asthma diagnosis case study

Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
Methacholine challenge: PC 20 : 1.0 mg/mL
Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
Sinus CT: Mild mucosal thickening
Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
Immunoglobulin E (IgE): 25 IU/mL
Allergy-skin test: Positive for dust, trees
Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

Esophagram/barium swallow: Negative
Esophageal manometry: Negative
Esophageal impedance: Within normal limits
ECG: Within normal limits
Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2 One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2 The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5 Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2 A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10 In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10 Shortly after the AIR trial, the Research in Severe Asthma (RISA) trial was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11 In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11 Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2 trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6 Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6 In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6 Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both the AIR and the AIR-2 trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12 Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12 This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7 This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

A woman with asthma: a whole systems approach to supporting self-management

Hilary Pinnock 1 ,
Elisabeth Ehrlich 1 ,
Gaylor Hoskins 2 &
Ron Tomlins 3

npj Primary Care Respiratory Medicine volume 24 , Article number: 14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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The self-management abilities test (SMAT): a tool to identify the self-management abilities of adults with bronchiectasis

Improving primary care management of asthma: do we know what really works?

A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Published: 21 February 2018

Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment

Virginia Mirra 1 ,
Silvia Montella 1 &
Francesca Santamaria 1

BMC Pediatrics volume 18 , Article number: 73 ( 2018 ) Cite this article

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The primary goal of asthma management is to achieve disease control for reducing the risk of future exacerbations and progressive loss of lung function. Asthma not responding to treatment may result in significant morbidity. In many children with uncontrolled symptoms, the diagnosis of asthma may be wrong or adherence to treatment may be poor. It is then crucial to distinguish these cases from the truly “severe therapy-resistant” asthmatics by a proper filtering process. Herein we report on four cases diagnosed as difficult asthma, detail the workup that resulted in the ultimate diagnosis, and provide the process that led to the prescription of omalizumab.

Case presentation

All children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β 2 -agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma. Three out four patients were treated with omalizumab, which improved asthma control and patients’ quality of life. We reviewed the current literature on the diagnostic approach to the disease and on the comorbidities associated with difficult asthma and presented the perspectives on omalizumab treatment in children and adolescents. Based on the evidence from the literature review, we also proposed an algorithm for the diagnosis of pediatric difficult-to-treat and severe asthma.

Conclusions

The management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma. The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism in the management of children and adolescents with atopic severe asthma.

Peer Review reports

Children with poor asthma control have an increased risk of severe exacerbations and progressive loss of lung function, which results in the relevant use of health resources and impaired quality of life (QoL) [ 1 ]. Therefore, the primary goal of asthma management at all ages is to achieve disease control [ 2 , 3 , 4 ].

According to recent international guidelines, patients with uncontrolled asthma require a prolonged maintenance treatment with high-dose inhaled corticosteroids (ICS) in association with a long-acting β 2 -agonist (LABA) plus oral leukotriene receptor antagonist (LTRA) (Table 1 ) [ 5 ].

Nevertheless, in the presence of persistent lack of control, reversible factors such as adherence to treatment or inhalation technique should be first checked for, and diseases that can masquerade as asthma should be promptly excluded. Finally, additional strategies, in particular anti-immunoglobulin E (anti-IgE) treatment (omalizumab), are suggested for patients with moderate or severe allergic asthma that remains uncontrolled in Step 4 [ 5 ].

Herein, we reviewed the demographics, clinical presentation and treatment of four patients with uncontrolled severe asthma from our institution in order to explain why we decided to prescribe omalizumab. We also provided a review of the current literature that focuses on recent advances in the diagnosis of pediatric difficult asthma and the associated comorbidities, and summarizes the perspectives on anti-IgE treatment in children and adolescents.

Case presentations

Table 2 summarizes the clinical characteristics and the triggers/comorbidities of the cases at referral to our Institution. Unfortunately, data on psychological factors, sleep apnea, and hyperventilation syndrome were not available in any case. Clinical, lung function and airway inflammation findings at baseline and after 12 months of follow-up are reported in Table 3 . In the description of our cases, we used the terminology recommended by the ERS/ATS guidelines on severe asthma [ 6 ].

A full-term male had severe preschool wheezing and, since age 3, recurrent, severe asthma exacerbations with frequent hospital admissions. At age 11, severe asthma was diagnosed. Sensitization to multiple inhalant allergens (i.e., house dust mites, dog dander, Graminaceae pollen mix, and Parietaria judaica ) and high serum IgE levels (1548 KU/l) were found. Body mass index (BMI) was within normal range. Combined treatment with increasing doses of ICS (fluticasone, up to 1000 μg/day) in association with LABA (salmeterol, 100 μg/day) plus LTRA (montelukast, 5 mg/day) has been administered over 2 years. Nevertheless, persistent symptoms and monthly hospital admissions due to asthma exacerbations despite correct inhaler technique and good adherence were reported. Parents refused to perform any test to exclude gastroesophageal reflux (GER) as comorbidity [ 6 ]. However, an ex-juvantibus 2-month-course with omeprazole was added to asthma treatment [ 7 ], but poor control persisted. Anterior rhinoscopy revealed rhinosinusitis that was treated with nasal steroids for six months [ 8 ], but asthma symptoms were unmodified. Treatment with omalizumab was added at age 12. Reduced hospital admissions for asthma exacerbations, no further need for systemic steroids, and improved QoL score (from 2.0 up to 6.7 out of a maximum of 7 points) were documented over the following months. Unfortunately, after one year of treatment, adherence to omalizumab decreased because of family complaints, and eventually parents withdrew their informed consent and discontinued omalizumab. Currently, by age 17, treatment includes inhaled salmeterol/fluticasone (100 μg/500 μg∙day -1 , respectively) plus oral montelukast (10 mg/day). Satisfactory symptom control is reported, with no asthma exacerbations.

A full-term male, who had a recurrent severe preschool wheezing, at 6 years of age developed exercise-induced asthma. At age 10, severe asthma was diagnosed. High serum IgE levels (1300 KU/l) and skin prick tests positive to house dust mites were found. Despite a 3-year treatment with progressively increasing doses of inhaled fluticasone (up to 1000 μg/day) combined with salmeterol (100 μg/day) and oral montelukast (5 mg/day), monthly hospital admissions with systemic steroids use were reported. At age 13, a 24-h esophageal impedance/pH study demonstrated the presence of acid and non-acid GER [ 7 ]. Esomeprazole was added to asthma medications, but with an incomplete clinical benefit for respiratory symptoms. Esomeprazole was withdrawn after 3 months, and parents refused to re-test for GER. As respiratory symptoms persisted uncontrolled despite treatment, severe asthma was definitively diagnosed [ 6 ]. BMI was within the normal range and anterior rhinoscopy excluded rhinosinusitis. Inhaler technique and adherence were good; thus we considered the anti-IgE treatment option [ 9 ]. Subcutaneous omalizumab was started, with fast improvement of both symptoms and QoL score (from 3.9 up to 6.5). Seventeen months later, the dose of ICS had been gradually tapered and oral montelukast definitely discontinued. Currently, at age 14, treatment includes the combined administration of bimonthly subcutaneous omalizumab and of daily inhaled salmeterol/fluticasone (50 μg/100 μg∙day - 1 , respectively). Asthma control is satisfactory and no side effects are reported. Omalizumab has been continuously administered for 2.6 years and is still ongoing.

A full-term male had severe preschool wheezing and, since age 3, recurrent, severe asthma exacerbations with acute respiratory failure that frequently required intensive care unit (ICU) admission. At age 6, sensitization to multiple perennial inhalant (i.e., house dust mites, dog and cat danders, Alternaria alternata , Graminaceae pollen mix, Artemisia vulgaris , Parietaria judaica , and Olea europaea pollen) and food allergens (i.e., egg, milk, and peanut) was diagnosed. Serum IgE levels were 2219 KU/l. Weight and height were appropriate for age and sex. The patient has been treated over 3 years with a combined scheme of high-dose inhaled fluticasone (up to 1000 μg/day) plus salmeterol (100 μg/day) and oral montelukast (5 mg/day), with correct inhaler technique and good adherence. Despite this, monthly hospital admissions with systemic steroids use were recorded. Rhinosinusitis and GER were excluded on the basis of appropriate testing; thus treatment with omalizumab was started when the patient was 9 years old. At age 11, adherence to treatment is satisfactory, with no side effects. More importantly, reduced hospital admissions for asthma exacerbations, no further need for systemic steroids, and improved QoL score (from 6.4 to 6.8) were reported. Finally, progressive step-down of anti-asthma treatment was started, and at present (by 11.5 years) inhaled fluticasone (200 μg/day) plus bimonthly subcutaneous omalizumab provide good control of symptoms. Omalizumab has been continuously administered for 2.6 years and is still ongoing.

A full-term male had severe preschool wheezing and, since age 4, recurrent, severe asthma exacerbations with frequent hospital admissions. At age 8, multiple perennial inhalants and food sensitization (i.e., house dust mites, dog dander, Graminaceae pollen mix, Olea europaea pollen, tomatoes, beans, shrimps, and peas) and high serum IgE levels (1166 KU/l) were found. The patient has been treated over 5 years with inhaled fluticasone (up to 1000 μg/day) in association with salmeterol (100 μg/day) and oral montelukast (5 mg/day). Despite this, monthly hospital admissions with systemic steroids need were recorded. After checking the inhaler technique and adherence to treatment, comorbidities including obesity, rhinosinusitis and GER were excluded. Omalizumab was proposed, but parents refused it. By 13.6 years, despite a treatment including the association of inhaled salmeterol/fluticasone (100 μg/1000 μg∙day − 1 , respectively) plus oral montelukast (10 mg/day), monthly exacerbations requiring systemic steroids are reported.

Discussion and conclusions

Most children and adolescents with asthma respond well to inhaled short-acting beta 2 -agonists (SABA) on demand if symptoms are intermittent, or to low dose controller drugs plus as-needed SABA if the risk of exacerbations increases [ 1 ]. Nevertheless, a proportion of patients is referred to specialists because this strategy is not working and asthma is persistently uncontrolled [ 4 ]. For these children, assessment is primarily aimed at investigating the reasons for poor control. Indeed, when the child is initially referred, before the label of “severe, therapy-resistant asthma” (i.e., not responding to treatment even when factors as exposure to allergens and tobacco smoke have been considered) is assigned, three main categories need to be identified: 1) “not asthma at all”, in which response to treatment is suboptimal because the diagnosis is wrong; 2) “asthma plus ”, when asthma is mild but exacerbated by one or more comorbidities; and 3) “difficult-to-treat asthma”, when asthma is uncontrolled because of potentially reversible factors [ 10 ].

The reported cases highlight some aspects of the disease process that may expand the diagnosis and improve patients’ care. At our institution, the severe asthma program includes a multidisciplinary approach with consultations by gastroenterologists as well as ear, nose and throat experts. Recently, sleep medicine experts joined this multidisciplinary team; thus, unfortunately, sleep-disordered breathing (SDB) could not be excluded at the time of our patients’ assessment. Inhalation technique is periodically evaluated by nurses or doctors in each patient. Unfortunately, in Italy an individual prescription database is not available and thus we cannot assess patients’ use of medication. In two cases, the filtering process eventually identified GER and rhinosinusitis, but poor control of asthma persisted even after comorbidities were treated. In all subjects, inhaler skills, treatment adherence, and environmental exposure to indoor/outdoor allergens as well as to second- and third-hand smoke were excluded as cause of lack of control. Eventually, three out of four patients started anti-IgE treatment; asthma control was obtained and maintenance drugs were progressively reduced. In the case that refused omalizumab therapy, pulmonary function, clinical features and controller treatment including high-dose ICS were unchanged.

Previous studies have highlighted an association between increasing asthma severity in children and reduced QoL [ 11 , 12 , 13 ]. Uncontrolled asthma symptoms not only affect children physically, but can impair them socially, emotionally, and educationally [ 13 ]. In line with previous observations, 3 out 4 of our cases had poor QoL, assessed by a standardized questionnaire [ 14 ]. It is well known that improving QoL in difficult asthma is not an easy task, despite a variety of treatments aimed at achieving control [ 12 ], and much more remains to be done to address the problem. Nevertheless, 2 of our 3 cases showed a remarkable improvement of QoL after one year of treatment with omalizumab.

Reduction in forced expiratory volume in the first second (FEV 1 ) is often used to define childhood asthma severity in treatment guidelines and clinical studies [ 5 , 11 , 15 ]. Nevertheless, children with severe asthma often have a normal FEV 1 that does not improve after bronchodilators, indicating that spirometry may be a poor predictor of asthma severity in childhood [ 6 , 16 , 17 ]. Actually, children with a normal FEV 1 , both before and after β 2 -agonist, may show a bronchodilator response in terms of forced expiratory flow between 25% and 75% (FEF 25–75 ) [ 18 ]. However, the utility of FEF 25–75 in the assessment or treatment of severe asthma is currently unknown. Interestingly, all the reported cases showed normal or slightly reduced values of FEV 1 but severe impairment of FEF 25–75 . Two cases showed a bronchodilator response in terms of FEV 1 (subjects 3 and 4), while 3 patients had a significant increase of FEF 25–75 (cases 1, 3 and 4). Unfortunately, we could not provide the results of bronchodilator response during or after the treatment with omalizumab in any case.

Available literature on the diagnostic approach to difficult asthma in children offers a number of reviews which basically summarize the steps needed to fill the gap between a generic diagnosis of “difficult asthma” and more specific labels (i.e., “severe” asthma, “difficult-to-treat” asthma, or even different diagnoses) [ 3 , 5 , 6 , 8 , 10 , 19 , 20 , 21 ]. So far, few original articles and case reports have been published, probably due to the peculiarity of the issue, which makes retrospective discussion of cases easier than the design of a prospective clinical study [ 4 , 22 , 23 , 24 , 25 , 26 ]. Available knowledge mainly derives from the experience of specialized centers.

The evaluation of a child referred for uncontrolled asthma should start with a careful history focused on typical respiratory symptoms and on the definition of possible triggers. In the “severe asthma” process, it is crucial for clinicians to maintain a high degree of skepticism about the ultimate diagnosis, particularly in the presence of relevant discrepancies between history, physical features and lung function, as many conditions may be misdiagnosed as asthma. In order to simplify this process, herein we propose an algorithm for the diagnosis of difficult-to-treat and severe asthma (Fig. 1 ). Confirmation of the diagnosis through a detailed clinical and laboratory re-evaluation is important because in 12–50% of cases assumed to have severe asthma this might not be the correct diagnosis [ 10 ]. Several documents have indicated the main steps of the process that should be followed in children with uncontrolled asthma [ 3 , 8 , 10 ]. The translation of these procedures into real life practice may deeply change from one subject to another due to the variability of individual patients’ history and clinical features, which will often lead the diagnostic investigations towards the most likely reason for uncontrolled asthma. For children with apparently severe asthma, the first step is to confirm the diagnosis and, before proceeding to broader investigations, to verify that the poor control is not simply determined by poor adherence to treatment, inadequate inhaler skills and/or environmental exposure to triggers. A nurse-led assessment, including a home visit, despite not being applicable in all settings, may be useful for identifying potentially modifiable factors in uncontrolled pediatric asthma [ 27 ].

A practical algorithm for the diagnosis of difficult-to-treat and severe asthma. ICS, inhaled corticosteroids; OCS, oral corticosteroids

A number of comorbidities have been increasingly recognized as factors that may impact asthma clinical expression and control in childhood [ 10 , 28 ]. Children with uncontrolled disease should be investigated for GER, rhinosinusitis, dysfunctional breathing and/or vocal cord dysfunction, obstructive sleep apnea, obesity, psychological factors, smoke exposure, hormonal influences, and ongoing drugs [ 3 , 6 , 8 , 20 ]. Indeed, the exact role played by comorbidities in pediatric asthma control is still debated [ 28 ]. The most impressive example is GER. Several pediatric documents recommend assessing for GER because reflux may be a contributing factor to problematic or difficult asthma [ 7 , 29 ]. Nevertheless, GER treatment might not be effective for severe asthma [ 30 , 31 ], as confirmed by current cases 1 and 2. There is an established evidence that chronic rhinosinusitis is associated with more severe asthma in children [ 32 , 33 , 34 ]. Therefore, examination of upper airways and ad hoc treatment if rhinosinusitis is evident are recommended in children with severe asthma [ 3 , 8 , 35 ]. However, intranasal steroids for rhinitis resulted in a small reduction of asthma risk in school-aged children [ 36 ], and actual placebo-controlled studies on the effect of treatment of rhinosinusitis on asthma control in children are lacking [ 10 , 37 ].

Dysfunctional breathing, including hyperventilation and vocal cord dysfunction, is associated with poorer asthma control in children [ 8 , 10 , 38 , 39 ]. Unfortunately, there is scarce literature on the effect of its treatment on the control of severe asthma in children [ 40 ]. SDB ranging from primary snoring to obstructive sleep apnea syndrome is very common in children [ 41 ], and an increased prevalence of SDB together with increasing asthma severity has been reported [ 42 ]. Interestingly, GER may also be worsened by recurrent episodes of upper airway obstruction associated with SDB, and this may further trigger bronchial obstruction. Asthma guidelines recommend the assessment of SDB through nocturnal polysomnography in poorly controlled asthmatics, particularly if they are also obese [ 5 ]. There are no studies examining whether pediatric asthma improves after SDB has been treated, for example, with nasal steroids, adenotonsillectomy, continuous positive airway pressure or weight reduction if the child is also obese [ 43 ]. The parallel increase in obesity and asthma suggests that the two conditions are linked and that they can aggravate each other [ 44 , 45 ], even though the exact mechanisms that underlie this association remain unclear [ 46 ]. Indeed, other coexisting comorbidities such as SDB or GER may play a confounding role in the development of the interactions between obesity and the airways [ 47 , 48 ]. Obesity is associated with increased markers of inflammation in serum and adipose tissue and yet decreased airway inflammation in obese people with asthma [ 49 ]. Several interventions, including behavioral and weight reduction programs or bariatric surgery, may result in improved asthma control, quality of life and lung function in adult obese asthmatics [ 50 ]. Although reports of adolescent bariatric surgery demonstrate a significant body weight decrease, this approach is not widely available and there are no published reports on its effect on pediatric severe asthma control [ 51 ]. Finally, although it is still unclear whether food allergy is causative or shares a common pathway with difficult asthma, it might explain the loss of asthma control at least in some children and thus be considered as a comorbid condition [ 10 , 16 , 52 ].

In conclusion, establishing the impact of comorbidities on asthma control may be cumbersome, and an ex-juvantibus treatment is sometimes necessary to assess their role. Comorbid conditions can also worsen each other, and symptoms arising from some of them may mimic asthma [ 6 ]. Although the ability to improve pediatric severe asthma by treating comorbidities remains unconfirmed, they should be treated appropriately [ 9 ].

