慈溪市乡镇医师支气管哮喘认知状况的调查分析

目的了解乡镇医师对支气管哮喘（简称哮喘）基本概念、治疗及管理的认知状况,为基层医师的培训提供依据。方法对慈溪市25家不同级别医院共198名内科医师进行有关哮喘相关知识问卷调查,其中,三级医院1家,内科医师24名;二级医院5家,内科医师70名;一级医院19家,内科医师104名。问题涉及：哮喘定义、一线控制药物、预后、治疗中抗菌药物应用情况、GINA知晓率及医院是否备有吸入激素药物等。结果对哮喘属气道慢性炎症及可控制性疾病,回答正确率分别为85．4％与96％,上述两问题在三级与一、二级医院间差异无统计学意义。对吸入糖皮质激素者为哮喘一线控制性用药、发作时是否应用抗菌药物、GINA知晓率方面,正确率分别为68．7％、29．3％和58．6％。三级医院与一、二级医院间存在显著差异（P〈0．05）。关于医院备有吸入糖皮质激素方面,全市共4家医院备有（1家三级医院、3家二级医院）,一级医院均无吸入激素的备药。结论基层医院,尤其是一、二级乡镇医院对哮喘的防治管理认知方面尚存在较多问题,知识较陈旧,对GINA知晓率较低,不利于基层大量哮喘患者的治疗及管理,规范培训基层医务人员,使其掌握哮喘防治指南,从而有效指导哮喘患者是基层哮喘管理亟待解决的问题。     

新疆和田地区内科医师支气管哮喘认知状况的调查分析

目的 了解新疆和田地区内科医师对支气管哮喘(简称哮喘)基本概念、治疗及管理的认知状况,为基层少数民族医师的培训提供依据.方法 对和田地区26家不同级别医院共246名内科医师进行有关哮喘相关知识问卷调查,其中二级甲等医院1家,内科医师68名;二级乙等医院7家,内科医师122名;一级医院18家,内科医师56名.问题涉及:哮喘定义及哮喘炎症本质、哮喘的症状和诊断、哮喘的药物治疗和首选治疗方法、哮喘防治中存在的误区、全球哮喘防治创议(GINA)知晓情况及医院是否备有吸入激素药物等.结果 对哮喘属气道慢性炎症及哮喘治疗方面如首选治疗方法、治疗目标及控制水平分级,回答正确率仅分别为11.8％、21.5％、8.5％和2.0％,且上述问题在二级与一级医院间差异有统计学意义(P＜0.05).对哮喘GINA知晓率、吸入方法的掌握及慢性疾病理念方面正确率分别为9.3％、13.8％和9.8％.二级甲等医院与二级乙等医院及一级乡镇医院相互间差异有统计学意义(P＜0.05).关于医院备有吸入支气管扩张剂或糖皮质激素方面,全地区七县一市共8家二级医院均备有药物(1家二级甲等地区医院、7家二级乙等县医院).一级乡镇医院均无短效支气管扩张剂和糖皮质激素吸入剂的备药.结论 我国边疆基层医院,尤其是新疆南疆一、二级县乡镇医院对哮喘的认知防治管理方面存在较多问题,知识陈旧,对GINA知晓率低,不利于基层大量哮喘患者的治疗及管理,规范培训基层少数民族医务人员,使其掌握哮喘防治指南,从而有效指导哮喘患者是基层哮喘管理亟待解决的问题.     

上海地区内科医师对哮喘药物知识掌握情况的纵向分析

目的:评价近年上海地区内科医师对哮喘药物知识的掌握情况。方法:于2004年度和2008年度以调查问卷形式对全市不同区县的三级、二级医院的内科医师进行调查,并根据医师专科情况进行亚组分析。结果:参与问卷调查的医师2004年度共124名,2008年度共623名,2个年度中医师在职称级别和二、三级医院比例方面类似,但2008年度受访医师绝大多数为非呼吸专科的大内科医师,占86.9%。对于常用吸入药物的种类和品名了解程度2个年度的调查情况均良好,且无显著差异。但在储存剂量型涡流式干粉吸入器和准纳器的使用正确性方面2008年度有显著下降。亚组分析显示,2008年度内科医师对于吸入激素的判别正确率显著上升,装置使用正确率显著下降,二级医院的情况类似。医师职称的亚组分析显示,主治以上的医师中不但吸入装置的正确使用率显著下降,在对吸入糖皮质激素的商品名熟悉程度上也有下降趋势。对于联合治疗药物的认识,无论是长效肾上腺素β2受体激动剂(LABA)还是白三烯受体调节剂(LTRA),2008年度较2004年度都有显著改善。结论:近4年来上海地区内科医师对于哮喘药物知识的掌握程度总体上有很大提高,尤其是对LABA和LTRA的认识上,但在吸入装置的正确使用等细节上还有待提高,对于高年资医师在这方面的继续教育不容忽视。     

