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Overreliance on short-acting ß2-agonists (SABA) has been a common feature of asthma management globally for at least 30 years. However, given the evidence against the long-term use of SABA, including potentially increased risk of exacerbations, emergency room visits, overall healthcare resource utilization, and mortality, the latest Global Initiative for Asthma report no longer recommends SABA only therapy. Since 2014, we implemented an ICS-containing reliever strategy at our asthma center at the G Baigorria Hospital in Argentina; we only administered budesonide/formoterol via a single inhaler device across the spectrum of asthma severity and completely eliminated the use of SABA therapy. In this article, we compare hospitalization data from our center, previously reported in the EAGLE study (when inhaled corticosteroids plus as-needed SABA was administered) for the years 1999 and 2004 with data from 2017 to 2018 (when budesonide/formoterol in a single inhaler device was administered as maintenance and/or anti-inflammatory reliever therapy [MART/AIR] without any SABA) from our center, to assess the impact of two distinct asthma management strategies on asthma-related hospitalizations. MART/AIR regimens in our SABA-free center reduced asthma hospitalizations from 9 (1999 and 2004) to 1 (2017 and 2018) (Fisher's exact test, p = 0.031; odds ratio = 0.11; 95% confidence interval [CI] = 0.013-0.98); the hospitalization rate was reduced by 92% (1.47% in 1999 and 2004 to 0.12% in 2017 and 2018). Our data provide preliminary real-world evidence that MART/AIR with budesonide/formoterol simultaneously with SABA elimination across asthma severities is an effective asthma management strategy for reducing asthma-related hospitalizations.
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OBJECTIVE: Examine whether caregiver depressive symptoms at baseline predict longitudinal child asthma outcomes in the two populations with the largest asthma disparities: Mexicans and Puerto Ricans. METHODS: Two hundred and sixty-seven Hispanic caregiver-child dyads (Mexican = 188, Puerto Rican = 79; children 5-12 years) were recruited from clinics and hospitals in Phoenix, AZ and the Bronx, NY. The Center for Epidemiological Studies Depression Scale assessed caregiver depressive symptoms; higher scores indicate greater depressive symptomology. Medical records verified child asthma diagnosis. Assessments for outcome variables occurred at baseline, 3, 6, 9, and 12-month follow-ups. Pulmonary function was measured by spirometry, asthma control was measured by the Asthma Control Test, steroid bursts and acute healthcare utilization were assessed by caregiver report and medical records, and adherence was measured by doser devices on controller medications. Structural equation modeling analyzed baseline caregiver depressive symptoms as a predictor of longitudinal child asthma outcomes, and differences between subgroups. RESULTS: Higher caregiver depressive symptoms predicted better pulmonary function (ß = .02, p = .001) in Mexican children, and fewer steroid bursts (ß = -.41, p = .01) and better medication adherence (ß = .02, p = .07) in Puerto Rican children. Caregiver depressive symptoms did not predict pediatric asthma control or acute healthcare utilization in either subgroup. CONCLUSIONS: Caregiver depressive symptomology had unexpected effects on child asthma outcomes. Results may be explained by the Hispanic paradox, caregiver resilience, acculturation, and the study's longitudinal nature. Further research is needed on social determinants of health that may influence differences in child asthma outcomes in heterogeneous Hispanic communities.
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Asma , Asma/tratamento farmacológico , Cuidadores , Criança , Depressão/epidemiologia , Hispânico ou Latino , Humanos , Porto Rico/epidemiologiaRESUMO
Background: Perceptions of asthma triggers provide important guidance for patients' disease management. A psychometrically valid instrument, the Asthma Trigger Inventory (ATI), is available in English and German language versions, however, a version in Spanish as major world language has been missing.Method: A Spanish-language version of the ATI was evaluated in 339 adult patients with asthma, 223 of these in Peru and 107 in the USA. Principal Component analysis (PCA) with Varimax rotation was used to identify coherent trigger domains across and within samples. Resulting subscales were evaluated for internal consistency.Results: PCA suggested differences in factor structures between sites. Whereas the USA sample largely replicated original factors for animal allergens, pollen allergens, physical activity, air pollution/irritants, infections, and psychology, the initial analysis of the Peru sample suggested substantial overlap of air pollution/irritant, infection, and allergen items. Subsequent analysis of an expanded research form of the ATI for the Peru site culminated in extraction of five factors related to psychology, climate/temperature, combined pollen and animal allergens, physical activity, and infection. Internal consistencies were in an acceptable to excellent range (α = 0.74 to 0.94). Additional free trigger responses confirmed the importance of climate variables for patients in Peru. Psychological triggers were reported by 26% (Peru) and 31% (USA) of patients.Conclusion: Coherent trigger domains are readily identified and measured reliably by a Spanish-language ATI version. However, factor structures vary between samples from different Hispanic/Latino cultural and geographic domains. Culturally adapted versions of this instrument are therefore required for Hispanic/Latino population studies.
