Current Asthma Control Research Articles

Childhood Asthma Control Test and spirometry values in school-age children

Objective To determine the relationship between child and parent reports of asthma control using the Childhood Asthma Control Test (C-ACT) and spirometry. Methods This descriptive study included 648 children ages 5–11 years from a school-based asthma program. Not well-controlled asthma was defined as forced expiratory volume in 1 s (FEV1) and by FEV1/forced vital capacity (FVC) of 80% predicted or lower. Sensitivity and specificity of C-ACT scores for low FEV1 and FEV1/FVC levels were calculated. Logistic regression was used to obtain the area under the receiver operating characteristic curve (AUC) for C-ACT score categories by FEV1 level. Results Mean child age was 8.2 years, mean C-ACT score was 20.3 (SD = 3.96), mean FEV1 was 94.3% (SD = 17.1), and mean FEV1/FVC was 81.3 (SD = 8.5). Children with an FEV1 of 80% or less had significantly lower C-ACT scores than those with an FEV1 > 80% (p = .023, t = −2.015, df = 167); 95% CI [. −1.79 to −0.018]). The sensitivity and specificity of a C-ACT score of 19 or less for an FEV1 of 80% predicted or lower were 44.9 and 66.4%. With a C-ACT score of 22 or less, sensitivity and specificity for low FEV1 were 67.7 and 30.9%. The AUC for a C-ACT score of 19 or less and FEV1 of 80% or lower was .444 while the AUC was higher at .507 for a CACT score of 22 or less. Conclusion The C-ACT is a useful screen but spirometry should be performed in children with persistent symptoms to assess current asthma control.

Are pregnant women with asthma receiving guideline-recommended antenatal asthma management? A survey of pregnant women receiving usual care in Australia

BackgroundAsthma affects 12.7% of pregnant women in Australia. Key recommendations for asthma management during pregnancy include: 4–6 weekly review of lung function, medications, written asthma action plan, inhaler device technique, current asthma control and triggers; smoking cessation and vaccination advice. It is unknown if these key recommendations are provided to pregnant women with asthma in Australia. AimTo explore usual antenatal asthma management (usual care) in Australia and the inclusion of key recommendations. MethodPregnant women with asthma were invited to complete an online survey distributed in 2 antenatal clinics and via social media platforms from July 2017-Jan 2019. ResultsThe survey was completed by 142 pregnant women with asthma. 87(61%) were enrolled in an asthma management clinical trial and were therefore not receiving ‘usual’ care. Data presented is from 55(39%) women receiving usual care at survey completion. Of these women, 36% did not have their asthma reviewed during their pregnancy, 31% had a written asthma action plan, 11% had lung function assessed, 38% had an asthma medication review and 35% had their inhaler technique reviewed. 65% were not questioned about their asthma symptoms, 85% were not asked about asthma triggers, 96% were not given information about vaccinations and 95% did not receive smoking cessation information. ConclusionsOverall, the key recommendations for antenatal asthma management were not always provided for this sample of pregnant women receiving usual care. Improved knowledge and implementation of these key recommendations by health professionals may alter this situation and improve maternal and infant outcomes.

Evaluating construct validity of the Asthma Impairment and Risk Questionnaire using a 3-month exacerbation recall

BackgroundRecurrent assessment of asthma control is essential to evaluating disease stability and intervention impacts. An assessment that can be administered between annual clinic visits is needed. The Asthma Impairment and Risk Questionnaire (AIRQ) is a cross-sectionally validated, 10-item, yes or no, composite control tool evaluating previous 2-week symptoms and previous 12-month exacerbations. ObjectiveTo evaluate the construct validity of the AIRQ using a 3-month recall period for exacerbation-based risk questions and retaining the 2-week recall for symptom-based impairment items. MethodsAt baseline, patients completed the AIRQ with 12-month recall exacerbation items, Asthma Control Test (ACT), St. George's Respiratory Questionnaire (SGRQ), and global self-assessments of asthma risk, control, and symptom severity. Patient-reported exacerbations were captured monthly. The AIRQ with 3-month recall exacerbation items, ACT, and global self-assessments was administered at months 3, 6, and 9, and SGRQ at month 6. ResultsA total of 1112 patients aged 12 years or older were enrolled (mean [SD] age, 43.9 [19.5] years). The AIRQ and each administration of the AIRQ with 3-month recall exacerbation items classified asthma control similarly to an ACT plus exacerbation validation standard. For both AIRQ versions, SGRQ scores were higher with worsening asthma control (P < .001). At months 3, 6, and 9, worse AIRQ control levels were associated with higher proportions of patients with 1 or more and 2 or more exacerbations in the previous 3 months and patient global self-assessments indicating greater asthma morbidity (all P < .001). ConclusionThe AIRQ using exacerbation risk items with a 3-month recall period exhibits construct validity for classifying current asthma control and can be administered between annual AIRQ assessments.

