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Background: Smoking is as prevalent in asthmatics as in the general population. Asthmatic smokers benefit less from inhaled corticosteroids (ICS) than non-smoking asthmatics, possibly due to more smoking-induced small airways disease. Thus targeting small airways may be important in treating asthmatic (ex-) smokers. We hypothesized that extrafine particle ICS improve small airways function more than non-extrafine particle ICS in asthmatic (ex-) smokers. Methods: We performed an open-label, randomized, three-way cross-over study comparing extrafine beclomethasone (HFA-QVAR) to non-extrafine beclomethasone (HFA-Clenil) and fluticasone (HFA-Flixotide) in 22 smokers and 21 ex-smokers with asthma (>= 5 packyears).Results: Improvement from baseline in PD20 adenosine after using QVAR, Clenil or Flixotide was 1.04 +/- 1.71, 1.09 +/- 2.12 and 0.94 +/- 1.97 doubling doses, mean +/- standard deviation (SD), respectively. The change from baseline in R-5-R-20 at PD20 adenosine after using QVAR, Clenil or Flixotide was -0.02 +/- 0.27, 0.02 +/- 0.21, and -0.02 +/- 0.31 kPa sL(-1), mean +/- SD, respectively. The change in PD20 adenosine and R5R20 at PD20 adenosine were neither statistically significant different between QVAR and Clenil (p = 0.86 and p = 0.82) nor between QVAR and Flixotide (p = 0.50 and p = 0.96).Conclusion: Similar effectiveness in improving small airways function was found for extrafine and non-extrafine particle ICS treatment for asthmatic smokers and ex-smokers. (C) 2017 Elsevier Ltd. All rights reserved.

Background: Our randomised controlled trial (RCT) evaluating the value of an inhaler-specific visual aid as adjunct to standard inhaler technique education, showed beneficial short-term (after 6-8 weeks) effects. Correct inhaler technique improved from 8% to 70% of patients with asthma or COPD. Aim: To evaluate the long-term effects of inhaler technique education in asthma or COPD. Methods: Patients who participated in our RCT and completed both visits (n=98) were invited for a 1-year follow-up (FU) visit as part of routine care. All patients had completed inhaler technique education, including the use of the visual aid at short-term FU. During long-term FU inhaler technique was (re)assessed using inhaler-specific checklists. Results: Inhaler technique was evaluated in 56 patients (mean age 64±12yrs, 52% male) with asthma (45%) or COPD (55%). Reasons for not attending long-term FU were: referral to primary care (n=13), unwilling (n=6), deceased (n=4), lost to follow-up (n=19). Inhaler technique was adequate in 37 patients (66%). The most common mistakes with incorrect technique (n=19) were: no complete exhalation before inhalation (n=10, DPI), no 5 times in- and exhaling through the mouthpiece (n=5, MDI with spacer). Incorrect technique occurred more in COPD (48%) as compared to asthma (16%). Patients with incorrect technique were significantly older (69yrs) as compared to patients with adequate technique (62yrs). Conclusion: This study demonstrates positive long-term effects of thorough inhaler technique education. Yet, the number of patients who inhaled incorrectly stresses the importance of monitoring and (repeatedly) educating correct inhaler technique, particularly in older COPD patients.

Background Bronchial provocation is often used to confirm asthma. Dyspnea sensation, however, associates poorly with the evoked drop in FEV1. Provocation tests only use the large airways parameter FEV1, although dyspnea is associated with both large- and small airways dysfunction. Aim of this study was to explore if adenosine 5′-monophosphate (AMP) and adenosine evoke an equal dyspnea sensation and if dyspnea associates better with large or small airways dysfunction. Methods We targeted large airways with AMP and small airways with dry powder adenosine in 59 asthmatic (ex)-smokers with ≥5 packyears, 14 ± 7 days apart. All subjects performed spirometry, impulse oscillometry (IOS), and Borg dyspnea score. In 36 subjects multiple breath nitrogen washout (MBNW) was additionally performed. We analyzed the association of the change (Δ) in Borg score with the change in large and small airways parameters, using univariate and multivariate linear regression analyses. MBNW was analyzed separately. Results Provocation with AMP and adenosine evoked similar levels of dyspnea. ΔFEV1 was not significantly associated with ΔBorg after either AMP or adenosine provocation, in both univariate and multivariate analyses. In multivariate linear regression, a decrease in FEF25–75 during adenosine provocation was independently associated with an increase in Borg. In the multivariate analyses for AMP provocation, no significant associations were found between ΔBorg and any large or small airways parameters. Conclusion AMP and adenosine induce equally severe dyspnea sensations. Our results suggest that dyspnea induced with dry powder adenosine is related to small airways involvement, while neither large nor small airways dysfunction was associated with AMP-induced dyspnea. Trail registration NCT01741285 at www.clinicaltrials.gov, first registered Dec 4th, 2012. Electronic supplementary material The online version of this article (10.1186/s12890-019-0783-0) contains supplementary material, which is available to authorized users.

