Search

Mild and moderate asthma cover a wide range of asthma presentations, phenotypes and symptom burden, and account for the majority of people with asthma worldwide. Mild asthma has been difficult to define because of its heterogeneity and wide spectrum of impact and outcomes, including being associated with severe exacerbations. Assessment of mild–moderate asthma is best made by combining asthma symptom control and exacerbation risk as the principle means by which to determine treatment needs. Incontrovertible evidence and guidelines support treatment initiation with anti‐inflammatory medication, completely avoiding reliever‐only treatment of mild asthma. Shared decision making with patients and a treatable traits approach will ensure that a holistic approach is taken to maximize patient outcomes. Most importantly, mild asthma should be regarded as a reversible, potentially curable condition, remaining in long‐term remission through minimizing triggers and optimizing care. [ABSTRACT FROM AUTHOR]

Since then, asthma research findings and management recommendations[31] have shown that this practice is no longer fit for purpose, indeed it is antiquated and harmful.[[30], [32]] There are few diseases that are still treated as they were 30 years ago, yet that is what is happening for many patients with asthma. Importantly, there are several non-pharmacological interventions that can help reduce the burden of asthma (and conditions treated as asthma) for many patients. Keywords: Asthma; Primary care; Community care; Chronic disease EN Asthma Primary care Community care Chronic disease 49 52 4 07/18/23 20230717 NES 230717 The burden of asthma for patients and doctors can be reduced through simple evidence-based approaches to care and self-management Asthma continues to be a major but avoidable burden on the Australian health care system.[1] It is a treatable and responsive disease, and much has been achieved in the years since asthma was declared a National Health Priority. [Extracted from the article]

This article discusses the current state of asthma treatment and explores potential future solutions. It highlights the need for improved asthma outcomes, particularly in low-middle-income countries where access to care and medications is limited. The article also examines the impact of the COVID-19 pandemic on asthma and emphasizes the importance of personal behaviors, such as social distancing and hand washing, in reducing asthma exacerbations. Additionally, the article discusses the potential of biologic agents and personalized treatment approaches to achieve better asthma control. The authors call for increased research and collaboration to address the global burden of asthma and improve patient outcomes. [Extracted from the article]

Despite improvements in medications, devices and understanding of the disease, about half of all asthma patients worldwide remain inadequately controlled, suggesting the need for a new approach to asthma management. Poor adherence to prescribed maintenance therapy and over‐reliance on SABA reliever medication is a common cause of inadequate control. This article reviews published data from 6‐ to 12‐month, double‐blind, RCT and open‐label real‐world studies involving budesonide/formoterol maintenance and reliever therapy (MART) and relevant comparator approaches to asthma management, and considers how these compare in achieving the treatment goals described in guidelines. The data confirm that patients with asthma treated with budesonide/formoterol MART achieved the same or better asthma symptom control compared with ICS/LABA plus SABA regimens at similar or higher ICS doses, with consistently lower rates of exacerbations and considerably lower annual requirement for oral corticosteroids. These findings have been confirmed across a range of severities of persistent asthma. With the MART approach, maintenance dosing ensures coverage for day‐to‐day control, and the use of a reliever with anti‐inflammatory properties (budesonide/formoterol) provides extra doses of ICS as soon as symptoms prompt the use of reliever, resulting in a 40–50% reduction of exacerbations compared with an ICS‐based treatment approach plus as‐needed SABA as reliever. As‐needed, budesonide/formoterol has also recently been shown to be more effective as a reliever in mild asthma than SABA alone, reducing exacerbations by up to 64% in the SYGMA studies. [ABSTRACT FROM AUTHOR]

