Worse Asthma Control Research Articles

The effect of obesity on asthma in children

Introduction: The prevalence of obesity and asthma is increasing in recent years. Obesity is a risk factor for asthma. The presence of obesity may affect the clinical course of the disease in patients with asthma. This study was conducted to determine the effect of obesity on clinical course of asthma and pulmonary function tests in children with asthma. Material and Method: One hundred and sixty children with asthma who were followed in Pediatric ImmunologyAllergy Clinic were included in this study. Patients were evaluated prospectively between January 2011-June 2011. The patients were interrogated with detailed history of allergic disease, age, kin marriage, familial atopy, exposure to tobacco smoke, number of asthma attacks within the previous year, and systemic steroid use. Asthma control test, pulmonary function tests, skin prick tests, eosinophilia and total immunoglobulin E measurements were performed. Patients with waist circumferences above the 90th percentile were considered obese. Results: Ninety-six (60%) patients were of normal weight and 64 (40%) of them were obese. There were no statistically significant difference between both groups in terms of age, gender, consanguinity, family history of atopy, smoking, and atopy. The number of attacks and need of systemic steroid within the previous one year were significantly higher in obese asthmatics compared to normalweight individuals (p<0.05). Asthma control in obese asthmatics was significantly worse (p<0.05). There were no statistically significant intergroup difference in terms of serum total IgE, eosinophilia and respiratory function parameters (p>0.05). Binary logistic regression analysis was used to investigate the variables that were effective on asthma control (age, family history of asthma, BMI, WC, number of attacks, systemic steroid use, FEV1, FVC, FEV1/FVC, PEF, and MEF 25-75). The effect of BMI was found to be greater (OR: 39 Cl: (0.36, 4435)). Discussion and Conclusion: Obesity worsens asthma control, increases systemic steroid use and the number of attacks in our patients with asthma. Weight loss together with appropriate treatment and avoidance from allergens may improve asthma control in these patients. 

Prevalence and characteristics of medication sharing behavior in a pediatric Medicaid population with asthma

Prevalence and characteristics of medication sharing behavior in a pediatric Medicaid population with asthma

Comorbidities in elderly patients with asthma: Association with control of the disease and concomitant treatment

The incidence of concomitant conditions increases with age. In elderly patients, the presence of comorbidities has been related to the course and severity of asthma. The aim of the present study was to assess the impact of comorbidities and concomitant treatment on asthma control and severity in older adults. A total of 93 elderly (age >65 years) and 78 younger (age 30-50 years) asthmatic patients were randomly selected from a database including 1755 asthmatics. Evaluation consisted of a questionnaire, spirometry and skin prick testing. In elderly asthmatics, a higher incidence of chronic comorbidities (mean 8.4 vs 4.7; P < 0.001) and a higher number of prescribed medicines (7.4 vs 4.5, P < 0.001) were observed, but the severity of asthma and the intensity of anti-asthma treatment were similar to that seen in younger patients. Asthma control was not strikingly different between the groups. There was no correlation between the presence of comorbid conditions and asthma control, severity or frequency of exacerbations in older patients. Elderly patients treated with statins had a lower risk of asthma exacerbation (OR 0.39, 95% CI 0.18-0.84, P = 0.017), whereas treatment with proton pump inhibitors was associated with a higher risk of exacerbations in older adults (OR 1.84, 95% CI 1.07-3.18, P = 0.029) and higher disease severity in younger patients (OR 2.49, 95% CI 1.1-5.67, P = 0.029). The higher prevalence of comorbidities observed in elderly asthmatics under specialist care do not seem to be associated with worsened asthma control or severity. However, concomitant medications can significantly affect asthma control in both elderly and younger asthmatics.