Asthmatic subjects stratification using autonomic nervous system information

Objectivethe aim of this study is to evaluate whether noninvasive autonomic activity assessment could represent a potential tool for the stratification of asthmatic subjects based on symptoms control, using only 10-min electrocardiographic and respiratory signals. Methodsseveral heart rate variability (HRV) derived indexes, which are regarded as surrogates of autonomic activity, were evaluated in a group of asthmatic patients classified based on their symptomatology control. The effect of respiration on HRV was mitigated by means of orthogonal subspace projection. The most relevant features were used for training different classifiers. Resultssimilar classification performance was obtained when using HRV or clinical features, with just a 10% decrease in accuracy when using the HRV features (80% vs. 70%). This classification performance is equivalent to that achieved in new patients using the current asthma control tests. Conclusionresults suggest that the noninvasive assessment of autonomic activity could represent an added value for the monitoring of asthmatic subjects outside the clinic, using less cumbersome equipment, and therefore being suitable for an objective asthma self-monitoring. Significance:This study provides evidence on the usefulness of noninvasive autonomic activity assessment for asthma control stratification, supporting it as a potential complement to the current clinical practice.

The association between control level and self-reported treatment adherence across different treatment types in Japanese asthma patients.

Poor control of asthma symptoms is associated with a higher asthma disease burden, and asthma medication adherence is a known predictor for a better control status. This study sought to describe the current asthma control status, self-reported treatment adherence, and the association between them, as well as to describe how control level and better adherence impact the health outcomes of asthma patients. This study used cross-sectional data from the 2018 Japan National Health and Wellness Survey (NHWS). Asthma control status and adherence were assessed using the Asthma Control Test (ACT) and Morisky Medication Adherence Scale-8 (MMAS-8), respectively. Asthma treatment and patients' health outcomes, i.e. health-related quality of life (HRQoL) and work productivity, were self-reported. Asthma control and self-reported treatment adherence were analyzed descriptively, and the association was investigated by comparing mean ACT scores across adherence levels. Health outcomes were compared across control and adherence levels by multivariate analyses. A total of 816 patients had a physician diagnosis of asthma, with 67.0% reporting at least well controlled (ALWC). Of 505 asthma patients receiving prescription medication, half reported low adherence to medication use. Among asthma patients reporting high adherence, 35.6% were not well controlled (NWC). After adjusting for covariates, NWC asthma patients had significantly worse health outcomes than ALWC patients. One-third of asthma patients in Japan suffer from poorly controlled asthma. Results of the 2018 NHWS show that poor control status negatively affects patients' HRQoL and work productivity, suggesting an unmet need for better treatments to lessen the burden of asthma.

CONFIRMATORY CROSS-SECTIONAL VALIDATION OF THE ASTHMA IMPAIRMENT AND RISK QUESTIONNAIRE (AIRQ)

CONFIRMATORY CROSS-SECTIONAL VALIDATION OF THE ASTHMA IMPAIRMENT AND RISK QUESTIONNAIRE (AIRQ)

Mobile Health App for Japanese Adult Patients With Asthma: Clinical Observational Study.

