Understanding Pediatric Inner-City Asthma: An Explanatory Model Approach

Explanatory models (EMs) for asthma among inner-city school-age children and their families were examined as a means of better understanding health behaviors. Children and parents were interviewed about their concepts of asthma etiology, asthma medications, and alternative therapies. Drawings were elicited from children to understand their beliefs about asthma. Nineteen children with 17 mothers from a variety of cultural backgrounds were interviewed. Among children, contagion was the primary EM for asthma etiology (53%). Twenty-five percent of children reported fear of dying from asthma, while fear of their child dying from asthma was reported by 76% of mothers. Mothers reported a variety of EMs, some culturally specific, but the majority reported biomedical concepts of etiology, pathophysiology, and triggers. Although 76% of mothers knew the names of more than one of their children's medications, 47% thought their child's medications all had similar functions. Thirty-five percent of families used herbal treatments and 35% incorporated religion into asthma treatment. Seventy-one percent of families had discontinued medications and 23% reported currently not giving anti-inflammatory medication. Reasons for discontinuing daily medications included fears of unknown side effects (53%), addiction (18%), tachyphylaxis (18%), and feeling that their child was being given too much medicine (23%). The traditional focus of asthma education is not sufficient to ensure adherence. Asthma education for children should address their views of etiology and fears about dying from asthma. Conversations with parents about their EMs and beliefs about medications and alternative therapies could assist in understanding and responding to parental concerns and choices about medications and help achieve better adherence.     

What Are the Determinates of Asthma Control?

The evolution of our understanding of treatment of asthma begins with assessment of severity which is primarily related to the natural history of the disease. Control is defined as normalizing of the physiologic abnormalities and lessening economic and social burden of the disease. This paper reviews the factors that influence the variability and determinants of asthma control. The tools to validate and access asthma control should be employed in daily clinical practice.

Therefore, it is important to determine asthma control based on a multidimensional approach including physiologic assessment, global assessment of functionality, daytime symptoms, nighttime symptoms, healthcare utilization, and adherence to therapy.     

Asthma Control and Patient Satisfaction Among Early Pediatric Users of Montelukast

Objective: To assess asthma control and patient satisfaction among pediatric users of montelukast in a clinical practice setting.

Study Design: A prospective study of 175 children with persistent asthma, 6 to 14 years of age, who initiated treatment with montelukast between Feb-1998 and Aug-1998, in primary care and pediatric offices across the United States. Data on asthma control and satisfaction with treatment was collected in physicians' offices after enrollment and by survey to the patients' homes at 1 month of treatment.

Results: Across the study population, improvements in mean scores for asthma control and parent satisfaction were observed at the 1-month follow-up compared with baseline. At 1 month, 57.7% of patients had none of four issues indicative of poor asthma control, compared with 19.4% at baseline. Similarly, after 1 month of treatment with montelukast, 2.7 times as many parents reported being very satisfied with asthma therapy (using montelukast) compared with the previous controller therapy regimen at baseline. During the 1-month follow-up period, montelukast was used as the only controller medication by 18.3% of patients, and in combination with another controller medication by 81.7%.

Conclusions: Observations from this study over one month suggest that a significant percentage of pediatric patients successfully managed their asthma with montelukast and their parents were satisfied with their medication, compared to baseline.     

Risk-Benefit Assessment of Fluticasone Propionate in the Treatment of Asthma and Allergic Rhinitis

Benefits

Fluticasone propionate (FP) is a new topical corticosteroid spray for the treatment of allergic rhinitis and asthma. FP has been shown to be effective for the treatment of adult and pediatric asthma, even at rather low doses (25 μg twice daily [b.i.d.]); many studies in asthma have shown clinical efficacy of fluticasone at half the dose of the comparison steroid (such as beclomethasone dipropionate [BDP) or budesonide [BUD]). However, exact dose comparisons cannot be made because dose-ranging comparison studies have not been done. Studies in allergic rhinitis in children and adults have shown good efficacy in FP-treated patients at a dose of 200 μg once daily (o.d.), intranasally. In summary, FP is effective in both asthma and allergic rhinitis.

Risks

FP has minimal systemic activity because the portion of drug that is swallowed is not absorbed from the gut. Thus, the amount available for systemic activity is only that which is absorbed through the nasal mucosa (in the treatment of rhinitis) or through the alveoli of the lungs (in the treatment of asthma). When laboratory assays of adrenal function or bone formation are measured, FP and other inhaled corticosteroids can be shown to cause suppression of these markers, especially at high doses. There have been no consistent reports of clinical adrenal suppression or osteoporosis caused by FP.