Mediator Effect of Depressive Symptoms on the Association Between BMI and Asthma Control in Adults

Obesity has been associated with worse asthma control. Depression has also been shown to be disproportionally prevalent among patients with asthma and among patients with obesity. However, no studies have examined the mediating effect of depression on the obesity-asthma relationship. This study examined the extent to which depressive symptoms may mediate the obesity-asthma relationship in an adult sample. A total of 798 patients with physician-diagnosed asthma were recruited from the outpatient asthma clinic at Hôpital du Sacré-Cœur de Montréal. Patients provided demographic and medical history information and completed a battery of questionnaires, including the Beck Depression Inventory (BDI)-II and the Asthma Control Questionnaire (ACQ). BMI was calculated from self-reported height and weight. Analyses adjusted for age, sex, years of education, cohabitation, and inhaled corticosteroid dose revealed an association between BMI and ACQ (β = 0.017, P = .026), between BMI and BDI-II (β = 0.189, P = .002), and between BDI-II and ACQ (β = 0.044, P < .001). However, when both BDI-II and BMI were entered into the same model, BDI-II (β = 0.044, P < .001) but not BMI (β = 0.009, P = .226) remained significantly associated with ACQ. The results indicate that depression and a high BMI are both associated with worse asthma control. However, consistent with our hypotheses, the relationship between BMI and worse asthma control was mediated by depressive symptoms. Future studies should examine the precise role of depressive symptoms in both weight and asthma control.

TLR2 activation causes tachyphylaxis to β2 -agonists in vitro and ex vivo: modelling bacterial exacerbation.

Asthma is a widespread chronic health problem exacerbated by common viral and bacterial infections. Further research is required to understand how infection worsens asthma control in order to advance therapeutic options in the future. Recent research has revealed that β2 -adrenergic receptor (β2 -AR) agonists lose bronchodilatory efficacy because the receptor-mediated molecular pathways responsible for their beneficial actions are desensitized by infection. To date, most studies have focussed on viral infection, leaving the impact of bacterial infection on β2 -AR desensitization relatively under-investigated. We address this in this study. Utilizing an in vitro model of bacterial exacerbation in airway smooth muscle (ASM) cells, we show that activation of toll-like receptor 2 (TLR2; mimicking bacterial infection) in the presence of an inflammatory stimulus leads to β2 -AR desensitization. This occurs via TLR2-dependent upregulation of cyclooxygenase 2 (COX-2) mRNA expression and increased secretion of PGE2 . Importantly, PGE2 causes heterologous β2 -AR desensitization and reduces cAMP production in response to short-acting (salbutamol) and long-acting (formoterol) β2 -agonists. Thus, bacterial infectious stimuli act in a PGE2 -dependent manner to severely curtail the beneficial actions of β2 -agonists. The impact of β2 -AR desensitization is demonstrated by reduced gene expression of the critical anti-inflammatory molecule MKP-1 in response to β2 -agonists, as well as impaired bronchodilation in a mouse lung slices. Taken together, our results show that, like viruses, bacteria induce prostanoid-dependent β2 -AR desensitization on ASM cells. Notably, COX-2 inhibition with the specific inhibitor celecoxib represses PGE2 secretion, presenting a feasible pharmacological option for treatment of infectious exacerbation in asthma in the future.

Asthma control in elderly asthmatics. An Italian observational study

The exponential increase of individuals aged >64 yrs is expected to impact the burden of asthma. We aimed to explore the level of asthma control in elderly subjects, and factors influencing it. A multicenter observational study was performed on consecutive patients >64 years old with a documented physician-diagnosis of asthma. Sixteen Italian centers were involved in this 6-month project. A total of 350 patients were enrolled in the study. More than one-third of elderly asthmatic patients, despite receiving GINA step 3-4 antiasthmatic therapy, had an Asthma Control Test score ≤19, with a quarter experiencing at least one severe asthma exacerbation in the previous year. Twenty-nine percent of patients (n = 101) were classified as having Asthma-COPD Overlap Syndrome (ACOS) due to the presence of chronic bronchitis and/or CO lung diffusion impairment. This subgroup of patients had lower mean Asthma Control Test scores and more exacerbations compared to the asthmatic patients (18 ± 4 compared to 20 ± 4, p < 0.01, and 43% compared to 18%, p < 0.01, respectively). Modified Medical Research Council dyspnea mMRC scores and airway obstruction, assessed on the basis of a FEV(1)/FVC ratio below the lower limit of normal, were more severe in ACOS than in asthma, without any difference in responses to salbutamol. In a multivariate analysis, the mMRC dyspnea score, FEV(1)% of predicted and the coexistence of COPD were the only variables to enter the model. Our results highlight the need to specifically evaluate the coexistence of features of COPD in elderly asthmatics, a factor that worsens asthma control.