BackgroundInappropriate asthma control reduces quality of life and causes increased exacerbations. Mobile health (mHealth) employs information and communication technology for surveying health-related issues.ObjectiveThis noninterventional, observational study assessed current real-world asthma control levels among Japanese patients with asthma and cough variant asthma (CVA) using the Zensoku-Log app.MethodsWe developed the app using the ResearchKit platform and conducted a mobile-based, self-reporting, observational survey among patients with asthma and CVA. The app was downloaded 7855 times between February 2016 and February 2018, and enabled collection of data on symptoms, comorbidities, quality of life, medications, asthma control, and adherence.ResultsOf the 1744 eligible participants (median age 33 years; range 20-74 years; male-to-female ratio 38.7:61.3), 50.97% (889/1744) reported unscheduled visits, 62.84% (1096/1744) reported regularly scheduled visits, 23.14% (402/1737) smoked, and 40.75% (705/1730) had pets. In addition, 91.89% (1598/1739) of participants had atopic predisposition, including allergic rhinitis and atopic dermatitis. Daily inhaled corticosteroid and oral corticosteroid treatment had been prescribed for 89.45% (1552/1735) and 22.07% (383/1735) of participants, respectively. Although an asthma control questionnaire demonstrated poor asthma control in 58.48% (1010/1727), a leukotriene receptor antagonist, theophylline, and a long-acting muscarinic antagonist had been prescribed for only 30.66% (532/1735), 15.91% (276/1735), and 4.38% (76/1735), respectively. The Adherence Starts with Knowledge 12 total score was 29. In the 421 participants who repeated the questionnaire, asthma control increased significantly between the initial and last rounds (P=.002).ConclusionsUsers of this mHealth app in Japan had poorly controlled asthma and may need more treatment for asthma and their comorbidities. Repeated app users demonstrated improved asthma control.Trial RegistrationUMIN Clinical Trial Registry UMIN000021043; https://upload.umin.ac.jp/cgi-open-bin/ctr_e/ctr_view.cgi?recptno=R000023913.

A study of factors related to asthma exacerbation using a questionnaire survey in Niigata Prefecture, Japan.

As indices of asthma control, exacerbations are equally important with symptoms and respiratory function. Thus, it is critical to recognize the risk factors of exacerbation. We conducted a questionnaire survey of asthma patients in Niigata Prefecture to clarify the factors involved in asthma exacerbation. The questionnaire survey was carried out in patients and their physicians from September to October 2014. In 2015, the same sample population also received a questionnaire about current asthma control and exacerbation. One hundred patients experienced asthma exacerbation during the 1-year period. There were significant differences in age, sex, history of hospitalization due to asthma, smoking history, Asthma Control Test, treatment step, and transient steroid treatment history in the previous year between the exacerbation group and non-exacerbation group. On multivariate analysis, there was a significant difference in history of transient steroid therapy, history of hospitalization associated with asthma attacks, and nonsmoking history. Cluster analysis of cases with exacerbation was classified into three clusters. Cluster 1 comprised slightly older cases with smoking history, Cluster 2 had more females, non-smoking and nonatopic cases with uncontrolled symptoms, and Cluster 3 had more females, non-smoking and mild atopic cases. Our findings suggest that patients with asthma exacerbation in the previous year and nonsmoking females are important targets for the study of asthma exacerbation. The adequate treatment of women patients might be important for the prevention of asthma exacerbation.

Clinical profile of chronic bronchial asthma patients in Poland: results of the PROKSAL study.

IntroductionAsthma is a complex condition characterized by the presence of chronic inflammation in the lower respiratory tract resulting in many disturbing symptoms. The study of the clinical profile of the population with asthma allows us to understand a trend of a specific disease taking into account several indicators and its clinical characteristics.AimEvaluation of the clinical profile of patients with chronic bronchial asthma in Poland.Material and methodsThe study included 10400 adult patients, of both sexes, diagnosed with chronic bronchial asthma who started therapy based on inhaled glucocorticosteroids accompanied by salmeterol, and 52 allergists. The examination was performed in a doctor’s surgery. Standardized questionnaire interviews were used in order to carry out the procedure.ResultsThe age of the patients ranged from 18 up to 97 years. Most of them suffer from overweight and obesity. 45.3% of the patients smoked cigarettes or declared to be passive smokers. Current asthma control was poor: over 56% of the patients suffered from diurnal symptoms more often than twice a week, almost 55% from nocturnal symptoms, in 72% of the patients’ physical activity was limited, whereas 57% required immediate treatment. Most commonly used drugs were inhaled glucocorticosteroids and short acting β2-mimetics. After treatment change, fewer patients suffered from asthma symptoms.ConclusionsAdjusting the therapy according to the current guidelines and to the patient’s needs helps to improve asthma control.