In summary, the risk-benefit ratio of FP at the usual doses (therapeutic ratio) is very favorable. High doses may show evidence of suppression of the hypothalamic pituitary axis as measured by in vitro tests, but evidence of corresponding clinical adverse effects is lacking.     

Feasibility of a National Fatal Asthma Registry: More Evidence of IRB Variation in Evaluation of a Standard Protocol

Purpose. Approximately 4,500 Americans die from asthma each year. Our objective was to determine the feasibility of creating a national fatal asthma registry to better understand this problem.

Methods. Using a standard questionnaire, 18 state vital statistics departments and 22 medical examiners offices were contacted in 2001 to assess availability of fatal asthma data. Funding was obtained in 2002 to implement a fatal asthma registry. During 2003, the project was put on hold due to uncertainty about the impact of the Health Insurance Portability and Accountability Act (HIPAA). The project was revived in 2004 when a standard protocol was submitted to Institutional Review Boards (IRBs) in four different states.

Results. All vital statistics departments reported that they were able to identify the decedent's name and demographic characteristics. Contact information for a relative or doctor was available in all states. Demographic characteristics and autopsy findings were available from 100% of the medical examiners offices. However, IRBs at the four institutions required major protocol modifications, including language and approach for contacting next of kin.

Conclusion. Availability of demographic and clinical data across states is consistent. The creation of a national fatal asthma registry appears feasible, but different IRB interpretations of what is permissible preclude a standard approach across states.     

Relationships Between Self-Reported Asthma Utilization and Patient Characteristics

Background: Identifying asthmatic individuals most likely to utilize medical care in the future will help to direct intervention and medical resources; however, there are currently limited models for future utilization.

Objective: This study investigated the relationship between patient characteristics and medical utilization, using an asthma disease management patient population.

Methods: We analyzed a sample of 1412 adults, enrolled for 6 months in an asthma disease management program, for relationships with utilization. Individuals answered demographic, socioeconomic, and medical questions via telephonic contact upon enrollment. Follow-up regarding medical utilization occurred during the subsequent 6 months. Relationships between utilization and enrollment answers were statistically modeled.

Results: Oral steroid bursts, day and night symptom frequencies, age, gender, education level, and employment status all had a significant relationship to medical utilization. Those individuals who had used oral steroids 6 months prior to enrollment, patients with more than five night-time asthma symptoms per month, and those with “continuous” day symptoms were more likely to report utilization. Those patients under 44 years old, females, those who were not high school graduates, and patients who defined themselves as unemployed because of their asthma were also more likely to report utilization. While those unemployed because of asthma were already more likely to report utilization, individuals in the 45+ age category were more likely than those 18-44.

Conclusions: Identifying asthma patients likely to utilize medical care is feasible, although more investigation is needed to demonstrate applicability to a general asthma population.     

Intractable or Uncontrolled Asthma: Psychosocial Factors

The purpose of this study was to address the question of why, when there is a comparable severity of asthma, medical facilities, and treatments, some children develop controlled asthma whereas other children do not and are frequently ill. The major research questions pertained to whether families with a child with uncontrolled asthma differ from families with a child with controlled asthma as regards family characteristics and child-rearing attitudes, whether particular psychosocial variables relate to the severity of the asthma, and whether the interaction between the severity of the asthma and its controllability may clarify the role of psychosocial variables. Two studies were conducted, in which 70 asthmatic children (age range 9-15 years) and their families participated. The children and their caregivers were presented with measures assessing parental child-rearing attitudes, the problem-solving abilities of the caregivers, family functioning, and emotional disorders in the asthmatic children. Contrary to the assumptions derived from the psychosomatic family model, the findings of these studies suggest, among other things, that cohesion of family members and rigid manner of function of caregivers may have a positive rather than a negative influence on the welfare of the asthmatic child. In addition, controlled asthma was found to relate to the correct use of medication, which was predominantly evident in more structured and interdependent family environments. Of major importance is the conclusion that a distinction between controlled and uncontrolled asthma leads to a better insight into the role of psychosomatic variables than a distinction on the basis of the severity of the asthma.     