This document contains supplementary Tables S1 and S2, as referred to in the text. Table S1 is The change (post - pre) in all pulmonary function parameters evoked by the provocation. Table S2 shows Spearmanâ s univariate correlation of the change in Borg dyspnea score with gender, smoking status, and all pulmonary function parameters. (DOCX 27â kb)

We performed a post-hoc analysis of the OLiVIA-study investigating whether current and ex-smoking asthmatics with small airways dysfunction (SAD) show a better response in airway hyperresponsiveness (AHR) to small particle adenosine after treatment with extrafine compared to non-extrafine particle inhaled corticosteroids (ICS), and to investigate which clinical parameters predict a favorable response to both treatments. We show that smoking and ex-smoking asthmatics with and without SAD have a similar treatment response with either extrafine or non-extrafine particle ICS. We also found that lower blood neutrophils are associated with a smaller ICS-response in smokers and ex-smokers with asthma, independent from the level of blood eosinophils. Electronic supplementary material The online version of this article (10.1186/s12931-018-0961-2) contains supplementary material, which is available to authorized users.

Aim: Incorrect inhaler use is common and is associated with poor disease control, outcomes and healthcare costs. Optimizing inhaler technique education is crucial. Applying an interdisciplinary might result in the development of a thorough and didactic-based inhaler technique instruction method. Method: We propose a new instruction method based on data from three sub studies: 1) interviews with 127 asthma and COPD patients in the Netherlands, Spain and Greece about experiences with inhaler instructions and inhaler use 2) six focus groups with healthcare professionals involved inhaler education (the Netherlands, Spain and Greece) 3) a literature review (46 papers) to reveal theories on motor skill acquisition was conducted. Results: Most patients did not receive inhaler technique instruction for years. A timely follow-up ( Conclusion: A proposal for a new inhaler technique instruction method based the results of the IRW study has been developed. Embedding this method in a well-organised healthcare system is crucial. The feasibility and the effectiveness of this promising new inhaler technique instruction method needs to be examined in future research.

Background: Bronchial provocation is often used to confirm asthma. Dyspnea sensation correlates poorly with the provocative dose that causes the FEV1 to drop ≥20% (PD20). Aim: To explore if dyspnea sensation associates better with small airways then large airways function. Methods: We induced dyspnea with dry powder adenosine and nebulized adenosine 5’‑monophosphate (AMP), targeting the small and large airways, respectively, 14±7 days apart. We obtained spirometry, impulse oscillometry (IOS), and Borg score in all subjects, but multiple breath nitrogen washout (MBNW) was only limited available. Subjects were asthmatic (ex‑)smokers with ≥5 packyears. We analyzed the correlation between the change (Δ) in large and small airways parameters to ΔBorg in univariate and multivariate linear regression analysis. MBNW was analyzed separately. Results: We included 61 subjects of which 36 performed MBNW. Provocation with adenosine and AMP evoked similar levels of dyspnea. The large airways parameter, ΔFEV1 was not significantly correlated with ΔBorg after either adenosine or AMP provocation, in both univariate and multivariate analyses. Multivariate linear regression models for ΔBorg included for adenosine: gender, smoking status, ΔFEV1, ΔFEF25-75, ΔR20, ΔR5‑R20, and ΔScond and for AMP: gender, smoking status, ΔFEV1, ΔFEF25-75, ΔR20, ΔX5, and ΔLCI5%. ΔFEF25-75 during adenosine provocation was independently associated with ΔBorg, but for ΔBorg during AMP provocation no significant associations were found. Conclusion: Our results suggest that dyspnea sensation induced with dry powder adenosine is related to small airways involvement, while neither large nor airways small airways dysfunction was associated with AMP induced dyspnea.

