Undiagnosed Asthma Research Articles

Unlikely any benefit from population wide case-finding strategies to identify people with undiagnosed asthma or chronic obstructive pulmonary disease.

Unlikely any benefit from population wide case-finding strategies to identify people with undiagnosed asthma or chronic obstructive pulmonary disease.

Association between lung function and sleep disorder symptoms in a community-based multi-site case-finding study.

Obstructive airway disease is associated with sleep disturbances. We aimed to assess the relationship between lung function and sleep disorder symptoms using cross-sectionally collected data between March 2017 and August 2021 from the Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population study, a prospective community-based multi-site case-finding study. Undiagnosed Chronic Obstructive Pulmonary Disease and Asthma Population study participants with respiratory symptoms but without diagnosed lung disease who completed spirometry and the Global Sleep Assessment Questionnaire were included. We conducted multivariate linear regression models for forced expiratory volume in 1 s, forced vital capacity and forced expiratory volume in 1 s/forced vital capacity by Global Sleep Assessment Questionnaire responses adjusted for confounders. The same models were employed to examine respiratory symptoms, as reported on the St George's Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test, by Global Sleep Assessment Questionnaire responses. Logistic regression models were used to assess the association of undiagnosed obstructive airway disease with sleep symptoms. Amongst 2093 adults included in the study, 48.3% were female and the median age was 63 years (interquartile range 53-72). Two-hundred and five (9.79%) subjects met spirometry criteria for undiagnosed chronic obstructive pulmonary disease, and 191 (9.13%) for undiagnosed asthma. There were no significant associations between spirometry measures and sleep symptoms (p > 0.5), controlling for age, sex, body mass index, smoking and comorbidities. Those with undiagnosed asthma were more likely to report insomnia "at least sometimes" versus "never" (odds ratio 2.58, 95% confidence interval: 1.27-6.19, p = 0.02). Respiratory symptoms were associated with sleep symptoms, with significant (p < 0.05) increases in St George's Respiratory Questionnaire and Chronic Obstructive Pulmonary Disease Assessment Test scores in those reporting most sleep symptoms. Overall, we found an association between undiagnosed asthma and insomnia, and between respiratory and sleep disorder symptoms.

Impact of Dyspnea on Adults With Respiratory Symptoms Without a Defined Diagnosis

BackgroundWe investigated dyspnea, its associated risk factors, and its impact on healthcare utilization, quality of life, and work productivity in adults with undiagnosed respiratory symptoms. Research QuestionWhat is the impact of dyspnea in adults with undiagnosed respiratory symptoms? Study Design and MethodsThis population-based study included 2857 adults who were experiencing respiratory symptoms. These individuals had not been previously diagnosed with any lung conditions and were recruited from 17 Canadian centers using random digit-dialing. Each participant underwent spirometry testing both before and after using a bronchodilator to determine if they met the diagnostic criteria for COPD, asthma, Preserved Ratio Impaired Spirometry (PRISm), or if their spirometry results were normal. An age-matched control group (n= 231) was similarly recruited using random-digit dialing. A dyspnea impact assessment score from 0 to 100 was produced using questions from the COPD Assessment Test and St. George’s Respiratory Questionnaire. ResultsIndividuals with PRISm (n=172) reported more impactful dyspnea (mean score 63.0, 95% CI: 59.5- 66.4) than those with undiagnosed asthma (n=265, mean score 56.6, 95% CI: 53.9-59.3) or undiagnosed COPD (n=330, mean score 57.5, 95% CI: 55.1-59.9). All groups reported significantly more impactful dyspnea compared to controls (mean score 13.8, 95% CI:11.8-15.7). Subject-specific risk factors including age, sex, BMI, smoking, and comorbidities explained 20.6% of the variation in dyspnea. An additional 12.4% of the variation was explained by disease classification and another 1.7% by the severity of lung function impairment assessed with spirometry. After adjusting for age, sex, and BMI, greater dyspnea impact was associated with increased healthcare utilization, lower quality of life, and reduced work productivity. InterpretationIn community-based adults with undiagnosed respiratory symptoms, those identified with PRISm experienced the greatest impact of dyspnea. Dyspnea imposes burdens on the healthcare system and is associated with impaired quality of life and work productivity.