The vast majority of asthmatic children exhibit a mild or at most a moderate disease that can be fully controlled with low-to-medium dose ICS associated or not with other controllers [ 5 , 6 ]. However, a subset of asthmatics remains difficult-to-treat [ 5 , 6 ]. With the advent of biologics, these severe steroid-dependent asthmatics have alternative options for treatment, as steroid-related adverse events are common in severe asthma [ 53 ]. Omalizumab, an anti-IgE monoclonal antibody, is the only biologic therapy recommended in children with moderate-to-severe asthma by the recent guidelines [ 5 , 6 ]. In Italy, this treatment is fully covered by the National Health System. Therefore, there is no influence by any funding on treatment decisions. It was approved by the US (Food and Drug Administration) in 2003 and by the European Union (European Medicines Agency) in 2005 as an add-on treatment for patients aged > 12 years with severe persistent allergic asthma and who have a positive skin test or in-vitro reactivity to a perennial aeroallergen, FEV 1 < 80% predicted, frequent daytime symptoms or nighttime awakenings, and multiple documented severe asthma exacerbations despite daily ICS plus a LABA [ 54 , 55 ]. In 2009, it also received approval in Europe for treating patients aged 6–12 years. Figure 2 illustrates current indications for treatment with omalizumab in children and adolescents with severe asthma.

Indications for omalizumab in children and adolescents with severe asthma

IgE antibodies, Th 2 -derived cytokines and eosinophils play a major role in the development of chronic airway inflammation in asthmatic subjects [ 56 ]. Once released from plasma cells, IgE binds principally to the high-affinity IgE receptor (FcεRI) on mast cells, triggering different effector responses, including the release of mediators leading to allergic inflammatory reactions [ 56 ]. The activation of the allergic cascade by IgE, under constant allergen stimulation, leads to the establishment of chronic allergic inflammation in the airways of asthmatic patients, with IgE being a key element of the vicious circle that maintains it. Cytokines produced during the late phase and subsequent chronic inflammation stage have been directly associated with the induction of airway remodelling, indirectly implicating IgE in the process [ 56 ]. At present, omalizumab is the only commercially available recombinant humanized anti-IgE monoclonal antibody that specifically binds serum free IgE at its CH 3 domain, in the proximity of the binding site for FcεRI, thus preventing IgE from interacting with its receptor on mast cells, basophils, antigen-presenting cells and other inflammatory cells [ 57 ]. The rapid reduction of free IgE levels leads to a downregulation of the FcεRI expression on inflammatory cells and an interruption of the allergic cascade, which results in the reduction of peripheral and bronchial tissue eosinophilia and of levels of granulocyte macrophage colony stimulating factor, interleukin (IL)-2, IL-4, IL-5, and IL-13 [ 58 ]. Moreover, basophils have a relevant role in the initiation and progression of allergic inflammation, suggesting that they may represent a viable therapeutic target. Indeed, in children with severe asthma, it has been reported that omalizumab therapy is associated with a significant reduction in circulating basophil numbers, a finding that is concurrent with improved clinical outcomes [ 59 ]. This finding supports a mechanistic link between IgE levels and circulating basophil populations, and may provide new insights into one mechanism by which omalizumab improves asthma symptoms.

Several clinical controlled and real-life studies of adults with severe, inadequately controlled allergic asthma have demonstrated the efficacy and safety of omalizumab in reducing asthma-related symptoms, corticosteroid use, exacerbation rates, and healthcare resource utilization, and in improving QoL and lung function [ 60 , 61 , 62 , 63 ]. Fewer studies have been published in children. In two double-blind, randomized, placebo-controlled trials (RCTs) of children aged 6 to 12 years with moderate-to-severe allergic asthma, treatment with omalizumab reduced the requirement for ICS and protected against disease exacerbations, but there was little change in asthma symptom scores or spirometry [ 9 , 64 ]. These findings were confirmed and extended in older children [ 65 , 66 , 67 ].

The results of the ICATA study, a multicenter RCT of 419 inner-city children, adolescents and young adults with persistent allergic asthma, showed that, compared to placebo, omalizumab reduces the number of days with asthma symptoms and the proportion of participants with at least one exacerbation by approximately 25% and 19%, respectively ( p < 0.001), thus reducing the need for asthmatic symptom controllers [ 68 ]. Another multicenter RCT of inner-city children and adolescents showed that the addition of omalizumab to ongoing guidelines-based care before patients return to school reduces fall asthma exacerbations (odds ratio, 0.48), particularly in subjects with a recent exacerbation [ 69 ]. Moreover, in a real-life study of 104 children and adolescents with severe allergic refractory asthma followed over 1 year, treatment with omalizumab resulted in good asthma control in 67% of the cases ( p < 0.001), while FEV 1 improved by 4.9% ( p = 0.02) and exacerbation rates and healthcare utilisation decreased approximately by 30% ( p < 0.001) [ 70 ]. The same authors also showed that, after two years of treatment, exacerbation rate and healthcare utilisation were further decreased by 83% and 100%, respectively, while level of asthma control, steroid use and lung function remained unchanged [ 71 ].

A systematic review of pediatric RCTs pooled the data of 1381 children and adolescents with moderate-to-severe allergic asthma in order to establish the efficacy of omalizumab as an add-on therapy [ 72 ]. During the stable-steroid phase, omalizumab decreased the number of patients with at least one exacerbation (risk ratio, 0.69; p < 0.001), the mean number of asthma exacerbations per patient (risk ratio, 0.35; p < 0.001), and the asthma symptom score (mean difference, 0.12; p = 0.005) when compared to placebo. During the steroid reduction phase, omalizumab further reduced the number of patients with at least one exacerbation (risk ratio, 0.48; p < 0.001) and the mean number of asthma exacerbations per patient (mean difference, 0.12; p < 0.05).

Given the cost of omalizumab, many authors have argued for the importance of identifying specific asthma populations who will have significant benefit from it [ 68 , 73 , 74 ]. In the ICATA study, baseline predictors of good response to treatment were sensitization and exposure to cockroach allergen, sensitization to house dust mite allergens, a serum IgE level of more than 100 IU per milliliter, a BMI of 25 or more, and a history of at least one unscheduled medical visit in the previous year [ 68 ].

Several studies have assessed the long-term safety of omalizumab in children and adults. A pooled analysis of 67 RCTs conducted over 2 decades on 4254 children and adults treated with omalizumab showed no association between omalizumab treatment and risk of malignancy [ 75 ]. In an RCT evaluating 225 school-aged children, omalizumab was well tolerated, there were no serious adverse events, and the frequency and types of all adverse events were similar to the placebo group [ 9 ]. These results have been further confirmed by a recent systematic review of RCTs that concluded that treatment with omalizumab does not result in increased risk of malignancy or hypersensitivity reactions [ 72 ].

While the rationale for long-term treatment with omalizumab is supported by pharmacokinetic-pharmacodynamic models [ 76 ], the duration of treatment is still under discussion. Results from published studies suggest that omalizumab should be continued for > 1 year [ 77 , 78 ]. In a retrospective study of adults and children with uncontrolled severe asthma treated with omalizumab, the response to treatment was ‘excellent’ in 52.5% of patients, particularly in the subgroup of children aged 6 to 11 years [ 77 ]. After the discontinuation of treatment, loss of asthma control was documented in 69.2% of the patients who had received omalizumab for < 1 year, 59.1% of the subjects treated for 1–2 years, and 46.1% of the cases treated for > 2 years. Time to loss of control was shorter in younger children and longer in patients with an ‘excellent’ response compared with patients with a ‘good’ response. No early loss of control (within 6 months) was observed among patients with > 3.5 years of continuous treatment with omalizumab. Finally, 20% of patients in whom omalizumab was re-prescribed because of loss of control did not respond to the treatment anymore [ 77 ]. Despite these encouraging findings, the impact of omalizumab on the natural history of severe asthma in children deserves to be further investigated by long-term studies that will also define the criteria and timing for discontinuing the treatment.

It is well known that asthma pharmacotherapy is effective in controlling symptoms and bronchial inflammation, but cannot affect the underlying immune response, thus leading to the possibility of symptom reappearance after its discontinuation [ 79 ]. In this scenario, allergen-specific immunotherapy (AIT) has been proposed as the only therapeutic method that can modulate the underlying immune pathophysiology in allergic asthma [ 80 ].

AIT is currently indicated in children and adults with mild-moderate allergic asthma that is completely or partially controlled by pharmacotherapy and with the evidence of a clear relationship between symptoms and exposure to a specific allergen [ 81 , 82 , 83 , 84 ]. However, according to recent guidelines, the efficacy of AIT in asthmatic subjects is limited, and its potential benefits must be weighed against the risk of side effects and the inconvenience and costs of the prolonged therapy [ 5 ]. Moreover, severe or uncontrolled asthma (regardless of its severity) is a major independent risk factor for non-fatal or even fatal adverse reactions, thus representing a contraindication for AIT [ 85 , 86 , 87 ]. Finally, children with severe asthma are often sensitized to multiple allergens, thus making AIT prescription even more complicated [ 88 ].

In subjects with uncontrolled and/or severe allergic asthma, a combination of omalizumab and AIT has been proposed [ 88 ]. Surprisingly, only a few studies have addressed this issue [ 89 , 90 , 91 , 92 ]. However, pre-treatment with omalizumab seems to improve the efficacy and tolerability of subcutaneous AIT in children and adults with severe allergic asthma both during omalizumab treatment and after its discontinuation [ 89 , 91 , 92 ]. Omalizumab has also been successfully used as a supplementary treatment to AIT in order to improve asthma control in children ≥6 years with severe persistent allergic asthma [ 90 ]. Given the scarcity of studies on AIT plus omalizumab in children with severe allergic asthma, further research is warranted to assess risks and benefits of the combined treatment.

Children with severe asthma require a detailed and individualized approach including re-assessment for differential diagnoses, comorbidities and contributory factors, environmental triggers, lung function and inflammation, adherence and response to therapy, and QoL. Treatment of pediatric severe asthma still relies on the maximal optimal use of corticosteroids, bronchodilators and other controllers recommended for moderate-to-severe disease. However, the management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma.

In the current paper, we described the characteristics of four children with severe asthma in whom omalizumab was prescribed. A review of the relevant literature on the topic was also performed. Finally, we provided an algorithm for the diagnosis of difficult-to-treat and severe asthma in children and adolescents, based on the evidence from the literature review. As all algorithms, it is not meant to replace clinical judgment, but it should drive physicians to adopt a systematic approach towards difficult and severe asthma and provide a useful guide to the clinician.

The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism of outcome improvements in patients with allergic severe asthma. As severe asthma is a heterogeneous condition consisting of different phenotypes, the future of asthma management will likely involve phenotypic and potentially even genotypic characterization in selected cases in order to determine appropriate therapy and thus to provide the highest possible benefit, especially if specific responder phenotypes can be identified and selected for this highly specific treatment.

Abbreviations

Anti-immunoglobulin E

Body mass index

IgE receptor

Forced expiratory flow between 25% and 75%

Forced expiratory volume in the first second

Gastroesophageal reflux

Inhaled corticosteroids

Intensive care unit

Interleukin

Long-acting β 2 -agonist

Oral leukotriene receptor antagonist

Quality of life

Randomized controlled trials

Short-acting β 2 -agonists

Sleep-disordered breathing

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The authors gratefully thank Dr. Marco Maglione for his contribution in the clinical assessment of the described cases. Medical writing assistance was provided by Stephen Walters on behalf of City Hills Proofreading.

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Virginia Mirra, Silvia Montella & Francesca Santamaria

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VM, SM and FS, authors of the current manuscript, declare that they have participated sufficiently in the work to take public responsibility for appropriate portions of the content. VM and SM carried out the initial investigations, drafted the initial manuscript, revised the manuscript, and approved the final manuscript as submitted. FS conceptualized and designed the study, and critically reviewed and approved the final manuscript as submitted. All authors read and approved the final manuscript.

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Correspondence to Francesca Santamaria .

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Mirra, V., Montella, S. & Santamaria, F. Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment. BMC Pediatr 18 , 73 (2018). https://doi.org/10.1186/s12887-018-1019-9

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Asthma: a case study, review of pathophysiology, and management strategies

Affiliation.

1 Medical College of Georgia, School of Nursing, Augusta, GA, USA.
PMID: 12426803
DOI: 10.1111/j.1745-7599.2002.tb00076.x

Purpose: To review the pathophysiology of asthma, present a case study, and provide management strategies for treating this common, yet complex disorder in children and adults.

Data sources: Selected clinical guidelines, clinical articles, and research studies.

Conclusions: Asthma is a chronic inflammatory airway disorder with acute exacerbations that currently affects approximately 14 million-15 million children and adults in the United States. Costs for asthma are staggering and nurse practitioners (NPs) are frequently presented with management decisions for the acute treatment and chronic management of this disorder. Disparities exist with the occurrence of asthma between race and gender. Additionally, there is an increased incidence in acute exacerbations resulting from poor long-term control and follow-up care among the socioeconomically disadvantaged.

Implications for practice: Standards of care, along with new and emerging treatment strategies, guide NPs in providing the most comprehensive care to those affected with this chronic disorder. Knowledge about the pathophysiology of asthma and correlated to the case presentation enhances understanding treatment strategies for NPs who are often faced with providing care for patients with this chronic disorder that may sometimes present in an acute exacerbation.

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Joanne Martin 1 , 2 , 3 ,
Jennifer Townshend 4 ,
http://orcid.org/0000-0003-4591-8299 Malcolm Brodlie 1 , 4
1 Translational and Clinical Research Institute , Newcastle University , Newcastle upon Tyne , UK
2 Northern Foundation School , Health Education England North East , Newcastle upon Tyne , UK
3 James Cook University Hospital , South Tees NHS Foundation Trust , Middlesbrough , UK
4 Paediatric Respiratory Medicine , Great North Children's Hospital, Newcastle upon Tyne Hospitals NHS Foundation Trust , Newcastle upon Tyne , UK
Correspondence to Dr Malcolm Brodlie; malcolm.brodlie{at}newcastle.ac.uk

Asthma is the the most common chronic respiratory condition of childhood worldwide, with around 14% of children and young people affected. Despite the high prevalence, paediatric asthma outcomes are inadequate, and there are several avoidable deaths each year. Characteristic asthma features include wheeze, shortness of breath and cough, which are typically triggered by a number of possible stimuli. There are several diagnostic challenges, and as a result, both overdiagnosis and underdiagnosis of paediatric asthma remain problematic.

Effective asthma management involves a holistic approach addressing both pharmacological and non-pharmacological management, as well as education and self-management aspects. Working in partnership with children and families is key in promoting good outcomes. Education on how to take treatment effectively, trigger avoidance, modifiable risk factors and actions to take during acute attacks via personalised asthma action plans is essential.

This review aimed to provide an overview of good clinical practice in the diagnosis and management of paediatric asthma. We discuss the current diagnostic challenges and predictors of life-threatening attacks. Additionally, we outline the similarities and differences in global paediatric asthma guidelines and highlight potential future developments in care. It is hoped that this review will be useful for healthcare providers working in a range of child health settings.

therapeutics

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/ .

https://doi.org/10.1136/bmjpo-2021-001277

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Key messages

Paediatric asthma outcomes are poor and many deaths are preventable.

Diagnosing asthma in childhood can be challenging, and the diagnosis should be reviewed during follow-up to ensure it is correct.

Asthma attacks should be viewed as never events. Postattack reviews are essential to optimise maintenance therapy and prevent future attacks.

Education is key to improving asthma outcomes.

Personalised asthma action plans are essential, and a significant number of children with asthma do not have one.

Introduction

Asthma is a chronic respiratory disease characterised by episodes of wheeze, cough, and shortness of breath. Around 14% of children worldwide have a diagnosis of asthma, making it the most common chronic respiratory disease of childhood. 1

Poor asthma control is associated with a number of negative effects on children and families. For example, they are more likely to be absent from school, have additional educational needs and have lower educational attainment. 2 Caregivers also experience missed work days and financial challenges as a result. 3 Some children will experience severe symptoms and life-threatening attacks. 4

Taking the UK as an example, paediatric asthma outcomes are poor overall with considerable associated morbidity and high rates of emergency hospital admissions, and most pertinently, there are several preventable deaths each year. 5 Alarmingly, the National Review of Asthma Deaths (NRAD) found that in almost all paediatric cases, there were a number of significant avoidable contributing factors and that these deaths may have been preventable. 6

There are several factors that make the diagnosis and management of asthma in children challenging. The aim of this review was to explore these issues and highlight good clinical practice in the diagnosis and management of paediatric asthma.

Presentation of asthma

Children with asthma typically present with a symptom triad of wheeze, shortness of breath and cough. However, ‘asthma’ is an umbrella term used to describe this collection of symptoms and, when present, should prompt practitioners to ask, ‘What type of asthma is this?’ There are a number of asthma subtypes that present and respond to treatment differently. Identification of the features of asthma and modifiable or treatable traits should only be the start of the diagnostic journey. 7 Asthma symptoms are normally intermittent in nature and may not be present at the time of clinical review, making the diagnosis challenging in some cases. 8 Additionally, disease phenotypes are not fixed and may evolve over time, necessitating ongoing review of symptoms and treatment. 9

Wheeze is a key feature of asthma and, if not present, a diagnosis of asthma in a child is unlikely. Wheeze is an expiratory high-pitched whistle that occurs as a result of inflammation and narrowing of the small airways. Parental understanding of wheeze varies, and clarifying what is meant when it is reported is key in making an accurate diagnosis. 10

The prevalence of ‘preschool wheeze’ is an additional challenge when diagnosing asthma in young children. In the first few years of life, many children will experience wheeze, but not all will go on to develop true asthma. The diagnosis of asthma should therefore be reviewed routinely to identify true asthma and alter treatment where necessary. 11 Favourable response to an appropriate trial of asthma treatment is an important confirmatory piece of diagnostic evidence.

Clinical examination may be normal in children and adolescents with asthma if they present during asymptomatic periods. During acute attacks, use of accessory muscles of respiration and widespread wheeze may be present. 12 Chest hyperinflation may be identified in acute and chronic disease settings.

Asthma triggers

Asthma attacks commonly occur following exposure to one or several triggers. Viral respiratory infections remain the leading cause, 13 but there are a number of other known triggers ( box 1 ), including aeroallergens, secondhand smoke exposure, or changes in ambient air temperature or humidity. Identification and documentation of specific asthma triggers should be part of routine care. Education on trigger recognition and avoidance is essential.