Table S1. Baseline characteristics. Table S2. Baseline values of measurements of small airways dysfunction. Table S3. Difference in Î PD20 adenosine in patients with and without small airways dysfunction after treatment with QVAR, Clenil and Flixotide. Table S4. Univariate linear regression analysis of baseline variables and change in airway hyperresponsiveness (Î PD20) in patients treated with QVAR, Clenil and Flixotide. Figure S1. Scatterplots of significant correlations between baseline variables and Î PD20 adenosine. (PDF 731 kb)

Background: It is generally known that inhaler technique is poor. This is illustrated by many stories form real-life clinical practice among which the story of dog Max. Max9s boss was prescribed with an inhaler, to be used max. 4 times a day. Patient9s symptoms did not improve and it appeared to be that the dog Max was the inhaler medication. 4 times a day. Aim: The Inhaler Research Workgoup (IRW) study aims to improve inhaler instructions in patients with asthma and COPD with a multidisciplinairy approach. Method: In the Netherlands we have interviewed 67 (age 6-90 years) patients and performed 2 focusgroups with 21 health care profesisonals. Moreover, we are performing a literature studie to detect effective theory based instruction methods that can be used to teach inhaler technique. Results: Patients provided us with relevant suggestions to improve inhaler technique. Asthmatics would like to know the reasoning behind the technique. COPD patients have sometimes difficulties with handling the device. We have videorecorded patients9 inhaler technique and permission to show at conferences. Communication between professionals is suboptimal and it is a challenge to obtain enough time for instructions. Literature provided us with promissing suggestions for evidence based teachning methods. Conclusion: We found several achievable options for improvement. At the ERS we would like to share this knowledge about inhaler technique. We wil provide suggestions for improvement at organisational level, at educational level and for contemplation of the correct inhaler technique. Epilogue: After explanation, Max9s boss started to use his inhaler...

Background: Smoking is as prevalent in asthmatics as in the general population. Asthmatic smokers benefit less from inhaled corticosteroids (ICS) than non-smoking asthmatics, possibly due to smoking-induced small airways disease. Aim: Targeting the small airways may be important in treating asthmatic smokers and ex-smokers. We hypothesized that extrafine particle ICS improves small airways function more than non-extrafine particle ICS in these patients. Methods: We performed a two-center, open-label, randomized, three-way cross-over study comparing two-week extrafine beclomethasone (HFA-QVAR 200 µg b.i.d.) to non-extrafine beclomethasone (HFA-Clenil 400 µg b.i.d.) and fluticasone (HFA-Flixotide 250 µg b.i.d.) in 22 smokers and 21 ex-smokers with asthma (≥5 packyears). Primary outcomes were the provocative dose of adenosine inducing a 20% fall in FEV1 (PD20) and peripheral airway resistance measured with impulse oscillometry (R5-R20) at PD20. Results: Improvement from baseline in the PD20 adenosine after using QVAR, Clenil or Flixotide was 1.04±1.71, 1.09±2.12 and 0.94±1.97 doubling doses mean ± standard deviation (SD), respectively. The change from baseline in R5-R20 at PD20 adenosine after using QVAR, Clenil or Flixotide was 0.02±0.27, 0.02±0.21, and -0.02±0.31 kPa·sL−1 mean ± SD, respectively. For the change in PD20 adenosine and R5-R20 at PD20 adenosine, the differences between QVAR and Clenil (p=0.86 and p=0.82) or between QVAR and Flixotide (p=0.50 and p=0.96) were not statistically significant. Conclusion: Similar results were found for extrafine and non-extrafine particle ICS treatment for asthmatic smokers and ex-smokers. Both were equally effective in improving airway hyperresponsiveness.

