement of NO produced in inflamed airways.