Interview with Grace E. Hardie, PhD, RN, UCSF, SF State Associate Professor San Francisco State University
Our understanding of how ethnicity influences how patients describe their asthma symptoms and how ethnicity impacts airway responsiveness is extremely limited. Ethnic influences on symptom
description and airway responsiveness were the subject of a 2010 study of induced bronchoconstrictor administration in African Americans and Hispanic, Latino & Mexican Americans with mild asthma (Journal of Asthma, 2010; 47:1-9).
If healthcare professionals are better able to understand the ethnic differences in symptom descriptors and airway responsiveness, then treatment decisions that are both culturally and ethnically sensitive may be applied and outcomes may be improved.
Using a standardized methacholine (McH)challenge (bronchoconstrictor) procedure a doubling dose (0.078-10mg/ml) of McH was used that would result in a 30% fall (PC30) in FEV1. Mild asthma was defined as FEV1?70% of predicted. Baseline FEV1 was comparable for both groups. Mean age of African Americans was 30.3 y and mean age of Hispanic/Latino/Mexican Americans was 30.9 y. Ethnic differences in both airway hyperresponsiveness and symptom presentation were documented. The dose of McH at PC30 for African Americans was 2.6 mg/ml; Hispanic, Latino & Mexican Americans was 2.62 mg/ml. The dose of McH at PC30 reflects the significance of the degree of airway hyperresponsiveness experienced by both ethnic groups during episodes of acute asthma. African Americans used only upper airway ethnic word descriptors (EWD) at PC30 including itchy throat, tight throat, voice tight, & itchy neck. Hispanic-Mexican Americans at PC30 used both upper and lower airway EWDs to describe their symptoms:
Upper airway: voice tight, itchy throat, itchy inside throat & chest, & tickle cough: Lower airway EWDs were-sore lung-chest, wheezing, can’t get air in/out. The EWDs reported and their differences across the differing ethnicities reflect the uniquely different perception of acute bronchoconstriction for each ethnic group. For the health professional, the EWDs provide an opportunity to expand our understanding of ethnic differences in symptom presentation and, also, to determine symptom management.
What is not fully understood is the relationship between EWDs, the regulation of beta-adrenergic airway responsiveness and ethnicity. The current word descriptors of wheezing, shortness of breath and chest tightness were derived from studies enrolling primarily Caucasian adults. These EWDs need to be expanded and revised to reflect our more diverse ethnic populations. As health care professionals asking your asthma patients what their primary asthma symptoms are when they seek care for an acute episode is an essential step forward if symptom management for all diverse ethnic groups are to be improved.
Aerocrine, a medical technology company focused on improving the treatment of patients with inflamed airways by identifying nitric oxide (NO) as a marker of inflammation. Aerocrine has HQ in Sweeden.
The founders of Aerocrine emerged from the highly prestigious Karolinska Institute in Sweden where they were the first to identify nitric oxide (NO) as a marker of inflammation. Aerocrine has taken this significant discovery from laboratory to listed company and is now established in some of the world’s largest markets. The company markets NIOX MINO. A highly reliable and effective tool to assist in the diagnosis and control of airways disease.
If you or someone you know suffers from severe Asthma and or COPD then you owe it to yourself and to others to listen in on this interview with Chris Garvey FNP, MSN, MPA, FAACVPR Manager, Seton Pulmonary & Cardiac Rehabilitation that took place at the California Thoracic Society (CTS) 2013 Conference Carmel California.
Key take aways:
•The importance of exercise
•Taking your meds
•The benefits of multidisciplinary teams
•Early identification
•Effective treatment based on evidence based guidelines to reduce Exacerbation’s
•Reduced cost of care
•Effective Care
•Understand your symptoms
•Education
•Honest and frank discussion your doctor and or health care provider
•Getting the right meds
•Follow up with your doctor and or health care provider
High Risk Factors in Asthma-COPD Overlap Syndrome: Highly Prevalent But Grossly Underappreciated
By Tinka Davi, World Asthma Foundation
The statistics are staggering:
Every four minutes someone dies of COPD or chronic obstructive pulmonary disease.
Every day nine people die from asthma.