Background: Inhaler medication is the cornerstone of treatments for patients with asthma and COPD. Unfortunately 70 to 80% of the patients have poor inhaler technique which leads to poor disease control, high burden of disease and high health care costs. Most studies focus on patients with poor inhaler technique in this study we want to evaluate patients with good inhaler technique and see what the can learn from them. Aim: Evaluate patient characteristics and illness perceptions of patients with correct inhaler technique Method: First we analysed a real-life database with 9676 primary care patients (49% asthma, 20% COPD, 9% overlap and other/unclear (22%) who have had their inhaler technique checked. We compared characteristics of patients with correct inhaler technique with patients with poor inhaler technique. Second we interviewed 12 patients and discussed their inhaler medication use and tools or information used to train inhaler technique. Finally we have performed a questionnaire study in primary care patients to the evaluates self-efficacy and illness perceptions. Results: patients with proper inhaler technique are somewhat younger (mean age: good 51 years, poor 54 years) and more likely to be men (good: 60% men, poor 56% men). The interviews showed that patients have found ways to incorporate their medication use in their daily lives and are well informed about their disease. No differences were found in self-efficacy. However, remarkably COPD patients with poor technique have poor knowledge about their COPD (see figure 1). Conclusion: We have learnt from patients with correct inhaler technique that inhaler technique is predomintly related with patients knowledge about their disease.

Background: Although the importance of teaching a correct inhalation technique in patients with asthma or COPD is recognised, the optimal method of inhalation technique education is unknown. To improve this, inhaler-specific visual instruction cards as an adjunct to standard education have been developed. Aim: To evaluate the value of these visual instruction cards in optimising inhalation technique in patients with asthma or COPD. Methods: Randomised controlled trial in 100 outpatients with asthma or COPD (49% male, mean age 63 years). Patients received either usual inhalation technique education (Usual Care) or received the visual instruction card in addition to the usual inhalation technique education (Usual Care + ). At baseline and follow-up (at 6-8 weeks) inhalation technique was assessed using inhaler-specific checklists. Disease control was measured by ACQ or CCQ. Results: In both groups the proportion of patients with an adequate inhalation technique significantly improved. The improvement in the Usual Care + group was significantly higher as compared to the Usual Care group (4% to 85% and 12% to 57% respectively, p + group as compared to the Usual Care group (-0.5 and -0.3 respectively, p + group (–0.5 in the Usual Care + and –0.3 in the Usual Care group, p=0.09). Conclusion: This study emphasises the importance of proper inhalation technique education, and in particular, the value of the newly developed visual instruction cards.

RATIONALE: Beneficial effects of anti-inflammatory therapy such as fluticasone propionate (FP) and montelukast (Mk) have been demonstrated in preschool children with asthma. However, comparative studies are lacking in this age group. Therefore, we conducted a study to evaluate and compare the effect of FP and Mk in preschool children with asthma-like symptoms.METHODS: In this multicenter, randomized, placebo-controlled, double-blind, double-dummy trial, children aged 2-6 years with asthma-like symptoms were included. In total, 63 children were randomly allocated to receive FP (25), Mk (18) or placebo (20) for 3 months. The primary outcome was the daily symptom score (wheeze, cough, shortness of breath) as recorded by caregivers in a symptom diary card. Secondary endpoints were rescue medication free days, blood eosinophils and lung function (interrupter technique and forced oscillation technique (FOT)).RESULTS: During the 3 months study period, symptoms improved in all 3 groups, with a statistically significant difference between FP and placebo in favor of the FP group (p=0.021). A significant reduction in circulating eosinophils after 3 months of treatment was found in the Mk group only (p=0.008), which was significantly different from the change found in the placebo group (p=0.045). With the exception of frequency dependence (measured by FOT), which showed a difference between FP and Mk after 3 months of treatment in favor of the FP group (p=0.048), no differences in lung function within or between groups were found.CONCLUSIONS: In spite of a lack of power, our results suggest that FP has a beneficial effect on symptoms and Mk on blood eosinophil level as compared to placebo. Except for a difference in one lung function parameter after 3 months between FP and Mk in favor of the FP group, this study revealed no differences between FP and Mk.

Huisartsen worden vaak geconsulteerd voor recidiverende luchtwegklachten bij kinderen jonger dan 5 jaar. Het is dan aan de huisarts om de diagnose astma te stellen en de juiste behandeling voor te schrijven. De dilemma’s die de diagnostiek en behandeling van deze groep kinderen met zich meebrengen, worden in dit artikel besproken. Het stellen van de diagnose astma is niet eenvoudig en er is nog geen duidelijkheid over de behandeling van deze groep kinderen in de huisartsenpraktijk, met name over de rol van inhalatiecorticosteroiden daarbij. Aangezien de diagnose astma moeilijk te stellen is bij kinderen onder de 5 jaar, is het lastig te bepalen welke kinderen baat hebben bij behandeling met deze ontstekingsremmers.