Background: Asthma management may involve a step up in treatment when symptoms are not well controlled. We examined whether budesonide/formoterol maintenance and reliever therapy (MRT) is as effective as higher, fixed-dose budesonide plus as-needed terbutaline in patients requiring step-up from Step 2 treatment (low-dose inhaled corticosteroids), stratified by baseline reliever use.Methods: A post-hoc analysis utilized data from three clinical trials of 6-12 months' duration. Patients aged ≥12 years with symptomatic asthma uncontrolled despite Step 2 treatment were included. Severe exacerbation rate, lung function and reliever use were analysed, stratified by baseline reliever use (<1, 1-2 and >2 occasions/day).Results: Overall, 1239 patients were included. Reductions in severe exacerbation rate with budesonide/formoterol MRT versus fixed-dose budesonide were similar across baseline reliever use levels, and were statistically significant in patients using 1-2 (42%, p = 0.01) and >2 (39%, p = 0.02) reliever occasions/day, but not <1 reliever occasion/day (35%, p = 0.11). Both treatments significantly increased mean FEV1 from baseline; improvements were significantly greater for budesonide/formoterol MRT in all reliever use groups. Reductions in reliever use from baseline were significantly greater with budesonide/formoterol MRT versus fixed-dose budesonide in patients using 1-2 and >2 reliever occasions/day (-0.33 and -0.74 occasions/day, respectively).Conclusions: Treatment benefit with budesonide/formoterol MRT versus higher, fixed-dose budesonide plus short-acting β2-agonist was found in Step 2 patients with relatively low reliever use, supporting the proposal that budesonide/formoterol MRT may be useful when asthma is uncontrolled with low-dose inhaled corticosteroid. [ABSTRACT FROM AUTHOR]

Summary: Background: Tools which assist practitioners to identify patient concerns and increase understanding of their needs can improve both the delivery of care and adherence to treatment. The aim of this study was to test the validity and reliability of a 14-item tool, to identify the unmet needs and concerns of older people with asthma. Methods: The Patient Asthma Concerns Tool (PACT) was developed from a pool of 55 items derived from a comprehensive literature review. After pilot and field testing, the initial 55 item questionnaire was administered to a community sample (n = 193), psychometrically tested, and refined to a 14 item PACT tool which was evaluated by a group of clinicians. Results: The PACT was shown to have good content and construct validity and was well received by clinicians. The PACT also correlated well with the Juniper ACQ and Brooks'' adherence score on related variables and showed good reliability with good–excellent Kappa and ICC scores. Internal consistency of factors was high, and the overall Cronbach''s α was 0.70. Conclusion: The PACT questionnaire was shown to be a valid and reliable tool clinically and psychometrically. We intend to test it in primary care settings and anticipate that its use will assist health professionals to identify the needs and concerns of older patients with asthma and direct tailored asthma management accordingly. [Copyright &y& Elsevier]

Summary: Background: Asthma guidelines recommend reducing inhaled corticosteroids (ICS) to the minimum effective dose, but the timing of long-acting β2-agonist (LABA) withdrawal is unclear. Recent FDA guidelines recommend LABA withdrawal once asthma is well-controlled. This 13-month double-blind study of patients taking high-dose combination therapy investigated the effect of discontinuation of LABA before ICS down-titration. Methods: Adults using salmeterol/fluticasone combination (SFC) 50/500 μg bd were randomized to SFC 50/500 μg bd or fluticasone propionate (FP) 500 μg bd, with subsequent ICS down-titration 8-weekly using a clinical algorithm. The primary outcome was mean daily FP dose, including ICS for exacerbations. Results: 82 subjects were randomized. Asthma was well-controlled at baseline, with mean FEV1 84.8% predicted and Asthma Control Questionnaire (ACQ) score 0.9. There was no significant difference in mean daily FP dose (SFC: 721 μg, FP:816 μg, p = 0.3), but final dose was lower with SFC (534 μg cf. 724 μg, p = 0.005). ICS dose was reduced by ≥80% in 41% SFC and 15% FP patients. Ambulatory lung function was significantly higher with SFC, but there were no differences between groups in rescue β2-agonist use, clinic spirometry, airway responsiveness, ACQ, sputum eosinophils or FeNO. Baseline airway responsiveness, and pre-reduction blood eosinophils, were significant predictors of mean daily FP dose and dose reduction failure respectively. Conclusions: Many patients prescribed high-dose combination therapy may be over-treated. Substantial reductions in dose can be achieved with a clinical algorithm, reaching lower FP doses with SFC than FP without losing asthma control or increasing disease activity. Trial Registration: This study was commenced before mandatory registration of clinical trials. [Copyright &y& Elsevier]

The article presents a cluster randomised control trial conducted by the authors with the aim of improving the outcomes of older people with asthma by evaluating the effectiveness of a multifaceted educational intervention for general practitioners (GPs) in Australia. This study was participated by a group of patients with asthma, aged 55 years or older. The authors have found no significant difference between the demographic variables of GPs in the control and intervention groups.