Fractional exhaled nitric oxide (FeNO) among school children in Java and Sumatra, Indonesia: associations with respiratory symptoms, house dust mite sensitization and the home environment

Objective To study associations between fractional exhaled nitric oxide (FeNO) and asthma, airway symptoms, sensitization to common allergens, outdoor pollution and home environment among 380 students in eight junior high schools in two areas in Indonesia. Methods Data on health and home were collected by a face-to face interview before measuring FeNO and performing skin prick test against common allergens. Exploratory linear mixed and logistic regression models were employed. Results Geometric mean of FeNO was 17.8 ppb (GSD 2.09) and 139 students (36.6%) had elevated FeNO (>20 ppb). In total, 107 students (28.2%) were sensitized to house dust mite (HDM) (Der p1 or Der f1), 4 (1.1%) to cat and 3 (0.8%) to mold (Cladosporium or Alternaria). Moreover, 20 students (5.3%) had diagnosed asthma, 38 (10.0%) had current wheeze, and 107 (28.2%) had current rhinitis. HDM sensitization, diagnosed asthma, current wheeze, and current rhinitis were associated with FeNO. In total, 281 students (73.9%) had mold or dampness, 232 (61.1%) had environmental tobacco smoke (ETS) and 43 (11.3%) had other odor at home. Indoor mold or dampness and other odor at home were associated with FeNO. ETS was negatively associated with FeNO. Conclusion HDM sensitization and elevated FeNO can be common among children in this part of Indonesia. The high prevalence of elevated FeNO indicate that undiagnosed childhood asthma is common. Dampness, mold and odor at home can be associated with increased FeNO while ETS can be associated with decreased FeNO.

Analysis of Patients Admitted for Asthma Exacerbation in a Tertiary Hospital in Spain.

To analyze the characteristics of adult patients admitted for asthma exacerbation and determine optimization, treatment adherence, and follow-up in clinics. Patients ≥ 18 years old admitted from May 2021 to June 2023 with a primary diagnosis of asthma exacerbation were included. Patients with a secondary diagnosis of asthma exacerbation and those without a confirmed diagnosis were excluded. A total of 186 patientswere analyzed, 63% were female, with a mean age of 49 ± 34 years, mean body mass index (BMI) of 26.4 ± 5 kg/m2, mean immunoglobulin E level of 132 ± 235 IU/mL (range: 25-2041), mean eosinophils count of 180 ± 443, and length of stay of 8.6 ± 5 days.Comparing patients with one admission to those with multiple admissions, differences were observed in age (39 ± 15 vs. 58 ± 20, p < 0.0001), BMI (25.2 ± 3 vs. 27.4 ± 4, p < 0.0003), comorbidity (15% vs. 60%, p < 0.0001), and length of stay (4.5 ± 2 vs. 11 ± 3, p < 0.0001). Of the patients, 15% had undiagnosed asthma, 28% had known asthma without maintenance therapy, 23% were managed by primary care, and 34% were followed by pneumology. The mean Test ofAdherenceto Inhalers (TAI) score was 42.5 ± 8 points, with 70% showing erratic non-adherence, 46% showing deliberate non-adherence, and 21% showing unconscious non-adherence. The young population represents a significant percentage of admissions for asthma exacerbation due to poor follow-up in pulmonology clinics, inadequate treatment optimization, and low adherence.This study adds that it is necessary to improve the approach to asthma in primary care to optimize treatment, reduce under-diagnosis, and avoid hospital admissions.

Early Diagnosis and Treatment of COPD and Asthma — A Randomized, Controlled Trial