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Asma/epidemiologia , Asma/fisiopatologia , Adolescente , Adulto , Idoso , Idoso de 80 Anos ou mais , Poluição do Ar/efeitos adversos , Alérgenos/efeitos adversos , Competência Cultural , Exercício Físico , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Peru/epidemiologia , Análise de Componente Principal , Psicometria , Reprodutibilidade dos Testes , Fatores Socioeconômicos , Inquéritos e Questionários , Tradução , Estados Unidos/epidemiologia , Adulto JovemRESUMO
INTRODUCTION: A quality improvement project was commenced to determine if personalized, patient-specific education can increase parent/guardian knowledge and reduce subsequent emergency department (ED) visits and inpatient admissions secondary to asthma. METHOD: Pre- and post-education survey scores were analyzed for a change in knowledge. A retrospective electronic health record (EHR) chart review was performed one year following the education to determine if the patients had additional ED visits or inpatient admissions. RESULTS: A statistically significant increase in post-education survey scores (p = 0.004) and decrease in post-education inpatient admissions was found (p = 0.005). There was no significant difference between the number of pre- and post-education ED visits. DISCUSSION: Asthma is a chronic medical condition that often requires life-long home management. These results revealed that parent/guardian knowledge regarding asthma can be increased and optimal home management improved by personalized, patient-specific education.
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Asma/diagnóstico , Broncodilatadores/uso terapêutico , Unidades de Observação Clínica , Educação de Pacientes como Assunto/organização & administração , Adolescente , Asma/tratamento farmacológico , Asma/fisiopatologia , Criança , Pré-Escolar , Feminino , Humanos , Masculino , Admissão do Paciente , Desenvolvimento de Programas , Melhoria de Qualidade , Estudos RetrospectivosRESUMO
BACKGROUND: Daily inhaled corticosteroids are widely recommended for mild persistent asthma. This study aimed to assess the efficacy of the intermittent use of beclomethasone as an alternative treatment for mild persistent asthma. METHODS: In this 16-week trial, children aged 6-18 years were evaluated. Subjects in the continuous treatment arm of the study received 500 µg/day of beclomethasone, whereas the intermittent ones were given 1000 µg/day (250 µg every 6 h) in combination with albuterol for 7 days upon exacerbations or worsening of symptoms. Primary outcome (i.e., treatment failure) was the occurrence of any asthma exacerbation requiring prednisone, and co-secondary outcomes were the mean/median differences for both, (1) the pre-bronchodilator FEV1 (% predicted) and (2) asthma control test (ACT/cACT) scores, from randomization to the last follow-up visit, and beclomethasone and albuterol consumption. RESULTS: Ninety-four subjects from each treatment arm were included. They were comparable regarding all baseline characteristics; prednisone was used by 10 (10.6%) and 7 (7.4%) patients, respectively (95% CI - 6.1 to 12.6%, for the difference; p = 0.47). Statistical analysis showed no statistically significant differences with respect to both FEV1 (p = 0.39) and ACT/cACT scores (p = 0.38). As assessed through canister weighting, children used from 0.5 to 0.7 and from 1.6 to 1.8 puffs per day of beclomethasone in the intermittent and continuous regimens, respectively. Regarding albuterol, received 0.3-0.4 (intermittent) and 0.1-0.2 (continuous) inhalations per day. There were no relevant clinical or functional differences between the two treatment regimens. CONCLUSION: Clinicians might consider intermittent inhaled steroid therapy as a therapeutic regimen for mild persistent asthma.Trial registration The Portuguese and English versions of the study protocol were submitted, approved, and registered in the Brazilian Network Platform for Clinical Trials (http://www.ensaiosclinicos.gov.br) under the primary identifier number "RBR-3gbyhk". This platform is part of the Primary Registries in the World Health Organization Registry Network, where the trial is registered under the following Universal Trial Number: 1111-1149-4774.
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OBJECTIVE: The objective of this study is to summarize the principal findings in the literature about acute asthma management in children. METHODS: Systematic reviews of randomized clinical trials (SRCTs) with or without meta-analysis in children (1-18 years) admitted to the emergency department (ED) were retrieved using five data bases. Methodological quality was determined using the AMSTAR tool. RESULTS: One hundred and three studies were retrieved. Among those, 28 SRCTs were included: seven SRCTs related to short-acting beta2-agonists (SABA), three to ipratropium bromide (IB), eight to corticosteroids, one to racemic adrenaline, one to leukotriene receptor antagonists (LTRA), four to magnesium sulfate, one to intravenous (IV) SABA, one to IV aminophylline, one to IV ketamine, and one to antibiotics. It was determined that administering SABA by MDI-VHC is superior to using a nebulizer, because it decreases the hospital admission rate, improves the clinical score, results in a shorter time in the ED, and causes fewer adverse effects. Levalbuterol and albuterol were similar. In patients with moderate to severe exacerbations, IB+SABA was superior to SABA, decreasing hospital admission and improving the clinical score. SABA heliox administered by nebulizer decreased exacerbation severity compared to oxygen. Inhaled corticosteroids (ICS), especially administered by nebulizer, showed results similar to oral corticosteroids (OCS) with respect to reducing hospital admission, unscheduled visits, and the requirement of additional systemic corticosteroids. ICS or OCS following ED discharge was similar with regard to relapse. Compared with a placebo, IV magnesium reduced hospital admission and improved lung function. CONCLUSIONS: SRCTs are useful for guiding decisions in acute asthma treatment.