Background: Rhinovirus infection is a major cause of asthma exacerbations. While rhinovirus infection is known to generate kinins in the upper respiratory track, little is known about the effect of rhinovirus on kinin generation in the lower airway. We previously identified human tissue kallikrein (hTK) as the principal lung kininogenase during allergic airway inflammation. In this report we investigate the effect of experimental rhinovirus infection on hTK activity in the airways of atopic subjects with and without asthma. Methods: Eight atopic subjects, 4 with asthma, underwent bronchoscopy with lavage. At least 1 month later, subjects were inoculated with rhinovirus, then underwent repeat bronchoscopy with lavage 4 and 18 days later. hTK mRNA was measured in nasal scrape samples by quantitative real-time PCR. hTK activity (chromogenic substrate assay) and IL-8 levels (ELISA) were assessed in the bronchoalveolar lavage fluid. Results: At day 4 after rhinovirus inoculation, nasal hTK mRNA was modestly increased in both the rhinitis (1.7-fold) and asthmatic (2.1-fold) groups. A doubling or greater increase in hTK activity after rhinovirus infection was observed in all 4 asthmatic subjects (mean 19-fold increase) but only in 1 of 4 atopic subjects without asthma (mean 2-fold increase). Rhinovirus infection also increased the IL-8 protein level in bronchoalveolar lavage fluid, which correlated with hTK activity (R = 0.82). Conclusion: Experimental rhinovirus infection in allergic asthmatic subjects is accompanied by increased lower airway hTK activation, which parallels the appearance of IL-8. Rhinovirus-induced hTK activation may contribute to airway inflammation and asthmatic exacerbations. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background and objective: There are limited data on the association and interaction between anxiety and depression comorbidity and asthma-related quality of life (AQOL) and symptom perception. This study evaluated these associations in patients subsequent to an emergency department (ED) visit for asthma. Methods: This was a cross-sectional study of 110 (38 male) adult asthma patients (mean age 42 years), who had visited an ED in the previous 18 months. Participants completed the hospital anxiety and depression scale, measures of AQOL and the asthma symptom checklist. Results: Depression symptoms independently showed a significant negative association with AQOL after controlling for depression/anxiety, age, gender, smoking status and ED visits in the previous 12 months (ED-12). Overall, anxiety and depression symptoms accounted for 28.3% of the variance in AQOL. Greater anxiety was associated with increased perception of asthma-specific panic-fear and hyperventilation symptoms during an asthma attack, irrespective of depression status. Categorical analyses of groups of patients, differentiated by psychometric properties on the hospital anxiety and depression scale (anxiety vs normal, anxiety and depression vs normal depression) confirmed most results. However, for the anxiety group there was a significant association with the AQOL domains of emotional functioning and response to environmental stimuli, after controlling for depression symptoms. Conclusions: The negative association of depression symptom scores with AQOL and of anxiety with increased panic-fear and hyperventilation symptoms suggests a potential role for interventions addressing this psychological comorbidity, in order to improve AQOL. [ABSTRACT FROM AUTHOR]

Background and objective: Asthma is a high-burden disease for which effective treatment is available. In Australia, there has been a public health campaign directed at increasing the implementation of effective management with the aim of improving asthma outcomes. The aim of this study was to assess the burden of asthma and describe current asthma management in Australia. Methods: A computer-assisted telephone interview survey was conducted in 2003/04 among randomly selected participants. Current asthma was defined as self-reported asthma, confirmed by doctor, which was still present and/or associated with symptoms in the last 12 months. Results: From 46 855 eligible telephone numbers dialled there were 14 271 (30.5%) responses to the screening questionnaire. Among 1734 respondents with current asthma, 1205 (69.5%) completed the detailed questionnaire. Among these, 24.2% of adults and 14.3% children had symptoms during the day or night on most days; 11.3% of adults and 6.0% of children avoided exercise because of asthma symptoms during exercise and 19.4% of adults and 29.7% of children had sought urgent medical care because of an exacerbation of asthma during the preceding year. Among adults with asthma, only 35.6% with daily symptoms and 41.4% with symptoms on most days were taking inhaled steroids. Only 31.1% of adults with daily symptoms had a written asthma action plan. Conclusion: Compared with similar international studies, this study revealed a lower prevalence of frequent asthma symptoms and a higher prevalence of use of inhaled steroids among people with asthma. However, there remains ample scope for improvement in management of patients with frequent symptoms. [ABSTRACT FROM AUTHOR]