Common asthma triggers

Viral respiratory tract infections 6

Exercise 6 59

Weather changes in temperature and humidity 6 59

Domestic pollutants (eg, pests, mould and dust mites) 6

Environmental pollutants (eg, air pollution) 6

Secondhand smoke exposure 13 59

Pets and animals 13

Strong odours 13

Anxiety or strong emotions 59

Drugs (eg, non-steroidal anti-inflammatory drugs and beta blockers) 59

Gastro-oesophageal reflux 59

Risk factors for asthma

There are a number of risk factors that should be explored in the history of children who present with features of asthma. In symptomatic children, a personal or family history of atopic features, including asthma, eczema or rhinitis, supports a diagnosis of asthma. Some additional risk factors are outlined in box 2 . Education on modifiable risk factors, for example, exposure to secondhand smoke or air pollution and obesity, should be delivered routinely during consultations and asthma reviews. A range of social determinants that are linked to poverty impact on outcomes and the health of children with asthma. 14

Asthma risk factors

Personal or family history of atopy: eczema, allergic rhinitis or nasal polyposis 60

Family history of asthma 60

Exposure to secondhand smoke 60

Preterm birth 21

Low birth weight 61

Poor housing quality/mould and dampness 6

Air pollution 63

Paediatric asthma phenotypes

Asthma is a heterogeneous disease in which there are several phenotypes and underlying endotypes. Phenotypes are subtypes of asthma that share clinical characteristics such as symptom triggers, atopic features, disease severity and response to treatment. Endotypes are subtypes of asthma that are characterised by similar underlying biological mechanisms. 15

Key endotypes include ‘type 2-high’ and ‘type 2-low’ asthma. 16 Identifying asthma phenotypes and endotypes can facilitate targeted treatment based on the pathophysiology occurring in a specific individual. 17 For example, allergic or eosinophilic asthma that frequently starts in childhood is type 2-high and is characterised by eosinophilic airway inflammation, raised IgE and fractional exhaled nitric oxide (FeNO) levels. 15 Typically, type 2-high asthma responds well to inhaled corticosteroid (ICS) treatment. 7 A number of biologic agents can be used in the management of asthma, under specialist supervision, and their use varies on asthma endotypes (table 8). 18

Differential diagnoses and diagnostic uncertainty

Misdiagnosis of asthma remains a major problem with rates of both underdiagnosis and overdiagnosis being high. 19 Overdiagnosis is problematic as it exposes children to unnecessary side effects of medications and runs the risk of trivialising asthma. 7

There are several conditions that may be associated with chronic cough, wheeze and/or shortness of breath in children and therefore present similarly to asthma ( table 1 ). Due to the difficulties with diagnosis, especially in young children where objective testing is not possible, the diagnosis of asthma should be reviewed at each clinical presentation and interaction.

View inline

Asthma differentials and clues in medical history

Diagnosing asthma in children

There is no single ‘gold-standard’ test that can be used to accurately diagnose asthma. In practice, a diagnosis should be made based on characteristic symptom patterns, evidence of variability in airflow limitation in the presence of airway inflammation, likelihood of alternative diagnoses and response to treatment. Getting the diagnosis correct is key for optimal management of paediatric asthma.

Lung function tests can be used to aid the diagnosis of asthma in children over the age of 5 years. Peak expiratory flow (PEF) and spirometry are commonly used to assess airflow obstruction and reversibility. PEF can be used to detect diurnal variation, which is a typical feature of asthma. The Global Initiative for Asthma (GINA) specifically recommends the use of either PEF or spirometry in the diagnosis of asthma in children over 5 years. 20 Once a child is old enough to reliably perform lung function testing, it is recommended that this be undertaken if the diagnosis of asthma has not been previously confirmed. In children under 5, lung function testing is rarely practical outside a research setting. This makes diagnosis in this age group additionally challenging. 21 Guidelines vary between countries and regions with regard to diagnostic criteria. An overview of the similarities and differences between these guidelines is displayed in table 2 . Lung function testing is frequently used to monitor progress of children with asthma as part of their care. Objective testing should be repeated if there is poor response to treatment or diagnostic uncertainty.

Summary of paediatric asthma national guidelines: focusing on diagnosis

FeNO is used to detect and quantify eosinophilic airway inflammation with levels elevated in those with eosinophilic asthma. 22 Once staff are trained, and provided equipment is available, FeNO is a practically useful test that is quick to perform in school-aged children. The exact positioning of FeNO testing varies between guidelines worldwide ( table 2 ). FeNO monitoring may also be useful in titrating dosage of ICS in those with an established diagnosis of asthma. 23

Allergy testing (skin prick testing or measurement of specific IgE levels) is not routinely carried out in the diagnostic process; however, it is recommended in a number of clinical guidelines and may identify individual triggers. 24–27

There are several aspects that make paediatric asthma diagnosis challenging. Most diagnoses are made in primary care where there is often limited access to objective testing at present. Despite guideline recommendations, objective testing is frequently only available in secondary or tertiary care settings where equipment and trained staff are available. The COVID-19 pandemic has served to exacerbate these issues and increase backlogs. Various solutions have been proposed, including community diagnostic hubs. 28 In some healthcare systems, the cost of undergoing objective testing is a cause of health inequalities.

Additionally, the symptom onset for most cases of paediatric asthma occurs before the age of 3 years 29 when lung function testing cannot be used to aid diagnosis. In this age group, response to an asthma treatment trial is useful to aid diagnostic decision making and is recommended in a number of national guidelines. 27 30–32

Management of asthma in children

The management of asthma is multifactorial, and to optimise disease control, a number of pharmacological, non-pharmacological and self-management aspects need to be considered.

Pharmacological management

The pharmacological management of asthma involves two key components: maintenance and reliever therapies. Maintenance therapies are the mainstay of asthma management, and the treatment aim is that no reliever therapies are required. Use of reliever therapy suggests asthma control is poor.

An overview of maintenance and reliever therapies is outlined in tables 3 and 4 , respectively. A stepwise approach to asthma management is encouraged, and pharmacological management varies on age, symptom control and the national guideline used. An overview of management approach in a number of national guidelines is summarised in table 5 .

Maintenance therapies

Reliever therapies

Summary of paediatric asthma national guidelines: focusing on management

Biologic agents used in the management of asthma

GINA guidelines recommend dual ICS and short-acting beta-2 agonist (SABA) therapy to children over the age of 5. 20 SABA monotherapy was previously the main management starting point; however, compared with combined treatment, SABA monotherapy has been shown to be associated with asthma mortality. 33 SABA monotherapy is now only recommended by GINA for use in children aged 5 or less. 20 As seen in table 5 , GINA recommends symptom-driven ICS use, compared with daily ICS use, as initial therapy in children over 6 years of age. In comparison to daily ICS use, symptom-driven use has demonstrated a similar exacerbation risk and reduces the risk of ICS adverse effects. 34

Single maintenance and reliever therapy (SMART) inhalers are combined inhalers offering both maintenance and reliever therapy in those with asthma. These inhalers contain a number of maintenance and reliever therapies in different combinations. The use of these inhalers have been shown to reduce the risk of asthma attacks and emergency department (ED) admissions, 35 improve lung function and decrease the need for reliever therapy. 36 There is limited evidence in the effectiveness of SMART inhalers in children, but children over 12 years may be prescribed a SMART inhaler, which acts as both a maintenance and reliever therapy, if symptoms are not well controlled. 37

There are a number of biologic agents ( table 6 ) that may be used in the management of paediatric asthma. These are endotype-specific, targeted therapies that should be used only under the supervision of specialists. Their availability and cost vary between countries and different healthcare systems. Detailed appraisal of the evidence base for their use is provided in the individual management guidelines and has been recently reviewed. 17

Non-pharmacological management

Non-pharmacological aspects of asthma management include providing education on modifiable risk factors and comorbidities to caregivers and conducting annual asthma reviews to assess control and future risk.

Education is key to improving caregiver and child understanding of asthma and its management. Clear information regarding modifiable risk factors, such as smoke exposure, domestic pollutants and obesity, should be given. Short-term educational interventions aimed to improve self-management have been shown to increase medication adherence, 38 improve symptom control and reduce mortality. 39

All young people with asthma should have asthma reviews at least annually. These reviews should focus on current symptom control and management, previous attacks, triggers, modifiable risk factors and personal asthma action plans (PAAPs). Asthma reviews are opportunities to assess child and caregiver understanding of asthma and provide education, if necessary. Annual asthma reviews are also opportunities to assess inhaler technique (including spacer use) and provide education on this if necessary. Poor inhaler technique is common in young people with asthma 40 and associated with poor disease control. 41

Taking time to understand the perceptions of young people and their caregivers in relation to their asthma diagnosis and management is important, and exploring such perceptions may enhance engagement during consultations, subsequently improving outcomes for young people. 42

Self-management

Self-management aspects of paediatric asthma management include asthma education and PAAPs. PAAPs are written documents that are given to young people and/or caregivers that advise them on day-to-day asthma management and what to do in the event of an attack. 43 Action plans should be created with patient/caregiver input, shared with relevant individuals (eg, school teachers) and should be reviewed and updated regularly. PAAPs have been shown to reduce ED attendance and missed school days and to increase caregiver confidence when managing attacks. 44 The 2018 Annual Asthma Survey found that over 50% of children with asthma in the UK had no PAAP, and around 20% of caregivers did not seek medical advice during acute asthma attacks, highlighting large gaps in education. 45

Diet and exercise are additional important self-management aspects within paediatric asthma care. A number of short-term exercise interventions have demonstrated improvements in lung function and symptom control. 46 Healthy eating interventions can help reduce body mass index and improve the quality of life of both young people and their caregivers. 47

Withdrawing management/stepping down

Asthma control should be reviewed at every medical contact. When asthma symptoms are well controlled on pharmacological therapy, stopping or stepping down medication should be considered to protect young people from unnecessary adverse effects.

The GINA 2021 guidelines advise that clinicians should consider stepping down asthma management to the lowest effective treatment regimen when good symptom control has been achieved for at least 3 months. 20 When stepping down treatment, an individualised risk–benefit approach should be taken with focus on the child’s medical history, including frequency of oral corticosteroid use, frequency of asthma attacks, and previous intensive or high-dependency care admissions. 48

When to refer to a specialist

Most paediatric asthma cases are diagnosed in primary care without the input of general paediatricians or paediatric respiratory physicians. 6 However, a number of children with asthma may need to be referred to specialists for diagnostic or management input. Common indications for specialist referral include no or poor response to asthma treatments, inconclusive objective testing, poor symptom control with appropriate treatment, frequent oral corticosteroid use or the occurrence of a severe asthma attack. 20 27 30 31 49 50 A key element of specialist care is a multidisciplinary team consisting of a number of professionals, including specialist nurses, psychologists, physiologists and pharmacists.

Healthcare professionals must consider any safeguarding implications at all paediatric asthma reviews as part of delivering holistic care. Unexplained or frequent ‘do not attend’ appointments or suspicion of poor medical management at home should be flagged and acted on locally.

Predictors of life-threatening attacks

The following features have been shown to increase the likelihood of future severe attacks, and particular attention should be given to these factors during asthma reviews:

Previous attack. The strongest risk factor for a future asthma attack is a personal history of a previous attack. One large systematic review and meta-analysis found that children with a recent history of ED attendance with an asthma attack were up to 5.8 times more likely to have another ED attendance and up to three times more likely to be admitted to the hospital with a future asthma attack. 51

Frequent SABA use and prescription requests. Frequent use of SABA reliever therapy suggests poor control of asthma symptoms. If asthma symptoms are well controlled, no more than two SABA inhalers should be required annually. 52 The UK NRAD found that excess SABA prescription and use were prominent in individuals who died of asthma attacks. For those with data available, around 40% had been prescribed 12 or more SABA inhalers in the 12 months before death. 6

Postattack review

Asthma attacks should be viewed as never events. It is essential that a postattack review is conducted to review asthma maintenance treatment, as this is likely to be suboptimal. Failure to review patients post attack, and to alter treatment where appropriate, is likely to predispose to future attacks, which could be life-threatening. Management of the current attack should be reviewed to ensure treatment is appropriate and symptoms are resolving. Some individuals may require additional courses of oral corticosteroids to settle symptoms. 7

Current NICE quality standards (UK) state that all individuals hospitalised with an asthma attack should receive a follow-up review in primary care within two working days of discharge, 49 to review maintenance management and ensure resolution of symptoms. However, the 2018 National Asthma Survey completed in the UK found that 64% of respondents had no primary care follow-up post attack, and most patients were not aware that this was required. 45

Salbutamol weaning

Salbutamol weaning plans are commonly used by a number of healthcare organisations following discharge after an asthma attack. These plans direct caregivers to provide regular SABA therapy, often in a reducing regime, in the days following discharge. There have been a number of concerns raised with regard to these plans with some believing that providing regular SABA therapy may potentially mask deterioration and could delay care givers seeking medical advice. 53 Healthcare professionals should enquire about salbutamol weaning plans during postattack reviews and urge caregivers to seek medical advice if they have concerns or the effects of SABA are not lasting the 4 hours of duration.

Future developments in care

The management of paediatric asthma is changing over time with, just as two examples, developments in technology and service structure:

Technology. The growing use of technology in asthma care has huge potential to improve clinical outcomes. Smartphone applications can be used to provide medication reminders to users, and this has been shown to increase ICS adherence. 54 Applications can also be used to provide educational content to young people and caregivers, 55 as well as store PAAPs. 56 ‘Smart’ inhalers, not to be confused with SMART inhalers, are devices that can provide audio reminders to users and record when they are used. One paediatric study found that the use of smart inhalers increased treatment adherence to 84%, compared with 30% in the control group. 57

Diagnostic hubs. In the UK, regional diagnostic hubs for asthma care have been recommended in NHS England’s Long Term Plan. 58 Implementation of diagnostic hubs is hoped to result in earlier and more accurate asthma diagnoses by improving access to objective testing and specialised interpretation. Hubs are designed to improve asthma outcomes by enabling most appropriate treatment initiation and monitoring. There is currently no evidence in the literature of the clinical effects of diagnostic hubs being used in the management of paediatric asthma.

Conclusions

Paediatric asthma outcomes are currently poor and many deaths are preventable. The aim should be to avoid asthma attacks occurring with appropriate maintenance therapy, and they should be viewed as never events. In order to improve outcomes, accurate diagnosis and management are essential. Good asthma care extends beyond providing medication and should include education, as well as supported self-management advice. The use of PAAPs remains limited and a significant number of young people with asthma do not have one. Postattack asthma reviews are a key opportunity to review maintenance medication and current symptom control.

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Not applicable.

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JT and MB contributed equally.

Contributors All authors conceived the ideas for the article. JM wrote the first draft that was then commented on by JT and MB.

Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

Competing interests MB received investigator-led research grants from Pfizer and Roche Diagnostics; speaker fees paid to Newcastle University from Novartis, Roche Diagnostics and TEVA; and travel expenses to educational meetings Boehringer Ingelheim and Vertex Pharmaceuticals.

Provenance and peer review Commissioned; externally peer reviewed.

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Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Cathy Benninger, RN, MS, CNP

The Ohio State University

Columbus, OH

John Mastronarde, MD

Submit your comments to the author(s).

A 29-year-old man with mild persistent asthma presented to an outpatient office for a follow-up visit. He was originally referred 6 months ago by his primary care provider after having an asthma exacerbation which required treatment in an emergency room.

At his initial visit, he reported wheeze and cough 4 days a week and nocturnal symptoms three times a month. Spirometry revealed forced vital capacity (FVC) 85% predicted, forced expiratory volume in 1 second (FEV 1 ) 75% predicted, FEV 1 /FVC 65%, and an increase in FEV 1 of 220 ml or 14% following an inhaled short-acting bronchodilator. He was placed on a low-dose inhaled corticosteroid twice a day and a short-acting inhaled beta-agonist as needed. He returned 4 weeks later improved, but with continued daytime symptoms 2 days a week. He also had symptoms of rhinitis; therefore he was referred to an allergist for evaluation. Skin testing was positive for trees, ragweed, dust mites, and cats, and he was prescribed a nasal steroid spray and nonsedating oral antihistamine. He presents today and reports no asthma exacerbations since his last visit. Furthermore, during the past 4 weeks, he has not been awakened by his asthma, experienced morning breathing symptoms, missed work, had any limitations in activities due to asthma, or required the use of rescue albuterol. He currently denies shortness of breath or wheezing. He performs aerobic exercise 4 days a week for 45 minutes per session without symptoms, provided he premedicates with a short-acting inhaled beta-agonist. His review of symptoms is otherwise unremarkable. His current medications include low-dose inhaled corticosteroid, 1 puff twice a day ; steroid nasal spray, 2 puffs each nostril daily; a nonsedating antihistamine, 1 tablet daily; and inhaled beta-agonist, 2 puffs as needed. His past medical history is significant for intermittent asthma diagnosed at age 13 and frequent “colds.” He has never required hospitalization for an asthma exacerbation . He works as a hospital microbiologist and does not smoke, drink alcohol, or use illicit drugs. He recently moved to a pet-free apartment complex and instituted dust mite protective barriers for his bedding . His family history is noncontributory.

Physical Exam

The goal of asthma therapy is to minimize risk and maintain asthma control with the least amount of medication (1). In patients with mild persistent asthma, recent studies have demonstrated several options for "step-down therapy." The American Lung Association Asthma Clinical Research Centers network study found that patients who stepped down from twice daily low-dose fluticasone to once daily combination therapy with fluticasone/salmeterol had equivalent asthma control scores, FEV 1 , and frequency of exacerbations compared with continued therapy with twice daily fluticasone (2). Once-daily montelukast demonstrated a slightly higher treatment failure compared with either of the regimens containing inhaled steroids. Despite the slight increase in treatment failure with montelukast, each of the treatment groups had equivalent symptom-free days and rates of clinically significant asthma exacerbations. Thus, while either regimen would be appropriate, stepping down to once-daily combination therapy with fluticasone/salmeterol appears to be more beneficial.

Recent studies also suggest that those with mild persistent asthma taking inhaled corticosteroids in combination with either a long-acting beta-agonist or a short-acting beta-agonist when symptomatic, had no increase in adverse outcomes compared with those taking scheduled daily inhaled doses. Boushey et al. (3) compared patients with mild persistent asthma using twice-daily budesonide versus twice-daily zafirlukast verses placebo. All three groups used budesonide as-needed following a symptom-based action plan. The study found that in comparison with patients on a daily controller (budesonide or zafikulast), participants using only as-needed budesonide had no significant difference in morning peak expiratory flow, postbronchodilator FEV 1 , quality of life, or frequency of asthma exacerbations. Results of this study raise the possibility of treating mild persistent asthmatics with as-needed inhaled corticosteroids. More recently, Papi et al. (4) found as-needed use of an inhaler containing both beclomethasone and albuterol for symptom relief was associated with fewer exacerbations and higher morning peak flow readings than using an inhaler with albuterol alone. The morning peak flow readings in the as-needed combination beclomethasone/albuterol group was equivalent to those taking scheduled daily doses of beclomethasone alone, or scheduled daily doses of beclomethasone/albuterol combined. The combination of an inhaled steroid and a short-acting beta-agonist in a single inhaler is not currently available in the United States.

In the mild persistent asthmatic there is now strong evidence to support multiple treatment approaches which provide good asthma control. Matching the drug regimen with the patient’s preferences, lifestyle, comorbidities, and financial limitations will help ensure drug adherence and maintain asthma control.

When spirometry is used to diagnose or confirm asthma, testing must include pre- and post-bronchodilator readings (1). A change in FEV 1 of >200 ml and ≥ 12% from the baseline measure following the administration of a short-acting bronchodilator is indicative of significant airway reversibility which has been shown to correlate with airway inflammation (7).

The Expert Panel (1) classifies asthma severity by FEV 1 , FEV 1 /FVC, short-acting beta-agonist use, or frequency of asthma symptoms. Parameters are measured at baseline with asthma severity determined by the worse parameter, e.g., daily symptoms with normal FEV 1 is classified as moderate persistent asthma. Correct identification of asthma severity guides the provider in choosing the appropriate type and amount of therapy.

