哮喘儿童吸入性糖皮质激素使用情况及用药依从性评价

目的探讨哮喘儿童吸入性糖皮质激素(Inhaled corticosteroids,ICS)使用情况及用药依从性。方法选择2016年1月至2018年1月期间本院儿科住院部和门诊收治的哮喘儿童共350例。采用问卷调查了解哮喘儿童的一般情况下、ICS使用情况和用药依从性,并分析用药依从性差的影响因素。结果350例儿童哮喘病例中,布地奈德、氟替卡松和倍氯卡松的使用率分别为81.14%、10.29%、8.57%。雾化器、压力定量气雾剂和干粉吸入剂的使用率分别为62.29%、27.43%和10.29%。哮喘儿童ICS用药依从性差占74.86%,而用药依从性佳仅占25.14%。儿童哮喘ICS用药依从性差的原因主要包括担心ICS的安全性、家庭经济困难、不配合治疗、自认痊愈而停药和吸入方法不正确等。单因素分析显示,哮喘严重程度、父母受教育程度、掌握ICS吸入装置、家庭经济困难、父母对哮喘认知、父母对医护人员的信任程度与ICS用药依从性具有紧密的关系。多因素logistic回归分析显示,哮喘病情程度、父母受教育程度、父母对哮喘认知程度和父母对医护人员的信任程度越高,儿童哮喘ICS用药依从性越高。结论哮喘儿童ICS的使用以布地奈德雾化吸入为主,但用药依从性与多种因素具有紧密的关系,针对上述因素进行有效干预可有利于提高用药依从性,最终改善治疗效果。     

Exploring community-dwelling stroke survivors’ experiences of receiving a nurse-led theory-based stroke self-management programme: A qualitative study

International evidence-based guidelines recommend self-management support for stroke survivors to improve their health outcomes. We developed a 4-week nurse-led stroke self-management programme (SSMP) and conducted a randomised controlled trial to assess its effects. This paper reports the findings of a qualitative study nested within the randomised controlled trial to explore stroke survivors’ experiences of SSMP participation. Semi-structured interviews were conducted with all adult participants who were clinically diagnosed with a first or recurrent ischaemic or haemorrhagic stroke, residing at home, communicable in Cantonese, had a Montreal Cognitive Assessment score below the second percentile, and participated in at least 1 SSMP session. All interviews were conducted in Cantonese, lasted approximately 45 minutes, and were audio-recorded. Interview data were transcribed verbatim and analysed thematically. Sixty-four stroke survivors (mean age 66.33 years, SD 12.34) were recruited, and 59 were interviewed via phone immediately after completion of SSMP. Three themes were derived. Overall, participants were satisfied with the SSMP. Their understanding of self-management was improved, and they recognised its importance in recovery. Their confidence in self-management was also enhanced through the use of multifaceted strategies. Suggestions were made to enhance their participation experiences, including increased home visits and group sessions, making group session attendance optional and arranging them more accessibly, meeting the survivors who shared their survival experiences in the videos, and access to the videos online. This study concurred that the SSMP enhanced stroke survivors’ self-efficacy in self-management. Rearrangement of the programme format and enhancements in accessibility could be further examined to enable more effective stroke self-management.     

Swimming and asthma: factors underlying respiratory symptoms in competitive swimmers

Background: Swimming is recommended for asthmatics. However, many competitive swimmers report asthmatic symptoms. While some studies identify the swimming environment as a trigger for allergy and asthmatic symptoms, even more studies suggest swimming to be suitable for people with allergies and asthma. The factors behind the symptoms were studied first by determining the prevalence of asthma, allergy and self‐reported asthmatic symptoms in experienced Finnish swimmers and then by examining the relationships between the reported symptoms and the main triggering factors: medical history, environment and exercise intensity. Materials and Methods: Top swimmers (n = 332) of the Finnish Swimming Association registry (N = 4578) were asked to complete a structured questionnaire on their medical history, swimming background, swimming environment and symptoms in different swimming intensities. Two hundred experienced swimmers, 107 females and 93 males, with an average age of 18.5 [standard deviation (SD) = 3.0] years and a swimming training history of 9 (SD = 3.8) years completed the questionnaire. Results: Physician‐diagnosed asthma was reported by 32 swimmers (16%), including 24 (12%) with exercise‐induced asthma. Physician‐diagnosed allergy was reported by 81 (41%) swimmers. Asthmatic symptoms during swimming were described by 84 subjects (42%). Most symptoms occurred when swimming exceeded speeds corresponding to the lactic/anaerobic threshold. Family history of asthma was significant and the most important risk factor for asthmatic symptoms. Conclusions: The prevalence of asthma in swimmers was higher than in the general population but not different from that in other endurance athletes. Family history of asthma and increased swimming intensity had the strongest associations with the reported asthmatic symptoms. Please cite this paper as: Päivinen MK, Keskinen KL and Tikkanen HO. Swimming and asthma: factors underlying respiratory symptoms in competitive swimmers. The Clinical Respiratory Journal 2010; 4: 97–103.     