But what takes a higher toll is a combination of the two diseases, which is recognized as Asthma-COPD Overlap Syndrome or ACOS.
Because this syndrome has not received much attention by the medical community, the frequency of deaths due to ACOS alone has not been compiled.
ACOS, which was formerly called “asthmatic bronchitis,” is a commonly experienced, yet loosely defined clinical entity. It accounts for approximately 15 to 25 percent of the general population of obstructive airway diseases who experience worse outcomes compared to asthma or COPD alone.
Patients with ACOS have the combined risk factors of smoking and atopy such as hay fever. These adults are generally younger than patients with COPD and experience acute exacerbations or attacks of their breathing requiring immediate attention with higher frequency and greater severity than lone COPD.
Physicians and other healthcare professionals at UC Davis have taken their clinical experience and research nationally to increase public awareness.
“ACOS is concerning because it’s much worse in terms of exacerbations, or acute attacks of breathlessness, as compared to COPD.” said Amir Zeki, MD, assistant professor of medicine pulmonary, critical, and sleep medicine at the Center for Comparative Respiratory Biology and Medicine at the University of California Davis School Of Medicine.
Samuel Louie, MD and Amir Zeki, MD
Exacerbation is an acute flare up or worsening of the disease usually over two to three days that causes patients with asthma, COPD or both to seek immediate medical attention and a change in their daily medications.
An exacerbation is a flare up or worsening of the disease, otherwise known as an “attack.”
With an acute attack, the risk of hospitalization, need for steroids, days of missed work or school increases with ACOS, Zeki said. The prevalence of frequent exacerbations in ACOS is nearly two-and-a-half times higher than COPD and risk of severe exacerbations in ACOS is twice as high as COPD.
Zeki and Samuel Louie, MD are collaborating efforts to educate the medical field and the public about ACOS.
Louie, professor of medicine, is director of the UC Davis Asthma Network (UCAN) since 1998 and director of the UC Davis Reversible Obstructive Airway Disease (ROAD) Center, which serves adults and adolescents in Northern California who have difficult to control asthma, bronchiectasis and COPD.
“We are entering a new era of public awareness of people living with chronic lung disease such as asthma and COPD,” Louie said. “Our mission at UC Davis is to transform health care by integrating and provide quality patient care services these conditions, which promote patient education and safety, social networking, and to align our goals with national efforts to transform people’s lives. But we can achieve success without recognizing the clear and present danger from not recognizing the Asthma-COPD Overlap syndrome.”
The incidence of ACOS is becoming more prevalent. “One in five patients in our clinic will likely have ACOS,” Zeki said.
Louie agrees. “When patients learn what they have, they begin to look for more information and help. That is where we have to be ready to provide comprehensive services that are integrated and coordinated to help patients and their families navigate the complex modern health care system,” he said.
That’s why the two physicians are zealous in their efforts in providing ACOS education, not only for patients but to the medical community which is not as familiar with the syndrome as it is with asthma or COPD. They’d also like to see extensive research for treatment options.
“There’s no cure for asthma and there’s no cure for COPD, but we can treat them to improve their quality of life and prevent acute exacerbations,” Zeki said.
However, standard treatment options are not as aggressive as needed to treat the asthma-COPD syndrome.
“It really all begins with empathy.” Louie said. “Empathy within healthcare providers for how asthma, COPD and ACOS patients suffer when they are given prescription drugs without education on an individual level. We have to ignite that empathy by increasing awareness and providing education.”
The two physicians are board members of the World Asthma Foundation, which provides educational resources that inform patients, medical professionals and the general public about the latest clinical advances, management and treatment options for asthma disorders, including ACOS.
“I am convinced that every patient who lives with asthma, COPD or ACOS has character and intelligence but what they often lack is willpower.” Louie said. “And when physicians and their colleagues think COPD is ‘irreversible,’ that is like a nail in the coffin to patients, but nothing could be further from the truth. There are no cures as Dr. Zeki said, but then there is no cure for diabetes or heart disease either.
“People with asthma, COPD and ACOS deserve better. It requires that we all take responsibility, patients too, but physicians must take their empathy one step further and realize how reversible asthma, COPD and ACOS can be” Louie said.