BackgroundMany persons with chronic obstructive pulmonary disease (COPD) or asthma have not received a diagnosis, so their respiratory symptoms remain largely untreated.MethodsWe used a case-finding method to identify adults in the community with respiratory symptoms without diagnosed lung disease. Participants who were found to have undiagnosed COPD or asthma on spirometry were enrolled in a multicenter, randomized, controlled trial to determine whether early diagnosis and treatment reduces health care utilization for respiratory illness and improves health outcomes. Participants were assigned to receive the intervention (evaluation by a pulmonologist and an asthma–COPD educator who were instructed to initiate guideline-based care) or usual care by their primary care practitioner. The primary outcome was the annualized rate of participant-initiated health care utilization for respiratory illness. Secondary outcomes included changes from baseline to 1 year in disease-specific quality of life, as assessed with the St. George Respiratory Questionnaire (SGRQ; scores range from 0 to 100, with lower scores indicating better health status); symptom burden, as assessed with the COPD Assessment Test (CAT; scores range from 0 to 40, with lower scores indicating better health status); and forced expiratory volume in 1 second (FEV1).ResultsOf 38,353 persons interviewed, 595 were found to have undiagnosed COPD or asthma and 508 underwent randomization: 253 were assigned to the intervention group and 255 to the usual-care group. The annualized rate of a primary-outcome event was lower in the intervention group than in the usual-care group (0.53 vs. 1.12 events per person-year; incidence rate ratio, 0.48; 95% confidence interval [CI], 0.36 to 0.63; P<0.001). At 12 months, the SGRQ score was lower than the baseline score by 10.2 points in the intervention group and by 6.8 points in the usual-care group (difference, −3.5 points; 95% CI, −6.0 to −0.9), and the CAT score was lower than the baseline score by 3.8 points and 2.6 points, respectively (difference, −1.3 points; 95% CI, −2.4 to −0.1). The FEV1 increased by 119 ml in the intervention group and by 22 ml in the usual-care group (difference, 94 ml; 95% CI, 50 to 138). The incidence of adverse events was similar in the trial groups.ConclusionsIn this trial in which a strategy was used to identify adults in the community with undiagnosed asthma or COPD, those who received pulmonologist-directed treatment had less subsequent health care utilization for respiratory illness than those who received usual care. (Funded by Canadian Institutes of Health Research; UCAP ClinicalTrials.gov number, NCT03148210.)

Anticipating undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry: a decision tool for bronchial challenge testing

BackgroundSome patients with asthma demonstrate normal spirometry and remain undiagnosed without further testing.ObjectiveTo determine clinical predictors of asthma in symptomatic adults with normal spirometry, and to generate a tool to help clinicians decide who should undergo bronchial challenge testing (BCT).MethodsUsing random-digit dialling and population-based case-finding, we recruited adults from the community with respiratory symptoms and no previous history of diagnosed lung disease. Participants with normal pre- and post-bronchodilator spirometry subsequently underwent BCT. Asthma was diagnosed in those with symptoms and a methacholine provocative concentration (PC20) of < 8 mg/ml. Sputum and blood eosinophils, and exhaled nitric oxide were measured. Univariate analyses identified potentially predictive variables, which were then used to construct a multivariable logistic regression model to predict asthma. Model sensitivity, specificity, and area under the receiver operating curve (AUC) were calculated.ResultsOf 132 symptomatic individuals with normal spirometry, 34 (26%) had asthma. Of those ultimately diagnosed with asthma, 33 (97%) answered ‘yes’ to a question asking whether they experienced cough, chest tightness or wheezing provoked by exercise or cold air. Other univariate predictors of asthma included female sex, pre-bronchodilator FEV1 percentage predicted, and percent positive change in FEV1 post bronchodilator. A multivariable model containing these predictive variables yielded an AUC of 0.82 (95% CI: 0.72–0.91), a sensitivity of 82%, and a specificity of 66%. The model was used to construct a nomogram to advise clinicians which patients should be prioritized for BCT.ConclusionsFour readily available patient characteristics demonstrated a high sensitivity and AUC for predicting undiagnosed asthma in symptomatic adults with normal pre- and post-bronchodilator spirometry. These characteristics can potentially help clinicians to decide which individuals with normal spirometry should be investigated with bronchial challenge testing. However, further prospective validation of our decision tool is required.

Influence of residential location on asthma symptoms in children: A cross-sectional study in Shanghai, China

IntroductionRapid industrialization and environmental and lifestyle modifications in China have led to the prevalence of asthma in children showing an increasing trend. However, few studies have assessed the influence of residential geographic location on asthma symptoms in this population. We aimed to explore the influence of residential location on asthma symptoms of children in Shanghai, China. MethodsThis cross-sectional study included 114 children with physician-diagnosed asthma. The inclusion criteria included an age <18 years and reported wheezing or asthma medication use over the previous 12 months. We excluded children with other respiratory diseases (e.g., pneumonia and laryngeal edema); severe diseases, disabilities, and mental illnesses; or undiagnosed asthma (with symptoms suggestive of asthma, yet having not been diagnosed with asthma by a physician). We evaluated asthma symptoms by assessing the number of asthma exacerbations in the previous 12 months, number of maximum symptom days, spirometry outcomes, respiratory resistance at 5 Hz, and fractional exhaled nitric oxide. Spatial analysis techniques of geographic information systems were used to assess the distance from the residence to major roadways. ResultsApproximately 66.7% of children reside in close proximity to urban expressways. The number of asthma exacerbations in the past 12 months increased if the children lived close to a national highway. Asthma symptom days was high in children living in Jiading District. Residential location was not significantly associated with spirometry outcomes, total specific airway resistance, and fractional exhaled nitric oxide. ConclusionsResidential location was associated with more severe asthma symptoms. To better prevent and control asthma symptom exacerbations, the construction of physical barriers around high-risk roads and areas, avoidance of smoking exposure from neighbors in the same building, and weight control are potential strategies; older children should be seriously considered. The traffic volume and flow effects should be further explored.