Asthma medication adherence among urban teens: a qualitative analysis of barriers,facilitators and experiences with school-based care

Objective: Teens with persistent asthma do not always receive daily preventive medications or do not take them as prescribed, despite established clinical guidelines. The purpose of this study was to understand urban teens’ experiences with asthma management, preventive medication adherence and participation in a school-based intervention. Methods: Teens (12–15 years) with persistent asthma, and prescribed preventive medication, participated in a pilot study that included daily observed medication therapy at school and motivational interviewing. Semi-structured interviews occurred at final survey. Qualitative content analysis enabled data coding to identify themes. Results: Themes were classified as “general asthma management” or “program-specific.” For general management, routines were important, while hurrying interfered with taking medications. Forgetfulness was most commonly linked to medication nonadherence. Competing demands related to school preparedness and social priorities were barriers to medication use. Independence with medications was associated with several benefits (e.g. avoiding parental nagging and feeling responsible/mature). Program-specific experiences varied. Half of teens reported positive rapport with their school nurse, while a few felt that their nurse was dismissive. Unexpected benefits and barriers within the school structure included perceptions about leaving the classroom, the distance to the nurse’s office, the necessity of hall passes and morning school routines. Importantly, many teens connected daily medication use with fewer asthma symptoms, incenting continued adherence. Conclusions: Teens with asthma benefit from adherence to preventive medications but encounter numerous barriers to proper use. Interventions to improve adherence must accommodate school demands and unique teen priorities. The school nurse’s role as an ally may support teens’ transition to medication independence.     

Asthma management in primary care: does increasing patient medication improve symptoms?

Aims: We set out to observe the General Practitioner (GP) management of a cohort of asthma patients over a 2‐year period by comparing asthma health status, spirometry, British Thoracic Society treatment step, inhaled medication uptake and psychological status. Changes in these parameters were assessed over the 2‐year period. Methods: One hundred fourteen subjects were recruited from four GP practices, two in the inner city and two in suburbia. Subjects were assessed at baseline and at 2 years using the Juniper asthma quality of life questionnaire, the locally devised Q score (a simple patient‐focused morbidity index) and the hospital anxiety and depression (HAD) scale. Spirometry (forced expiratory volume in 1 s, forced vital capacity and peak expiratory flow) was recorded using a Micro Medical portable spirometer (Micro Medical Ltd, Chatham, UK); the best values from three acceptable attempts were recorded. Results: Data for 90 subjects reviewed at baseline and at 24 months were compared to the original cohort of 114 subjects. Patients who had the treatment increased showed no apparent benefit over 2 years. They had similar physiology and symptom scores at baseline but had higher HAD scores (particularly depression element P < 0.05) initially. The picture remained constant over the 2 years. Conclusion: Asthma guidelines define the aim of treatment to minimise or abolish symptoms. We suggest that if the symptoms are not measured, they remain unrecognised. This is something that could and should be incorporated routinely into clinical practice because this is morbidity that is largely treatable. Please cite this paper as: Rimington LD and Pearson MG. Asthma management in primary care: does increasing patient medication improve symptoms? The Clinical Respiratory Journal 2008; 2: 92–97.     