Obesity and symptoms of depression contribute independently to the poor asthma control of obesity

Obesity is a major risk factor for poorly controlled asthma, but the reasons for poor asthma control in this patient population are unclear. Symptoms of depression have been associated with poor asthma control, and increase with higher body mass index (BMI). The purpose of this study was to assess whether depressive symptoms underlie poor asthma control in obesity. We determined the relationship between BMI, psychological morbidity and asthma control at baseline in a well-characterized patient population participating in a clinical trial conducted by the American Lung Association-Asthma Clinical Research Centers. Obese asthmatic participants had increased symptoms of depression (Center for Epidemiologic Studies Depression Scale score in lean 10.1 ± 8.1, overweight 10.0 ± 8.1, obese 12.4 ± 9.9; p = 0.03), worse asthma control (Juniper Asthma Control Questionnaire score in lean 1.43 ± 0.68, overweight 1.52 ± 0.71, obese 1.76 ± 0.75; p < 0.0001), and worse asthma quality of life (scores in lean 5.21 ± 1.08, overweight 5.08 ± 1.05, obese 4.64 ± 1.09; p < 0.0001). Asthmatics with obesity and those with symptoms of depression both had a higher risk of having poorly controlled asthma (adjusted odds ratio of 1.83 CI 1.23-3.52 for obesity, and 2.08 CI 1.23-3.52 for depression), but there was no interaction between the two. Obesity and symptoms of depression are independently associated with poor asthma control. As depression is increased in obese asthmatics it may be an important co-morbidity contributing to poor asthma control in this population, but factors other than depression also contribute to poor asthma control in obesity.

Socioeconomic status and asthma control in African American youth in SAGE II

Objective: African Americans are disproportionately burdened by asthma. We assessed the individual and joint contribution of socioeconomic status (SES) on asthma morbidity among African American youth. Methods: We examined 686 African Americans (8–21 years) with asthma. To account for the joint effects of SES, a composite index was derived from maternal educational attainment, household income, and insurance status. Ordinal logistic regression was used to estimate the individual and joint effect of SES on asthma control. Models were adjusted for age, sex, controller medication use, in utero smoke exposure, family history of asthma, family history of rhinitis, breastfeeding, daycare attendance, and mold exposure. Results: Participants were classified as Poorly Controlled Asthma (40.8%), Partially Controlled Asthma (29.7%), or Controlled Asthma (30.2%). Of the individual SES indicators, low income was the strongest predictor of poor asthma control. Children with low income had worse asthma control than those with higher income (OR 1.39; 95% CI 0.92–2.12). The SES index ranged from 4–9. SES was associated with 17% increased odds of poor asthma control with each decrease in the index (95% CI 1.05–1.32). The SES index was associated with asthma-related symptoms, nocturnal awakenings, limited activity, and missed school days. Conclusions: The negative effects of SES were observed along the entire socioeconomic gradient, and the adverse asthma outcomes observed in African American youth were not limited to the very poor. We also found that the SES index may be a more consistent and useful predictor of poor asthma outcomes than each indicator alone.

Pulmonary vasculature and critical asthma syndromes: a comprehensive review.