Asthma prevalence and environmental exposure in children and adolescent in Slovenia – a pilot study

Abstract Background The last data on asthma prevalence (13.9 and 17.4%) in children in Slovenia is from 2002. The aim is to assess the asthma prevalence and environmental risk factors in two selected schools in Slovenia, as a pilot study for a national cross-sectional survey. Methods We conducted a cross-sectional pilot study in two primary schools in Slovenia. Observed population were children and adolescents aged 6-7 and 12-13 years. Observed outcome was current asthma diagnosed by a physician, reported by parents. To get the desired information we formulated a new questionnaire which was content validated. In the School 1 teacher distributed the questionnaires for parents to fulfill it. In the School 2 the questionnaires were delivered to parents at the parental meeting together with the presentation of the study and short lecture. We calculated the response rate, the prevalence of asthma, asthma symptoms, allergy, genetic background and exposure to environmental risk factors. Results Response rate in the School 1 was 24%, in the School 2 was 100%. We got data about 53 out of 127 children and adolescent. None of the parents reported a diagnosed asthma in their child or adolescent, 17% reported symptoms of asthma, 11% wheezing, 8% allergic rhinitis, 40% of children were living within 200 meters of a busy road, 34% were exposed to moisture and mold, 9% had chronic respiratory infection in their early childhood and 13% mothers smoked during pregnancy. Conclusions Newly developed questionnaire efficiently acquired information about exposure to environmental risk factors and asthma or allergy symptom. To get higher response rate, delivering the questionnaires at the parental meeting was more effective. Considering the reported symptoms of asthma in undiagnosed cases, further investigation of health records is needed to recognize the potential undiagnosed asthma cases. The latter suggests the benefits of the HIS / HES (Health Interview / Examination Survey) methodology. Key messages • HIS (Health Interview Survey) and HES (Health Examination Survey) design type methodology ensure us the quality data on asthma prevalence. • To efficiently assess the asthma prevalence, the adherence to medical guidelines and unification of the methodology to diagnose asthma in children by pediatricians is of an extreme importance.

Spontaneous Pneumomediastinum Secondary to Undiagnosed Asthma inMilitary Adult.

Spontaneous pneumomediastinum (SPM) is a rare but described complication of exercise-induced bronchoconstriction (EIB), more commonly observed in children with asthma. We present a 23-year-old active duty military male and avid distance runner who developed progressive radiating retrosternal chest pain preceded by wheezing and coughing paroxysm. A chest computed tomography revealed extensive pneumomediastinum. SPM results from increased intrathoracic pressure with alveolar rupture and subsequent tracking of air between fascial planes. Like most cases of SPM, our patient remained hemodynamically stable and responded well to conservative therapies with complete resolution. After thorough evaluation, undiagnosed asthma was determined to be the inciting etiology. The patient is now well controlled and symptom free on a daily low-dose inhaled corticosteroid without SPM reoccurrence. In young adult patients presenting with SPM, EIB and asthma should be considered on the differential diagnosis as appropriate medical therapy will improve symptoms and reduce risk of reoccurrence.