An integrated operational definition and conceptual model of asthma self-management in teens

Objectives: A previous definition of adolescent asthma self-management was derived from interviews with clinicians/researchers and published literature; however, it did not incorporate perspectives of teens or parents. Therefore, we conducted in-depth interviews with teens and parents and synthesized present findings with the prior analysis to develop a more encompassing definition and model. Methods: Focal concepts were qualitatively extracted from 14-day self-management voice-diaries (n = 14) and 1-hour interviews (n = 42) with teens and parents (28 individuals) along with concepts found in the previous clinical/research oriented analysis. Conceptual structure and relationships were identified and key findings synthesized to develop a revised definition and model of adolescent asthma self-management. Results: There were two primary self-management constructs: processes of self-management and tasks of self-management. Self-management was defined as the iterative process of assessing, deciding, and responding to specific situations in order to achieve personally important outcomes. Clinically relevant asthma self-management tasks included monitoring asthma, managing active issues through pharmacologic and non-pharmacologic strategies, preventing future issues, and communicating with others as needed. Self-management processes were reciprocally influenced by intrapersonal factors (both cognitive and physical), interpersonal factors (family, social and physical environments), and personally relevant asthma and non-asthma outcomes. Conclusion: This is the first definition of asthma self-management incorporating teen, parent, clinician, and researcher perspectives, which suggests that self-management processes and behaviors are influenced by individually variable personal and interpersonal factors, and are driven by personally important outcomes. Clinicians and researchers should investigate teens' symptom perceptions, medication beliefs, current approaches to symptom management, relevant outcomes, and personal priorities.     

Assessing adherence and factors associated with adherence in young children with asthma

Background and objective:   Adherence with preventive asthma medication by young children is an important factor when evaluating a suboptimal response to treatment. However, few data exist regarding the accuracy of subjective measures of adherence and factors associated with adherence in young children.
Methods:   Fifty-one asthmatic children aged 18 months to 7 years had their use of preventive asthma medication monitored using an electronic monitoring device (Smartinhaler) for 1 month. At a follow-up visit the child's parent was asked how often medication had been given and they also completed a confidential questionnaire that included questions about medication usage, barriers to optimal adherence and parenting. The treating physician made an estimate of the child's likely use of medication.
Results:   The median use of medication as determined by the Smartinhaler was 70.5% (range 21.4–100%). The parents' verbal reports (85.1%) and questionnaire responses (84.2%) overestimated medication usage. The physician was not able to determine which parents correctly estimated their child's use of medication ( P  = 0.28). The child's age, level of parental education and annual family income did not influence adherence. Parents reported simply 'forgetting' or their child's 'reaction to being given medication' as the principal barriers to adherence. There was a significant association between how stressful the parent found parenting and adherence ( P  = 0.05).
Conclusion:   Adherence with preventive medication, even within the context of a research study, was generally low and highly variable. Subjective measures of adherence were found to overestimate adherence in young asthmatics.     

Children with asthma and their caregivers help improve written asthma action plans: A pilot mixed-method study

Objective: The objectives of this study were to (a) qualitatively examine caregiver and child feedback about a gold standard written asthma action plan (WAAP), and (b) determine whether having an asthma action plan was associated with child and caregiver self-efficacy in managing an exacerbation. Methods: This was a cross-sectional analysis of structured interviews with 22 children with persistent asthma that collected feedback about the WAAP as well as self-efficacy. An analysis of interviews used the constant comparative method to identify themes of child and caregiver statements. Caregivers completed a questionnaire that measured asthma management self-efficacy, barriers to managing asthma, and belief in the treatment efficacy using validated scales. Results: Approximately 36% of the caregivers reported having a WAAP for their child from their child's pediatrician. Most caregivers stated that having pictures would improve the WAAP, while most children stated that the layout needed to be improved by adding more space between the sections. Caregivers who reported knowing what the asthma action plan was had greater self-efficacy than caregivers who did not (z = ?1.99, p = 0.047). Conclusions: Re-designing the current WAAP layout and including pictures of inhalers may promote patient understanding. Future research needs to examine if a re-designed WAAP improves asthma management of children with asthma and their caregivers.     