One of the important factors and consequences in persistent asthma is the change in the vasculature of the airways and lung parenchyma. These changes could contribute to worsening asthma control and predispose asthmatics to critical asthma syndromes. For many years, the contribution of vasculature to severe asthma was limited to discussion of small and medium vessel vasculitis commonly referred to as Churg − Strauss syndrome. This comprehensive review will explore the known mechanisms that are associated with remodeling of the vasculature in a variety of critical asthma presentations. Inflammation of pulmonary and bronchial small blood vessels may contribute significantly but silently to asthma pathobiology. Inflammation in the vasculature of the lung parenchyma can decrease lung capacity while inflammation in airway vasculature can decrease airflow. This review will provide a modern perspective on Churg–Strauss syndromes with a focus on phenotyping, mechanism, and ultimately modern therapeutic approaches. Vascular remodeling and airway remodeling are not mutually exclusive concepts in understanding the progression of asthma and frequency of acute exacerbations. Furthermore, the contribution of vascular leak, particularly in the parenchymal vasculature, has become an increasingly recognized component of certain presentations of poorly controlled, severe persistent asthmatic and during exacerbations. We highlight how these mechanisms can contribute to some the severe presentations of influenza infection in patients with a history of asthma. The ultimate aim of this review is to summarize the current literature concerning vasculitis and the contribution of airway and parenchymal vascular remodeling to presentation of persistent asthma and its consequences during acute exacerbations and critical asthma syndromes.

Is obesity related to worse control in children with asthma?

Asthma and obesity are related diseases however the influence of obesity on asthma severity is not clear yet. Therefore, the aim of our study was to evaluate the association between obesity and asthma control evaluated on the basis of symptoms and asthma control questionnaire (ACQ). We enrolled 98 children with asthma aged 4 to 14 years consecutively and recorded their disease characteristics and severity parameters as well as the symptom scores. All children filled in the ACQ. Children were classified as obese and non-obese according to body mass index. Obesity was defined as body mass index over 90th percentile. Mean age of the children in the obese group (n= 27) was 8.1 ± 2.6 while that in the non-obese group (n= 71) was 8.6 ± 2.9 (p= 0.41). Asthma symptom score in obese and non-obese groups were not significantly different (p= 0.73). Children in the obese group had lower ACQ scores when compared to the non-obese group (1.2 ± 0.9 vs 1.7 ± 1.0, p= 0.04) however this significance was lost when controlled for age and gender in the regression model. The results of this study suggest that obesity is not significantly associated with worse asthma control when adjusted for age and gender.

Between-visit variability of small airway obstruction markers in patients with asthma

To the Editor: Clinical trials in patients with airway diseases often use forced expiratory volume in 1 s (FEV1) as the sole physiological outcome measure. However, FEV1 is thought to be insensitive to obstruction of the smaller airways, which may be particularly relevant in asthma [1]. Putative markers of small airway obstruction include measures of airway resistance using impulse oscillometry (IOS) [2] and indices of ventilation heterogeneity derived from multiple-breath inert gas washout (MBW) [3]. We recently showed that increased airway resistance at 5 Hz ( R 5) and 20 Hz ( R 20) is associated with worse asthma control and more frequent exacerbations [4], and Farah et al. [5] demonstrated that MBW parameters may be responsive to asthma therapy. In order to conduct clinical trials using these alternative outcome measures, it is necessary to be assured of their repeatability and stability over time. Moreover, an estimate of between-visit variability in the stable state is required so that sample size calculations can be performed. We therefore aimed to determine the between-visit variability of a range of IOS and MBW indices in a group of patients with asthma in the stable state. We investigated between-visit variability over two time intervals, namely 2 weeks and 3 months, in order to encompass the typical lengths of treatment period that are used in clinical trials. We recruited 18 adults (age >18 years) with moderate-to-severe asthma (Global Initiative for Asthma treatment steps 3–5 [6]), diagnosed by a specialist asthma physician in a secondary care setting, according to British Thoracic Society guidelines [ …