Recommendations from a Canadian Delphi consensus study on best practice for optimal referral and appropriate management of severe asthma

BackgroundIn Canada, severe asthma affects an estimated 5–10% of people with asthma and is associated with frequent exacerbations, poor symptom control and significant morbidity from the disease itself, as well as the high dose inhaled, and systemic steroids used to treat it. Significant heterogeneity exists in service structure and patient access to severe asthma care, including access to biologic treatments. There appears to be over-reliance on short-acting beta agonists and frequent oral corticosteroid use, two indicators of uncontrolled asthma which can indicate undiagnosed or suboptimally treated severe asthma. The objective of this modified Delphi consensus project was to define standards of care for severe asthma in Canada, in areas where the evidence is lacking through patient and healthcare professional consensus, to complement forthcoming guidelines.MethodsThe steering group of asthma experts identified 43 statements formed from eight key themes. An online 4-point Likert scale questionnaire was sent to healthcare professionals working in asthma across Canada to assess agreement (consensus) with these statements. Consensus was defined as high if ≥ 75% and very high if ≥ 90% of respondents agreed with a statement.ResultsA total of 150 responses were received from HCPs including certified respiratory educators, respirologists, allergists, general practitioners/family physicians, nurses, pharmacists, and respiratory therapists. Consensus amongst respondents was very high in 37 (86%) statements, high in 4 (9%) statements and was not achieved in 2 (5%) statements. Based on the consensus scores, ten key recommendations were proposed. These focus on referrals from primary and secondary care, accessing specialist asthma services, homecare provision for severe asthma patients and outcome measures.ConclusionsImplementation of these recommendations across the severe asthma care pathway in Canada has the potential to improve outcomes for patients through earlier detection of undiagnosed severe asthma, reduction in time to severe asthma diagnosis, and initiation of advanced phenotype specific therapies.

LOWER RESPIRATORY TRACT SCREENING USING FRACTIONAL EXHALED NITRIC OXIDE IN PATIENTS WITH EOSINOPHILIC CHRONIC RHINOSINUSITIS

It is known that eosinophilic chronic rhinosinusitis is often associated with adult-onset bronchial asthma, and undiagnosed bronchial asthma is also known to be included. The purpose of this study is to screen patients with eosinophilic chronic rhinosinusitis using fractional exhaled nitric oxide, and to examine its usefulness in detecting undiagnosed bronchial asthma. We retrospectively examined the data of patients with eosinophilic chrnoic rhinosinusitis who underwent surgical treatment at Kagawa University from April 2015 to July 2022. Patients were included if they received examinations of fractional exhaled nitric oxide and spirometry before surgical treatment. Of the 127 subjects, 52 had no history of treatment or diagnosis of bronchial asthma at the initial consultation. Among them, 15 patients who had high fractional exhaled nitric oxide value were diagnosed with bronchial asthma by the respiratory medicine department. Comorbid of bronchial asthma was eventually increased to 70.9% even though it was 59.1% at initial consultation. A certain number of patients with eosinophilic chronic rhinosinusitis have undiagnosed bronchial asthma, which can be difficult to detect with basic examination alone therefore fractional exhaled nitric oxide is useful as an additional screening examination.

Analysis of school-based asthma screenings and need for care coordination in underserved urban communities

BackgroundAsthma is one of the most common chronic childhood disease states in the United States and continues to become more prevalent. Data suggest the incidence, morbidity, and mortality of asthma are higher among minority children of lower socioeconomic status living in urban settings. There is a lack of data evaluating the impact of mass school-based asthma screenings and care coordination in underserved communities. ObjectiveThis study aimed to determine whether a school-based asthma screening program is effective in identifying children who are at risk of undiagnosed and uncontrolled asthma and whether there is a need for care coordination. MethodsThis study is a retrospective review describing the outcomes of the 2021 school-based asthma screening program. Asthma screening data from 6 participating school districts (prekindergarten to twelfth grade) in the greater Pittsburgh area were included in this review. An asthma screening questionnaire was distributed school-wide and included questions about demographics, previous asthma diagnosis, repeated episodes of asthma, and frequency of symptoms. Based on caregiver-reported answers, children who screened positive for previously diagnosed asthma, uncontrolled asthma, or undiagnosed asthma received care coordination for follow-up care. ResultsThis study included asthma screening results for 561 participants. Approximately 13% of participants (n = 73) displayed asthma symptoms but did not have a diagnosis of asthma. Of those 73 participants, 9.6% (n = 54) were at risk of uncontrolled asthma. The screening tool also identified 5.6% of participants (n = 32) who had a diagnosis of asthma and were at risk of uncontrolled asthma. ConclusionsThe school-based asthma screening program was effective in identifying children at risk of undiagnosed and uncontrolled asthma. Pharmacists are well positioned to implement asthma screening programs in schools and throughout the community.