上海地区内科医师对哮喘药物知识掌握情况的纵向分析

目的评价近年上海地区内科医师对哮喘药物知识的掌握情况。方法以调查问卷形式,分别于2004年度和2008年度对全市分布于不同区县的三级、二级甲等医院的内科医师进行调查。结果 2004年度共124名医师参与了问卷调查,2008年度共623名医师参与,2个年度中医师在职称级别和二、三级医院比例方面类似,但2008年度受访医师绝大多数为非呼吸专科的大内科医师,占86.9%。对于常用吸入药物的种类和品名了解程度,2个年度的调查情况均良好,且无显著差异。但在都保和准纳器的使用正确性方面2008年度有显著下降。亚组分析显示,2008年度内科医师对于吸入激素的判别正确率显著上升,装置使用正确率显著下降,二级医院的情况类同。医师职称的亚组分析显示,主治以上的医师中不但吸入装置的正确使用率显著下降,在对吸入糖皮质激素的商品名熟悉程度上也有下降趋势。对于联合治疗药物的认识,无论是长效β2受体激动剂（LABA）还是白三烯受体调节剂（LTRA）,2008年度较2004年度都有显著改善,且内科医师、二级医院医师以及不同职称的医师调查情况均显示认知程度有很大提高。结论近4年来上海地区内科医师对于哮喘药物知识的掌握程度总体上有很大提高,尤其是LABA和LTRA的认识上,但在吸入装置的正确使用等细节上还有待提高,对于高年资医师在这方面的继续教育不容忽视。     

中国原发性醛固酮增多症诊断现状调查研究

目的了解国内原发性醛固酮增多症的诊断现状。方法对中国13个城市的45家三级医院的内分泌专科和心血管专科医师、44家二级医院和22家一级医院的内科医师进行问卷调查, 并对医师原发性醛固酮增多症诊断知识的掌握程度进行评分。结果获得三级医院内分泌专科(n=119)、心血管专科(n=88)、二级医院内科(n=137)、一级医院内科(n=45)医师的有效问卷389份, 结果显示分别有88.2%、84.1%、40.9%、8.9%的医师表示筛查过原发性醛固酮增多症;44.5%、63.6%、83.9%、97.8%的医师对原发性醛固酮增多症诊断知识掌握评分≤60分。结论国内医生对原发性醛固酮增多症诊断知识的掌握存在欠缺、对原发性醛固酮增多症筛查不足的情况较普遍。     

陕西省地区级城市中心医院支气管哮喘相关科室医师的调查分析

目的调查陕西省地区级城市中心医院支气管哮喘(简称哮喘)相关科室医师对哮喘知识的了解程度,旨在评估前期哮喘协作组在医师教育方面的成果,为陕西省下一步的医师教育工作部署提供理论依据。方法在陕西省的6个地区级城市中各选取一所三级医院,以问卷调查的形式了解2007年10月至12月门诊医师对哮喘知识的知晓程度,涉及专业包括呼吸内科、综合内科、儿科和急诊科。调查内容包括哮喘发病机制、防治知识、2006版全球哮喘防治创议(global initiative for asthma,GINA)及相关组织结构等。结果收回调查问卷187份,呼吸内科、综合内科、儿科和急诊科分别占29.9%、23.0%、26.7%和20.3%。①在对哮喘相关组织的了解方面:58.9%～62.5%的呼吸内科医师对哮喘相关指导机构很清楚,远远高于其他专业;但仍有10.7%的呼吸内科医师不知道GINA的含义。知道世界哮喘日的医师已占到87.6%;②在2006版GINA内容方面:认识到哮喘的气道慢性炎症本质的医师为69.9%,其中呼吸内科医师最高为78.6%,综合内科医师最低为55.8%。了解按控制水平分类的呼吸内科医师为69.6%,远远高于其他专科。54.8%～75.0%的医师认识到吸入糖皮质激素(ICS)在哮喘防治中的重要地位。但只有7.1%、42.9%的呼吸内科医师清楚哮喘控制测试、短效β2受体激动剂在哮喘管理中与救治中的作用。清楚长效β2受体激动剂需与ICS联用的医师只有37.8%。了解白三烯受体拮抗剂为控制药物的已达52.0%～76.4%。仍有51.9%的医师认为医院自产的过敏原提取物能够用于临床脱敏治疗。只有35.3%的医师知道肺功能检测能做为确诊哮喘的重要依据。12.3%的医师认为口服是最佳的给药途径。20.9%的医师表示不会用药物吸入装置,19.3%的医师表示没见过。42.2%的医师表示近三年曾参加过哮喘知识新进展的教育或研讨会。54.5%的医师表示为每位接诊的?     