Integrating asthma management and care in Maryland Head Start Programs: A qualitative assessment of opportunities and needs

PurposeTo understand the role of Maryland Head Start (HS) programs in asthma care and identify resources and needs to improve health outcomes. MethodsA qualitative needs assessment was conducted with Maryland HS staff (n = 35) and parents/caregivers of enrolled children with asthma (n = 16) from all 14 grantee programs in Maryland. Focus group discussions and interviews addressed strengths and challenges in current asthma control and opportunities for integration of an asthma care program into HS services. Transcripts were thematically analyzed using a modified Framework approach. ResultsHS programs actively communicate with families about asthma management and facilitate communication between families and primary care providers (PCPs). Both HS staff and families reported a strong trusting relationship allowing HS staff to provide asthma management support. HS needs strong linkages with supportive services and PCP offices to engage families, address environmental triggers, and educate staff. While families across the state report interest in peer education on asthma through HS, there were some region-specific asthma care barriers for urban and rural programs. ConclusionThis needs assessment confirmed interest among all stakeholders in integrating asthma care through HS and identified communication strategies, supportive infrastructure, and addressing regional access to care as key elements for program design.

Development and Validation of Personalized Prediction to Estimate Future Risk of Severe Exacerbations and Uncontrolled Asthma in Patients with Asthma, Using Clinical Parameters and Early Treatment Response

Current level of asthma control can be easily assessed by validated instruments, but it is currently difficult to assess individuals' level of future risk. Develop, and validate, a risk prediction score for level of future risk, including patient characteristics and information on early treatment response. We used data of 304 adult patients with asthma from a 12-month primary care randomized controlled trial with 3-monthly assessments. With logistic regression we modeled the association between the level of future risk and patient characteristics including early treatment response. Future risk was defined as Asthma Control Questionnaire (ACQ) score of 1.5 or more at 12 months or the experience of at least 1 exacerbation during the final 6 months. We developed a risk prediction score on the basis of regression coefficients. Performance of the risk prediction score improved, taking into account data on early treatment response (area under receiver-operating curve [AUROC]= 0.84) compared with a model containing only baseline characteristics (AUROC= 0.78). The score includes 6 easy-to-obtain predictors: sex, ACQ score and exacerbations in the previous year at baseline and at first follow-up, and smoking status and exacerbations in the previous 3 months (indicating early treatment response). External validation yielded an AUROC of 0.77. The risk prediction score classified patients into 3 risk groups: low (absolute risk, 11.7%), intermediate (47.0%), and high (72.7%). We developed and externally validated a risk prediction score, quantifying both level of current asthma control and the guideline-defined future risk. Patients' individual risk can now be estimated in an easy way, as proposed but not specified, by asthma management guidelines.

Asthma exacerbation prediction: recent insights.

Asthma attacks are frequent in children with asthma and can lead to significant adverse outcomes including time off school, hospital admission and death. Identifying children at risk of an asthma attack affords the opportunity to prevent attacks and improve outcomes. Clinical features, patient behaviours and characteristics, physiological factors, environmental data and biomarkers are all associated with asthma attacks and can be used in asthma exacerbation prediction models. Recent studies have better characterized children at risk of an attack: history of a severe exacerbation in the previous 12 months, poor adherence and current poor control are important features which should alert healthcare professionals to the need for remedial action. There is increasing interest in the use of biomarkers. A number of novel biomarkers, including patterns of volatile organic compounds in exhaled breath, show promise. Biomarkers are likely to be of greatest utility if measured frequently and combined with other measures. To date, most prediction models are based on epidemiological data and population-based risk. The use of digital technology affords the opportunity to collect large amounts of real-time data, including clinical and physiological measurements and combine these with environmental data to develop personal risk scores. These developments need to be matched by changes in clinical guidelines away from a focus on current asthma control and stepwise escalation in drug therapy towards inclusion of personal risk scores and tailored management strategies including nonpharmacological approaches. There have been significant steps towards personalized prediction models of asthma attacks. The utility of such models needs to be tested in the ability not only to predict attacks but also to reduce them.