Willaim Cullifer, executive director of the World Asthma Foundation, said, “This is a fascinating new development in the understanding of asthma and COPD and it’s fantastic to be on the forefront of educating the public and the healthcare community about this issue.”
With their concern and enthusiasm for serving ACOS patients as well as those living with asthma alone or COPD alone, the dedicated physicians are bound to make a difference, hopefully in their lifetimes.
“My hope is to gain a better understanding of this syndrome, which may indeed be on the continuum of airway diseases such as COPD and asthma,” Zeki said. “We hope to garner the support and funding needed to study it given its high prevalence and public health significance.”
“When you get done taking care of the disease, you’re taking care of people,” Louie said.
“We must fight indifference. The only way to do that is to get the word out that we all have much more to achieve together to empower patients with reversible obstructive airway diseases.” Louie said.
A recent asthma activity population study suggests that once you’ve been diagnosed with asthma, you’re trapped with the disease for life.
According to published reports in the Journal of Allergy and Clinical Immunology research conducted from 1993 to 2008 by scientists at Ontario’s Institute for Clinical Evaluative Sciences (ICES) studied 613,394 people with asthma. Eighty-two per cent of participants continued to have active asthma through the study.
For nearly 75 per cent of that group, the condition seemed inactive for years.
“Over 15 years, most individuals with asthma in Ontario were found to have active disease which was interspersed by periods of inactivity when they did not seek medical attention and were likely in remission,” states Dr. Andrea Gershon in a news release. Gershon is a respirologist and scientist at Sunnybrook Health Sciences Centre in Toronto, and the study’s lead author.
“These analyses offer insight into the natural course of asthma activity that may help improve the ability to predict an individual’s course of disease.”
Children, seniors, and those diagnosed with chronic obstructive pulmonary disease (COPD) were more likely to have active asthma.
A recent study conducted by Dr. Mark Holbreich, an allergist reflect that children growing up in the Amish culture in Switzerland have significantly less asthma and allergies than Swiss children who didn’t grow up on a farm according to publish reports.
According to National Jewish Health Dr. Mark Holbreich began to offer free allergy clinics in the 1980s to the Amish community in Northern Indiana. “The Amish accept no insurance and live a life separate from the ‘outside world,'” said Dr. Holbreich. “They are committed to a traditional agrarian lifestyle and their faith.”
Dr. Holbreich noticed that the majority of the 20 to 30 patients who visited each clinic had no evidence of food or inhalant allergy, eczema, allergic rhinitis or asthma. Skin tests were often negative. His observations were different from the experience in his Indianapolis practice where most patients seeking advice have allergies.
Endotoxin Exposure
In 2000, Dr. Holbreich read National Jewish Health physician Dr. Andy Liu’s first observations on endotoxin exposure and allergy prevention. Amish have large families; children are in the barn and around farm animals from a very early age and drink unpasteurized milk. Dr. Holbreich wondered if the Amish community could be exemplifying the hygiene hypothesis. He contacted Dr. Liu and, in 2004, the two doctors together visited an Amish community. Their informal survey found no one with knowledge of any allergic individuals.
“I am grateful and appreciative of Dr. Holbreich’s willingness to share his experience,” said Dr. Liu. “While I came out of scientific interest, I left with a profound admiration for the Amish way of life. There may be benefits of the Amish lifestyle that go beyond early endotoxin exposure to account for the low incidence of atopy.”
Cooperation among former fellows and current faculty is a great strength of the National Jewish experience. Drs. Liu and Holbreich continue to work together on ways to further define the incidence of allergic disease in the Amish population and to explore what can be learned about prevention and well-being from this unique community.
A new study has found the addition of long-acting beta-agonist therapy to be the most effective of three step-up, or supplemental, treatments for children whose asthma is not well controlled on low doses of inhaled corticosteroids alone.
The study was designed to provide needed evidence for selecting step-up care for such children and was supported by the National Heart, Lung, and Blood Institute (NHLBI), part of the National Institutes of Health. Researchers also identified patient characteristics, such as race, that can help predict which step-up therapy is more likely to be the most effective for a child with persistent asthma.