安徽省怀远县支气管哮喘诊治现况分析

目的了解安徽省怀远县乡卫生院及县级医院支气管哮喘（简称哮喘）诊治现况，以及内科、儿科医师对支气管哮喘防治指南掌握情况。方法采用问卷调查与走访结合，共访问10家乡卫生院、2家县级医院门诊、药房、急诊室及部分内科、儿科医师。结果12家医院均无哮喘门诊，无肺功能仪及峰流速仪，无储雾罐及雾化吸入装置。查阅2009年6月至8月的门诊日志及住院病历，有2例门诊哮喘患者，无住院患者。1家县级医院有吸入糖皮质激素，1家县级医院和2家乡卫生院有吸入短效13z受体激动剂。受访医师中44％正确回答典型哮喘临床特点，15％回答只有听到哮呜音才能诊断为哮喘，23％回答控制哮喘首选吸人激素，治疗3个月仍未控制的哮喘患者，19％的受访医师给予升级治疗，56％的受访医师回答哮喘管理中的最基本环节是医师对患者进行教育，10％的受访医师回答哮喘需要长期治疗管理。结论哮喘在安徽省怀远县是被忽视的疾病，医师没有掌握支气管哮喘防治指南，基层医师的继续教育工作有待加强。     

陕西省地区级城市中心医院支气管哮喘相关科室医师的调查分析

目的 调查陕西省地区级城市中心医院支气管哮喘(简称哮喘)相关科室医师对哮喘知识的了解程度,旨在评估前期哮喘协作组在医师教育方面的成果,为陕西省下一步的医师教育工作部署提供理论依据.方法 在陕西省的6个地区级城市中各选取一所三级医院,以问卷调查的形式了解2007年10月至12月门诊医师对哮喘知识的知晓程度,涉及专业包括呼吸内科、综合内科、儿科和急诊科.调查内容包括哮喘发病机制、防治知识、2006版全球哮喘防治刨议(global initiative for asthma,GINA)及相关组织结构等.结果 收回调查问卷187份,呼吸内科、综合内科、急诊科和儿科分别占29.9%、23.0%、26.7%和20.3%.①在对哮喘相关组织的了解方面:58.9%-62.5%的呼吸内科医师对哮喘相关指导机构很清楚,远远高于其他专业;但仍有10.7%的呼吸内科医师不知道GINA的含义.知道世界哮喘日的医师已占到87.6%;②在2006版GINA内容方面:认识到哮喘的气道慢性炎症本质的医师为69.9%.其中呼吸内科医师最高为78.6%,综合内科医师最低为55.8%.了解按控制水平分类的呼吸内科医师为69.6%.远远高于其他专科.54.8%～75.0%的医师认识到吸入糖皮质激素(inhaled corticosteroid,ICS)在哮喘防治牟的重要地位.但只有7.1%、42.9%的呼吸内科医师清楚哮喘控制测试、短效β2受体激动剂在哮喘管理中与救治中的作用.清楚长效β2受体激动剂需与ICS联用的医师只有37.8%.了解白三烯受体拮抗剂为控制药物的已达52.0%～76.4%.仍有51.9%的医师认为医院自产的过敏原提取物能够用于临床脱敏治疗.只有35.3%的医师知道肺功能检测能做为确诊哮喘的重要依据.12.3%的医师认为口服是最佳的给药途径.20.9%、19.3%的医师表示不会用或没见过粉吸入装置.42.2%的医师表示近3年曾参加过哮喘知识新进展的教育或研讨会.54.5%的医师表示为每位接诊的哮喘患者制定了长期用药方案及随访计划.结论 通过调查了解了陕西省地区级城市中心医院医师对哮喘知识的掌握程度.总体来看,呼吸内科医师的掌握程度高于其他专科,但距离普及规范化治疗理念还任重而道远.这些资料将为联盟在西部地区的医师教育工作提供参考.     