Lung function and symptom perception in children with asthma and their parents

A large proportion of children with asthma are managed without recourse to specialized care, and treatment decisions are based solely on symptoms as reported by the children and their parents. We investigated 90 school-age children with the diagnosis of asthma and their accompanying parent to evaluate whether we can obtain better information by using three different means of asking for asthma symptoms: a questionnaire for children (QSR(children)), "smilies," and a visual analogue scale for children (VAS(children)). Furthermore, we analyzed the relationship between these symptom reports and lung function results. Finally, we attempted to determine whether performing a lung function test contributes relevant information toward improving asthma management. Multiple linear regression adjusted for age and gender showed a significant relationship between VAS for children and forced expiratory volume in 1 sec (FEV(1)) (P = 0.047) and maximal expiratory flow at 50% of forced vital capacity (MEF(50)) (P = 0.037). Neither age, gender, QSR for children, "smilies for children" nor all the parents' scores showed a significant association with lung function measurement in the regression model. Subgroup analysis with Spearman's rank correlation coefficients by age group revealed significant correlation in children <10 years between VAS for children, QSR for parents, smilies for parents, and the lung function parameters FEV(1), and MEF(50). Above age 10 years there was no correlation at all, with the accuracy correlation ranging from -0.04 to +0.21. Our data demonstrate that reported symptoms do not reliably correlate with lung function results in asthmatic children and the childrens' parents, and correlation is dependent on the instrument used for symptom evaluation. In children, the VAS, and in parents, the QSR were the most valuable means of obtaining best information on asthma symptoms. This underlines the importance of supplementing information on asthma symptoms with lung function measurements to more reliably assess the severity of asthma.     

Mepolizumab improves work productivity,activity limitation,symptoms, and rescue medication use in severe eosinophilic asthma

Patients with severe eosinophilic asthma experience daily activity limitations and reduced productivity at work. Using anonymized individual patient‐level data from two previously conducted randomized, double‐blind, placebo‐controlled studies (MENSA [GSK ID:115588/{"type":"clinical-trial","attrs":{"text":"NCT01691521","term_id":"NCT01691521"}}NCT01691521]; MUSCA [GSK ID:200862/{"type":"clinical-trial","attrs":{"text":"NCT02281318","term_id":"NCT02281318"}}NCT02281318]), we investigated the effect of mepolizumab on work productivity, activity limitation, symptoms, and rescue medication use. Patient‐reported outcomes including Work Productivity and Activity Impairment–General Health (WPAI‐GH) scores (impairment percentages, 0%–100%), global activity limitation (scale 1–4), and perceived change in activity limitation (Likert scale 1–7) since the start of the study were analyzed. WPAI‐GH scores from MENSA were analyzed post hoc for employed patients using mixed model repeated measures; global activity limitation and perceived change in activity limitation from MUSCA were analyzed by ordinal logistic regression. Mean changes from baseline in daily asthma symptom scores (scale 0–5) and rescue medication use (occasions/day) were also assessed, via a post hoc meta‐analysis of MENSA and MUSCA. At study end, WPAI‐GH scores indicative of overall work impairment, impairment while working, and activity impairment consistently improved with mepolizumab versus placebo. Overall, 76% versus 54% of patients rated their activity as “much better,” “better,” or “slightly better” since the start of the study with mepolizumab versus placebo. Mepolizumab was associated with numerically larger improvements from baseline in asthma symptoms (treatment difference 0.21–0.29 points) and rescue medication use (treatment difference −0.08 to −0.22 occasions/day) versus placebo. Our results indicate that patients with severe eosinophilic asthma may experience improved activity limitation, work productivity, symptoms, and rescue medication use with mepolizumab.     

‘You have to learn to live with it’: a qualitative and quantitative study of older people with asthma

Introduction: Asthma mortality has declined overall because of a range of public health initiatives. In western countries, the majority of asthma deaths now occur in people over the age of 50. The reasons for the poorer response of older age groups to public health asthma initiatives are not known. Objectives: We undertook a study to investigate the disease perspectives of older people with asthma and barriers which may exist and prevent optimal asthma care. Methods: Fifty‐five participants (16 male and 39 female) aged over 50 from an inner city, suburban area and a rural region were recruited. Lung function was measured, and questionnaire data on asthma symptoms, knowledge and control, medication use and respiratory health were collected. Participants were also interviewed in‐depth, and the quantitative and qualitative data were triangulated. Results: Participants with a duration of asthma for >30 years reported significantly fewer symptoms and better quality of life irrespective of asthma severity, indicating less appreciation of symptoms in those with a long asthma duration. Interviews revealed this was related to previous asthma management strategies when treatment options were limited. Participants with a recent diagnosis sought understanding of asthma and the reason for their illness. Initiatives to improve asthma care in older people need to reflect these findings. Conclusions: Self‐management strategies for older people need to be tailored according to the time of disease onset and the duration of disease. Please cite this paper as: Goeman DP, O’Hehir RE, Jenkins C, Scharf SL and Douglass JA. ‘You have to learn to live with it’: a qualitative and quantitative study of older people with asthma. The Clinical Respiratory Journal 2007; 1:99–105.     