Visual analogue scale (VAS) as a monitoring tool for daily changes in asthma symptoms in adolescents: a prospective study

BackgroundSuccess in asthma management hinges on patients’ competency to detect and respond to ever-changing symptom severity. Thus, it is crucial to have reliable, simple, and sustainable methods of symptom monitoring that can be readily incorporated into daily life. Although visual analogue scale (VAS) has been considered as a simple symptom assessment method, its utility as a daily symptom monitoring tool in adolescents is unknown. This study was to determine the concurrent validity of VAS in capturing diurnal changes in symptoms and to examine the relationships between VAS and asthma control and pulmonary function.MethodsForty-two adolescents (12–17 years old) with asthma completed daily assessment of symptoms twice per day, morning and bedtime, for a week using VAS and 6-item symptom diary concurrently. Asthma control was measured at enrollment and 6 month later, and spirometry was conducted at enrollment. Pearson correlations, multilevel modeling and regression were conducted to assess the relationships between VAS and symptom diary, asthma control and FEV1.ResultsMorning and evening VAS was positively associated with symptom diary items of each corresponding time frame of the day (r = 0.41–0.58, p < 0.0001). Morning VAS was significantly predicted by morning diary data reflecting nocturnal wakening (β = 2.13, p = 0.033) and morning symptoms (β = 4.09, p = 0.002), accounting for 57% of the total variance of morning VAS. Similarly, changes in four evening diary items, particularly shortness of breath (β = 2.60, p = 0.028), significantly predicted changes in evening VAS, accounting for 55% of the total variance. Average VAS scores correlated with asthma control (r = 0.65, p < 0.001) and FEV1 (r = −0.38, p = 0.029), and were predictive of asthma control 6 months later (β = 0.085, p = 0.006).ConclusionsVAS is a valid tool capturing diurnal changes in symptoms reflected in a multi-item symptom diary. Moreover, VAS is a valid measure predicting concurrent and future asthma control. The findings suggest VAS can be a simple alternative to daily dairies for daily symptom monitoring, which can provide invaluable information about current and future asthma control without substantially increasing self-monitoring burdens for adolescent patients.Clinical Trial Registration NCT01696357. Registered 18 September 2012

Long-term outcome after pediatric intensive care unit asthma admissions.

Patients with asthma admitted to the pediatric intensive care unit (PICU) are often found to have had previous severe asthma exacerbations. To prospectively evaluate the outcome of children after PICU admission. Patients, ages 218 years, admitted to the PICU at Assaf Harofeh Medical Center over a 10-year period were assessed at a mean of 10 years after their admission and compared with matched patients admitted to the pediatric ward. Each patient filled out a questionnaire on subsequent hospitalizations and current asthma treatment and control. Pulmonary function studies and allergy skin tests were performed. Compared with patients admitted to the pediatric ward, those admitted to the PICU had more hospitalization and ICU admissions after their index admission (p = 0.022 and p = 0.021, respectively). Most patients in both groups (6070%) had uncontrolled asthma, and 47% of those (PICU) and 33% (ward) were not receiving controller therapy. Patients in the PICU group had more recent asthma exacerbations (p = 0.014), weekly wheezing (p = 0.017), and bronchodilator use (p = 0.007). Lung function tests were comparable between the two groups, but 3045% in each group had airflow obstruction. No significant differences were found between preschool and school-age children in any of the parameters. Compared with patients admitted to the pediatric ward, those admitted to the PICU with asthma exacerbations, experienced more asthma-related hospitalizations and their asthma was less controlled even years later. The lack of regular follow-up and controller therapy in most patients after asthma hospitalization indicated that this increased morbidity might be prevented.

Routine primary care data-the new crystal ball?