湖南省县级医院支气管哮喘防控现状分析

目的了解湖南省基层地区哮喘防控现状。方法采用问卷调查方式,于2009年4月共调查湖南省72家县级医院,每家医院抽取1名哮喘归口科室医生,共72名医生接受调查。结果仅有20.83%(15/72)的医院开展肺通气功能检查,但均未开展支气管激发试验或舒张试验。仅有48.61%的医生选择吸入型糖皮质激素作为一线药物,而30.56%和9.72%的医生分别将口服激素和静脉应用激素作为一线药物。中(成)药、肾上腺素等非常规药物被部分医生作为一线药物应用。仅有19.44%的医生表示了解并且执行了哮喘指南,多数医生处于"听说过但不了解(50%)"及"了解但从未执行(26.39%)"的状态。91.67%(66/72)的医生对哮喘的防控现状不满意,其中86.36%(57/66)的医生认为其主要原因是经济因素。结论推出适合基层应用的改良哮喘防治方案势在必行。     

不同级别的医院医生高血压防治能力调查

目的：了解新疆不同级别医院医生的高血压防治知识及防治水平。方法：于2007年8月18日针对新疆不同级别医院的150名基层医生采用不记名闭卷笔试的方法进行问卷调查。结果：①有89．33％的医生选择≥140／90mmHg为高血压的诊断标准,其中一级医院的正确率是78．26％;②正确选择高血压指南所推荐的一般高血压患者血压控制目标值的为52．00％,而一级医院的医生仅达34．78％;③正确选择高血压指南所推荐的开始非药物治疗血压水平的医生只有44．67％,其中二级医院和一级医院的正确率（29．35％、39．13％）明显低于三级医院的正确率（88．57％）。结论：新疆基层医生对高血压知识的认识处于较低水平．不同级别医院医生的高血压防治水平有较大差异．应加强对一、二级医院医生的再教育。     

Management Preferences of Pediatricians in Moderate and Severe Acute Asthma

Objective. To assess and compare management preferences of physicians for moderate and severe acute asthma based on case scenarios and to determine the factors influencing their decisions.Methods. A questionnaire based on the Global Initiative on Asthma (GINA) guideline and comprising eight questions on management of acute asthma was delivered to participants of two national pediatric congresses. Management of moderate and severe acute asthma cases was evaluated by two clinical case scenarios for estimation of acute attack severity, initial treatment, treatment after 1h, and discharge recommendations. A uniform answer box comprising the possible choices was provided just below the questions, and respondents were requested to tick the answers they thought was appropriate. Results. Four-hundred and eighteen questionnaires were analyzed. All questions regarding moderate and severe acute asthma case scenarios were answered accurately by 15.8% and 17.0% of physicians, respectively. The initial treatment of moderate and severe cases was known by 100.0% and 78.2% of physicians, respectively. Knowledge of the appropriate plan for treatment after 1h was low both for moderate (45.0%) and severe attacks (35.4%). Discharge recommendations were adequate in 32.5% and 70.8% of physicians for moderate and severe attacks, respectively. Multiple logistic regression analysis revealed that working at a hospital with a continuing medical education program was the only significant predictor of a correct response to all questions regarding severe attacks (p = .04; 95%CI, 1.02–3.21). No predictors were found for information on moderate attacks. Conclusions. Pediatricians have difficulty in planning treatment after 1 hour both for moderate and severe asthma attacks. Postgraduate education programs that target physicians in hospitals without continuing medical education facilities may improve guideline adherence.     