Asthma symptoms should be assessed at each office visit to determine asthma control. Validated self-assessment tools such as the Asthma Control Test (ACT), Asthma Therapy Assessment Questionnaire (ATAQ), or Asthma Control Questionnaire (ACQ) can facilitate consistent measurement and documentation of asthma symptoms during office visits (1, 8). All asthmatics are at risk for a severe asthma attack regardless of their asthma classification; therefore, providers are encouraged to teach patients to recognize symptoms of inadequate asthma control and provide them with specific instructions for adjusting their medications or seeking medical care (1).

When studied, only approximately 25% of patients are able to properly demonstrate use of a meter dose inhaler when asked. The remaining 75% improved with specific instruction and practice which reinforces the need to incorporate proper inhaler use during the office visit (9,10). The use of a spacer significantly improves accuracy and dose delivery, particularly in patients with poor coordination skills (9,10).

Assessing patient adherence is best approached with a nonjudgmental attitude. Adherence to inhaled corticosteroids is estimated at < 50% (11). Causes of nonadherence are multifactorial but may be improved by providing asthma education, encouraging self management through use of an asthma action plan, and facilitating open communication (11). Financial barriers often transcend all other efforts to improve adherence and must be taken into account when prescribing asthma therapy (11).

Methacholine challenge testing is useful to demonstrate airway hyperresponsiveness in those with normal spirometry and a suspicion of asthma, but is not recommended as a serial procedure. Biomarkers for inflammation such as eosinophils or nitric oxide are being investigated in clinical trials but currently have no indication in routine asthma care (1). Peak flow monitoring is useful for long-term home assessment of asthma control and medication response, but is not indicated for regular office assessment or diagnostic purposes (1).

Expert Panel Report 3 (EPR 3). Guidelines for the Diagnosis and Management of Asthma. Bethesda, Md: National Institutes of Health; 2007. NIH Publication No. 08-4051.
The American Lung Association Asthma Clinical Research Centers. Randomized comparison of strategies for reducing treatment in mild persistent asthma. N Engl J Med 2007;356:2027-2039.
Boushey HA, Sorkness CA, King TS, et al. Daily versus as-needed corticosteroids for mild persistent asthma. N Engl J Med 2005;352:1519-1528.
Papi A, Giorgio GW, Maestrelli P, et al. Rescue use of beclomethasone and albuterol in a single inhaler for mild asthma. N Engl J Med 2007;356:2040-2052.
Gibson PG, Powell H. Written action plans for asthma: an evidence-based review of the key components. Thorax 2007;59:94-99.
Miller MR, Hankinson J, Brusasco V, et al. Series ATS/ERS Task Force: Standardization of lung function testing. Eur Respir J 2005;26:319-338.
Pellegrino R, Viegi G, Brusasco V, et al. Interpretative strategies for lung function tests. N Engl J Med 2005;26:948-968.
Global Initiative for Asthma. Pocket guide for asthma management and prevention. Bethesda, Md: National Institutes of Health; 2006.
Giraud V, Roche N. Misuse of corticosteroid metered-dose inhaler is associated with decreased asthma stability. Eur Respir J 2002;19(2):246-251.
Johnson DH, Robart P. Inhaler technique of outpatients in the home. Respir Care 2000;45(10):1182-1187.
Elliott RA. Poor adherence to anti-inflammatory medication in asthma reasons, challenges, and strategies for improved disease management. Dis Manage Health Outcomes 2006;14(4):223-233.

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Patient Care & Health Information
Diseases & Conditions

Physical exam

Your doctor will perform a physical exam to rule out other possible conditions, such as a respiratory infection or chronic obstructive pulmonary disease (COPD). Your doctor will also ask you questions about your signs and symptoms and about any other health problems.

Tests to measure lung function

You may be given lung function tests to determine how much air moves in and out as you breathe. These tests may include:

Spirometry. This test estimates the narrowing of your bronchial tubes by checking how much air you can exhale after a deep breath and how fast you can breathe out.
Peak flow. A peak flow meter is a simple device that measures how hard you can breathe out. Lower than usual peak flow readings are a sign that your lungs may not be working as well and that your asthma may be getting worse. Your doctor will give you instructions on how to track and deal with low peak flow readings.

Lung function tests often are done before and after taking a medication to open your airways called a bronchodilator (brong-koh-DIE-lay-tur), such as albuterol. If your lung function improves with use of a bronchodilator, it's likely you have asthma.

Additional tests

Other tests to diagnose asthma include:

Methacholine challenge. Methacholine is a known asthma trigger. When inhaled, it will cause your airways to narrow slightly. If you react to the methacholine, you likely have asthma. This test may be used even if your initial lung function test is normal.
Imaging tests. A chest X-ray can help identify any structural abnormalities or diseases (such as infection) that can cause or aggravate breathing problems.
Allergy testing. Allergy tests can be performed by a skin test or blood test. They tell you if you're allergic to pets, dust, mold or pollen. If allergy triggers are identified, your doctor may recommend allergy shots.
Nitric oxide test. This test measures the amount of the gas nitric oxide in your breath. When your airways are inflamed — a sign of asthma — you may have higher than normal nitric oxide levels. This test isn't widely available.
Sputum eosinophils. This test looks for certain white blood cells (eosinophils) in the mixture of saliva and mucus (sputum) you discharge during coughing. Eosinophils are present when symptoms develop and become visible when stained with a rose-colored dye.
Provocative testing for exercise and cold-induced asthma. In these tests, your doctor measures your airway obstruction before and after you perform vigorous physical activity or take several breaths of cold air.

How asthma is classified

To classify your asthma severity, your doctor will consider how often you have signs and symptoms and how severe they are. Your doctor will also consider the results of your physical exam and diagnostic tests.

Determining your asthma severity helps your doctor choose the best treatment. Asthma severity often changes over time, requiring treatment adjustments.

Asthma is classified into four general categories:

Asthma classification	Signs and symptoms
Mild intermittent	Mild symptoms up to two days a week and up to two nights a month
Mild persistent	Symptoms more than twice a week, but no more than once in a single day
Moderate persistent	Symptoms once a day and more than one night a week
Severe persistent	Symptoms throughout the day on most days and frequently at night

Care at Mayo Clinic

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Asthma care at Mayo Clinic

Asthma: Testing and diagnosis

Prevention and long-term control are key to stopping asthma attacks before they start. Treatment usually involves learning to recognize your triggers, taking steps to avoid triggers and tracking your breathing to make sure your medications are keeping symptoms under control. In case of an asthma flare-up, you may need to use a quick-relief inhaler.

Medications

The right medications for you depend on a number of things — your age, symptoms, asthma triggers and what works best to keep your asthma under control.

Preventive, long-term control medications reduce the swelling (inflammation) in your airways that leads to symptoms. Quick-relief inhalers (bronchodilators) quickly open swollen airways that are limiting breathing. In some cases, allergy medications are necessary.

Long-term asthma control medications, generally taken daily, are the cornerstone of asthma treatment. These medications keep asthma under control on a day-to-day basis and make it less likely you'll have an asthma attack. Types of long-term control medications include:

Inhaled corticosteroids. These medications include fluticasone propionate (Flovent HFA, Flovent Diskus, Xhance), budesonide (Pulmicort Flexhaler, Pulmicort Respules, Rhinocort), ciclesonide (Alvesco), beclomethasone (Qvar Redihaler), mometasone (Asmanex HFA, Asmanex Twisthaler) and fluticasone furoate (Arnuity Ellipta).

You may need to use these medications for several days to weeks before they reach their maximum benefit. Unlike oral corticosteroids, inhaled corticosteroids have a relatively low risk of serious side effects.

Leukotriene modifiers. These oral medications — including montelukast (Singulair), zafirlukast (Accolate) and zileuton (Zyflo) — help relieve asthma symptoms.

Montelukast has been linked to psychological reactions, such as agitation, aggression, hallucinations, depression and suicidal thinking. Seek medical advice right away if you experience any of these reactions.

Combination inhalers. These medications — such as fluticasone-salmeterol (Advair HFA, Airduo Digihaler, others), budesonide-formoterol (Symbicort), formoterol-mometasone (Dulera) and fluticasone furoate-vilanterol (Breo Ellipta) — contain a long-acting beta agonist along with a corticosteroid.
Theophylline. Theophylline (Theo-24, Elixophyllin, Theochron) is a daily pill that helps keep the airways open by relaxing the muscles around the airways. It's not used as often as other asthma medications and requires regular blood tests.

Quick-relief (rescue) medications are used as needed for rapid, short-term symptom relief during an asthma attack. They may also be used before exercise if your doctor recommends it. Types of quick-relief medications include:

Short-acting beta agonists. These inhaled, quick-relief bronchodilators act within minutes to rapidly ease symptoms during an asthma attack. They include albuterol (ProAir HFA, Ventolin HFA, others) and levalbuterol (Xopenex, Xopenex HFA).

Short-acting beta agonists can be taken using a portable, hand-held inhaler or a nebulizer, a machine that converts asthma medications to a fine mist. They're inhaled through a face mask or mouthpiece.

Anticholinergic agents. Like other bronchodilators, ipratropium (Atrovent HFA) and tiotropium (Spiriva, Spiriva Respimat) act quickly to immediately relax your airways, making it easier to breathe. They're mostly used for emphysema and chronic bronchitis, but can be used to treat asthma.
Oral and intravenous corticosteroids. These medications — which include prednisone (Prednisone Intensol, Rayos) and methylprednisolone (Medrol, Depo-Medrol, Solu-Medrol) — relieve airway inflammation caused by severe asthma. They can cause serious side effects when used long term, so these drugs are used only on a short-term basis to treat severe asthma symptoms.

If you have an asthma flare-up, a quick-relief inhaler can ease your symptoms right away. But you shouldn't need to use your quick-relief inhaler very often if your long-term control medications are working properly.

Keep a record of how many puffs you use each week. If you need to use your quick-relief inhaler more often than your doctor recommends, see your doctor. You probably need to adjust your long-term control medication.

Allergy medications may help if your asthma is triggered or worsened by allergies. These include:

Allergy shots (immunotherapy). Over time, allergy shots gradually reduce your immune system reaction to specific allergens. You generally receive shots once a week for a few months, then once a month for a period of three to five years.
Biologics. These medications — which include omalizumab (Xolair), mepolizumab (Nucala), dupilumab (Dupixent), reslizumab (Cinqair) and benralizumab (Fasenra) — are specifically for people who have severe asthma.

Bronchial thermoplasty

This treatment is used for severe asthma that doesn't improve with inhaled corticosteroids or other long-term asthma medications. It isn't widely available nor right for everyone.

During bronchial thermoplasty, your doctor heats the insides of the airways in the lungs with an electrode. The heat reduces the smooth muscle inside the airways. This limits the ability of the airways to tighten, making breathing easier and possibly reducing asthma attacks. The therapy is generally done over three outpatient visits.

Treat by severity for better control: A stepwise approach

Your treatment should be flexible and based on changes in your symptoms. Your doctor should ask about your symptoms at each visit. Based on your signs and symptoms, your doctor can adjust your treatment accordingly.

For example, if your asthma is well controlled, your doctor may prescribe less medication. If your asthma isn't well controlled or is getting worse, your doctor may increase your medication and recommend more-frequent visits.

Asthma action plan

Work with your doctor to create an asthma action plan that outlines in writing when to take certain medications or when to increase or decrease the dose of your medications based on your symptoms. Also include a list of your triggers and the steps you need to take to avoid them.

Your doctor may also recommend tracking your asthma symptoms or using a peak flow meter on a regular basis to monitor how well your treatment is controlling your asthma.

Asthma inhalers: Which one's right for you?
Asthma medications
Asthma treatment: 3 steps
Allergy shots
Dry powder disk inhaler
Dry powder tube inhaler
Single-dose dry powder inhaler
Using a metered dose asthma inhaler and spacer

Clinical trials

Explore Mayo Clinic studies testing new treatments, interventions and tests as a means to prevent, detect, treat or manage this condition.

Lifestyle and home remedies

Although many people with asthma rely on medications to prevent and relieve symptoms, you can do several things on your own to maintain your health and lessen the possibility of asthma attacks.

Avoid your triggers

Taking steps to reduce your exposure to asthma triggers is a key part of asthma control. To reduce your exposure, you should:

Use your air conditioner. Air conditioning reduces the amount of airborne pollen from trees, grasses and weeds that finds its way indoors. Air conditioning also lowers indoor humidity and can reduce your exposure to dust mites. If you don't have air conditioning, try to keep your windows closed during pollen season.
Decontaminate your decor. Minimize dust that may worsen nighttime symptoms by replacing certain items in your bedroom. For example, encase pillows, mattresses and box springs in dustproof covers. Avoid using down-filled pillows and blankets. Throughout the house, remove carpeting and install hardwood or linoleum flooring. Use washable curtains and blinds.
Maintain optimal humidity. If you live in a damp climate, talk to your doctor about using a dehumidifier.
Prevent mold spores. Clean damp areas in the bathroom, kitchen and around the house to keep mold spores from developing. Get rid of moldy leaves or damp firewood in the yard.
Reduce pet dander. If you're allergic to dander, avoid pets with fur or feathers. Having pets regularly bathed or groomed may also reduce the amount of dander in your surroundings.
Clean regularly. Clean your home at least once a week. If you're likely to stir up dust, wear a mask or have someone else do the cleaning. Wash your bedding regularly.
Cover your nose and mouth if it's cold out. If your asthma is worsened by cold or dry air, wearing a face mask can help.

Stay healthy

Taking care of yourself can help keep your symptoms under control, including:

Get regular exercise. Having asthma doesn't mean you have to be less active. Treatment can prevent asthma attacks and control symptoms during activity.

Regular exercise can strengthen your heart and lungs, which helps relieve asthma symptoms. If you exercise in cold temperatures, wear a face mask to warm the air you breathe.

Maintain a healthy weight. Being overweight can worsen asthma symptoms, and it puts you at higher risk of other health problems.
Control heartburn and gastroesophageal reflux disease (GERD). It's possible that the acid reflux that causes heartburn may damage lung airways and worsen asthma symptoms. If you have frequent or constant heartburn, talk to your doctor about treatment options. You may need treatment for GERD before your asthma symptoms improve.
Asthma diet
Ozone air purifiers
Video: How to use a peak flow meter

Alternative medicine

Certain alternative treatments may help with asthma symptoms. However, keep in mind that these treatments are not a replacement for medical treatment, especially if you have severe asthma. Talk to your doctor before taking any herbs or supplements, as some may interact with the medications you take.

In most cases, more research is needed to see how well alternative remedies work and to measure the extent of possible side effects. Alternative asthma treatments include:

Breathing exercises. These exercises may reduce the amount of medication you need to keep your asthma symptoms under control.
Herbal and natural remedies. A few herbal and natural remedies that may help improve asthma symptoms include black seed, caffeine, choline and pycnogenol.

Coping and support

Asthma can be challenging and stressful. You may sometimes become frustrated, angry or depressed because you need to cut back on your usual activities to avoid environmental triggers. You may also feel limited or embarrassed by the symptoms of the disease and by complicated management routines.

But asthma doesn't have to be a limiting condition. The best way to overcome anxiety and a feeling of helplessness is to understand your condition and take control of your treatment. Here are some suggestions that may help:

Pace yourself. Take breaks between tasks and avoid activities that make your symptoms worse.
Make a daily to-do list. This may help you avoid feeling overwhelmed. Reward yourself for accomplishing simple goals.
Talk to others with your condition. Chat rooms and message boards on the internet or support groups in your area can connect you with people facing similar challenges and let you know that you're not alone.
If your child has asthma, be encouraging. Focus attention on the things your child can do, not on the things he or she can't. Involve teachers, school nurses, coaches, friends and relatives in helping your child manage asthma.

Preparing for your appointment

You're likely to start by seeing your family doctor or a general practitioner. However, when you call to set up an appointment, you may be referred to an allergist or a pulmonologist.

Because appointments can be brief, and because there's often a lot of ground to cover, it's a good idea to be well prepared. Here's some information to help you get ready for your appointment, as well as what to expect from your doctor.

What you can do

These steps can help you make the most of your appointment:

Write down any symptoms you're having, including any that may seem unrelated to the reason for which you scheduled the appointment.
Note when your symptoms bother you most. For example, write down if your symptoms tend to get worse at certain times of the day, during certain seasons, or when you're exposed to cold air, pollen or other triggers.
Write down key personal information, including any major stresses or recent life changes.
Make a list of all medications, vitamins and supplements that you're taking.
Take a family member or friend along, if possible. Sometimes it can be difficult to recall all the information provided to you during an appointment. Someone who accompanies you may remember something that you missed or forgot.
Write down questions to ask your doctor.

Your time with your doctor is limited, so preparing a list of questions will help you make the most of your time together. List your questions from most important to least important in case time runs out. For asthma, some basic questions to ask your doctor include:

Is asthma the most likely cause of my breathing problems?
Other than the most likely cause, what are other possible causes for my symptoms?
What kinds of tests do I need?
Is my condition likely temporary or chronic?
What's the best treatment?
What are the alternatives to the primary approach that you're suggesting?
I have these other health conditions. How can I best manage them together?
Are there any restrictions that I need to follow?
Should I see a specialist?
Is there a generic alternative to the medicine you're prescribing me?
Are there any brochures or other printed material that I can take home with me? What websites do you recommend visiting?

In addition to the questions that you've prepared to ask your doctor, don't hesitate to ask other questions during your appointment.

What to expect from your doctor

Your doctor is likely to ask you a number of questions. Being ready to answer them may reserve time to go over any points you want to spend more time on. Your doctor may ask:

What exactly are your symptoms?
When did you first notice your symptoms?
How severe are your symptoms?
Do you have breathing problems most of the time or only at certain times or in certain situations?
Do you have allergies, such as atopic dermatitis or hay fever?
What, if anything, appears to worsen your symptoms?
What, if anything, seems to improve your symptoms?
Do allergies or asthma run in your family?
Do you have any chronic health problems?
Weinberger SE, et al. Asthma. In: Principles of Pulmonary Medicine. 7th ed. Elsevier; 2019. https://www.clinicalkey.com. Accessed March 30, 2020.
Asthma. National Heart, Lung, and Blood Institute. https://www.nhlbi.nih.gov/health-topics/asthma. Accessed March 25, 2020.
AskMayoExpert. Asthma (adult). Mayo Clinic; 2020.
Global strategy for asthma management and prevention (2019 update). Global Initiative for Asthma. https://ginasthma.org/gina-reports/. Accessed March 27, 2020.
Khurana S, et al. Systematic approach to asthma of varying severity. Clinics in Chest Medicine. 2019; doi:10.1016/j.ccm.2018.10.004.
Ferri FF. Asthma. In: Ferri's Clinical Advisor 2020. Elsevier; 2020. https://www.clinicalkey.com. Accessed March 30, 2020.
Wu TD, et al. Asthma in the primary care setting. Medical Clinics of North America. 2019; doi:10.1016/j.mcna.2018.12.004.
Fanta CH. An overview of asthma management. https://www.uptodate.com/contents/search. Accessed March 30, 2020.
Santino TA, et al. Breathing exercises for adults with asthma. Cochrane Database of Systematic Reviews. 2020; doi:10.1002/14651858.CD001277.pub4.
Amaral-Machado L, et al. Use of natural products in asthma treatment. Evidence-based Complementary and Alternative Medicine. 2020; doi:10.1155/2020/1021258.
Montelukast. IBM Micromedex. https://www.micromedexsoluitions.com. Accessed April 6, 2020.
Whyand T, et al. Pollution and respiratory disease: Can diet or supplements help? A review. Respiratory Research. 2018; doi:10.1186/s12931-018-0785-0.
O'Keefe JH, et al. Coffee for cardioprotection and longevity. Progress in Cardiovascular Diseases. 2018; doi:10.1016/j.pcad.2018.02.002.
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Article Contents

Case 1 diagnosis: allergy bullying, clinical pearls.