Measuring airway resistance in pre-school children with the interrupter technique has proven to be feasible and reliable in daily clinical practice and research settings. Whether it contributes to diagnosing asthma in pre-schoot children still remains uncertain. From the results of previous studies a need for standardisation of the technique has emerged. In this overview we will elaborate on research concerning the position of the interrupter technique in the difficult process of diagnosing asthma in pre-school children. (c) 2005 Published by Elsevier Ltd.

OBJECTIVE: To evaluate the effectiveness of inhaled corticosteroid therapy in asthmatic children in the age group of 0–6 years. STUDY DESIGN: Systematic review of randomised double blind placebo controlled trials of inhaled corticosteroid therapy for preschool children with asthma. 12 Trials were identified for this review. Data on symptom scores, parents' sleep disturbance, parents' assessment of asthma status/medication, concomitant drug use, exacerbation rate, lung function measurement, and adverse effects were retrieved form the trials. RESULTS: Most parallel trials showed significant improvements in symptom scores, concomitant drug use, exacerbation rate, or lung function measurements. Most improvements were seen in wheeze and concomitant drug use. The pooled odds ratio (95% confidence interval (CI)) for outcome measure ‘patients with at least one exacerbation’ was 0.47 (0.3 to 0.73). Two crossover trials showed significant improvements in symptom scores, ß-agonist use, and lung function. Significant differences in adverse effects between the active and placebo groups were not detected. CONCLUSION: In conclusion, this systematic review of literature shows beneficial effects on symptoms, exacerbation rate, and pulmonary function for the use of inhaled corticosteroids in preschool children with asthma.

Chronic obstructive pulmonary disease (COPD) is a prevalent disease, with cigarette smoking being the main risk factor. Prevention is crucial in the fight against COPD. Whereas primary prevention is targeted on whole populations, patient populations are the focus of primary care; therefore, prevention in this setting is mainly aimed at preventing further deterioration of the disease in patients who present with the first signs of disease (secondary prevention). Prevention of COPD in primary care requires detection of COPD at an early stage. An accurate definition of COPD is crucial in this identification process. The benefits of detecting new patients with COPD should be determined before recommending screening and case-finding programs in primary care. No evidence is available that screening by spirometry results in significant health gains. Effective treatment options in patients with mild disease are lacking. Smoking cessation is the cornerstone of COPD prevention. Because cigarette smoking is not only a major cause of COPD but is also a major cause of many other diseases, a decline in tobacco smoking would result in substantial health benefits.

Objective: To evaluate prescriptions of asthma medication for children in primary care.Methods: Data on prescriptions of asthma medication for children aged 0-9 years were collected from a general practice-based network in the north eastern part of the Netherlands. Prevalence, incidence, indications, continuation beyond the age of 6 years, and predictors of continuation, were determined.Results: Prevalence of prescriptions was about 80 per 1000 person years. An asthma diagnosis was registered in 40% of the children with a first prescription and in 70% of the children with six or more prescriptions. Discontinuation of asthma medication was between 60 and 90%. Continuation was more likely in children with a first prescription at age 2 or 3 as compared to children starting treatment at ageConclusion: Continuation of asthma medication in children is low. Age at first prescription and the type of asthma medication are predictors of continuation of asthma medication from preschool into school-age. (C) 2010 Primary Care Respiratory Society UK. All rights reserved. S Schokker et al. Prim Care Resp J 2010; 19(1): 28-34. doi:10.4104/pcrj.2009.00039