Asthma is associated with bullying victimization in rural adolescents

Objective We characterized bullying among rural adolescents and examined the association between asthma and bullying victimization. Methods Participants (N = 1905; 44.5% Black) were students attending rural high schools who were screened for a randomized trial to address uncontrolled asthma. Screening questions asked students about asthma diagnosis and symptoms, bullying victimization, and demographic characteristics. Logistic regression analyses with school as a fixed effect were employed to examine the extent to which demographic factors, asthma diagnosis, asthma status (i.e. current asthma, no asthma, possible undiagnosed asthma), and among those with current asthma, asthma severity, were associated with bullying victimization. Sensitivity analyses using bullying frequency as the outcome were also conducted. Results 26.0% reported being bullied. Younger age and self-identifying as White were associated with increased risk of bullying victimization. Compared to those with no asthma, those with current asthma or possible undiagnosed asthma were at increased risk for bullying victimization (adjusted odds ratio [AOR] = 2.46; 95% confidence interval (CI) = 1.76–3.46 and AOR = 2.42; 95% CI = 1.87–3.14, respectively). Among those with current asthma, persistent symptoms increased the risk for bullying victimization (AOR = 2.59; 95% CI = 1.45–4.71). Similar results were obtained with sensitivity analyses. Conclusions In a large rural community cohort, asthma was associated with bullying victimization. Findings suggest that rural students with asthma, with or without diagnosis, could benefit from schools creating inclusive environments that reduce victimization based on this medical condition. School administrators should foster environments that are accepting of all students’ abilities and statuses, and healthcare providers can provide proper asthma management education to these adolescents.

CC16 polymorphisms in asthma, asthma subtypes, and asthma control in adults from the Agricultural Lung Health Study

BackgroundThe club cell secretory protein (CC16) has anti-inflammatory and antioxidant effects and is a potential early biomarker of lung damage. The CC16 single nucleotide polymorphism (SNP) rs3741240 risk allele (A) has been inconsistently linked to asthma; other tagging SNPs in the gene have not been explored. The aim was to determine whether CC16 tagging polymorphisms are associated with adult asthma, asthma subtypes or asthma control in the Agricultural Lung Health Study (ALHS).MethodsThe ALHS is an asthma case-control study nested in the Agricultural Health Study cohort. Asthma cases were individuals with current doctor diagnosed asthma, likely undiagnosed asthma, or asthma-COPD overlap defined by questionnaire. We also examined asthma subtypes and asthma control. Five CC16 tagging SNPs were imputed to 1000 Genomes Integrated phase 1 reference panel. Logistic regression was used to estimate associations between CC16 SNPs and asthma outcomes adjusted for covariates.ResultsThe sample included 1120 asthma cases and 1926 controls of European ancestry, with a mean age of 63 years. The frequency of the risk genotype (AA) for rs3741240 was 12.5% (n = 382). CC16 rs3741240 was not associated with adult asthma outcomes. A tagging SNP in the CC16 gene, rs12270961 was associated with uncontrolled asthma (n = 208, ORadj= 1.4, 95% CI 1.0, 1.9; p = 0.03).ConclusionThis study, the largest study to investigate associations between CC16 tagging SNPs and asthma phenotypes in adults, did not confirm an association of rs3741240 with adult asthma. A tagging SNP in CC16 suggests a potential relationship with asthma control.

Patient and physician factors associated with symptomatic undiagnosed asthma or COPD.

It remains unclear why some symptomatic individuals with asthma or COPD remain undiagnosed. Here, we compare patient and physician characteristics between symptomatic individuals with obstructive lung disease (OLD) who are undiagnosed and individuals with physician-diagnosed OLD. Using random-digit dialling and population-based case finding, we recruited 451 participants with symptomatic undiagnosed OLD and 205 symptomatic control participants with physician-diagnosed OLD. Data on symptoms, quality of life and healthcare utilisation were analysed. We surveyed family physicians of participants in both groups to elucidate differences in physician practices that could contribute to undiagnosed OLD. Participants with undiagnosed OLD had lower mean pre-bronchodilator forced expiratory volume in 1 s percentage predicted compared with those who were diagnosed (75.2% versus 80.8%; OR 0.975, 95% CI 0.963-0.987). They reported greater psychosocial impacts due to symptoms and worse energy and fatigue than those with diagnosed OLD. Undiagnosed OLD was more common in participants whose family physicians were practising for >15 years and in those whose physicians reported that they were likely to prescribe respiratory medications without doing spirometry. Undiagnosed OLD was more common among participants who had never undergone spirometry (OR 10.83, 95% CI 6.18-18.98) or who were never referred to a specialist (OR 5.92, 95% CI 3.58-9.77). Undiagnosed OLD was less common among participants who had required emergency department care (OR 0.44, 95% CI 0.20-0.97). Individuals with symptomatic undiagnosed OLD have worse pre-bronchodilator lung function and present with greater psychosocial impacts on quality of life compared with their diagnosed counterparts. They were less likely to have received appropriate investigations and specialist referral for their respiratory symptoms.