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Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation

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Lopamudra Das, Michelle GK Ward, Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation, Paediatrics & Child Health , Volume 19, Issue 2, February 2014, Pages 69–70, https://doi.org/10.1093/pch/19.2.69

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A 12-year-old girl with a history of asthma presented to the emergency department with a three-day history of increased work of breathing, cough and wheezing. She reported no clear trigger for her respiratory symptoms, although she had noted some symptoms of a mild upper respiratory tract infection. With this episode, the patient had been using a short-acting bronchodilator more frequently than she had in the past, without the expected resolution of symptoms.

On the day of presentation, the patient awoke feeling ‘suffocated’ and her mother noted her lips to be blue. In the emergency department, her oxygen saturation was 85% and her respiratory rate was 40 breaths/min. She had significantly increased work of breathing and poor air entry bilaterally to both lung bases, with wheezing in the upper lung zones. She was treated with salbutamol/ipratropium and received intravenous steroids and magnesium sulfate. Her chest x-ray showed hyperinflation and no focal findings.

Her medical history revealed that she was followed by a respirologist for her asthma, had good medication adherence and had not experienced a significant exacerbation for six months. She also had a history of wheezing, dyspnea and pruritis with exposure to peanuts, chickpeas and lentils; she had been prescribed an injectible epinephrine device for this. However, her device had expired at the time of presentation. In the past, her wheezing episodes had been seasonal and related to exposure to grass and pollens; this presentation occurred during the winter. Further history revealed the probable cause of her presentation.

Although reluctant to disclose the information, our patient later revealed that she had been experiencing significant bullying at school, which was primarily related to her food allergies. Three days before her admission, classmates had smeared peanut butter on one of her schoolbooks. She developed pruritis immediately after opening the book and she started wheezing and coughing later that day. This event followed several months of being taunted with peanut products at school. The patient was experiencing low mood and reported new symptoms of anxiety related to school. The review of systems was otherwise negative, with no substance use.

The patient's asthma exacerbation resolved with conventional asthma treatment. Her pulmonary function tests were nonconcerning (forced expiratory volume in 1 s 94% and 99% of predicted) after her recovery. The trigger for her asthma exacerbation was likely multifactorial, related to exposure to the food allergen as well as the upper respiratory infection. A psychologist was consulted to assess the symptoms of anxiety and depression that had occurred as a result of the bullying. During the hospitalization, the medical team contacted the patient's school to provide education on allergy bullying, treatment of severe allergic reactions and its potential for life-threatening reactions with exposure to allergens. The medical team also recommended community resources for further education of students and staff about allergy bullying and its prevention.

Allergy bullying is a form of bullying with potentially severe medical outcomes. In recent years, it has gained increasing notoriety in schools and in the media. Population-based studies have shown that 20% to 35% of children with allergies experience bullying. In many cases (31% in one recent study [ 1 ]), this bullying is related directly to the food allergy. From a medical perspective, there are little published data regarding allergy bullying, and many health care providers may not be aware of the issue.

Allergy bullying can include teasing a child about their allergy, throwing food at a child, or even forcing them to touch or eat allergenic foods. Most episodes of allergy bullying occur at school, and can include episodes perpetrated by teachers and/or staff ( 2 ).

Allergy bullying can lead to allergic reactions, which may be mild or severe (eg, urticaria, wheezing, anaphylaxis), but may also lead to negative emotional consequences (sadness, depression) ( 2 ) and an overall decrease in quality of life measures ( 1 ). Adolescents commonly resist using medical devices, such as injectible epinephrine devices, and bullying may be a contributing factor for this ( 3 ). Attempting to conceal symptoms in a bullying situation may place children at risk for a worse outcome.

Physicians can play a key role in detecting allergy bullying and its health consequences. In many cases, children have not discussed this issue with their parents ( 1 ). Given the prevalence of bullying, its potential to lead to severe harm, including death, and the lack of awareness of this issue, clinicians should specifically ask about bullying in all children and teens with allergies. Physicians can also work with families and schools to support these children, educate their peers and school staff, and help prevent negative health outcomes from allergy bullying.

Online resources

www.anaphylaxis.ca − A national charity that aims to inform, support, educate and advocate for the needs of individuals and families living with anaphylaxis, and to support and participate in research. This website includes education modules for schools and links to local support groups throughout Canada.

www.whyriskit.ca/pages/en/live/bullying.php − A website for teenagers with food allergies; includes a segment that addresses food bullying.

www.foodallergy.org − Contains numerous resources for children and their families, including a significant discussion on bullying and ways to prevent it.

Allergy bullying is common but is often unrecognized as a factor in clinical presentations of allergic reactions.

Physicians should make a point of asking about bullying in patients with allergies and become familiar with resources for dealing with allergy bullying.

Physicians can play roles as advocates, educators and collaborators with the school system to help make the school environment safer for children with allergies who may be at risk for allergy bullying.

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Assessment and...

Assessment and management of adults with asthma during the covid-19 pandemic

Read our latest coverage of the coronavirus pandemic.

Related content
Peer review
Thomas Beaney , academic clinical fellow in primary care 1 ,
David Salman , academic clinical fellow in primary care 1 ,
Tahseen Samee , specialist registrar in emergency medicine 2 ,
Vincent Mak , consultant in respiratory community integrated care 3
1 Department of Primary Care and Public Health, Imperial College London, London, UK
2 Barts Health NHS Trust, London, UK
3 Imperial College Healthcare NHS Trust, London, UK
Correspondence to: T Beaney Thomas.beaney{at}imperial.ac.uk

What you need to know

In patients with pre-existing asthma, a thorough history and structured review can help distinguish an asthma exacerbation from covid-19 and guide management

In those with symptoms of acute asthma, corticosteroids can and should be used if indicated and not withheld on the basis of suspected covid-19 as a trigger

Assessment can be carried out remotely, ideally via video, but have a low threshold for face-to-face assessment, according to local arrangements

A 35 year old man contacts his general practice reporting a dry cough and increased shortness of breath for the past three days. He has a history of asthma, for which he uses an inhaled corticosteroid twice daily and is now using his salbutamol four times a day. Because of the covid-19 outbreak, he is booked in for a telephone consultation with a general practitioner that morning.

Asthma is a condition commonly encountered in primary care, with over five million people in the UK prescribed active treatment. 1 While seemingly a routine part of general practice, asthma assessment is a particular challenge in the context of the covid-19 pandemic, given the overlap in respiratory symptoms between the two conditions and the need to minimise face-to-face assessment. Over 1400 people died from asthma in 2018 in England and Wales, 2 while analyses of non-covid-19 deaths during the covid-19 outbreak have shown an increase in deaths due to asthma, 31 highlighting the need to distinguish the symptoms of acute asthma from those of covid-19 and manage them accordingly.

This article outlines how to assess and manage adults with exacerbations of asthma in the context of the covid-19 outbreak ( box 1 ). We focus on the features differentiating acute asthma from covid-19, the challenges of remote assessment, and the importance of corticosteroids in patients with an asthma exacerbation.

Asthma and covid-19: what does the evidence tell us?

Are patients with asthma at higher risk from covid-19.

Some studies, mostly from China, found lower than expected numbers of patients with asthma admitted to hospital, suggesting they are not at increased risk of developing severe covid-19. 3 4 5 However, these reports should be viewed cautiously, as confounding by demographic, behavioural, or lifestyle factors may explain the lower than expected numbers. Recent pre-print data from the UK suggest that patients with asthma, and particularly severe asthma, are at higher risk of in-hospital mortality from covid-19. 6 In the absence of more conclusive evidence to indicate otherwise, those with asthma, particularly severe asthma, should be regarded as at higher risk of developing complications from covid-19. 7

Can SARS-CoV-2 virus cause asthma exacerbations?

Some mild seasonal coronaviruses are associated with exacerbations of asthma, but the coronaviruses causing the SARS and MERS outbreaks were not found to be. 8 9 In the case of SARS-CoV-2 virus, causing covid-19, data from hospitalised patients in China did not report symptoms of bronchospasm such as wheeze, but the number of patients with pre-existing asthma was not reported. 10 More recent pre-print data from hospitalised patients in the UK identified wheeze in a minority of patients with Covid-19. 11 Given the overlap of symptoms, such as cough and shortness of breath, until further published data emerges, SARS-CoV-2 may be considered as a possible viral trigger in patients with an asthma attack.

What you should cover

Challenges of remote consultations.

Primary care services have moved towards telephone triage and remote care wherever possible to minimise the risk of covid-19 transmission. This brings challenges to assessment as visual cues are missing, and, unless the patient has their own equipment, tests involving objective measurement, such as oxygen saturation and peak expiratory flow, are not possible. In mild cases, assessment via telephone may be adequate, but, whenever possible, we recommend augmenting the consultation with video for additional visual cues and examination. 12 However, many patients, particularly the elderly, may not have a phone with video capability. If you are relying on telephone consultation alone, a lower threshold may be needed for face-to-face assessment.

Presenting symptoms

Start by asking the patient to describe their symptoms in their own words. Note whether they sound breathless or struggle to complete sentences and, if so, determine whether immediate action is required. If not, explore what has changed, and why the patient has called now. The three questions recommended by the Royal College of Physicians—asking about impact on sleep, daytime symptoms, and impact on activity—are a useful screening tool for uncontrolled asthma. 13 Alternative validated scores, such as the Asthma Control Questionnaire and Asthma Control Test, which include reliever use, are also recommended. 14 In assessing breathlessness, the NHS 111 symptom checker contains three questions—the answers may arise organically from the consultation, but are a useful aide memoire:

Are you so breathless that you are unable to speak more than a few words?

Are you breathing harder or faster than usual when doing nothing at all?

Are you so ill that you’ve stopped doing all of your usual daily activities?

Consider whether an exacerbation of asthma or covid-19 is more likely. Both can present with cough and breathlessness, but specific features may indicate one over the other (see box 2 ). Do the patient’s current symptoms feel like an asthma attack they have had before? Do symptoms improve with their reliever inhaler? Do they also have symptoms of allergic rhinitis? Pollen may be a trigger for some people with asthma during hay fever season.

History and examination features helping distinguish asthma exacerbation from covid-19 10 11 14 15 16

Exacerbation of asthma*.

Improvement in symptoms with reliever inhaler

Diurnal variation

Absence of fever

Coexisting hay fever symptoms

Examination:

Reduced peak expiratory flow

Close contact of known or suspected case

Dry continuous cough

Onset of dyspnoea 4-8 days into illness

Flu-like symptoms including fatigue, myalgia, headache

Symptoms not relieved by inhaler

Absence of wheeze

Peak expiratory flow may be normal

*Note SARS-CoV-2 infection may be a trigger for an asthma exacerbation

Risk factors and medications

To assess the risk of deterioration, ask specifically about any previous hospital admissions for asthma and about oral corticosteroid use over the past 12 months. Does the patient have any other high risk conditions or are they taking immunosuppressive drugs? Ask the patient if they smoke and take the opportunity to offer support to quit.

Are they prescribed an inhaled corticosteroid (ICS) or a long acting β agonist (LABA) and ICS combination inhaler? Are they using this regularly? Are they using a spacer device, and do they have a personal asthma action plan to guide management?

Psychosocial factors

Taking a psychosocial history can be more challenging over the telephone, where cues are harder to spot. Lessons from asthma deaths have shown that adverse psychosocial factors are strongly associated with mortality. 14 17 These include a history of mental health problems, lack of engagement with healthcare services, and alcohol or drug misuse, along with employment and income problems. Social isolation is also a risk factor, which may be exacerbated during social distancing measures. 17 The covid-19 outbreak is an anxious time for many patients, and symptoms of anxiety can contribute to the overall presentation.

Examination

In remote assessment, video can help guide decision making, and we recommend its use in asthmatic patients presenting with acute symptoms. First, assess the general appearance of the patient. A fatigued patient sitting up in bed, visibly breathless, and anchoring their chest will raise immediate concerns, as opposed to someone who is walking around while talking. Vocal tone and behaviour may indicate any contributing anxiety. Observe if the patient can speak in complete sentences, listen for audible wheeze, and count the respiratory rate. Assess the work of breathing, including the use of accessory muscles, and consider the use of a chaperone where appropriate. The Roth score is not advocated for assessment of covid-19 or asthma. 18

Further objective assessment can be made, such as measuring peak expiratory flow (PEF). If the patient does not have a PEF device at home, one can be prescribed, though this may not be feasible in an acute scenario. We recommend that PEF technique be witnessed via video to assess reliability. Silent hypoxia may be a feature of covid-19, and oxygen saturations should be measured if this is a concern. 19 In some regions, oxygen saturation probe delivery services are being implemented, which may facilitate this. Heart rate can also be provided by the patient if they use conventional “wearable” technology, although, given the potential inaccuracies with different devices, the results should not be relied on. 20 If time allows, inhaler technique can also be checked.

What you should do

Determine the most likely diagnosis.

Decide on the most likely diagnosis on the basis of the history and clinical features (see box 2 and fig 1 ) or consider whether an alternative or coexisting diagnosis is likely, such as a bacterial pneumonia or pulmonary embolus. If you suspect covid-19 without asthmatic features, manage the patient as per local covid-19 guidance.

Assessment and management of patients with known asthma during the covid-19 outbreak 14

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Determine severity and decide if face-to-face assessment is necessary

If asthmatic features are predominant, determine severity and treat according to Scottish Intercollegiate Guidelines Network (SIGN) and British Thoracic Society (BTS) guidance ( fig 1 ). 14 If the patient cannot complete sentences or has a respiratory rate ≥25 breaths/min, treat the case as severe or life threatening asthma and organise emergency admission. A peak expiratory flow (PEF) <50% of best or predicted or a heart rate ≥110 beats/min also indicate severe or life threatening asthma. If the patient does not meet these criteria, treat as a moderate asthma attack—a PEF of 50-75% of best or predicted helps confirm this. If they do not have a PEF meter, or if you are unsure as to severity, brief face-to-face assessment to auscultate for wheeze and assess oxygen saturations can help confirm the degree of severity and determine if the patient may be suitable for treatment at home with follow-up. Do not rely solely on objective tests and use clinical judgment to decide on the need for face-to-face assessment, based on knowledge of the patient, risk factors, and any adverse psychosocial circumstances.

Wheeze has been reported as a presenting symptom in a minority of patients with confirmed covid-19, and it may be difficult to rule out the presence of SARS-CoV-2 via remote assessment. 11 We recommend that, when a face-to-face assessment is needed, it should take place via local pathways in place to safely assess patients with suspected or possible covid-19—for example, at a local “hot” clinic. At present, performing a peak flow test is not considered to be an aerosol generating procedure, but the cough it may produce could be, so individual risk assessment is advised. 21 Consider performing PEF in an open space or remotely in another room via video link. Any PEF meter should be single-patient use only and can be given to the patient for future use.

Initial management when face-to-face assessment is not required

For moderate asthma exacerbations, advise up to 10 puffs of a short acting β agonist (SABA) inhaler via a spacer, administered one puff at a time. There is no evidence that nebulisers are more effective: 4-6 puffs of salbutamol via a spacer is as effective as 2.5 mg via a nebuliser. 22 Alternatively, if the patient takes a combined inhaled corticosteroid and long acting β agonist (LABA) preparation, then maintenance and reliever therapy (MART) can be used according to their action plan. 14 Management of an acute exacerbation should not rely solely on SABA monotherapy, so advise patients to follow their personal asthma action plan and continue corticosteroid treatment (or start it if they were not taking it previously) unless advised otherwise ( box 3 ). Antibiotics are not routinely recommended in asthma exacerbations.

Risks and benefits of inhaled and oral corticosteroids in asthma and covid-19

There is substantial evidence for the benefits of steroids in asthma. Regular use of inhaled steroids reduces severe exacerbations of asthma 23 and the need for bronchodilators, 24 while the prompt use of systemic corticosteroids during an exacerbation reduces the need for hospital admissions, use of β agonists, 25 and relapses. 26

The evidence for corticosteroid use in early covid-19 is still emerging. A systematic review of steroid use in SARS reported on 29 studies, 25 of which were inconclusive and four of which suggested possible harm (diabetes, osteoporosis, and avascular necrosis) but no reported effects on mortality. 27 WHO have cautioned against the use of systemic corticosteroids for the treatment of covid-19 unless indicated for other diseases. 28

In light of the strong evidence of benefits in patients with asthma, inhaled and oral corticosteroids should be prescribed if indicated in patients with symptoms of bronchoconstriction. Steroids should not be withheld on the theoretical risk of covid-19 infection, in line with guidance from the Primary Care Respiratory Society (PCRS), British Thoracic Society (BTS), and Global Initiative for Asthma (GINA). 15 22 29

Response to initial SABA or MART treatment can be assessed with a follow-up call at 20 minutes. If there is no improvement, further treatment may be necessary at a local hot clinic for reviewing possible covid-19, emergency department, or direct admission to an acute medical or respiratory unit depending on local pathways. For those who do respond, BTS-SIGN and GINA advise starting oral corticosteroids in patients presenting with an acute asthma exacerbation (such as prednisolone 40-50 mg for 5-7 days). 14 15 There is an increasing move in personalised asthma action plans to early quadrupling of the inhaled corticosteroid dose in patients with deteriorating control for up to 14 days to reduce the risk of severe exacerbations and the need for oral steroids. 15 30 However, there may be a ceiling effect on those who are already on a high dose of inhaled corticosteroid (see BTS table 14 ), so quadrupling the dose may not be effective in this group of patients. A personalised asthma action plan is an extremely helpful guide to treatment and should be completed or updated for all patients.

Follow-up and safety-netting

We recommend that all patients with moderate symptoms are followed up via remote assessment within 24 hours. Asthma attacks requiring hospital admission tend to develop relatively slowly over 6-48 hours. 14 However, deterioration can be more rapid, and symptoms can worsen overnight. Patients should be advised to look out for any worsening breathing or wheeze, lack of response to their inhalers, or worsening PEF. They should receive clear advice on what to do, including use of their reliever, and who to contact (such as the local out-of-hours GP provider, 111, or 999). With potential long waits for remote assessment, particularly out of hours, they should be advised to have a low threshold to call 999 if their symptoms deteriorate. If covid-19 infection is also suspected, advise them to isolate for seven days from onset of symptoms and arrange testing, according to the latest guidance. 7

How this article was created

We performed a literature search using Ovid, Medline, and Global Health databases using the search terms (asthma OR lung disease OR respiratory disease) AND (coronavirus OR covid-19)). Articles from 2019-20 were screened. We also searched for specific guidelines, including NICE, British Thoracic Society, Scottish Intercollegiate Guidelines Network, Primary Care Respiratory Society, European Respiratory Society, International Primary Care Respiratory Group, Global Initiative for Asthma, and the American Academy of Allergy, Asthma and Immunology.