Frequent exacerbators – a distinct phenotype of severe asthma

Exacerbations represent a major source of morbidity and mortality in asthma and are a prominent feature of poorly controlled, difficult-to-treat disease. The goal of our study was to provide a detailed characterization of the frequent exacerbator phenotype and to identify risk factors associated with frequent and seasonal exacerbations. Ninety-three severe asthmatics (SA) and 76 mild-to-moderate patients (MA) were screened and prospectively followed up for 1 year (NCT00555607). Medical history, baseline clinical data and biomarkers were used to assess risk factors for frequent exacerbations. During the study, 104 exacerbations were recorded in the SA group and 18 in the MA. Frequent exacerbators were characterized by use of higher doses of inhaled (1700 vs. 800 μg) and oral (6.7 vs. 1.7 mg) glucocorticosteroids, worse asthma control (ACQ score 2.3 vs. 1.4), lower quality of life (SGRQ score 48.5 vs. 33.3), higher sputum eosinophils (25.7% vs. 8.2%) and a more rapid decline in FEV1 /FVC ratio (-0.07 vs. -0.01 ΔFEV1 /FVC, frequent vs. non-frequent, respectively, P < 0.05). Exhaled NO > 45 p.p.b. and a history of smoking were associated with an increased risk of frequent exacerbations (odds ratios: 4.32 and 2.90 respectively). We were able to distinguish and characterize a subphenotype of asthma subjects--frequent exacerbators--who are significantly more prone to exacerbations. Patients with FeNO > 45 p.p.b. and a history of smoking are at increased risk of frequent exacerbations and require careful monitoring in clinical practice.

Pharmacotherapy of Critical Asthma Syndrome: Current and Emerging Therapies

The critical asthma syndrome (CAS) encompasses the most severe, persistent, refractory asthma patients for the clinician to manage. Personalized pharmacotherapy is necessary to prevent the next acute severe asthma exacerbation, not just the control of symptoms. The 2007 National Asthma Education and Prevention Program Expert Panel 3 provides guidelines for the treatment of uncontrolled asthma. The patient's response to recommended pharmacotherapy is highly variable which risks poor asthma control leading to frequent exacerbations that can deteriorate into CAS. Controlling asthma symptoms and preventing acute exacerbations may be two separate clinical activities with their own unique demands. Clinicians must be prepared to use the entire spectrum of asthma medications available but must concurrently be aware of potential drug toxicities some of which can paradoxically worsen asthma control. Medications normally prescribed for COPD can potentially be useful in the CAS patient, particularly those with asthma-COPD overlap syndrome. Immunomodulation with drugs like omalizumab in IgE-mediated asthma syndromes is one important approach. New and emerging drugs address unique aspects of airway inflammation and biology but at a significant financial cost. The pharmacology and toxicities of the agents that may be used in the treatment of CAS to control asthma symptoms and prevent severe exacerbations are reviewed.

Asthma in pregnancy

Key content Asthma is a common condition that affects ˜10% of pregnant women. Pregnancy worsens asthma control in one‐third of women, improves it in one‐third and has no effect on one‐third. Poor asthma control has adverse effects upon maternal and fetal outcomes. Good asthma management to maintain control is important in line with national guidelines. Standard therapy with inhaled corticosteroids with or without the addition of short and long‐acting β‐agonists can be used in pregnancy. Learning objectives Comprehensive overview of asthma in pregnancy. Review asthma management in pregnancy. Ethical issues Are women appropriately counselled on the pregnancy risks of asthma? Are doctors aware of the safety of routine asthma treatments in pregnancy?