Background: Therapy with inhaled corticosteroids (ICS) is beneficial in patients with asthma. However, in preschool children with symptoms like cough, wheeze, or shortness of breath diagnosing asthma is difficult. Therefore, the role of ICS in the management of preschool children with recurrent respiratory symptoms is unclear. We assessed the effectiveness of ICS in preschool children with recurrent respiratory symptoms in general practice.Methods: In this multicenter, randomized, double blind.. placebo controlled trial, 96 children aged 1-5 years consulting their general practitioners for recurrent respiratory symptoms and in whom treatment with ICS was considered by the general practitioner were randomly allocated to receive ICS (fluticasone propionate 200 mcg/day by metered dose inhaler/spacer combination) or placebo for 6 months. Outcome assessments were carried out 1, 3, and 6 months after randomization, The primary outcome measure was the symptom score (cough, shortness of breath and wheeze during day and night) as measured by a symptom diary card. Secondary endpoints were symptom-free days, use of rescue medication, adverse events, and lung function variables as measured by the interrupter technique and forced oscillation technique.Results: During the 6 months treatment period, symptoms improved in both groups, with no differences between ICS and placebo. In addition, none of the secondary outcome parameters showed differences between both treatment groups.Conclusion: ICS treatment has no beneficial effect in preschool children with recurrent respiratory symptoms in general practice. We therefore recommend a watchful waiting policy with only symptomatic treatment in these children. General practitioners and pediatricians should be aware of the high probability of overtreatment when prescribing ICS in these children. (C) 2007 Elsevier Ltd. All rights reserved.

INTRODUCTION: The severity of BHR in asthmatics is a useful parameter to adjust the dose of inhaled corticosteroids (Sont et al., AmJRCCM 1999). Therefore BHR needs to be assessed repeatedly, using challenge tests. These tests are expensive, time consuming and unpleasant for patients. A questionnaire, specifically designed to assess BHR, could be an alternative. The aim of this study was to generate a list of possible items for such a questionnaire. METHODS: Item-generation was done by extensive review of literature, 11 interviews and a focusgroup discussion with asthmatic patients on symptoms and stimuli, related to BHR. RESULTS: From available asthma questionnaires, few individual items showed correlation's with the severity of BHR. The interviews and the group discussion yielded a set of 30 symptoms and 68 stimuli (table 1). Symptoms Stimuli Sneeze 66 Smoky places 84 Acute tightness of the chest 66 Respiratory infections 75 Inability to breathe deeply 58 Fog 66 Chest tightness 100 Dusty places 92 Cough 66 Exercise 84 Shortness of breath 66 Change from warm to cold 66 Tight belt around chest 50 Grass, pollen 66 Wheeze 75 Tobacco smoke 84 Headache 66 Cold air 75 Irritated mucous membranes 58 Fireplaces 66 Fatigue 50 Chlorine 66 Table 1. Symptoms and stimuli, as mentioned by patients with percentage of patients who mentioned the item. CONCLUSION: In this qualitative study, a variety of symptoms and stimuli that patients relate to BHR were identified. By item reduction, a subset that relates to BHR will be selected. In the future its usefulness in monitoring asthma control will be tested. FUNDING: This study was supported by AstraZeneca, The Netherlands

BACKGROUND: Symptoms are the most prominent and bothersome characteristic of patients with Chronic Obstructive Pulmonary Disease (COPD). However, no validated questionnaires are available to measure symptom control in COPD. The aim of this study was to develop and validate the international COPD Control Questionnaire (CCQ). METHODS: Development: Interviews and focus group discussions with patients were conducted and clinicians were consulted to generate all possible items to evaluate symptom control. From these items an item reduction questionnaire was generated and sent to 77 international experts in the field of COPD. They were asked to rank the symptoms and to score each one for importance in determining symptom control. Sixty-seven experts responded and from the results the 10 most important items were included in the CCQ. VALIDATION: Cross sectional data were collected in two studies. RESULTS: Data of 119 subjects (58 patients with airway obstruction (COPD), 19 patients without airway obstruction (chronic bronchitis) and 42 healthy (ex)smokers were collected. Cronbach's alpha was high (>0.78). The CCQ scores in patients with COPD or CB were significant higher than in healthy (ex) smokers. Furthermore, significant moderate to high correlations were found between the CCQ and the SF-36 and the SGRQ, supporting the validity of the CCQ. Lower correlations were found between the CCQ and FEV(1)%pred. CONCLUSIONS: The CCQ is the first questionnaire specifically developed to measure symptom control in patients with COPD and the cross sectional validity of the CCQ is supported by this data.