Education into practice

Do you feel confident in completing personalised asthma plans in collaboration with patients?

How often do you start or increase inhaled corticosteroids in patients at initial presentation with an exacerbation of asthma?

If you manage a patient with acute asthma remotely, what safety netting advice would you give and how could you check understanding?

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

This is part of a series of occasional articles on common problems in primary care. The BMJ welcomes contributions from GPs.

Contributors: TB and TS conceived the article. TB, DS, and TS carried out the literature review and wrote the initial drafts. All four authors contributed to editing and revision, and VM provided expert advice as a respiratory specialist. All authors are guarantors of the work.

Competing interests: We have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.

Provenance and peer review: Commissioned, based on an idea from the author; externally peer reviewed.

Mukherjee M ,
Stoddart A ,
↵ Asthma UK. Asthma facts and statistics. https://www.asthma.org.uk/about/media/facts-and-statistics/ .
Scabini S ,
Mornese Pinna S ,
Di Perri G ,
De Rosa FG ,
Williamson E. ,
Walker AJ ,
Bhaskaran KJ ,
↵ Public Health England. Guidance on social distancing for everyone in the UK [Withdrawn]. 2020. https://www.gov.uk/government/publications/covid-19-guidance-on-social-distancing-and-for-vulnerable-people/guidance-on-social-distancing-for-everyone-in-the-uk-and-protecting-older-people-and-vulnerable-adults .
Shaker MS ,
Oppenheimer J ,
Grayson M ,
China Medical Treatment Expert Group for Covid-19
Docherty AB ,
Harrison EM ,
Greenhalgh T ,
Pinnock H ,
Campbell S ,
↵ Scottish Intercollegiate Guidelines Network & British Thoracic Society. Sign 158 British guideline on the management of asthma. 2019. https://www.sign.ac.uk/sign-158-british-guideline-on-the-management-of-asthma .
↵ Primary Care Respiratory Society. PCRS Pragmatic Guidance: Diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020. https://www.pcrs-uk.org/sites/pcrs-uk.org/files/resources/COVID19/PCRS-Covid-19-Pragmatic-Guidance-v2-02-April-2020.pdf .
Rapoport AB
Royal College of Physicians
↵ Centre for Evidence-Based Medicine. Question: Should the Roth score be used in the remote assessment of patients with possible COVID-19? Answer: No. 2020. https://www.cebm.net/covid-19/roth-score-not-recommended-to-assess-breathlessness-over-the-phone/ .
Goldstein BA ,
↵ Public Health England. Guidance: COVID-19 personal protective equipment (PPE). 2020. https://www.gov.uk/government/publications/wuhan-novel-coronavirus-infection-prevention-and-control/covid-19-personal-protective-equipment-ppe .
↵ British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ .
Pauwels RA ,
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Bestall JB ,
Lasserson TJ ,
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Spooner CH ,
Stockman LJ ,
Bellamy R ,
↵ World Health Organization. Clinical management of severe acute respiratory infection (SARI) when COVID-19 disease is suspected: Interim guidance 13th March 2020. 2020. https://www.who.int/docs/default-source/coronaviruse/clinical-management-of-novel-cov.pdf .
↵ Global Initiative for Asthma (GINA). 2020 GINA report, global strategy for asthma management and prevention. 2020. https://ginasthma.org/gina-reports/ .
McKeever T ,
Mortimer K ,
↵ Office for National Statistics. Analysis of death registrations not involving coronavirus (COVID-19), England and Wales: 28 December 2019 to 1 May 2020. Release date: 5 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/analysisofdeathregistrationsnotinvolvingcoronaviruscovid19englandandwales28december2019to1may2020/technicalannex .

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Health Expect
v.26(1); 2023 Feb

Patient views on asthma diagnosis and how a clinical decision support system could help: A qualitative study

1 Asthma UK Centre for Applied Research, Usher Institute, University of Edinburgh, Edinburgh UK

Eddie Donaghy

Victoria murray, leo campbell, carol stonham.

2 NHS Gloucestershire Clinical Commissioning Group, Gloucester UK

3 Primary Care Respiratory Society (PCRS), Knowle UK

Andrew Bush

4 Imperial Centre for Paediatrics and Child Health and National Heart and Lung Institute, Imperial College, London UK

5 Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London UK

Brian McKinstry

6 Centre for Population and Health Sciences, Usher Institute, University of Edinburgh, Edinburgh UK

Heather Milne

7 South East GP Unit, NHS Education for Scotland, Edinburgh UK

Hilary Pinnock

Luke daines, associated data.

The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.

Introduction

Making a diagnosis of asthma can be challenging for clinicians and patients. A clinical decision support system (CDSS) for use in primary care including a patient‐facing mode, could change how information is shared between patients and healthcare professionals and improve the diagnostic process.

Participants diagnosed with asthma within the last 5 years were recruited from general practices across four UK regions. In‐depth interviews were used to explore patient experiences relating to their asthma diagnosis and to understand how a CDSS could be used to improve the diagnostic process for patients. Interviews were audio recorded, transcribed verbatim and analysed using a thematic approach.

Seventeen participants (12 female) undertook interviews, including 14 individuals and 3 parents of children with asthma. Being diagnosed with asthma was generally considered an uncertain process. Participants felt a lack of consultation time and poor communication affected their understanding of asthma and what to expect. Had the nature of asthma and the steps required to make a diagnosis been explained more clearly, patients felt their understanding and engagement in asthma self‐management could have been improved. Participants considered that a CDSS could provide resources to support the diagnostic process, prompt dialogue, aid understanding and support shared decision‐making.

Undergoing an asthma diagnosis was uncertain for patients if their ideas and concerns were not addressed by clinicians and were influenced by a lack of consultation time and limitations in communication. An asthma diagnosis CDSS could provide structure and an interface to prompt dialogue, provide visuals about asthma to aid understanding and encourage patient involvement.

Patient and Public Contribution

Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team and piloted with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Findings were regularly discussed within the research group and with PPI colleagues to aid the interpretation of data.

1. INTRODUCTION

Asthma is a chronic respiratory disease accounting for at least 6.4 million primary care consultations each year in the United Kingdom. 1 Although a common condition, making a diagnosis of asthma is not always straightforward for clinicians and estimates from primary care suggest that asthma is often misdiagnosed. 2 , 3 , 4 Overdiagnosis can lead to costly, potentially harmful treatment and may affect job and lifestyle decisions; whilst underdiagnosis risks inadequate treatment and avoidable morbidity and mortality. 5 , 6

Asthma is a variable condition with different phenotypes meaning that individuals with asthma can experience and present with a range of symptoms of varying severity. 7 The aim is to demonstrate objective evidence of variability over time, and investigations such as spirometry and fractional exhaled nitric oxide (FeNO) can increase or decrease the likelihood of a diagnosis of asthma. However, in primary care, timely access to tests is not guaranteed and false positive and false negative results are common. 5 Consequently, it may take months before a clinician feels able to confirm (or refute) a diagnosis of asthma. 8 The potentially long timescale can lead to frustration and uncertainty amongst patients 9 and needs to be handled confidently and accurately by clinicians. 10

In addition to increasing the availability and use of objective tests, 11 clinical decision support systems (CDSS) could provide a solution for improving the accuracy of an asthma diagnosis and may help improve the patient experience. CDSS are usually designed to aid the decision‐making of clinicians 12 but may be utilized to facilitate shared decision‐making with patients. For instance, CDSS can be used to collect, calculate and present information about the likelihood of a diagnosis or treatment benefit. For example, AsthmaTuner, a self‐management system which collects lung function and symptom data via Bluetooth spirometer and patient app, respectively, provides automated treatment recommendations for patients and an interface for health professionals. 13 For diagnosis, a CDSS could be used to calculate the likelihood of a particular condition, and present the probability and options for confirming a diagnosis. In a Norwegian study, a web‐based CDSS designed to aid the diagnosis and classification of chronic obstructive pulmonary disease (COPD) in primary care was found to reduce misdiagnosis and increase the number of patients receiving smoking cessation advice but did not improve the prescription of pharmacological treatment. 14

Having derived and validated a clinical prediction model for asthma diagnosis, 15 , 16 we plan to implement the model in primary care as a CDSS. Being aware that a previous systematic review found that CDSS for asthma were infrequently utilized, 17 we wanted to understand patient views on asthma diagnosis and how a CDSS could help to maximize the potential value of a future CDSS for patients. Therefore, to inform the development of the CDSS, this study aimed to explore patient experiences regarding asthma diagnosis and to understand how a CDSS could also be used to improve the diagnostic process for patients.

To inform the development of an intervention (the CDSS), the study design was guided by the Medical Research Council (MRC) framework for developing and evaluating complex interventions. 18 To understand which design features would be most important for an asthma diagnosis CDSS, the experiences and views of patients (and parents of children) who had undergone an asthma diagnosis were sought using qualitative methods. We undertook interviews with young people, adults and the parents of children, who had a recent diagnosis of asthma (ideally within the past 5 years). Interviews took place between 1 October 2020 and 31 January 2021. All participants provided informed consent before interviews were conducted.

2.1. Recruitment and sampling

Participants were recruited from general practices across four regions within the United Kingdom (Greater Glasgow and Clyde, Lothian, West Midlands, Yorkshire and Humber). Participating practices identified adults and young people (≥12 years) and parents of children (≥5 years) who had ‘active asthma’ and a diagnosis of asthma coded in the electronic health records within the last 5 years. ‘Active asthma’ was defined as a coded diagnosis of asthma and having had a prescription for any asthma treatment within the previous year. 19 Children below 5 years of age were excluded as viral‐associated wheeze is common in this age group and can complicate asthma diagnosis. Based on the age of legal consent, we offered young people aged ≥12 years the chance to take part in an interview themselves. A clinician from each practice screened the list of selected patients for eligibility and excluded individuals who had COPD, were unable to give informed consent (e.g., due to cognitive impairment) or for social/clinical reasons (e.g., significant co‐morbidity, recently bereaved or on a palliative care register).

Potential participants were mailed an information sheet and an expression of interest form which included questions about age, gender, age at diagnosis, how asthma was confirmed (i.e., symptoms, examination, tests) and the confidence they had in their asthma diagnosis (agree, not sure, do not agree with diagnosis). Responses to these questions were used to purposively sample individuals to represent a range of participants in terms of age, gender, length of time since asthma diagnosis, confidence in the diagnosis and who made the diagnosis.

2.2. Data collection

Semistructured in‐depth interviews were conducted by telephone (to comply with social distancing during the COVID‐19 pandemic). Interviews were conducted by a male (E. D.) or female (V. M.) postdoctoral researchers, both of whom have experience in health services research. Interviews lasted between 30 and 45 min and were audio recorded, transcribed verbatim and redacted of identifiable information. No repeat interviews were necessary. Transcripts were not returned to participants for comment.

2.3. Topic guides

Prespecified semistructured interview topic guides (young person and adult versions) were developed by the research team (see Supporting Information). To consider the validity and reliability of the topic guides, we conducted pilot interviews with members of the Asthma UK Centre for Applied Research Patient and Public Involvement (PPI) group. Topic guides mapped to the study objectives and were designed to allow a focused yet flexible approach 20 that facilitated exploration of experiences of asthma diagnosis; perceptions and expectations of patient involvement in the diagnostic process and how a computer system/CDSS could have helped or hindered their experiences.

2.4. Data analysis

We used a thematic approach to data analysis. 21 Using Nvivo 10 (QSR International), transcripts were read and manually coded using overarching themes. In an attempt to maximize reliability, after the initial transcripts had been coded, three researchers (V. M., L. D., H. P.) conducted a thematic analysis with selected transcripts during this iterative process. Emerging themes were discussed before deciding on an initial coding framework. Transcripts were coded on an ongoing basis concurrently with interviews and revisited as the study progressed so that new themes could be included, and the coding framework refined. The final coding framework was thus a combination of themes proposed in advance together with other themes generated during the analysis, 21 which represents both a deductive and inductive approach to qualitative analysis. 22 The consolidated criteria for reporting qualitative research was used to guide reporting (see Supporting Information). 23

2.5. Interpretation

We took a critical‐realist perspective when interpreting the data, 24 which helped when considering the experiences, motivations and meanings of participants' lived realities. 21 To aid interpretation, findings were regularly discussed within the research group and with PPI colleagues. The concept of medical dominance emerged as relevant, and we used this to guide interpretation. 25 , 26 Medical dominance is based on the view that in relation to health and illness, medical professionals hold power and control which shape and influence health professional/patient interactions and experiences. 27 , 28 , 29

We received 53 expressions of interest within the study period and using purposive sampling, 27 individuals were invited to take part. 17 participants contributed to interviews, including 14 individuals with asthma and 3 parents of children with asthma (Table 1 ). All participants had been diagnosed with asthma before the COVID‐19 pandemic. Of the 26 individuals not invited, 23 had been diagnosed several years before and 3 children had been diagnosed before 5 years of age.

Patient demographics

Characteristics	Participant ( )
Sex
Female	12
Male	5
Age (years)
<16	3
16–30	2
31–40	3
41–50	5
51–60	2
61–70	2
Years since diagnosis (years)
<2	3
2–4	7
4–6	1
6–8	1
8–10	3
>10	2
Diagnosis made by
Asthma nurse	3
General practitioner	10
Hospital staff	4
Confidence about their asthma diagnosis?
Yes	12
Not sure	5
Parents of children interviewed	3
Location (type, practice size)
Site 1 (urban, 10,361)	5
Site 2 (urban, 6576)	4
Site 3 (urban, 5465)	1
Site 4 (urban, 10,123)	4
Site 5 (semiurban, 12,578)	2
Site 6 (urban, 3851)	1

3.1. Overview of themes

Analysis of data sought to answer two key research questions: patient experiences during an asthma diagnosis and patient views and experiences of a CDSS. Four subthemes were identified regarding patient experiences during the diagnostic process; knowledge and understanding of asthma, communication, receiving and retaining information and self‐management. An additional four themes emerged in relation to patient experiences and views of a CDSS; patient experiences of screen sharing, online health information use, patient views on an asthma CDSS and barriers and facilitators to a CDSS being used. Topics are reported in this order.

3.2. Key theme 1: Diagnosis: The patient experience

3.2.1. knowledge and understanding of asthma.

Several participants recalled being uncertain about what asthma was or how it might present. For instance, participant adult/1 (female, age 41–50, site 1), recalled that she ‘didn't know that coughing was a sign of asthma’, despite having a sister and a best friend who had been diagnosed with the condition as teenagers. Other participants believed asthma always started in childhood:

It was a bit weird 'cause I'd never had it before and [obviously it] was … like, I thought it was quite late. I thought it was one of those things you just had as a kid and then, like, you had it from the beginning and that was that. (P/young person/1, female, 16–30, site 5)

Participants often had their own ideas about the cause of symptoms, and without prior knowledge or experience of asthma, some individuals worried about what they viewed as the worst‐case scenario such as cancer:

Somehow you associate it (asthma) with really sick people. I don't know. I didn't sort of think of it as a kind of a manageable issue. Sort of, these people who had maybe asbestos poisoning to their lungs or something like that. A very dramatic thing. (P/adult/6, male, 41–50, site 1)

In a similar vein, some participants, held a lack of familiarity with asthma symptoms leading them to assume their symptoms were a consequence of lifestyle choices or personal stresses so achieving a diagnosis was a relief:

We bought a house which we then discovered had a lot of hidden mould issues and I think that's been a contributor to all of this [….] The asthma diagnosis really helped. (P/adult/6, male, 41–50, site 1)

For some participants, an asthma diagnosis came as a surprise and was made co‐incidentally during an appointment for another problem:

I was actually diagnosed accidentally, but I was glad I was diagnosed at the time. I was actually meant to go about my toe because I was arguing with my son when he was about five years old and I got my toe jammed under the door and it was bruised. So anyway, I went to the doctor about it and he noticed that I was a bit wheezy so he decided that he would do a test. And he turned round and said, yeah, you're asthmatic. (P/adult/4, female, 41–50, site 2)

3.2.2. Communication

The importance of communication during the assessment for an asthma diagnosis was a common theme arising from interviews. Some participants were surprised that being diagnosed with asthma had taken a long time, and another participant remained unsure if they had asthma:

Cause all along they're like, oh there's no official test so this might not be, so you'll just need to try this and try that and see if it works or not. So, it's quite a … like, unsure and quite a long process sometimes. (P/young person/1, female, 16–30, site 5)

There was never any concrete diagnosis, so I don't know whether I have a pre‐existing condition now or not. (P/adult/9, male, 41–50, site 4)

However, many patients were satisfied with the step‐by‐step processes they experienced and the principles of parsimony by problem‐solving through the simplest means available to enable an accurate diagnosis:

‘It took a while. It was sort of an ongoing thing over … well, I'd had sort of recurring colds and kind of persistent things like that, with kind of wheezing and coughing and so on. And […] my GP, I think was quite methodical about this so there were various tests and eliminations and so on. So, it had come over a couple of years’. Yeah, but I think it's the right way to do it. I was very happy with it. (P/adult/6, male, 41–50, site 1)

A lack of communication about the variable nature of asthma during the early stages of the diagnostic process left some respondents unsure if they had asthma or not. P/young person/2, reported feeling ‘a wee bit shocked’ when diagnosed with asthma because she considered herself to be ‘the fittest I'd ever been’. Participant adult/8 (male, 61–70, site 3) was told he had asthma but said ‘it wasn't explained how my lungs work or anything’. Participant young person/2, felt disappointed with the support she had received, explaining she had been ‘just told and then left with that information’:

You sometimes feel that people are just giving you a decision but not explaining it in enough detail. [….] Even like when my mum's been there with me, it's just been, kind of […] like none of us have fully understood how I have asthma. (P/young person/2, female, 16–30, site 2)

A perceived lack of time and the use of complex language were reasons participants gave for communication being poor. Participants generally understood why time may be an issue. For instance, P/adult/6 (male, 41–50, site 1), who had been diagnosed for 1 year, felt that ‘the system is congested’. Similarly, P/adult/2 (adult, female, 21–30, site 1), talked about General Practitioners (GP) as being ‘obviously very busy’ and her GP did not have time to explain the diagnostic process or use language that the patient understood. Consequently, she preferred to see the asthma nurse who provided ‘more of an understanding about what's going to happen’:

I think the thing about the nurses are … especially the asthma nurses, they, kind of, already […] I mean, they only see you once a year but they know you a bit better so they can, kind of, explain things in a bit more user‐friendly way, I guess. (P/adult/2, female, 21–30, site 1)

Parents of children undergoing the diagnostic process felt communication was particularly problematic, and reported feeling frustrated and helpless during a lengthy and often inconclusive testing process:

You know, I was really annoyed because, you know, like every second week she was ill and [had a] high temperature. And like even, you know, we went to emergency hospital appointment, and nobody could say nothing. And I thought because she was … she has a twin sister, and they were born two weeks before due. Yeah, and […], another problem, like, because she is the second twin, she's the youngest one. And when she had cough and the doctor said, because (twin 1) has asthma, (twin 2) probably has asthma as well. And for me it's like, she never had a test. (P/parent of child/2, female, age 9, site 2)

3.2.3. Receiving and retaining information

Whilst one participant (P/adult/4, female, 41–50, site 2) reported her diagnosis was explained to her satisfaction and she remembered everything she was told, most respondents reported leaving their appointment(s) with little information or not being able to recall the information later. For some respondents, much of the asthma information received was new to them and felt overwhelming. One individual felt relief at finally having a label for their condition. Others suggested they had appeased their GP by pretending to follow the conversation:

It takes me sometimes a while to cotton on to things. And I may say, ‘yes, I understand’ at first. I suppose I'm fairly typical of most people in that way. I say ‘yes, I understand’ but I don't think I've got a full grasp of it, you know? (P/adult/3, male, 61–70, site 1)

The provision of paper handouts to support asthma information during consultations was useful for some, met with indifference by others, and received poorly by one or two participants. Handouts were unlikely to be kept and the information on them was not well retained:

I probably got a leaflet or something like that, that had two or three pages in it, then, and then, well, a leaflet, you put it down and then it disappears. (P/adult/7, female, 51–60, site 1)

I'm a digital person. I hate bits of paper, 'cause I lose bits of paper. (P/adult/10, male, 61–70, site 4)

3.2.4. Self‐management

In keeping with the perceived lack of information provided at the time of diagnosis, some individuals felt underconfident in managing their asthma after they had been diagnosed, for example, taking their inhaler correctly:

The only problem, if it could be said to be a problem, was I didn't know how to use the inhalers correctly. I don't believe, I don't remember being told how to use an inhaler. (P/adult/3, male, 61–70, site 1)

Although some participants talked about their personal asthma action plan (a key component of asthma self‐management), 5 several respondents said they had not been provided with one, and others did not know what they were:

I know everybody talks about their asthma plan, but mine is not like … I've not got any asthma plan written down, but I mean […] I know myself and I've got an oximeter in the house as well now that I will test on these various things. (P/adult/13, female, 41–50 site 4)

3.3. Key theme 2: CDSS: Patient experience and views

Participants spoke about a range of topics relating to how a computer, the internet or a CDSS could be used to enhance a consultation for a possible asthma diagnosis. Four subthemes were identified: patient experiences of screen sharing, online information use, patient views of an asthma CDSS and barriers and facilitators to CDSS use.