Determination of asthma control using administrative data regarding short-acting beta-agonist inhaler purchase

Background: Symptom control is a primary goal in asthma. We hypothesized that administrative data regarding rescue inhaler purchases may correlate with asthma symptom control. Methods: We identified all patients who purchased short-acting beta-agonist (SABA) inhalers during the course of one year in the database of a Health Maintenance Organization (HMO). Primary physicians identified asthma patients and classified their asthma symptom control into three groups according to the Global Initiative for Asthma (GINA) guidelines. Asthma patients were asked to answer symptom questionnaires and grade their asthma control. SABA inhaler purchases were compared between asthma control groups as classified by the guidelines, the physicians and the patients. We also compared the agreement on asthma control between the three methods of classification. Results: Of 241 asthma patients, 83 completed the questionnaires. Using the GINA guidelines criteria, 26 were symptom controlled, 46 were partially controlled and 11 were uncontrolled. SABA inhaler purchases were not significantly lower in the controlled group. Using patients' overall impression of their asthma control, the mean numbers of SABA inhalers purchased were 1.5, 4.4 and 6.4 per year in the controlled, partially controlled and uncontrolled groups, respectively (p = 0.03). Patients' classification of asthma control had better agreement (kappa = 0.34) with GINA guidelines than physician's' agreement (kappa = 0.05). Conclusion: When using administrative data for asthma patients, 2 or more SABA inhaler purchases in one year should alert the physician for the need for asthma control evaluation. Purchase of at least 4 SABA inhalers a year may be regarded as a marker for asthma that is not controlled.     

Hospital-Based Management of Acute Asthmatic Exacerbation: An Assessment of Physicians' Behavior in Taiwan

This retrospective study was conducted to assess Taiwanese emergency physicians for their preference in management and adherence to guidelines in treating patients with acute exacerbation of asthma. One hundred twenty patients from hospitals of three different levels were evaluated by reviewing their medical records. Our study revealed that physicians from medical centers and regional hospitals assessed patients more often with arterial blood gas or pulse oxymetry; prescribed more doses of β₂-agonist nebulizers; administered more doses of β₂-agonist nebulizers before administering parenteral aminophylline; and prescribed ipratropium nebulizers more often as adjunctive therapy. On the other hand, physicians from district hospitals more frequently prescribed parenteral aminophylline as the first-line medication and more often prescribed only a single dose of β₂-agonist nebulizer. Most emergency physicians in Taiwan did not adhere to guidelines. Specifically, these included omission of peak expiratory flow as the means to assess the severity of asthma exacerbation and response to treatment; suboptimal use of inhaled bronchodilators, such as β₂-agonists and ipratropium; and inappropriate use of parenteral aminophylline as the first-line medication.     

Disease burden of mild asthma in China

Background and objective

The impact, treatment patterns and control of mild asthma are poorly understood for Chinese patients. This study describes the characteristics, therapeutic interventions and burden of mild asthma on patients residing in major cities of China.

Methods

The Respiratory Disease Specific Program 2015, a cross‐sectional survey, was conducted with Chinese physicians and their patients. The survey assessed clinical characteristics, asthma symptoms, exacerbations, rescue inhaler usage, treatment adherence, asthma control, work and activity impairments and healthcare utilization for patients prescribed Global Initiative for Asthma (GINA) Step 1 or 2 treatment defined mild asthma.

Results

From a total sample of 988 patients, 229 patients met the criteria for mild asthma, with 25.3% classified as Step 1 and 74.7% as Step 2. Overall, 12.6% of patients were considered of high adherence to prescribed treatment. Physicians reported that 75% of patients overall were well controlled, although well‐controlled asthma as defined by GINA was achieved in only 14.2% of patients. 26.5% of patients indicated daily use of as‐needed rescue medication in the last 4 weeks. 17.8% of patients experienced ≥1 exacerbations in the last 12 months and impaired work productivity was 27.2% overall.

Conclusion

Less than 15% of patients were well controlled according to GINA criteria despite physicians reporting the majority of patients were well controlled. Over one‐fourth of patients relied on daily rescue inhaler medication, while exacerbation frequency and work and activity impairment were higher than might reasonably be expected in a mild asthmatic population.

     

Using Global Initiative for Asthma guidelines to assess asthma severity in populations.