Background and objective: Long-term adherence to inhaled corticosteroids is poor despite the crucial role of preventer medications in achieving good asthma outcomes. This study was undertaken to explore patient preferences in relation to their current inhaled corticosteroid medication, a hypothetical preventer or no medication. Methods: A discrete choice experiment was conducted in 57 adults with mild–moderate asthma and airway hyper-responsiveness, who were using inhaled corticosteroid ≤500 µg/day (beclomethasone equivalent). In the discrete choice experiment, subjects evaluated 16 hypothetical scenarios made up of 10 attributes that described the process and outcomes of taking asthma medication, with two to four levels for each attribute. For each scenario, subjects chose between the hypothetical medication, the medication they were currently taking and no asthma medication. A random parameter multinomial logit model was estimated to quantify subject preferences for the aspects of taking asthma medication and the influence of attributes on medication decisions. Results: Subjects consistently made choices in favour of being able to do strenuous and sporting activities with or without reliever, experiencing no side-effects and never having to monitor their peak flow. Frequency of collecting prescriptions, frequency of taking the medication, its route of administration and the strength of the doctor recommendation about the medication were not significant determinants of choice. Conclusions: The results of this study suggest that patients prefer a preventer that confers capacity to maximize physical activity, has no side-effects and does not require daily peak flow monitoring. [ABSTRACT FROM AUTHOR]

Background: Previous studies have shown that breathing techniques reduce short acting β2 agonist use and improve quality of life (QoL) in asthma. The primary aim of this double blind study was to compare the effects of breathing exercises focusing on shallow nasal breathing with those of non-specific upper body exercises on asthma symptoms, QoL, other measures of disease control, and inhaled corticosteroid (ICS) dose. This study also assessed the effect of peak flow monitoring on outcomes in patients using breathing techniques. Methods: After a 2 week run in period, 57 subjects were randomised to one of two breathing techniques learned from instructional videos. During the fallowing 30 weeks subjects practised their exercises twice daily and as needed far relief of symptoms. After week 16, two successive ICS downtitration steps were attempted. The primary outcome variables were QoL score and daily symptom score at week 12. Results: Overall there were no clinically important differences between the groups in primary or secondary outcomes at weeks 12 or 28. The QoL score remained unchanged (0.7 at baseline v 0.5 at week 28, p=0.11 both groups combined), as did lung function and airway responsiveness. However, across both groups, reliever use decreased by 86% (p<0.0001) and ICS dose was reduced by 50% (p<0.0001; p>0.10 between groups). Peak flow monitoring did not have a detrimental effect on asthma outcomes. Conclusion: Breathing techniques may be useful in the management of patients with mild asthma symptoms who use o reliever frequently, but there is no evidence to favour shallow nasal breathing over non-specific upper body exercises. [ABSTRACT FROM AUTHOR]

Consumer interest in complementary and alternative medicine (CAM) has grown dramatically in Western countries in the past decade. However, very few patients volunteer information about CAM use unless directly questioned by their health-care practitioner. Therefore, by being informed about the prevalence and modality of CAM use for asthma, as well as characteristics of users, health-care practitioners may be better able to identify patients who use CAM. In turn, this may facilitate proactive discussion and optimization of the patient’s overall asthma management. This review aims to summarize the current knowledge about use of CAM by people with asthma, and to assess the applicability of the available studies to the broader asthmatic population. Computerized literature searches were conducted on Medline, Embase, Cochrane and Allied and Complementary Medicine (AMED) databases from their inception to 13 April 2005. Search terms included: complementary medicine/therapies, alternative medicine/therapies and asthma. The bibliographies of accessible articles were searched for further papers. Seventeen studies have examined the use of CAM by people with asthma. The reported level of use for adults ranged from 4% to 79%, and for children from 33% to 89%. Among the most commonly used CAMs were: breathing techniques, herbal products, homeopathy and acupuncture. There is no strong evidence for effectiveness for any of these modalities. There is little consistency among available prevalence studies making conclusions difficult. Nevertheless, the high rates of CAM use reported in some studies indicate that CAM use should be taken into account when managing patients with asthma. [ABSTRACT FROM AUTHOR]