Asthma and self-management: Improving support for teenagers

The prevalence and severity of allergic diseases is still rising in those aged 11–25 years ( Venkataraman et al, 2018 ; Mallol et al, 2019 ). An estimated 800 000 teenagers in the UK have asthma. This figure could be higher as teenagers can have undiagnosed asthma ( Siersted et al, 1998 ; BTS/SIGN, 2019).A person-centred approach to all aspects of care is central to supporting adolescents to self-manage their asthma and therefore minimise concerns around morbidity and mortality. School nurses have a key role in communicating strategies that support self-management, and the use of tools can be helpful.

Withdrawal of inhaled corticosteroids from patients with COPD with mild or moderate airflow limitation in primary care: a feasibility randomised trial

BackgroundInhaled corticosteroids (ICS) are frequently prescribed outside guidelines to patients with chronic obstructive pulmonary disease (COPD) with mild/moderate airflow limitation and low exacerbation risk. This primary care trial explored the...

Disease burden in individuals with symptomatic undiagnosed asthma or COPD

BackgroundThe actual burden of COPD and asthma may be much higher than appreciated, since a large proportion of individuals are not diagnosed. Our study objective was to compare health care utilization, burden of symptoms and quality of life in subjects with self-reported respiratory symptoms who were subsequently found to have undiagnosed airflow obstruction compared to those having no airflow obstruction. MethodsThis cross-sectional case-finding study used data from the Undiagnosed COPD and Asthma Population (UCAP) study. Adult subjects with respiratory symptoms who had no history of diagnosed lung disease were recruited in a two-step case-finding process using random digit-dialling of land lines and cell phones located within a 90-min radius of 16 Canadian study sites. Participants were assessed for COPD, asthma or no airflow obstruction using pre- and post-bronchodilator spirometry based on American Thoracic Society diagnostic criteria. Results1660 participants were recruited, of these 1615 had adequate spirometry and 331 (20.5%) subjects met spirometry criteria for undiagnosed asthma or COPD. Subjects with undiagnosed asthma or COPD had increased respiratory symptoms as assessed by the COPD Assessment Test (CAT), and higher St. George's Respiratory Questionnaire (SGRQ) scores indicating worse health-related quality of life, compared to subjects with no airflow obstruction. No between-group differences were found in health care utilization or work or school absenteeism. ConclusionUndiagnosed asthma and COPD are common in Canadian adults experiencing breathing problems and are associated with a greater burden of symptoms and poorer health-related quality of life. These results suggest that patients may benefit from early identification and treatment of undiagnosed asthma and COPD.

Assessing socioeconomic bias in machine learning algorithms in health care: a case study of the HOUSES index.

Artificial intelligence (AI) models may propagate harmful biases in performance and hence negatively affect the underserved. We aimed to assess the degree to which data quality of electronic health records (EHRs) affected by inequities related to low socioeconomic status (SES), results in differential performance of AI models across SES. This study utilized existing machine learning models for predicting asthma exacerbation in children with asthma. We compared balanced error rate (BER) against different SES levels measured by HOUsing-based SocioEconomic Status measure (HOUSES) index. As a possible mechanism for differential performance, we also compared incompleteness of EHR information relevant to asthma care by SES. Asthmatic children with lower SES had larger BER than those with higher SES (eg, ratio = 1.35 for HOUSES Q1 vs Q2-Q4) and had a higher proportion of missing information relevant to asthma care (eg, 41% vs 24% for missing asthma severity and 12% vs 9.8% for undiagnosed asthma despite meeting asthma criteria). Our study suggests that lower SES is associated with worse predictive model performance. It also highlights the potential role of incomplete EHR data in this differential performance and suggests a way to mitigate this bias. The HOUSES index allows AI researchers to assess bias in predictive model performance by SES. Although our case study was based on a small sample size and a single-site study, the study results highlight a potential strategy for identifying bias by using an innovative SES measure.