INTRODUCTION: Therapy with inhaled corticosteroids (ICS) is beneficial in patients with asthma. However, in preschool children with symptoms like cough, wheeze and shortness of breath diagnosing asthma is difficult. In these children the benefits of ICS are less clear. AIM: To evaluate the effectiveness of fluticasone propionate (FP) in preschool children with recurrent respiratory symptoms in general practice. SUBJECTS AND METHODS: 96 children aged 1–5 year (mean age 2.6; 69%male) consulting their general practitioner (GP) for respiratory symptoms and in whom treatment with ICS was considered by the GP participated in a multi-center, doubleblind, placebo controlled study (ASTERISK). Participants were randomly assigned to either FP 100 mcg or placebo twice daily via MDI+spacer for 6 months. Daily record cards completed by the parents were used to evaluate symptoms (cough, wheeze, and shortness of breath) at 1, 3, and 6 months. In addition, lung function was measured by means of the interrupter technique and the forced oscillation technique. RESULTS: Both groups showed a significant improvement in total symptom score during the study period, with no difference between both treatment groups. No differences in lung function variables were found between the two treatment groups. CONCLUSION: Treatment with ICS has no beneficial effect in preschool children with recurrent respiratory symptoms in general practice. Conflict of interest and funding Funded by: GSK and the Stichting Astma Bestrijding.

The new Global Obstructive Lung Disease (GOLD) guidelines advice to focus treatment in Chronic Obstructive Pulmonary Disease (COPD) on improvement of functional state, prevention of disease progression and minimization of symptoms. So far no validated questionnaires are available to measure symptom and functional state in daily clinical practice. The aim of this study was to develop and validate the Clinical COPD Questionnaire (CCQ). Qualitative research with patients and clinicians was performed to generate possible items to evaluate clinical COPD control. Thereafter, an item reduction questionnaire was sent to 77 international experts. Sixty-seven experts responded and the 10 most important items, divided into 3 domains (symptoms, functional and mental state) were included in the CCQ (scale: 0 = best, 6 = worst). Cross-sectional data were collected from 119 subjects (57 COPD, GOLD stage I-III; 18 GOLD stage 0 and 44 (ex)smokers). Cronbach's α was high (0.91). The CCQ scores in patients (GOLD 0-III) were significantly higher than in healthy (ex)smokers. Furthermore, significant correlations were found between the CCQ total score and domains of the SF-36 (ρ = 0.48 to ρ = 0.69) and the SGRQ (ρ = 0.67 to ρ = 0.72). In patients with COPD, the correlation between the CCQ and FEV1%pred was ρ =-0.49. Test-retest reliability was determined in 20 subjects in a 2-week interval (Intra Class Coefficient = 0.94). Thirty-six smokers with and without COPD showed significant improvement in the CCQ after 2 months smoking cessation, indicating the responsiveness of the CCQ. The CCQ is a self-administered questionnaire specially developed to measure clinical control in patients with COPD. Data support the validity, reliability and responsiveness of this short and easy to administer questionnaire.

BACKGROUND: Diagnosing asthma in pre-school children with asthma or asthma-like symptoms is a major problem because of the similarity of the symptoms. The initial treatment of these young patients is often performed by general practitioners. Currently very much attention is paid to the use of inhalation corticosteroids (ICS) in these young children while optimal treatment regiments are still unclear. The precise place of ICS has yet to be clarified in children with recurrent wheezing. Although several studies have shown that ICS is effective in the treatment of asthma we do not know which of these children should be given maintenance therapy with inhaled corticosteroids and which not.Only a small percentage of early wheezers go on to develop classic asthma. It is possible that children with transient wheeze do not respond to ICS in the same way true asthmatics do. The ability to predict accurately those wheezy pre-school children who will develop asthma eludes us. AIM: To focus on these diagnostic and therapeutic dilemmas. DESIGN: A multicentre, parallel group, randomised, double blind study to investigate the efficacy of ICS in 1 to 5 year old children with asthma or asthma-like symptoms. Study population: children with asthma or asthma-like symptoms in which in normal daily practice the general practitioner considers treatment with ICS because of symptoms. In this study we try to answer the question which children will benefit from maintenance treatment with ICS; as part of this study we have developed an Asthma Diagnostic Questionnaire. By using this questionnaire and by collecting additional lung function data (Forced Oscillation Technique and Resistance Interrupter Technique) we try to distinguish children with probably asthma from children with probably non-asthma. The results of our study may lead to an improvement in the diagnosis and treatment of asthma or asthma-like symptoms in pre-school children.