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Antiasmáticos/uso terapêutico , Asma/tratamento farmacológico , Broncodilatadores/uso terapêutico , Serviço Hospitalar de Emergência/organização & administração , Administração por Inalação , Adolescente , Corticosteroides/uso terapêutico , Agonistas de Receptores Adrenérgicos beta 2/uso terapêutico , Antiasmáticos/administração & dosagem , Broncodilatadores/administração & dosagem , Criança , Pré-Escolar , Doença Crônica , Esquema de Medicação , Quimioterapia Combinada , Hélio/uso terapêutico , Humanos , Lactente , Ipratrópio/uso terapêutico , Antagonistas de Leucotrienos/uso terapêutico , Nebulizadores e Vaporizadores , Oxigênio/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Literatura de Revisão como AssuntoRESUMO
El asma es una enfermedad frecuente de fisiopatología compleja. El asma severa constituye aproximadamente el 5% de la población de asmáticos, sin embargo representa un desafío clínico y una carga sanitaria importante. Estudios recientes demuestran la existencia de fenotipos en todo el espectro de gravedad. La eosinofilia en esputo y sangre ha demostrado utilidad como marcador de inflamación Th-2 y de respuesta clínica a esteroides, sin embargo aún no existe mucho conocimiento sobre el asma no-eosinofílica. Los tratamientos actuales en asma se enfocan a estrategias de terapia escalonada según severidad, pero en pacientes con asma severa se requiere también del manejo multidisciplinario de las comorbilidades y la determinación del fenotipo, para aplicar terapias más especificas. El desarrollo acelerado de nuevos tratamientos en asma severa como consecuencia del mejor conocimiento de los distintos fenotipos ha ampliado el arsenal terapéutico para un enfrentamiento personalizado y específico en los pacientes con asma severa.
Asthma is a common disease of complex pathophysiology. Severe asthma accounts about 5% of asthma population, however represents a clinical challenge and a significant health burden. Recent studies show the existence of phenotypes through all the spectrum of severity. Eosinophilia in blood and sputum has proven as a useful marker of Th-2 inflammation and clinical steroid response, however there is still little knowledge about non-eosinophilic asthma. Current treatments for asthma are focused on step-up approaches according to severity, but severe asthma patients also require multidisciplinary management of comorbidities and phenotyping to apply more specific therapies. The fast development of new treatments in severe asthma as a result of better understanding of different phenotypes has broadened the therapeutic arsenal for a personalized and targeted management in severe asthma patients.
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Humanos , Adulto , Asma/diagnóstico , Asma/terapia , Fenótipo , Asma/classificação , Asma/tratamento farmacológico , Biomarcadores , Comorbidade , Cooperação do Paciente , Diagnóstico Diferencial , Termoplastia BrônquicaRESUMO
OBJECTIVE: To summarize the principal findings pertaining to most effective long-term pharmacologic treatment of childhood asthma. METHODS: Systematic reviews of randomized clinical trials (SRCTs) on pharmacologic chronic treatment in children (1-18 years) with persistent asthma were retrieved through MEDLINE, EMBASE, CINAHL, SCOPUS, and CDSR (up to January2014). RESULTS: One hundred eighty-three SRCTs were searched from databases. Among those, 39 SRCTs were included: two were related to step 1, 24 to step 2, nine to steps 3 and 4, and four to step 5 (according with NAEPP and GINA guidelines). The methodological quality of these SRCTs was determined by using the AMSTAR tool. RESULTS: For step 1: addition of ipatropium bromide to short-acting beta2-agonists does not show any benefit. For step 2: in preschoolers, inhaled corticosteroids (ICSs) reduce severe exacerbations and improve other clinical and lung function parameters. In children, ICSs are superior to leukotriene receptor antagonist (LTRA), cromones, or xantines in reducing severe exacerbations, improving lung function and other clinical outcomes. Fluticasone propionate (FP) is better than beclomethasone dipropionate (BDP) or budesonide only for lung function; but similar to hydrofluoroalkane-BDP or to ciclosenide. Compared to low ICSs doses, moderate doses result in only better lung function, but this is not true for FP. For steps 3 and 4: adding LTRA to ICS confers a small benefit; adding LABA improves lung function but does not reduce exacerbations more than double or higher ICS doses. For step 5: adding omalizumab decreases exacerbations. CONCLUSIONS: SRCTs are useful for guiding decisions in chronic childhood asthma treatment.