The emerging role of Vitamin D in asthma management

Vitamin D deficiency and asthma share risk factors. Epidemiologists suggest that the U.S. prevalence of Vitamin D deficiency has increased as a result of the Westernization of culture and less time spent outdoors. Numerous studies support a patient's Vitamin D deficiency as a contributing cause to increased asthma symptoms, lower lung function levels, increased airway reactivity, and worsening asthma control. The purpose of the review article is to discuss the emerging role of Vitamin D in asthma management. A review of original research identified through MEDLINE and CINAHL and published in English was performed. Research suggests promising benefits of Vitamin D supplementation in asthma patients with low (<30 ng/mL) Vitamin D levels. Evidence supports several possible mechanisms, including downregulation of allergen sensitivity and enhanced steroid responsiveness. Studies demonstrate that Vitamin D modifies airway hyperresponsiveness by minimizing airway inflammation. Ongoing studies seek to further evaluate the effects of Vitamin D supplementation on asthma and asthma morbidity. While there is no consensus on the use of Vitamin D as a mainstay in asthma treatment, research supports its consideration for use in asthma patients with low Vitamin D levels. Current evidence reinforces the need to measure Vitamin D levels for all asthma patients.

Depressive symptomatology, quality of life and disease control among individuals with well-characterized severe asthma

Objectives: A thorough examination of the relationship of asthma severity and control with symptoms of depression is needed to identify groups of asthmatics at high risk for poor disease control outcomes. This study examines the relationship of symptoms of depression with severity and control in a well-characterized cohort of asthmatics and healthy controls. Methods: Depressive symptoms and quality of life were assessed using the Beck Depression Inventory. Disease control was measured by a composite index incorporating symptoms, activity limitation and rescue medication use. Results: Individuals with asthma (n = 91) reported more symptoms of depression than controls (n = 36; p < 0.001). Those with severe asthma (n = 49) reported more symptoms of depression (p = 0.002) and poorer asthma control (p < 0.0001) than those with not severe asthma. Worse asthma control was associated with more depressive symptoms in severe (r = 0.46, p = 0.002) but not in not severe (r = 0.13, p = 0.40) asthmatics. The relationship of symptoms of depression among severe asthmatics was attenuated by disease control. Exploratory analyses identified specific disease symptom characteristics, as opposed to exacerbations, as associated with symptoms of depression. Conclusions: Among individuals with severe asthma, increased symptom burden is positively associated with risk for co-morbid depression. These findings point to a need for regular mood disorder screenings and treatment referrals among this group. Further research is warranted to examine whether treatment of comorbid depression improves treatment adherence and asthma-related quality of life.

Childhood Obesity and Asthma Control in the GALA II and SAGE II Studies

Obesity is associated with increased asthma morbidity, lower drug responsiveness to inhaled corticosteroids, and worse asthma control. However, most prior investigations on obesity and asthma control have not focused on pediatric populations, considered environmental exposures, or included minority children. To examine the association between body mass index categories and asthma control among boys and girls; and whether these associations are modified by age and race/ethnicity. Children and adolescents ages 8-19 years (n = 2,174) with asthma were recruited from the Genes-environments and Admixture in Latino Americans (GALA II) Study and the Study of African Americans, Asthma, Genes, and Environments (SAGE II). Ordinal logistic regression was used to estimate odds ratios (OR) and their confidence intervals (95% CI) for worse asthma control. In adjusted analyses, boys who were obese had a 33% greater chance of having worse asthma control than their normal-weight counterparts (OR, 1.33; 95% CI, 1.04-1.71). However, for girls this association varied with race and ethnicity (P interaction = 0.008). When compared with their normal-weight counterparts, obese African American girls (OR, 0.65; 95% CI, 0.41-1.05) were more likely to have better controlled asthma, whereas Mexican American girls had a 1.91 (95% CI, 1.12-3.28) greater odds of worse asthma control. Worse asthma control is uniformly associated with increased body mass index in boys. Among girls, the direction of this association varied with race/ethnicity.