3.3.1. Patient experiences of screen sharing

Respondents were asked about their experiences of using the screen alongside their clinician during appointments. 30 One or two participants talked about screen sharing with their asthma nurse, but most could not recall being invited to look at the computer screen during a GP consultation. Few participants realized that they could be invited to look at the screen, or even understood why they might want to see it:

GPs certainly not, I don't think they ever share screens. The asthma nurse … I think they have like, they've shown us, but they are just graphs, not really to do with asthma necessarily. They are to do with like height and weight and where you should be and then your peak flow, that stuff. (P/parent of child/1, male, age 14, site 4)

Well, I don't really think like that is a nice thing to do … Aye, I'm just thinking that (screen) was a bit private, you know, would that not be a bit private to them? (P/adult/12, male, age 51–60, site 6)

That said, some participants had experience screen sharing during clinical consultations:

Certainly, in the hospital in most sessions. I'm quite curious as an individual anyway, and dangerous because I have a little bit of knowledge, so I've been looking at the numbers they were copying down. I think in the consultant conversation he was definitely pivoting the monitor so we could look at it. I can't remember what was on it, but I do remember that seating arrangement to both look at it. (P/adult/9, male, 41–50, site 4)

Some respondents felt that a CDSS which allowed them to see how the clinician worked through their diagnosis, might have helped them to understand more about the variability of asthma and other aspects to help understand the condition.

So, yes anything that provides better, broader information from a multitude of directions, so not just ‘Here is a piece of writing for you’. Like you are seeing with visuals, you know, I think is only going to make it better. (P/parent of child/1, male, age 14, site 4)

3.3.2. Online health information use

When asked about accessing health information online pre‐diagnosis, a lack of trust in the quality of information online alongside patient perceptions of GP dislike of the practice, meaning that most respondents avoided using the internet to try and self‐diagnose.

I think I'm of the generation that what the doctor tells me I believe him. I tend not to look up illnesses myself. (P/adult/11, female, 61–70, site 4)

I don't go online so much […] because I work for a health organisation. And I know that doctors get annoyed with, sort of, patients looking up symptoms online before actually going to see them; and then thinking they've got something when they've not actually got it. So, that's maybe one of the reasons I don't tend to sort of go online to look out for health problems and things like that. (P/adult/1, female, 41–50, site 1)

However, participants noted that they accessed information online post‐diagnosis to expand their knowledge or define their condition better:

I looked it up, which I never normally do, asthma symptoms. And it's because I was still coughing and I'm … the thing I says to my brother and sister, I'm not convinced I've got asthma. I think it's a chest infection […] So … what I read on the Internet, sadly […] confirmed what I was feeling [was asthma]. (P/adult/8, male, 61–70, site 3)

There was a perception that negative clinical attitudes existed towards patients exploring online information before a GP diagnostic appointment (P/adult/1, female, 41–50, site 1). Conversely, some held the view that ‘Dr Google’ was useful particularly in terms of searching for groups to exchange views and experiences of asthma.

Everything seems to be online, and everybody seems to have an opinion and so easily accessible […] information that you need, and you know, you've got your asthma, you know, groups online. (P/adult/13, female, 51–60, site 4)

3.3.3. Patient views on an asthma CDSS

The most popular output for the CDSS was the ability to provide the probability of an asthma (ideally visually) during diagnostic consultations. Moreover, respondents agreed that being able to see the factors which could lead towards an asthma diagnosis would be useful alongside further information to improve treatment management:

And he could say, I don't know, let's say there's various fields on your screen, if five out of these ten fields are ticked, the chances are, that you've got asthma or whatever disease and as you can see you've got seven of them ticked; you know, something like that. A visual representation. (P/adult/10, male, 61–70, site 4)

In keeping with the lack of confidence that individuals had about their understanding of asthma, participants suggested that incorporating an educational section within the CDSS which could be used during the consultation to show a visual representation of how asthma affects the lungs would be of interest and could assist communication and their understanding:

I actually think that kind of thing would be really helpful for children and young people…. because it's very abstract, and especially if it's just something that you think is just how your body is, you never question it, you never really think about it in terms of the actual physiological processes that are happening, you are just like, ‘Oh I've got asthma, right’. (P/parent of child/1, male, age 14, site 4)

If there's a simulation or something like that, ‘Here's how it looks when it's really bad’ and ‘Here's how, what’, ‘Here's how an inhaler, what it does to your lungs’, ‘Here's what specific medication does’ and stuff like, yeah, I think that would be very interesting […] just looking at it on a piece of paper, is not the best. I think seeing some kind of simulation would be much more helpful. (P/adult/7, female, 51–60, site 1)

Respondents also noted that it would be beneficial to understand where they fit into an overall picture of asthma severity, with P/adult/9 (male, 41–50, site 4), two years since diagnosis asking, ‘What's normal and where am I versus normal?’ Some participants felt that understanding the significance of their diagnosis could have helped them take the diagnosis more seriously from the beginning. Participants also suggested that a website associated with the CDSS which could be used after the consultation would be more beneficial to them in the long run than the traditional handouts:

I think it's a good idea. I think it would help quite a lot 'cause the big problem I had was that I wasn't using my inhaler correctly and then I wasn't seeing an improvement on … kind of, on my, like, lung capacity essentially. So, I think if I'd, kind of, had that understanding earlier on then I would have been more dedicated to using my inhaler the way that I'm meant to. (P/adult/2, female, 21–30, site 1)

There were others who were sceptical, believing their diagnosis would not have been speedier or different with the aid of a CDSS.

I mean, I have to say that on these indicators alone, my family history was ‘no none’. At that point I didn't really have any allergies, they have come on since. Also, my coughing had, ironically, stopped by the time … after the first episode my coughing had stopped because of the operation. Also, I didn't have a wheeze. (P/adult/13, female, 51–60, site 4)

3.3.4. Barriers and facilitators to a CDSS being used

Respondents expressed interest in the potential role of the CDSS and could see areas where the CDSS might improve the diagnostic experience. However, respondents also highlighted that whether the potential was realized depended on how the CDSS was used:

So, I think this system would be good but if it's just the system and then a very overworked GP that doesn't make eye contact, it's not really going to work. It would be, kind of … you know, you'd have to have the right person who was interacting in … on it with you. (P/adult/2, female, 21–30, site 1)

To this end, most respondents viewed the CDSS as an avenue through which communication between patients and clinicians could be facilitated:

Between yourself and the health professionals, this might be a little bit of a focal point for the conversation. So, I think that's likely to work well. (P/adult/6, male, 41–50, site 1)

The ability to aid understanding between clinicians and patients was viewed as the most important aspect of the CDSS, especially for those respondents who found the initial diagnosis ‘daunting’ (P/adult/7, female, 51–60, site 1). Moreover, screen‐sharing was viewed as an opportunity to be ‘treated like an intelligent adult’ (P/adult/6, adult male, 41–50, site 1). Using the CDSS could provide a framework for clinicians and patients to use together to provide a better‐shared understanding of potential routes to diagnosis.

4. DISCUSSION

Being diagnosed with asthma could feel like an uncertain process for participants in this study, who felt that limited consultation time or poor communication made it difficult to understand how and why the diagnosis had been made. Some participants felt they retained information about asthma diagnosis poorly and considered online or digital resources more useful than paper handouts. Participants felt possible advantages of a CDSS for asthma diagnosis may be prompting dialogue, improving understanding and encouraging a shared diagnostic process between patients and clinicians.

4.1. Interpretation

The hallmark of asthma is variability. Symptoms vary over time and in severity and making a diagnosis of asthma can require time or repeated investigations to build up the information required. 5 , 8 , 9 For patients, preconceived concepts about what asthma is, and who is at risk of developing the condition influence the credibility of an asthma diagnosis. For clinicians, weighing up the probability of an asthma diagnosis, differentiating between asthma and other conditions and excluding red flags can all influence how a consultation is conducted. 8 , 10 Thus, the perceptions of both clinician and patient can shape a consultation and a mismatch in these perceptions may lead to dissatisfaction. 30 Involvement of patients in consultations to allow shared decision‐making is widely accepted in medical practice and may lead to better asthma control, quality of life, adherence to medication and patient satisfaction. 31 Yet for shared decision‐making to occur, clinicians need to have time and resources to provide information on the pros and cons of a particular course and patients need to feel able to understand and question the medical explanations while contributing what is important for them. 32 , 33 , 34

Amongst the diagnostic experiences recalled in this study, there were instances where participants felt their diagnosis was a fait accompli or did not feel empowered to ask questions or engage in meaningful interactions, believing the professional opinion was final. Additionally, and often because of perceived time constraints during GP appointments, patients were reluctant to ask for clarification or explore their diagnosis further, even though they were often dissatisfied with the information provided. One patient deliberately refrained from seeking further asthma information online, believing that doing so would be annoying for their GP. These examples may indicate a mismatch in the perceptions of health between patients and clinicians during the consultation. One influencing factor may be patient/clinician power imbalance, whereby the health professional was perceived to hold power within the consultation. 26 , 27 , 28 A perceived superiority of clinicians in the eyes of patients can impact their willingness to share their opinions, 34 and engage in consultation because they trusted that the clinician knew best. 35 On the other hand, some patients may prefer a more direct consulting style and not be actively involved in decision‐making. 36

Consequently, strategies/interventions to support a more egalitarian partnership between patient and professional may encourage more supportive patient care, an increased understanding of individual illness and facilitate patient empowerment. 28 , 29 In this study, there were a few examples of reduced medical dominance; participants described screen sharing and the layout of seating in the consultation room. In keeping with a prior study 30 ; screen sharing did contribute to patients feeling involved in the consultation, yet few participants had direct experience of it occurring. Whilst the theory of medical dominance extends beyond doctors to allied health professionals and nurses, 28 , 29 some participants in this study preferred to see their asthma nurse (compared to a GP) because they found the consultation more understandable. Other factors such as the length of the appointment may also have influenced this view.

To promote shared decision‐making, Agoritsas et al. 33 suggested clinicians need ‘skills and tools’ while patients require ‘information and support’. CDSS has traditionally been seen as technology to support clinicians, but can also promote patient‐focussed practice 37 through the involvement of patients in decision‐making about their health and well‐being. 38 , 39 In this study, participants liked the idea of visualizing the probability of asthma, seeing simulations of lung physiology and being able to see how the clinician worked through their diagnosis. However, some participants had reservations, explaining there would be no point in a CDSS if the clinician did not have time to engage. In keeping with this view, some have argued that the barriers to using CDSS set them up for failure. 40 , 41 , 42 For instance, with a lack of guidance on how decision support systems could be used, clinicians were more likely to rely on their training and experience than on new technologies. 43 Additionally, a lack of appointment time could result in reduced patient involvement, as the clinician focuses on the CDSS rather than inviting the patient to become part of the decision‐making. 40

4.2. Implications for research and practice

The importance of diagnostic tests was noted by participants in this sample, and the lack of access to tests is a source of frustration and uncertainty for patients and health professionals alike. 10 In Germany and Sweden, spirometry can be achieved at the time of presentation, or within 2 weeks, respectively. 10 Yet in other health systems, including the United Kingdom, the time between the first presentation and achieving spirometry or FeNO can be months. Therefore, in the United Kingdom, one implication of this work is to improve capacity and timely access to diagnostic tests for asthma. 44 , 45 Digital solutions, such as the AsthmaTuner self‐management system, could transform the diagnosis and management of asthma. 13 , 46 The use of connected technologies such as wearable sensors, Bluetooth spirometers and digital peak expiratory flow devices could increase access to diagnostic information and allow measurements to be performed when a patient is symptomatic. 13 , 46 CDSS which collates data from such devices and supports interpretation could lead to improvements in the diagnostic accuracy of asthma though further high‐quality studies are needed.

In situations where testing remains difficult to achieve, where the outcome of tests makes the diagnostic process protracted (i.e., false negatives), or variable symptoms occur over an extended timescale, considering how best to achieve shared diagnosis‐making through explanation of the current situation and deciding on the most appropriate next steps may help patients remain involved. The role that an asthma diagnosis CDSS may have in engaging patients through the diagnostic process is planned to be evaluated during a feasibility pilot study.

4.3. Strengths and limitations

The study was designed and piloted using input from a multidisciplinary advisory group and PPI members to develop topic guides and trial interviews which ensured that the topics covered were important to those with asthma and the study team. We sought views from a wide range of individuals who had been recently diagnosed with asthma from different areas across England and Scotland. Despite invitations being sent to those who had a diagnosis of asthma coded in the electronic health records within the last 5 years, we received many expressions of interest from individuals who had been diagnosed over 5 years before, and from individuals over 50 years of age.

Recruitment was severely hampered by the COVID‐19 pandemic for the following reasons: non‐COVID studies (such as ours) were paused to prioritize urgent research which meant the planned study period was restricted; GP practices faced high workload and reduced staffing which made it more difficult to recruit practices; it took longer for clinical research network staff to gain access to GP practices and send out invitations to patients. Despite these challenges, we managed to recruit parents of children with asthma, young people and older adults, with a range of diagnostic experiences. Having interviewed 14 participants, we considered that with respect to adults over 30 years, no new information was being collected and no new codes were developed. 47 In line with our purposive sampling approach, we chose to complete further interviews to enhance the diversity of the sample, specifically parents of children and young people. Before the study period closed, we were able to include more parents of children and one participant in the 16–30 age group. 47 Overall, we felt that data saturation had been achieved because the themes had been fully described with no new information being obtained in the later interviews. However, we acknowledge that had we been able to recruit more males, participants aged 16–30 years and individuals from rural GP practices we may have heard about different experiences.

This study sought views on a proposed CDSS being developed by the research team. Regarding reflexivity, we acknowledge the desire to create a successful CDSS may have influenced data collection and interpretation by being eager to pick up on positive aspects during interviews and identifying favourable opinions when analysing the data. We attempted to minimize the influence of any one individual by having two researchers conduct interviews and several team members (including a steering group) contribute to the interpretation of results.

5. CONCLUSIONS

The process of diagnosing asthma was uncertain for patients if their ideas and concerns were not addressed by clinicians and were often related to a perceived lack of consultation time and limitations in communication. A CDSS designed with patients' needs in mind could encourage a more shared diagnostic process between patients and clinicians, and improved communication relating to the nature of the condition and its management, including the patient's role in self‐management.

AUTHOR CONTRIBUTIONS

Luke Daines and Hilary Pinnock conceived the idea and achieved funding. Victoria Murray and Eddie Donaghy conducted patient interviews. Anne Canny, Eddie Donaghy, Luke Daines, Hilary Pinnock and Victoria Murray wrote the first draft and Leo Campbell, Carol Stonham, Andrew Bush, Brian McKinstry and Heather Milne were involved in the interpretation of data, revising it critically. All authors gave final approval for the article to be published.

CONFLICT OF INTEREST

The authors declare no conflict of interest.

ETHICS STATEMENT

The study received ethical approval from London Stanmore Research Ethics Committee (ref: 19/LO/1722).

Supporting information

Supplementary information.

ACKNOWLEDGEMENTS

We are grateful to Optimum Patient Care and Tactuum, our collaborators on the Asthma + Lung UK/Innovate UK‐funded research grant to develop an asthma diagnosis clinical decision support system. We thank the Asthma UK Centre for Applied Research Patient and Public Involvement team for their help during the study. This study was funded by Asthma + Lung UK/Innovate UK grant number: AUK‐PG‐2018‐404. L. D. was supported by a clinical academic fellowship from the Chief Scientist Office (CAF/17/01).

Canny A, Donaghy E, Murray V, et al. Patient views on asthma diagnosis and how a clinical decision support system could help: a qualitative study . Health Expect . 2023; 26 :307‐317. 10.1111/hex.13657 [ PMC free article ] [ PubMed ] [ CrossRef ] [ Google Scholar ]

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Patient J is a boy, 5 years of age, residing in Southwest Michigan. One March evening, Patient J was home with a conscientious babysitter. He had experienced several coughing episodes during the previous days and began to cough while playing hide-and-seek with the babysitter. She noticed that the coughing was continuing and that the more he coughed, the more he cried. She was not able to calm the patient and telephoned his parents at a nearby restaurant. Within 20 minutes, the parents returned home and found Patient J upset, crying, and coughing. They could hear audible wheezing on exhalation and could see the young boy's chest retract on inspiration. A physician was called immediately, and the parents were instructed to meet the pediatrician at his office located next to the area's hospital; they arrived within 30 minutes. The pediatrician administered a nebulizer treatment with albuterol in a 0.083% solution for inhalation, which seemed to resolve the cough, wheeze, and labored breathing after 15 to 20 minutes.