The classification of asthmatics into severity categories is a crucial issue for assessing the asthma burden within a community, in which a proportion of patients is currently treated. There is no epidemiological method currently available. The Global Initiative for Asthma (GINA) was used to classify 4,362 patients aged 16-45 yrs (49% males, 42% taking inhaled corticosteroids), enrolled by 545 chest specialists in France with short standardized questionnaires including forced expiratory volume in one second (FEV1) measurements. Two independent GINA classifications were combined, one based only on symptoms and FEVI, and the other based only on current medication, to construct a final "symptom-FEV1 medication" classification. Almost 40% of the patients classed as step 1, 30% of those classed as step 2 and 13% of those classed as step 3 in the initial symptom-FEV1-classification, were allocated to categories of higher severity in the final classification. The approach was validated by showing that the proportions of: 1) patients considered by the physicians as having severe or moderately severe asthma; 2) patients with a history of hospital admission for asthma; and 3) patients with a history of emergency department visits for asthma, increased with severity steps in the final classification, for each step of the two initial independent classifications. The treatment manage plan in the Global Initiative for Asthma was not developed for assessing severity of asthma but rather to describe the recommended therapy for asthma with different severity. This is the first attempt to assess the severity of asthma in a large population of asthmatics mostly taking treatment, based on the Global Initiative for Asthma guidelines. The authors propose this simple and pragmatic procedure for a potential classification which should be put to the test in other studies.     

Asthma management and asthma control in São Paulo,Brazil and Uppsala,Sweden: a questionnaire‐based comparison

Background and Aims: The Global Initiative Against Asthma (GINA) was developed to meet the global challenge of asthma. GINA has been adopted in most countries and comparison of asthma management in different parts of the world may be of help when assessing the global dissemination of the guideline. The overall goals in GINA include that asthma patients should be free of symptoms, acute asthma attacks and activity limitations. The aim of the present study was to compare asthma management and asthma control in São Paulo, Brazil and Uppsala, Sweden. Materials and Methods: Information was collected from asthmatics in São Paulo and Uppsala with a questionnaire. The questionnaire dealt with the following issues: symptoms, smoking, self‐management, hospital visits, effect on school/work and medication. Results: The São Paulo patients were more likely to have uncontrolled asthma (36% vs 13%, P < 0.001), having made emergency room visits (57% vs 29%, P < 0.001) and having lost days at school or work because of their asthma (46% vs 28%, P = 0.03) than the asthmatics from Uppsala. There were no difference in the use of inhaled corticosteroids, but the Brazilian patients were more likely to be using theophylline (18% vs 1%, P = 0.001) and less likely to be using long‐acting beta‐2 agonists (18% vs 37%, P < 0.001). Conclusion: We conclude that the level of asthma control was lower among the patients from São Paulo than Uppsala. Few of the patients in either city reached the goals set up by GINA. Improved asthma management may therefore lead to health–economic benefits in both locations. Please cite this paper as: Skorup P, Rizzo LV, Machado‐Boman L and Janson C. Asthma management and asthma control in São Paulo, Brazil and Uppsala, Sweden: a questionnaire‐based comparison. The Clinical Respiratory Journal 2009; 3: 22–28.     

Practice patterns for oral corticosteroid burst therapy in the outpatient management of acute asthma exacerbations

The use of a short course of oral corticosteroids (OCS), or "steroid burst," is standard practice in the outpatient management of acute severe exacerbations of asthma. Despite published guidelines, the actual practice patterns are unknown. A Web-based survey about typical patterns of OCS administration and total steroid burst dose was administered to pulmonologists (n = 150), allergists (n = 150), primary care physicians (n = 153), and pediatricians (n = 150). No predominant dosing regimen was observed, although a fixed single daily dose was the most commonly prescribed regimen (59%). The majority of physicians treating patients ≥12 years of age prescribed a total burst dose of ≤200 mg and essentially all (99.7%) prescribed ≤600 mg. Among physicians treating younger children, approximately one-quarter prescribed ≤1 mg/kg per day for 3 days (27.8% for children aged 5-11 years of age and 28.1% for children aged <5 years, respectively) and essentially all prescribed ≤2 mg/kg per day for 10 days (99.8% for children aged 5-11 years and 100% for children aged <5 years of age). When prescribing OCS burst therapy for asthma exacerbations, physicians tend to prescribe less than the upper dose recommended in the guidelines; with many physicians prescribing a total steroid burst dose below the lower end of the recommended dose range. Additional study is needed to determine the optimal dose and duration for treating exacerbations of asthma with OCS to minimize both side effects and time to reestablishing asthma control.