Key Findings:
The study found that almost all of its participants had a different response to the three different treatments. Although adding the long acting beta-agonist step-up was one and one-half times more likely to be the best treatment for most of the study group, many children responded best to other two treatments instead.
The results were presented March 2 at the American Academy of Asthma, Allergy and Immunology 2010 Annual Meeting in New Orleans and are published online in the New England Journal of Medicine.
“These results fill an important gap in our asthma guidelines,” said NHLBI Acting Director Susan B. Shurin, M.D., a board-certified pediatrician. “At the time the guidelines were written, there were very few comparison studies conducted in children whose asthma was poorly controlled with low-dose inhaled corticosteroids. Now that we have these study data, we can more confidently make recommendations for these children.”
The NHLBI’s Guidelines for the Diagnosis and Management of Asthma (EPR-3) recommend three treatment options for children with mild to moderate persistent asthma – for example, those experiencing symptoms at least two days per week – whose asthma is not well controlled on low doses of inhaled corticosteroids. These treatments, which were featured in the study, are adding a long acting beta agonist to the low-dose inhaled corticosteroids; adding a leukotriene receptor antagonist to the low-dose inhaled corticosteroids; and doubling the dose of inhaled corticosteroids. These recommendations were based on data collected from adults.
The study, called Best Add on Therapy Giving Effective Responses (BADGER), compared how effectively the three different step-up treatments improved asthma control in 182 children ages 6 to 18 years. All participants had mild to moderate persistent asthma that was not controlled on low-dose inhaled corticosteroids. Participants received each of the three treatments, with each treatment period lasting 16 weeks.
Responses were measured based on three factors: number of asthma episodes requiring oral corticosteroids, number of days of well controlled asthma, and lung function as measured by the amount of air exhaled in one second.
Overall, adding a long-acting beta-agonist to inhaled corticosteroids was significantly more likely (1.5 times) to be the best step-up therapy as compared to adding a leukotriene receptor antagonist to inhaled corticosteroids or to doubling inhaled corticosteroids.
Nearly all the children responded differently to the three treatments, with 45 percent of children responding best to adding a long-acting beta-agonist, 28 percent responding best to adding leukotriene receptor antagonist, and 27 percent responding best to doubling the dose of inhaled corticosteroids.
The study also identified several patient characteristics that increased the likelihood of identifying which step-up treatment would be more effective for an individual child. For example, African-American study participants were equally likely to respond best to long-acting beta-agonist step-up or inhaled corticosteroids step-up, and least likely to respond best to leukotriene receptor antagonist step-up. For white participants, the addition of a long-acting beta-agonist was clearly the most likely step-up therapy to give the best response, with inhaled corticosteroids step-up the least favorable therapy.
In addition, a long-acting beta-agonist was more likely to be the most effective step-up therapy among children who started the study with high scores on the Asthma Control Test, a five-item health survey used to measure asthma control, and among those who did not have eczema, an allergic skin condition.
“This study underscores the fact that individuals respond differently to different therapies ” childhood asthma treatment is not one-size-fits-all,” said Robert F. Lemanske, Jr., M.D., of the University of Wisconsin Hospital-Madison, one of the principal investigators of the study and lead author of the paper. “It is important to monitor the child’s response closely and, if necessary, adjust therapy with one of the other options within this step of care before moving to a higher step of care.”
The benefit of adding a different class of medication may be because of a possible ceiling effect for low-dose inhaled corticosteroids in some children, Dr. Lemanske said.
The observed overall best performance of long-acting beta-agonist step-up should be weighed against the increased risk of severe worsening of asthma symptoms leading to hospitalization and, in rare cases, death, as noted in the U.S. Food and Drug Administration approved labeling for long-acting beta agonists. Although there were no safety differences among the treatments during this study, the researchers assert the BADGER trial was not designed or powered to evaluate long-term safety of long-acting beta-agonists in children.
“This is the kind of study that will advance strategies for personalized medicine and improve treatment for children who have asthma,” said James Kiley, Ph.D, director of the NHLBI Division of Lung Diseases.
According to the Centers for Disease Control and Prevention, almost 7 million children in the United States have asthma, a leading cause of hospitalizations and school absenteeism. Common asthma symptoms include wheezing, shortness of breath, chest tightness, and coughing. While there is no cure for asthma, most children who receive effective treatment are able to control symptoms.