The patient's history was reviewed. According to his parents and office records, Patient J's first few years of life were essentially medically uneventful with the exception of occasional benign rashes, several that were specifically found to be related to a wood sensitivity. By 4 years of age, Patient J had experienced a number of cold viruses and allergies, with severe bouts of nasal and chest congestion. He had no history of medical emergencies related to labored breathing or otherwise.

As a precaution, the physician was prepared to recommend hospital admission to provide intensive respiratory tent therapy in the event that the symptoms did not improve. However, the symptoms seemed to resolve completely, and Patient J was sent home with his parents and placed on a 10-day period of antibiotic therapy and an albuterol aerosol inhaler, one or two inhalations every four to six hours as needed. It was also recommended that a nebulizer be kept at home, for faster results in case of sudden onset of moderate-to-severe coughing, chest congestion, wheezing, and/or tightness in the chest.

Patient J was subsequently diagnosed with an extrinsic, mild-intermittent asthma, triggered by several sensitivities, specifically to wood, dust, pollen, and cold weather. Recommendations for control of the patient's asthma symptoms were made to the patient and his family in an effort to manage the condition. He was encouraged to sleep with his head propped up with pillows about 30 degrees. Outdoor play and activities at home or at school were evaluated for appropriate participation based on severe weather, particularly when accompanied by wind. On very cold days or days with high mold or pollen counts, Patient J was instructed to wear a mask. Spring and fall proved to be difficult times for outdoor activities. His lungs became sensitive to the smoke from burning leaves and the mold-infested fallen leaves in autumn.

At home, Patient J's room was evaluated for sources of asthma triggers. Stuffed animals, carpeting, and heavy draperies were kept to a minimum. He had no feather-filled pillows, and his bedding was washed weekly in hot water. He slept with a room air purifier. When his asthma flared up, the patient was given his prescribed medications and warm liquids. A soothing bath or shower allowed him to be in an area of humidified, misty air, which often relaxed and dilated the bronchial airways.

One decade later, Patient J's asthma remains in control. At 15 years of age, he continues to take his medication and stays aware of his asthma triggers. The frequency and severity of asthma episodes have gradually lessened over time. He and his family, however, are aware that the condition is capable of changing or worsening at any time and may return with increased frequency and severity in later years. For now, Patient J is living a normal, healthy, active adolescent life.

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Rilzabrutinib Improves Asthma Symptoms in the First 2 Weeks of Treatment, Study Finds

Leda Mannent, MD, global project head, Immunology and Inflammation, Sanofi, discusses efficacy outcomes in patients with asthma who received rilzabrutinib.

Patients experienced rapid improvement in asthma symptoms, even with withdrawal from inhaled corticosteroids (ICS) and long-acting β-agonists (LABA), Leda Mannent, MD, global project head, Immunology and Inflammation, Sanofi, said in an interview.

The findings from the double-blind, placebo-controlled phase 2 study were presented at the American Thoracic Society (ATS) 2024 International Conference .

This transcript was lightly edited.

What were the notable findings from the study that warrant further investigation? Are there plans to explore rilzabrutinib's efficacy in other respiratory conditions?

The most striking findings of the study was the very rapid improvement in symptoms, and this is unprecedented. This was seen from the first 2 weeks of the treatment, and symptoms continued to improve despite the withdrawal of the ICS and LABA. In addition to that, we also could see this reduction in the loss of asthma control events despite withdrawal of the ICS LABA. So, we are, of course, exploring all the data that we have on hand, and we will we are working to see what the future indications are in respiratory.

I would also like to highlight that rilzabrutinib is also developed in multiple immune indications. We just got phase 3 positive data in immune thrombocytopenia, and we are very excited about this new therapy for these patients that have failed all other treatment options. A month ago, we also presented at AAAAI [2024 American Academy of Allergy, Asthma and Immunology Annual Meeting] the effects of rilzabrutinib from a phase 2b study in chronic spontaneous urticaria. 1 So, there are multiple avenues in these diseases and immunologic diseases. These patients very often have comorbidities. Patients with asthma have other diseases, including chronic spontaneous urticaria or other atopic diseases.

Can you elaborate on the potential long-term benefits of rilzabrutinib in managing asthma, such as preventing exacerbations or improving lung function?

Our first study was a short study; however, it tells us what could be the potential effect rilzabrutinib in the long term. We know that by controlling symptoms, there is a strong correlation between the control of symptoms and the exacerbation. So, we believe that rilzabrutinib has this potential by reducing and improving the symptoms to reduce exacerbation in the future. However, this needs to be proven, of course. We are planning to investigate rilzabrutinib in larger, long-term studies in asthma. As for any other chronic treatment, these clinical studies will provide the robust evidence for benefit and also the safety of real use of rilzabrutinib in patients with asthma.

1. Campbell P. Rilzabrutinib reduces itch, hives in chronic spontaneous urticaria in phase 2 trial. HCPLive . February 24, 2024. https://www.hcplive.com/view/rilzabrutinib-reduces-itch-hives-in-chronic-spontaneous-urticaria-in-phase-2-trial

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Association between serum lipids and asthma in adults—a systematic review.

1. Introduction

Background/rationale, 2. materials and methods, 2.1. electronic search strategy, 2.2. study selection, 4. discussion, 4.1. ldl cholesterol, 4.2. hdl cholesterol, 4.3. sleep quality, 4.4. blood eosinophil counts, 4.5. obesity and metabolic syndrome, 4.6. nutrition, 4.7. murine model, 5. conclusions, author contributions, conflicts of interest.

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Click here to enlarge figure

Filters Applied: Humans, Adults: 19+ Years, from 2017 to 2024
Terms	Query	Results
(high-density lipoprotein) AND (asthma)	((“lipoproteins, hdl”[MeSH Terms] OR (“lipoproteins”[All Fields] AND “hdl”[All Fields]) OR “hdl lipoproteins”[All Fields] OR (“high”[All Fields] AND “density”[All Fields] AND “lipoprotein”[All Fields]) OR “high density lipoprotein”[All Fields]) AND (“asthma”[MeSH Terms] OR “asthma”[All Fields] OR “asthmas”[All Fields] OR “asthma s”[All Fields])) AND ((humans[Filter]) AND (alladult[Filter]) AND (2017:2024[pdat]))	23
(low-density lipoprotein) AND (asthma)	((“lipoproteins, ldl”[MeSH Terms] OR (“lipoproteins”[All Fields] AND “ldl”[All Fields]) OR “ldl lipoproteins”[All Fields] OR (“low”[All Fields] AND “density”[All Fields] AND “lipoprotein”[All Fields]) OR “low density lipoprotein”[All Fields]) AND (“asthma”[MeSH Terms] OR “asthma”[All Fields] OR “asthmas”[All Fields] OR “asthma s”[All Fields])) AND ((humans[Filter]) AND (alladult[Filter]) AND (2017:2024[pdat]))	26
(cholesterol) AND (asthma)	((“cholesterol”[MeSH Terms] OR “cholesterol”[All Fields] OR “cholesterol s”[All Fields] OR “cholesterole”[All Fields] OR “cholesterols”[All Fields]) AND (“asthma”[MeSH Terms] OR “asthma”[All Fields] OR “asthmas”[All Fields] OR “asthma s”[All Fields])) AND ((humans[Filter]) AND (alladult[Filter]) AND (2017:2024[pdat]))	81
(lipid profile) AND (asthma)	((“lipid s”[All Fields] OR “lipidate”[All Fields] OR “lipidated”[All Fields] OR “lipidates”[All Fields] OR “lipidation”[All Fields] OR “lipidations”[All Fields] OR “lipide”[All Fields] OR “lipides”[All Fields] OR “lipidic”[All Fields] OR “lipids”[MeSH Terms] OR “lipids”[All Fields] OR “lipid”[All Fields]) AND (“profile”[All Fields] OR “profiled”[All Fields] OR “profiler”[All Fields] OR “profilers”[All Fields] OR “profiles”[All Fields] OR “profiling”[All Fields] OR “profilings”[All Fields]) AND (“asthma”[MeSH Terms] OR “asthma”[All Fields] OR “asthmas”[All Fields] OR “asthma s”[All Fields])) AND ((humans[Filter]) AND (alladult[Filter]) AND (2017:2024[pdat]))	43
(serum lipid) AND (asthma)	((“serum”[MeSH Terms] OR “serum”[All Fields] OR “serums”[All Fields] OR “serum s”[All Fields] OR “serumal”[All Fields]) AND (“lipid s”[All Fields] OR “lipidate”[All Fields] OR “lipidated”[All Fields] OR “lipidates”[All Fields] OR “lipidation”[All Fields] OR “lipidations”[All Fields] OR “lipide”[All Fields] OR “lipides”[All Fields] OR “lipidic”[All Fields] OR “lipids”[MeSH Terms] OR “lipids”[All Fields] OR “lipid”[All Fields]) AND (“asthma”[MeSH Terms] OR “asthma”[All Fields] OR “asthmas”[All Fields] OR “asthma s”[All Fields])) AND ((humans[Filter]) AND (alladult[Filter]) AND (2017:2024[pdat]))	72
(triglyceride) AND (asthma)	((“triglycerid”[All Fields] OR “triglycerides”[MeSH Terms] OR “triglycerides”[All Fields] OR “triglyceride”[All Fields] OR “triglycerids”[All Fields]) AND (“asthma”[MeSH Terms] OR “asthma”[All Fields] OR “asthmas”[All Fields] OR “asthma s”[All Fields])) AND ((humans[Filter]) AND (alladult[Filter]) AND (2017:2024[pdat]))	20

First Author, Year	Country	Study Duration	Study Design	Number of Participants	Age and Sex of Participants
Barochia Amisha V. et al. (2017) [ ]	USA	1999–2015	Cohort study	n = 333	NN—mean age 32 ± 12.4 years, 70% women and 30% men. AN—mean age 34 ± 12.4 years, 49% women and 51% men AA—mean age 37.3 ± 14.2 years, 64% women and 35% men.
Adan Hassan Alwan et al. (2018) [ ]	Iraq	2010–2012	Case–control	n = 348	Mean age 34.34 ± 11.58 years, 61% women and 39% men
Scaduto Federica et al. (2018) [ ]	Italy	2018	Observational	n = 80	Age >18 years, 52.5% women and 47.5% men
Won Heo Jung et al. (2020) [ ]	South Korea	2019	Retrospective and observational	n = 167	PFT—mean age 52.2 ± 18.8 years, 24.7% male PD—mean age 58 ± 18.1 years, 27% male.
Zhenwei Tang et al. (2022) [ ]	England, Scotland, Wales	2006–2010	Observational	n = 502.505	Mean age 56.5 years, 52.7% women
Liu Lei et al. (2022) [ ]	China	2015–2019	Observational	n = 477	NL—mean age 42.2 ± 13.73, 70.3% women DL—mean age 50.14 ± 12.61, 58.3% women
Yan Shu and Wei Wang (2022) [ ]	USA	2004–2006	Cross-sectional	n = 1013	Mean age 52.5 years, 44.91% men.
Vaibhav Sharawat et al. (2023) [ ]	India	2023	Observational	n = 77	Age range: 18–60 years 41.6% women and 58.4% men
Yao Xianglan et al. (2023) [ ]	USA	1999–2016	Longitudinal study	n = 300	A: 39 ± 15.2 years, 66% women NA: 34.5 ± 13.6 years, 55% women
Wen Jun et al. (2023) [ ]	USA	2011–2018	Cross-sectional	n = 2.544	Age > 18 years, 58.96% women
Yi-Shian Liu et al. (2024) [ ]	Taiwan	2012–2019	Bidirectional two-sample Mendelian randomization study	n = 24.853	Mean age 48.8 years, 49.8% women
Singh Pratibha et al. (2024) [ ]	North India	2021-2022	Observational prospective cohort	n = 107	Mean age 32.97 ± 11.75 years, 51.40% women

Author, Year	Studied Parameters		Statistical Significance	Explanations
Adnan Hassan Alwan et al., 2018 [ ]		Serum cholesterol	= 0.42 < 0.001 < 0.001	Lack of physical activity and unhealthy eating habits lead to obesity and metabolic syndrome. Hypercholesterolemia stimulates inflammation in asthma.
		Serum triglyceride	= 0.0125 < 0.001 < 0.001
		HDL-C	= 0.1215 < 0.001 < 0.001
		LDL-C	= 0.0179 < 0.001 < 0.001
Yan Shu et al., 2022 [ ]	Total cholesterol	Global sleep score (subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbance, use of sleep medication, and daytime dysfunction)	p = −0.062	HDL-C has anti-inflammatory effects and exerts antioxidant activity.
	Triglycerides		p = 0.136
	HDL-C		p = −0.199
	LDL-C		p = −0.018
	Total/HDL-C ratio		p = 0.154
Jung Won Heo et al., 2021 [ ]	TC	FeNO (Asthma confirmed via 1. pulmonary function test or 2. physician-diagnosis)	= 0.03 = 0.20	Metabolic syndrome and dyslipidemia are known to involve systematic inflammation, and are associated with asthma development and progression. Association between dyslipidemia and eosinophilic airway inflammation represented by FeNO.
	HDL		= 0.42 = 0.78
	LDL		= 0.01 = 0.05
	TG		= 0.49 = 0.05
	ApoA		= 0.34 = 0.84
	ApoB		= 0.02 = 0.25
Amisha V. Barochia et al., 2017 [ ]	TC	Eosinophil counts (1. non-asthmatic & 2. asthmatic)	= 0.53 = 0.92	HDL has antioxidant, anti-thrombotic, and anti-inflammatory functions—these properties may contribute to the negative correlation with blood eosinophil counts.
	Triglycerides		= 0.99 = 0.01
	LDL-C		= 0.43 = 0.76
	HDL-c–HDL particles (Total HDL NMR and large HDL NMR)		= 0.41 = 0.04 (Total HDL: p = 0.01)
Zhenwei Tang et al., 2022 [ ]	TG	Asthmatic status	p < 0.001, β = −0.005	Serum lipid dysregulation can contribute to the onset of atopic diseases.
	LDL		p < 0.001, β = −0.003
	TC		p < 0.001, β = −0.002
	HDL		p < 0.001, β = 0.004
Lei Liu et al., 2023 [ ]	FEV1 (% predicted)	Normal lipidemia vs. dyslipidemia	p = 0.012	Dyslipidemia is independently linked to pulmonary function and sensitization.
	FEV1/FVC (%)	Normal lipidemia vs. dyslipidemia	p = 0.004
	Severe asthma exacerbation	Normal lipidemia vs. dyslipidemia	p = 0.022
Pratibha Singh et al., 2023 [ ]	TC	Controlled vs. uncontrolled asthma	p = 0.569	Concomitant asthma, airway blockage, and, in particular, airway resistance are linked with high levels of LDL, while high levels of HDL are linked with lower bronchial hyperresponsiveness and improved specific airway resistance.
	TG		p = 0.704
	LDL		p = 0.030
	HDL		p = 0.636
	TC/HDL		p = 0.047
Jun Wen et al., 2023 [ ]	TC	Eosinophil counts	p = 0.5402	Metabolic syndrome and dyslipidemia contribute to the development of an asthmatic pro-inflammatory state. Eosinophilic airway inflammation has emerged as a defining characteristic of one severe form of asthma.
	LDL-C		p = 0.7836
	HDL-C		p = 0.004
	Triglyceride		p = 0.5443
Yi-Shian Liu et al., 2023 [ ]	TC	Asthma status	p = 0.001	Cholesterol is an important component of pulmonary surfactant. The synthesis of lung cholesterol is primarily derived from serum lipoproteins. Moreover, high-density lipoproteins play a central role in the acceleration of pulmonary surfactant production, and higher levels of HDL cholesterol were negatively associated with airway resistance and might reduce the risk of bronchial responsiveness.
	LDL-C		p = 0.001
	HDL-C		p = 0.01 (inversely correlated)

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Maștaleru, A.; Popescu, G.; Abdulan, I.M.; Cumpăt, C.M.; Costache, A.D.; Grosu, C.; Leon, M.M. Association between Serum Lipids and Asthma in Adults—A Systematic Review. Nutrients 2024 , 16 , 2070. https://doi.org/10.3390/nu16132070

Maștaleru A, Popescu G, Abdulan IM, Cumpăt CM, Costache AD, Grosu C, Leon MM. Association between Serum Lipids and Asthma in Adults—A Systematic Review. Nutrients . 2024; 16(13):2070. https://doi.org/10.3390/nu16132070

Maștaleru, Alexandra, Gabriela Popescu, Irina Mihaela Abdulan, Carmen Marinela Cumpăt, Alexandru Dan Costache, Cristina Grosu, and Maria Magdalena Leon. 2024. "Association between Serum Lipids and Asthma in Adults—A Systematic Review" Nutrients 16, no. 13: 2070. https://doi.org/10.3390/nu16132070

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Study suggests depictions of depression are often misleading

by University of Turku

A Finnish study , appearing in the journal Psychopathology , shows that people are commonly given misleading information about depression. According to the researchers, inaccurate information makes it harder for people to understand the causes of their distress.

Most psychiatric diagnoses are purely descriptive. For example, a diagnosis of depression is only a description of the various psychological symptoms—not the cause. Yet depression is often talked about as a disorder that causes low mood and other symptoms.

Researchers describe this as a form of circular reasoning, which means that psychiatric diagnoses are frequently talked about circularly, as if they described the causes for symptoms. This makes it difficult for people to understand their distress.

"Depression should be considered as a diagnosis similar to a headache. Both are medical diagnoses, but neither explains what causes the symptoms. Like a headache, depression is a description of a problem that can have many different causes. A diagnosis of depression does not explain the cause of depressed mood any more than a diagnosis of headaches explains the cause of pain in the head," says Jani Kajanoja, a postdoctoral researcher and a medical doctor specializing in psychiatry at the University of Turku in Finland.

This misconception is also perpetuated by mental health professionals , shows a recent study by the University of Turku and the University of the Arts Helsinki.

In the study, the researchers analyzed publicly-available information on depression provided by leading international health organizations.

The researchers selected the websites of English-language organizations whose information on depression was the most influential according to search engine results. The organizations included the World Health Organization (WHO), the American Psychiatric Association (APA), National Health Service (NHS) in the UK, and Harvard and Johns Hopkins Universities, among others.

Most organizations portrayed depression on their websites as a disorder that causes symptoms and/or explains what causes the symptoms, although this is not the case. None of the organizations presented the diagnosis as a pure description of symptoms, as would have been accurate.

"Presenting depression as a uniform disorder that causes depressive symptoms is circular reasoning that blurs our understanding of the nature of mental health problems and makes it harder for people to understand their distress," says Kajanoja.

The researchers suggest that the problem may be caused by cognitive bias.

"People seem to have a tendency to think that a diagnosis is an explanation even when it is not. It is important for professionals not to reinforce this misconception with their communication, and instead help people to understand their condition," says Professor and Neuropsychologist Jussi Valtonen from the University of the Arts Helsinki.

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Introduction

Presentation of asthma

Asthma triggers

Common asthma triggers

Risk factors for asthma

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Paediatric asthma phenotypes

Differential diagnoses and diagnostic uncertainty

Diagnosing asthma in children

Management of asthma in children

Pharmacological management

Non-pharmacological management

Self-management

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