On occupational allergic asthma of different kinds newly found in our allergy clinic

The following four kinds of occupational allergic asthma newly found by the author and his associates are reported here

1) Inhalative asthma caused by mulberry lumber among the lumber processors, 2) Inhalative asthma caused by the spores of lycopodium clavatum (“sekishoshi”) among dental technicians, 3) Buckwheat allergose among the cooks of a buckwheat-noodle service shop, and 4) Pancreatin allergose among the pharmaceutists. Including the cases introduced by the author, new sorts of occupational asthma have been yearly discovered as the fruits of untiring researches by the members of the Research Group on Occupational Allergy in Japan.

Nevertheless, various kinds of working circumstances exist in our surroundings, and occupational allergy of many kinds may still be unknown. Now the problem of occupational allergy comes into the limelight, likewise the question of public injury. We stand in need of looking at our surroundings again from this point of view.

In closing, the author would like to express his gratitude to his associates Drs. Tokuo Hirai, Jitsuro Ueno, Binzaburo Murohisa, Tatsuya Kawasaki and Michiko Mori, for their close cooperation and generous aid.     

Asthma and Human Excellence

Superior intelligence, creative genius, extraordinary personality, and/or social prominence have been associated with asthma often enough to raise the question of a nonrandom concurrence. With no intent to prove any developmental correlation, this section of the Journal of Asthma presents such “case reports” (more biographical than biological) for two main reasons: (A) to document the experience of asthma in the life of outstanding persons and (B) to make everyone better acquainted-using asthma as an “excuse”- with the work and times of some unique human beings.

Seneca and His Asthma: The Illnesses, Life, and Death of a Roman Stoic Philosopher     

Asthma and Human Excellence

Superior intelligence, creative genius, extraordinary personality, and/or social prominence have been associated with asthma often enough to raise the question of a nonrandom concurrence. With no intent to prove any developmental correlation, this section of the journal of Asthma presents such “case reports” (more biographical than biological) for two main reasons: to document the experience of asthma in the life of outstanding persons and to make everyone better acquainted—using asthma as an “excuse”—with the work and the times of some unique human beings.

Arnold Schoenberg and Alban Berg The Serial Music and Serious Asthma of Two Leading 20th-century Composers     

Effect of Indoor Mold Concentrations on Daily Symptom Severity of Children with Asthma and/or Rhinitis Monosensitized to Molds

Little is known about the contribution of indoor molds to the symptoms of asthma and/or rhinitis in children monosensitized to molds. We aimed to investigate the effect of indoor mold spore concentrations on daily symptoms of asthma and/or rhinitis in children monosensitized to molds.

Nineteen children with asthma and/or rhinitis sensitized only to molds recorded their daily symptoms and peak expiratory flow (PEF) values to the diaries, from February 2005 to January 2006. In this study period, indoor mold concentrations were measured monthly from the living rooms/bedrooms.

The median indoor mold concentration was 37.5 CFU/m³. Most commonly recovered indoor molds were Cladosporium (26.4%), Penicillium (24.7%), and Aspergillus (7%). Significant correlation was not found between indoor mold concentrations and daily rhinitis score (r = -0.021, p = 0.932), daily asthma score (r = 0.155, p = 0.554), daily morning PEF (r = -0.056, p = 0.475), and evening PEF (r = -0.057, p = 0.471).

The effect of indoor molds is not evident on the symptoms of our patients with asthma and/or rhinitis monosensitized to molds.     

What Nurses in Primary Care Practices Know About Asthma Care: Results from a National Survey

Objectives: The purpose of this study was to characterize what nurses working in primary care settings know about asthma care. Current views on the care of persons with asthma suggest the need for sound knowledge of guideline-based care and a health care team that includes both physicians, nurses, and other providers. While there are reports of physician-related asthma care practices in the United States, there are few, if any, reports of nursing knowledge, attitudes, or beliefs about asthma care.

Methods: A national, randomly selected, representative sample of nurses working in ambulatory primary care settings was interviewed by telephone using a structured interview format.

Results: Of a sample of 80 nurses, less than 10% identified inflammation of the airways as the underlying condition that causes asthma symptoms. Fifty-one percent believed the underlying condition could be treated, while 44% believed only the symptoms could be treated, and 5% didn't know. Only 35% said they were aware of the National Heart, Lung, and Blood (NHLBI) asthma guidelines.

Conclusions: Nurses working in ambulatory primary care settings may lack sufficient knowledge to effectively teach and participate in asthma care.     