The study was conducted by researchers with the NHLBI’s Childhood Asthma Research and Education Network (CARE) centers. The CARE Network was established in 1999 to evaluate treatments for children with asthma; study sites are Penn State College of Medicine, Hershey, Pa.; National Jewish Health, Denver; University of Wisconsin – Madison; University of California, San Diego/Kaiser Permanente Medical Center; Washington University School of Medicine, St. Louis, Mo.; and University of Arizona College of Medicine, Tucson.
CARE centers also received support for this study from the National Center for Research Resources and the National Institute of Allergy and Infectious Disease, both part of NIH. Medications were provided by GlaxoSmithKline and Merck, Inc.
Discovery that could lead to new treatments for Asthma
Press reports reflect that a Prof Padraic Fallon from Trinity College Dublin and his collaborators in Britain have found a pathway leading to the development of white blood cells that cause allergic inflammation.
Professor Fallon describes his discovery of a novel cell implicated in allergies. The discovery has the potential for new strategies to treat asthma and other allergic diseases. The research findings have just been published in the leading international journal Nature Immunology.
Two years ago he and Dr Andrew McKenzie from Cambridge University announced the discovery of a new white cell, the nuocyte — a previously missing link in the immune pathway that is activated in asthma attacks.
A recent study conducted by the University of Adelaide in Australia reflect a link to heavy consumption of soft drinks and increased risk of asthma and chronic obstructive pulmonary disease according to published reports in the February issue of Respirology.
The researchers found that, among 16,907 participants 16 years of age or older, 11.4 percent reported daily soft drink consumption of more than half a liter. High levels of soft drink consumption were positively linked with asthma and COPD. Overall, 13.3 percent of participants with asthma and 15.6 percent of those with COPD reported drinking more than half a liter of a soft drink per day. After adjusting for sociodemographic and lifestyle factors, the odds ratio (OR) for asthma was 1.26 (95 percent confidence interval [CI], 1.01 to 1.58) and the OR for COPD was 1.79 (95 percent CI, 1.32 to 2.43) among those consuming more than a half-liter of a soft drink daily compared with those not consuming soft drinks.
Zumin Shi, M.D., Ph.D., of the University of Adelaide in Australia, and colleagues collected data using a risk factor surveillance system. Each month, a representative sample of South Australians were randomly selected from the electronic White Pages for interviews using computer-assisted telephone interviewing.
Improved Medication Use Could Reduce Severe Asthma Attacks
Researchers at Henry Ford Hospital have found that one-quarter of severe asthma attacks could be prevented if only patients consistently took their medication as prescribed.
Moreover, an asthma attack was only significantly reduced when patients used at least 75 percent of their prescribed dose, according to the study.
Patients often poorly take their medication based on the onset and degree of symptoms.
Henry Ford researchers say this is the first time that asthma medication use has been tracked closely over time and related to the likelihood of severe asthma attacks. The findings are published online in the December issue of The Journal of Allergy and Clinical Immunology http://www.jacionline.org/article/S0091-6749%2811%2901481-3/abstract
“Our findings demonstrated a relationship between medication adherence and asthma events in a manner that accounts for the changing patterns of inhaler use over time,” says lead author Keoki Williams, M.D., MPH, an Internal Medicine physician and associate director of Henry Ford’s Center for Health Policy and Health Service Research.
Inhaled corticosteroid (ICS) medication is the most effective treatment for controlling symptoms and preventing attacks, which can lead to a visit to the emergency department or hospitalization or death if left untreated.
Working from their theory that ICS use changes with the episodic nature of asthma, Dr. Williams and his team of researchers set out to measure changes in medication use over time and to estimate the effect of ICS use on asthma attacks among 298 patients. Patients were followed on average for two years and had 435 asthma attacks during that time.
“We found that every 25 percent increase in ICS adherence was associated with an 11 percent decrease in asthma attacks,” Dr. Williams says. “But most importantly, we found that causal use of these medications is not enough, especially among patients whose asthma is not controlled. Patients must use their asthma controller medication as prescribed if they want to have the best chance of preventing serious asthma attacks.”