Effect of asthma compliance enhancement training on asthma control in patients on combination therapy with salmeterol/fluticasone propionate: a randomised controlled trial

Objective: We investigated if a higher proportion of adults with previously uncontrolled asthma can achieve total control when given salmeterol/fluticasone propionate (50/250 µg) bid and compliance enhancement training (CET) compared to those given medication alone. Methods: Open comparison of stable, but uncontrolled, adult asthmatics. After a 12‐week treatment period on salmeterol/fluticasone propionate (period 1), patients who failed to achieve control were randomised to continuing treatment with or without CET for 12 weeks (period 2). The primary end point was the proportion achieving total control of their asthma in 7 of the last 8 consecutive weeks of period 2. Results: A total of 361 subjects (50.4% males, mean age 40.0 ± 14.4 years) in 29 centres were included, of whom 75.9% were randomised into treatment period 2 (n = 140 in the intervention group). The proportion of subjects achieving total asthma control was 8.8% and 7.6%, respectively, in the intervention and control group [not significant (NS)]. Mean morning peak flow, forced expiratory volume in one second (FEV₁), asthma symptom score and quality of life improved significantly over the study period in both treatment groups. Furthermore, proportion of days with use of rescue medication declined from 59.7% ± 34.6% (55.7% ± 35.3%) during screening to 20.3% ± 29.2% (19.4% ± 30.9%) during treatment period 2 (NS). Conclusion: CET failed to increase the likelihood of achieving total control in asthmatics on salmeterol/fluticasone propionate compared to subjects receiving medication only. However, both groups had a significant improvement in asthma control. (Clinical Trials.gov number, NCT00351143) Please cite this paper as: Ulrik CS, Claudius BK, Tamm M, Harving H, Siersted HC, Backer V, Hellquist B, Dahl R, Høgholm A and Jøhnk IK. Effect of asthma compliance enhancement training on asthma control in patients on combination therapy with salmeterol/fluticasone propionate: a randomised controlled trial. The Clinical Respiratory Journal 2009; 3: 161–168.     

The challenge of asthma in adolescence

The adolescents with asthma are a distinct group of patients with different problems and needs compared to children and adults. Specific issues of asthma in adolescence are the variability of the clinical spectrum, the presence of particular risk factors for the persistence of symptoms, underdiagnosis and undertreatment of the disease. Refusal of the sick role, denial of symptoms, carelessness about dangerous inhalation exposure, erratic self-medication, overexertion without taking precautions against exercise-induced asthma, and a poor relationship between patients, their families, and often doctors are the main obstacles to successful management of asthma in this critical age. There are also major problems of compliance for these patients. The goal of optimal quality of life will be achieved only if the physician thoroughly understands the adolescent's needs and provides optimal care.     

Evaluation of daily home spirometry for school children with asthma: new insights

Home spirometers are useful for monitoring asthma therapy and for research, but the validity of maneuvers in children is in question. We evaluated the quality of PEF, FEV(1), and FVC data obtained from 67 children with persistent asthma who self-administered spirometry at home using the hand-held ndd EasyOne Frontline Spirometer with full expiratory curve data, electronic measurements of maneuver quality, and on-screen incentives. Half were studied in 2003 in one region, and half in 2004 in another region of Southern California. Subjects were followed at home weekly over 2 months and daily over 10 consecutive days. We retained completed spirometry sessions (9,916) consisting of three of six best maneuvers in the morning, afternoon, and evening. Percent compliance, software assessed repeatability and acceptability modified from American Thoracic Society criteria, and visually assessed quality of maneuvers, were compared across daily and weekly follow-up, study regions, and subject characteristics. Compliance was higher for daily (>90%) than for weekly follow-up (>84%), but not significantly different, and was consistent across subject characteristics. The number with two reproducible and acceptable maneuvers was significantly lower in the first than second region for daily (70 vs. 90%) and weekly follow-up (66 vs. 87%). Of 22,926 software accepted maneuvers, 1,944 (8.5%) were visually rejected (variable effort, cough, glottic closure). Maneuver quality was significantly lower for subjects age 9-12 versus 13-18 years, for subjects not taking anti-inflammatory medications, and for subjects with <80% predicted FEV(1). Longitudinal data collection is possible in children with asthma by employing repeated home training and follow-up, and using spirometers with built in quality assurance and incentive software. Region, age, and multiple indicators of persistent asthma, predict ability to perform reliable and accurate lung function maneuvers.     