Patient Education Provided to Asthmatic Children: A Historical Cohort Study of the Implementation of NIH Recommendations

NIH guidelines for treatment of childhood asthma emphasize educating both patients and family about avoiding triggers and providing information to support self-management of asthma. To determine the extent to which primary care providers had implemented these recommendations, we examined the patient education provided to a cohort of asthmatic children (n = 331) between January and December 1994.

During 1994 education of any type was documented for less than half the children. Provision of education was associated with asthma severity: An action plan for exacerbations was discussed with the majority with moderate or severe asthma (61%). Avoiding triggers (aOR: 2.38, 95% CI: 1.37-4.12) and treatment goals (aOR: 3.14, 95% CI: 1.46-6.75), were more likely to be discussed with children who were prescribed inhaled anti-inflammatory medication, after adjustment for asthma severity and age.

Limited implementation of the NIH recommendations by primary care providers in our study may have reduced their impact on the management of childhood asthma.     

Effect of Suplatast Tosilate on Airway Hyperresponsiveness and Inflammation in Asthma Patients

Because eosinophilic airway inflammation is a characteristic of bronchial asthma, the treatment of such inflammation is important in the management of this disease. Suplatast tosilate is a novel anti-asthma drug that suppresses eosinophil proliferation and infiltration through selective inhibition of Th2 cytokine synthesis.

We investigated the effect of oral suplatast tosilate therapy in patients with mild and moderate asthma.

Twenty-eight asthma patients were randomized into two groups with or without suplatast tosilate treatment (100 mg t.i.d. for 28 days). We examined the blood eosinophil counts, eosinophilic cationic protein level, sputum eosinophil count, exhaled nitric oxide level, and airway responsiveness before and after treatment.

In patients treated with suplatast tosilate, the eosinophil count in the blood and sputum was significantly decreased after treatment, while there was no such change in the patients without suplatast treatment. The exhaled nitric oxide level and airway responsiveness (measured using an Astograph) were also decreased after treatment with suplatast tosilate, while there were no significant changes in patients without suplatast tosilate.

These results strongly suggest that oral administration of suplatast tosilate suppresses airway hyperresponsiveness in asthma patients by reducing eosinophilic inflammation in the airways.     

Anxiety in Children with Asthma

The purpose of this study was to examine associations between levels of state and trait anxiety in children with asthma and increased asthma morbidity immediately following an acute asthmatic attack. A total of 155 children, aged 7-12 years, diagnosed with asthma, were administered the State-Trait Anxiety Inventory for Children (STAIC) while the State-Trait Anxiety Inventory Form Y (STAI) was administered to the mother.

The mother's state and trait anxiety scores were consistently higher than the child's scores, and there was no significant correlation between child and mother anxiety levels. Almost two-thirds of children reported feeling “panic” at the beginning of the index asthma attack, which was significantly associated with child state anxiety. Health professionals must be sensitive to child as well as maternal anxiety in families of children with asthma.     

The Allocation of Family Responsibility for Asthma Management Tasks in African-American Adolescents

The allocation of responsibilities for asthma management within African-American families was examined in 60 adolescents and their primary caretakers. Separate structured interviews were conducted with adolescents and primary caretakers, and perceptions of family management, adherence to asthma treatment regimen, and functional morbidity were assessed. Support for the primary hypothesis that higher levels of nonadherence and functional morbidity would be observed in families where caretakers overestimated the level of adolescent involvement in asthma self-care was found. Implications for family-based asthma management in ethnic minority adolescents are discussed.     

The Allocation of Family Responsibility for Asthma Management Tasks in African-American Adolescents

The allocation of responsibilities for asthma management within African-American families was examined in 60 adolescents and their primary caretakers. Separate structured interviews were conducted with adolescents and primary caretakers, and perceptions of family management, adherence to asthma treatment regimen, and functional morbidity were assessed. Support for the primary hypothesis that higher levels of nonadherence and functional morbidity would be observed in families where caretakers overestimated the level of adolescent involvement in asthma self-care was found. Implications for family-based asthma management in ethnic minority adolescents are discussed.     

Living with Asthma

This paper traces the roots of Living with Asthma, a self-management program for childhood asthma, from the Children's Asthma Research Institute and Hospital (CARIH), a residential treatment center in Denver, Colorado. The basic components of the program were developed and tested over the 40-year history of CARIH; the findings of an educational unit were added to this accumulated knowledge and expertise to complete the system.