In their 2014 recommendation update, the Global Initiative for Asthma (GINA) called for a more risk-focused approach to management. If used appropriately primary care records capturing routine data can be used not only to characterize current asthma control and current/prior practice, but also to “predict future risk”. By considering aggregate patient data, it is possible to identify common characteristics associated with future events and to explore combinations of factors that, together, may have a stronger association with specific future risks, such as exacerbations, multiple exacerbations, hospitalisations. Used in this way, clinical records can point to opportunities to modify risk and to intervene to mitigate against future events. This presentation will consider examples of how primary are records have been used in this risk prediction capacity within asthma and, in particular, at how they have been used to examine the potential role of routinely collected blood eosinophils (rather than more invasive and less routinely recorded sputum eosinophils) as biomarkers in asthma and allergy. Future opportunities for biometric use of primary care databases (e.g., IgE, FeNO and multi-allergen screening) will also be discussed.

A 12-year prognosis of adult-onset asthma: Seinäjoki Adult Asthma Study

RationaleLong-term prognosis of adult-onset asthma is poorly known. ObjectiveTo evaluate 12-year prognosis of adult-onset asthma and the factors associated with disease prognosis. MethodsSeinäjoki Adult-onset Asthma Study (SAAS) is a 12-year real-life single-center follow-up study of new-onset asthma diagnosed at adult age and treated in primary and specialized care. Remission was defined by no symptoms and no asthma medication use for 6 months. Asthma control was evaluated according to Global Initiative for Asthma 2010. Factors associated with current asthma control were analyzed by multinomial multivariate logistic regression. Main resultsA total of 203 patients (79% of the baseline population) were followed for 12 years. Remission occurred in 6 (3%) patients. In 34% asthma was controlled, in 36% it was partially controlled and in 30% uncontrolled. Uncontrolled asthma was predicted by elevated body-mass index at baseline, smoking (pack-years) and current allergic or persistent rhinitis. Elevated blood eosinophils and good lung function (FEV1) at baseline protected from uncontrolled asthma. In contrast, gender, age at the onset or baseline symptoms (Airways Questionnaire 20) were not significant predictors of uncontrolled disease. ConclusionsDuring a 12-year follow-up, remission of adult-onset asthma was rare occurring in only 3% of patients. The majority of patients (66%) presented either with uncontrolled or partially controlled asthma.This study is registered at ClinicalTrials.gov with identifier number NCT02733016.

The impact of allergic rhinitis on the management of asthma in a working population.

BackgroundCurrently, little data is available about the management of asthma in the working population. The aim of this study was to describe asthma control and severity among workers according to current or previous allergic rhinitis comorbidity.MethodsA network of occupational physicians participated in this pilot study on a voluntary basis. They included a random sample of salaried workers during their systematic occupational medical check-up. All subjects completed a self-administered questionnaire based on the European Community Respiratory Health Survey screening questionnaire, and if they reported any respiratory symptoms including allergic rhinitis, the physician filled in a medical questionnaire. Current asthma control and severity were evaluated according to 2006 Global Initiative for Asthma guidelines.ResultsA total of 110 occupational physicians from two French regions participated. Out of the 6906 employees screened, 3102 identified respiratory symptoms and completed the medical questionnaire and performed spirometry. Overall, 374 were identified as current asthmatics, including 271 (72.5 %) with allergic rhinitis. Among current asthmatics with current allergic rhinitis (n = 95), 68.8 % had partially controlled asthma or uncontrolled asthma, including 51.6 % who received insufficient anti-asthmatic treatment. Partly or no control asthma was not associated with current rhinitis (OR = 1.4; 95 % CI: 0.8-2.7). Current asthmatics with current or previous allergic rhinitis had a significantly lower risk of emergency department visits than current asthmatics without allergic rhinitis (respectively 11.6, 17.1 and 29.1 %; P = 0.002).ConclusionsMost current asthmatics both with and without allergic rhinitis had uncontrolled asthma, with inappropriate treatment. Future intervention strategies need to be developed for effective control and prevention of asthma in the workplace.