A randomized trial of peak-flow and symptom-based action plans in adults with moderate-to-severe asthma

OBJECTIVE: Peak flow meters (PFM) continue to be recommended as an important part of asthma self-management plans. It remains unclear if there is an advantage in using PFM in people with moderate-to severe asthma who are not poor perceivers of bronchoconstriction. METHODOLOGY: Prospective, randomized controlled trial of 134 adults with moderate-to-severe asthma who did not have evidence of poor perception of bronchoconstriction on histamine challenge testing, who were recruited from inpatients and outpatients of a university teaching hospital. Comparison was made over 12 months of the effectiveness of written action plans using either peak flow monitoring or symptoms to guide management. Subjects were contacted at monthly intervals by telephone for reinforcement and evaluation of use of the action plans, and to provide ongoing education. Spirometry and PD20 histamine were measured at 3-monthly intervals. Measures of health care utilization and morbidity (asthma exacerbations; hospitalizations; emergency department (ED) visits; days absent from work or school due to asthma; medication use and a self-rating of asthma severity) were made monthly. A psychosocial questionnaire (attitudes and beliefs, state-trait anxiety, denial) was given at entry and at 12-months or at withdrawal from the study. RESULTS: There were significant improvements for both groups for hospitalizations, ED visits, days off from school or work, and PD20 histamine, but no between-group differences. Appropriate use of action plans was 85% in the symptoms group and 86% in the PFM group. For all subjects, those who subsequently had an ED visit had significantly higher levels of denial (P=0.04) and lower scores for self-confidence (P=0.04), compared to those who did not have an ED visit. CONCLUSIONS: Use of written action plans, combined with regular contact to reinforce self-management, improved airway reactivity and reduced health care utilization. However, use of PFM was not superior to symptom-based plans.     

Difficult asthma in adults: recognition and approaches to management

Difficult asthma must be distinguished from severe asthma. It is then important in patients with suspected difficult asthma to ensure that the diagnosis is correct, and that if the patient has asthma that the attributed symptoms are indeed all genuinely due to the asthma and not to coexisting physical or psychogenic respiratory conditions. It is also important to be alert when there is discordance between symptoms and objective lung function in order to recognize both poor perceivers and over-reactors. Difficult asthma can occur in patients with objectively mild, moderate or severe disease, but the consequences are most dramatic in patients with severe asthma. Asthma may be difficult for the patient, for the clinician or both because of disease factors, doctor or nurse therapist factors, and/or patient factors. Investigation requires access to the full range of respiratory, imaging and allergy tests. It also requires a multidisciplinary approach involving ear, nose and throat specialists and speech therapists, and access to psychiatric and psychological assessment and therapies. Poor compliance is associated with significantly poorer asthma and asthma-related health outcomes. Poor compliance can be recognized in two-thirds of such patients by their not attending scheduled appointments. Poor compliance is significantly associated with anxiety, social deprivation and adverse family circumstances, and these characteristics and adversities probably contribute to the poorly compliant behaviour. In difficult asthma it is important to identify and manage the condition causing the symptoms rather than prescribing more and more asthma therapy. Recognizing psychosocial adversity is essential. A structured approach is essential. There remains a small number of patients with genuine steroid-resistant asthma, some with predominately neutrophilic rather than eosinophilic airway inflammation, and others for whom the secondary gain of continuing symptoms is overwhelming. There is a need for further research using agreed definitions, structured approaches and a full range of investigations in patients with difficult asthma.