The program rests heavily on social learning theory, particularly two major tenets: 1) the concept of reciprocal determinism and 2) the learning/performance dichotomy. The crucial role of these concepts is described here, especially with respect to the design of the program and the selection of dependent variables.

The remainder of this article describes the essentials of Living with Asthma, particularly the skills taught and performed by patients in a formal evaluation of the system. The design of the study, characteristics of patients enrolled in the program, and results obtained with the system are discussed. The program proved highly effective in significantly improving the knowledge of asthma in parents and their children, and in developing positive attitudes in both groups. It also produced significant reductions in the number of attacks experienced by the youngsters and improved their peak flow values. Participation in the program resulted in changes in morbidity indices of asthma, including significant reductions in school absenteeism and health-care costs incurred because of the disorder. These changes, it was concluded, reflected the result of the performance by patients of the self-management skills taught in Living with Asthma, coupled with the exceptional medical treatment they received.     

Abstracts

Trends in Childhood Asthma: Prevalence, Health Care Utilization, and Mortality; Akinbami, L.J., and Schoendork, K.C. Pediatrics 2002; 110:315-322

Objective. The objectives of the authors were to use the data from National Health Interview Survey, National Ambulatory Medical Care Survey, National Hospital Ambulatory Medical Care Survey, National Hospital Discharge Survey and Mortality Component, and National Vital Statistic System to compose a comprehensive summary of the trends in childhood asthma, prevalence, health care utilization, and mortality to better evaluate changes in disease burden among U.S. children.

Clinical Population. The population included children ages 0-17 years with asthma, who were analyzed using five databases from the National Center for Health Statistics summarized above. Children were surveyed from 1988 to 2000.

Clinical Findings. Asthma prevalence increased on an average of 4.3% annually from 1980 to 1996 and from 3.6% to 6.2% over the entire period. The prevalence peaked at 7.5% in 1995. In 1997, asthma attack prevalence was recorded as 5.4%, but alterations in the NHIS design in 1997 to include only physician diagnosed asthma prevents comparison with previous estimates. Asthma attack prevalence remained stable from 1997 to 2000. After a decline between 1980 and 1989, the asthma office visit rate increased by an average of 3.8% per year from 1989 to 1999. The asthma hospitalization rate increased by 1.4% from 1980 to 1998. Children ages 0-4 years have the largest increment in the prevalence and had the greater health care utilization, but adolescents had the highest mortality. The asthma burden was disproportionately higher in black children throughout the period. Racial disparities were most apparent with asthma hospitalizations and mortality. Compared to Caucasian children in 1988 to 1999, black children were more than three times greater likelihood of being hospitalized and more than four times as likely to have mortality from asthma.

Conclusions. The conclusions of the authors are that these recent data suggest that the overwhelming burden of childhood asthma may have plateaued recently after several years of increasing, although additional data collection will be necessary to confirm this alteration of the trend. Racial and ethnic disparities remain for asthma care utilization and mortality.

Reviewer's Comments. These national statistics combined from five databases indicate that the asthma attack prevalence may have stabilized from 1997 to 2000, but this trend must be cautiously interpreted. The asthma attack prevalence was obtained by questions relating to diagnosis by health care professional rather than by caretaker assessment only.

Christopher Randolph, M.D.

Waterbury, CT     

Contrast of Pediatric Asthma Management Approaches in a Multicultural and Collectivistic Population

Background. Although asthma is the most prevalent chronic illness in childhood and affects approximately 9 million children, the management approaches used by practitioners may not be efficient from the perspective of families. Clinicians often maintain their usual customs of practice, and the context of the clinical encounter is defined in terms of an individual illness management. In collectivistic and multiethnic settings, the extended kin group or extended family shares responsibility for illness management. The goal of this study is to describe health care providers' strategies to manage children with asthma in a multicultural and collectivistic cultural context. Methods. Data were obtained through semistructured in-depth practitioner interviews. Western-trained and traditional practitioners participated. Results. Narrative analysis strategies produced two major themes: 1) fix the asthma and 2) making connections. Practitioners who perceived their responsibility to fix the asthma (make things physiologically normal) often ran into constraints with dealing with the extended family group. Other practitioners who used strategies of making connections often capitalized on the assistance of others to problem-solve the asthma management. Conclusion. In terms of asthma management, the barriers most frequently reported by practitioners were related to the sociocultural and physical environment. There may be vast differences in asthma management approaches for populations from collectivistic cultural orientation.