Asthmatic children that are uncontrolled despite inhaled corticosteroids have a distinct breathprint (the pacman2 study)

Method VOCs were measured in thirty-three asthmatic children (age: 11.8 yrs, SD 2.3 yrs) who participated in the PACMAN2 study. All children were current users of ICS. Current asthma control was assessed using the Asthma Control Questionnaire. Long-term asthma control was based on reported symptoms in the four seasons preceding baseline and follow-up visit. A single vital capacity volume of exhaled air was collected upon 5 minutes of normal breathing through a three-way non-re-breathing valve with a VOC filter in a Tedlar bag. The VOCs in the breath sample were subsequently captured on Tenax GR Tubes and analyzed offline on a validated panel of four eNoses with different sensor technologies (Owlstone Lonestar, Sensigent Cyranose 320, Comon Invent eNose and Tor Vergata TEN). Breathprints were analysed per eNose using principal component analyses (PCA). ROC curves and cross-validated accuracy values of significant (t-test) principal components were used to assess the accuracy of the devices to discriminate between controlled and uncontrolled patients. Additionally, the fraction of exhaled nitric oxide (FeNO) was measured with a NIOX Mino and an expiration time of 6 seconds.

Development and validation of a novel risk score for asthma exacerbations: The risk score for exacerbations

Identifying patients at risk of future severe asthma exacerbations, those whose asthma might be less treatment responsive, or both might guide treatment selection. We sought to investigate predictors for failure to achieve Global Initiative for Asthma (GINA)-defined good current asthma control and severe exacerbations on treatment and to develop a simple risk score for exacerbations (RSE) for clinical use. A large data set from 3 studies comparing budesonide/formoterol maintenance and reliever therapy with fixed-dose inhaled corticosteroid/long-acting β2-agonist therapy was analyzed. Baseline patient characteristics were investigated to determine dominant predictors for uncontrolled asthma at 3months and for severe asthma exacerbations within 12 months of commencing treatment. The RSE, right censored at 6 months to include all 3 studies, was based on the dominant predictors for exacerbations in two thirds of the data set and validated in one third. Patients (n= 7446) whose symptoms were not controlled on GINA treatment steps 3 and 4 and with 1 or more exacerbations (as judged by a clinician based on patient records, history, or both) in the previous year were included. On multivariate analysis, GINA step, reliever use, postbronchodilator FEV1, and 5-item Asthma Control Questionnaire score were dominant (all P< .001) predictors for both the risk of uncontrolled asthma and severe exacerbations. Additional dominant predictors for uncontrolled asthma were smoking status and asthma symptom scores and an additional predictor for severe exacerbation was body mass index. An exponential increase in risk was observed with increments in RSE based on 5 selected predictors for exacerbations. Risk of uncontrolled asthma at 3 months and a severe exacerbation within 12 months can be estimated from simple clinical assessments. Prospective validation of these predictive factors and the RSE is required. Use of these models might guide the management of asthmatic patients.

Chinese expert consensus on bronchial asthma control.

Chinese and international guidelines for prevention and treatment of bronchial asthma (hereinafter referred to as asthma) indicate: the goal of asthma management is to achieve and maintain symptom control; treatment protocols need to be adjusted according to asthma control levels during asthma management; asthma management is a long-term process which incorporates three essential aspects—evaluation, treatment, and monitoring (1,2). These guidelines highlight that asthma control as the goal of treatment can be achieved by medication in the majority of patients, particularly with effective asthma management (1,2). The 2009 updates on the Global Initiative for Asthma (GINA) proposed a new conception of “overall asthma control”, which expanded the previous understanding of asthma control to emphasize the equal importance of achieving current asthma control and reducing future risk (3). However, a number of surveys in China and other countries have revealed that the rate of asthma control in the real world is far below as proposed by the guidelines (4-9). Poorly controlled asthma was shown to seriously affect the daily life, work and school of patients, and was associated with recurrent asthma exacerbations, unscheduled hospital visits and stay, and impaired lung functions, which eventually lead to increased treatment cost, lost productivity, as well as heavy social and economic burden (4-9). Therefore, with the updated understanding, efforts to improve the current pattern of asthma management and to reinforce the treatment strategies will have a long way to go for better outcomes of overall asthma control. In this regard, the Asthma Workgroup of Chinese Thoracic Society convened a panel meeting of experts in the related fields, which formed the following consensus. In order to guide clinical practicing, the present consensus was developed with reference to related guidelines and consensus documents published elsewhere, in particular, the important papers on asthma control that appeared in the recent years.