Background: T cells of intraepithelial phenotype have previously been detected in bronchoalveolar lavage (BAL) fluid in a range of lung diseases; these cells express the adhesion molecule alpha(E)beta(7) integrin, CD103, the ligand for epithelial cell E-cadherin. In subjects with asthma CD4+ lymphocytes are the predominant T cell subtype found in bronchial biopsy specimens and in BAL fluid, whereas CD8+ lymphocytes have been shown to predominate in subjects with chronic obstructive pulmonary disease (COPD). The aim of this study was to analyse the expression of CD103, activation markers (CD25 and CD69), and chemokine receptors (CXCR3, CCR5 and CCR3) on CD4+ and CD8+ lymphocytes from sputum and peripheral blood of subjects with asthma, COPD, and healthy controls.Methods: T cell surface markers were assessed by immunofluorescence labelling and flow cytometry of gated lymphocytes among CD45+ leucocytes in sputum cell suspensions.Results: Sputum lymphocytes expressed higher levels of CD103 and CD69 than blood lymphocytes in all subject groups, with CD103 expressed at higher levels on CD8+ than on CD4+ cells. There were no detectable differences in numbers of CD4+ and CD8+ T cells between subjects with asthma, COPD and controls. The percentage of sputum lymphocytes expressing CXCR3 was lower in subjects with asthma or COPD than in healthy controls; CCR3 was not detectable on sputum or blood lymphocytes.Conclusions: Sputum T lymphocytes are predominantly of activated intraepithelial phenotype (CD103+ CD69+), and normal numbers of CD4+ and CD8+ T cell populations are found in the sputum of patients with asthma and COPD. [ABSTRACT FROM AUTHOR]

Background: T cells of intraepithelial phenotype have previously been detected in bronchoalveolar lavage (BAL) fluid in a range of lung diseases; these cells express the adhesion molecule αEβ7 integrin, CD103, the ligand for epithelial cell E-cadherin. In subjects with asthma CD4+ lymphocytes are the predominant T cell subtype found in bronchial biopsy specimens and in BAL fluid, whereas CD8+ lymphocytes have been shown to predominate in subjects with chronic obstructive pulmonary disease (COPD). The aim of this study was to analyse the expression of CD103, activation markers (CD25 and CD69), and chemokine receptors (CXCR3, CCR5 and CCR3) on CD4+ and CD8+ lymphocytes from sputum and peripheral blood of subjects with asthma, COPD, and healthy controls. Methods: T cell surface markers were assessed by immunofluorescence labelling and flow cytometry of gated lymphocytes among CD45+ leucocytes in sputum cell suspensions. Results: Sputum lymphocytes expressed higher levels of CD103 and CD69 than blood lymphocytes in all subject groups, with CD103 expressed at higher levels on CD8+ than on CD4+ cells. There were no detectable differences in numbers of CD4+ and CD8+ T cells between subjects with asthma, COPD and controls. The percentage of sputum lymphocytes expressing CXCR3 was lower in subjects with asthma or COPD than in healthy controls; CCR3 was not detectable on sputum or blood lymphocytes. Conclusions: Sputum T lymphocytes are predominantly of activated intraepithelial phenotype (CD103+ CD69+), and normal numbers of CD4+ and CD8+ T cell populations are found in the sputum of patients with asthma and COPD. [ABSTRACT FROM AUTHOR]

Background: Written asthma action plans based on personal best peak expiratory flow (PEF) consistently improve health outcomes, whereas those based on predicted PEF do not. Guidelines state that personal best PEF should be assessed over 2-3 weeks during good asthma control, but it is unclear how long to wait after commencing or changing treatment. Methods: Electronically recorded spirometric data from 61 subjects with initially poorly controlled asthma from a 72 week budesonide study were analysed. For each week, average morning pre-bronchodilator PEF was calculated and personal best PEF was determined as the highest PEF in the previous 2 weeks. The time to plateau was defined as the week beyond which no further improvement occurred. Results: At baseline, average morning PEF was 61 % predicted and personal best PEF was 87% predicted. Personal best PEF from twice daily monitoring increased to a plateau of 95% predicted (p < 0.0001) after only 3 weeks of budesonide treatment. However, average morning PEF continued to improve for 3 months and "as needed" reliever use for 7 months. Conclusions: Personal best PEF is a useful concept for asthma self-management plans when determined as the highest PEF over the previous 2 weeks. With twice daily monitoring, personal best PEF reaches plateau levels after only a few weeks of corticosteroid treatment. [ABSTRACT FROM AUTHOR]

The article discusses the incident of asthma among indigenous Australians from the report "Asthma in Australia 2008." Asthma as identified in the report is a prevalent health problem, which is one of the common causes of hospitalization among indigenous Australians. Reasons for this which include life-long exposure to pulmonary toxicants, uncertainty about the nature of the disease, and long-term undertreatment, are speculated. There is also a high prevalence of comorbid conditions that may complicate the management of asthma including diabetes mellitus.