Small-airways dysfunction associates with respiratory symptoms and clinical features of asthma: A systematic review

Traditionally, asthma has been considered a disease that predominantly involves the large airways. Today, this concept is being challenged, and increasing evidence has become available showing that abnormalities in the small airways also contribute to the clinical expression of asthma. The small airways can be affected by inflammation, remodeling, and changes in the surrounding tissue, all contributing to small-airways dysfunction. In this article we have performed a systematic review of the literature on the association between small-airways dysfunction and clinical signs and symptoms of asthma. This review shows that small-airways dysfunction associates with worse control of asthma, higher numbers of exacerbations, the presence of nocturnal asthma, more severe bronchial hyperresponsiveness, exercise-induced asthma, and the late-phase allergic response. Importantly, small-airways dysfunction can already be present in patients with mild asthma. Our review provides suggestive evidence that a better response of the small airways to inhaled steroids or montelukast associates with better asthma control. For this reason, an early recognition of small-airways dysfunction is important because it enables the physician to start timely treatment to target the small airways. It is important to develop simpler and more reliable tools (eg, questionnaires or bronchial provocation tests with small-particle stimuli) to assess the presence and extent of small-airways dysfunction in daily clinical practice.

Biologic Mechanisms of Environmental Tobacco Smoke in Children with Poorly Controlled Asthma: Results from a Multicenter Clinical Trial

Environmental tobacco smoke (ETS) negatively affects children with asthma. The prevalence of ETS exposure among children with poor asthma control may be changing. Importantly, the mechanisms by which ETS worsens asthma control are poorly understood. We describe how ETS affects gastroesophageal reflux (GER), respiratory infections, and leukotriene production among children with poor asthma control. We analyzed data from 306 children between 6 and 17 years of age with poorly controlled asthma enrolled in a 6-month clinical trial. We evaluated prevalence and determinants of ETS exposure by interview, questionnaire, and urinary cotinine and the association of ETS exposure on leukotriene production, respiratory infections, GER, lung function, and asthma control. We used multivariable linear, logistic, and Poisson regressions to assess outcomes. ETS prevalence estimates ranged from 6% to 30%. Children with domestic indoor exposure had worse asthma control (c-Asthma Control Test, 17.8 vs 21.5; P = .04), worse FEV1 % predicted (84.1 vs 90.7; P = .02), and a trend for increased mean urinary leukotriene E4. ETS from any setting was associated with increased symptomatic respiratory infections (adjusted incidence rate ratio: 1.30; P = .02). However, children exposed to ETS did not have symptoms or pH probe results, suggestive of heightened GER. Domestic smoking exposure was associated with both higher rates of symptomatic respiratory infection and poorer asthma control despite generally intensive controller therapy. ETS exposure is common among asthmatic children with poor control and may worsen asthma control by promoting respiratory infections. Further investigation is required to elucidate ETS mechanisms in poor asthma control.

Management of asthma in the elderly patient.

A significant number of older asthmatics, more often than in previous ages, have poorly controlled asthma, leading to increased morbidity and mortality. On the other hand, current guidelines suggest that most asthmatics can obtain achievement and maintenance of disease control and do not include sections specific to the management of asthma in the elderly so that it is more evident the contrast between poor control of asthma in the elderly and the lack of specific guidance from guidelines on asthma management in older asthmatics. Inhaled corticosteroids are the cornerstone for older asthmatics, eventually with add-on inhaled long-acting beta-agonists; inhaled short acting beta-agonists can be used as rescue medications. Triggers exacerbating asthma are similar for all ages, but inhaled viruses and drug interactions have greater clinical significance in the elderly. Older asthmatics have an increased likelihood of comorbidities and polypharmacy, with possible worsening of asthma control and reduced treatment adherence. Physicians and older asthmatics probably either do not perceive or accept a poor asthma control. We conclude that specific instruments addressed to evaluate asthma control in the elderly with concomitant comorbidities and measurements for improving self-management and adherence could assure better disease control in older asthmatics.