asthma case study adult

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• Published: 16 October 2014

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

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

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

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

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

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

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

Supported self-management reduces asthma morbidity.

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

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

Personalised asthma action plans

Key features of effective self-management approaches are:

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

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

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

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

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

Supported self-management

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

The challenge of implementation

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

The solution will need a whole systems approach

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The case study continues...

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

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

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

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

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Hilary Pinnock & Elisabeth Ehrlich

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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• Assessment and...

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

Read our latest coverage of the coronavirus pandemic.

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

What you need to know

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

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

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

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

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

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

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

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

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

Can SARS-CoV-2 virus cause asthma exacerbations?

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

What you should cover

Challenges of remote consultations.

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

Presenting symptoms

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

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

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

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

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

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

Exacerbation of asthma*.

Improvement in symptoms with reliever inhaler

Diurnal variation

Absence of fever

Coexisting hay fever symptoms

Examination:

Reduced peak expiratory flow

Close contact of known or suspected case

Dry continuous cough

Onset of dyspnoea 4-8 days into illness

Flu-like symptoms including fatigue, myalgia, headache

Symptoms not relieved by inhaler

Absence of wheeze

Peak expiratory flow may be normal

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

Risk factors and medications

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

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

Psychosocial factors

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

Examination

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

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

What you should do

Determine the most likely diagnosis.

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

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

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

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

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

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

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

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

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

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

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

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

Follow-up and safety-netting

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

How this article was created

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

Education into practice

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

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

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

How patients were involved in the creation of this article

No patients were involved in the creation of this article.

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

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

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

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

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• Stoddart A ,
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• ↵ Primary Care Respiratory Society. PCRS Pragmatic Guidance: Diagnosing and managing asthma attacks and people with COPD presenting in crisis during the UK Covid 19 epidemic. 2020. https://www.pcrs-uk.org/sites/pcrs-uk.org/files/resources/COVID19/PCRS-Covid-19-Pragmatic-Guidance-v2-02-April-2020.pdf .
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• ↵ British Thoracic Society. Advice for healthcare professionals treating people with asthma (adults) in relation to COVID-19. 2020. https://www.brit-thoracic.org.uk/about-us/covid-19-information-for-the-respiratory-community/ .
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• ↵ Global Initiative for Asthma (GINA). 2020 GINA report, global strategy for asthma management and prevention. 2020. https://ginasthma.org/gina-reports/ .
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• ↵ Office for National Statistics. Analysis of death registrations not involving coronavirus (COVID-19), England and Wales: 28 December 2019 to 1 May 2020. Release date: 5 June 2020. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/analysisofdeathregistrationsnotinvolvingcoronaviruscovid19englandandwales28december2019to1may2020/technicalannex .

Case Study: Management of a Middle-Aged Patient with Multiple Comorbidities

—a 52-year-old woman reports a 2-week history of dyspnea and wheezing, and presents with mild respiratory distress with audible wheezing. what should next steps be to provide optimal care.

By Shawn E. Kuhmann, PhD Reviewed by Joe G. Zein, MD

Societies are now caring for a higher number of older individuals with multiple chronic diseases, including asthma. 1  In addition to age-related comorbidities, older asthma patients are at a particular risk for severe asthma due to lower lung function compared with younger adults with asthma. 2  Consistent with this,  cluster analyses based on the National Heart, Lung, and Blood Institute (NHLBI)-Severe Asthma Research Program (SARP) cohort  identified a unique phenotype of older asthmatics with severe symptoms and reduced lung function. 3  Similarly, older asthmatics have been observed to have increased asthma treatment failures and to respond less well to inhaled corticosteroids (ICS). 4

Case presentation and patient history

Dr. L is a 52-year-old college professor with no significant medical history except for obesity (body mass index of 36). She reports occasional heartburn, which is self-medicated with over-the-counter antacids.

She presented in June to the emergency room (ED) reporting a 2-week history of dyspnea and wheezing. Upon arrival, she was in mild respiratory distress with audible wheezing. Yet, she was able to speak in full sentences and had a room air oxygen saturation of 92%. The physical exam was significant for tachycardia (heart rate of 110 bpm), tachypnea, and bilateral inspiratory and expiratory wheezing. There was no accessory muscle use. The peak expiratory flow (PEF) rate was only 250 L/min.

In the ED, she received nebulized albuterol and a corticosteroid injection. Albuterol resulted in significant improvement in her symptoms and resolution of the respiratory distress. She was discharged home with a 5-day prednisone taper and referred to the asthma center for further management.

In the asthma clinic, she continued to have mild expiratory wheezing. Upon additional questioning, she reported that she entered menopause about a year prior and was recently started on hormone replacement therapy (HRT) by her primary care physician for hot flashes and vaginal dryness. Since then, she started noticing more respiratory symptoms occurring mostly at night, which she linked to menopause. Similarly, she noticed more heartburn symptoms.

She did not report any previous history of childhood asthma, but her 17-year-old daughter is being treated with inhaled fluticasone and oral contraceptives for severe premenstrual asthma. She did not report having any food or environmental allergies or any pets at home. She also did not report any significant occupational or smoking history.

An office spirometry revealed a baseline forced expiratory volume in 1 second (FEV1) of 1.8 L (61%), which improved to 2.76 L (94%) after bronchodilator use. The percent FEV1 change was 53%, meeting the American Thoracic Society criteria for positive bronchodilator response. The measured exhaled nitric oxide was 16 ppb.

Dr. L is a middle-aged obese nonatopic woman with a lung function test showing airway obstruction and a positive bronchodilator response. Such clinical characteristics suggest late-onset asthma, and meet "cluster 3" phenotypic criteria according to the NHLBI-SARP cluster phenotypes, which include: 3  

• Moderate reductions in FEV1
• Mostly older obese women
• Increased medication requirements, including high-dose ICS
• Frequent oral corticosteroid use
• High healthcare utilization

It is likely that her asthma was triggered or exacerbated by HRT and gastroesophageal reflux disease (GERD).

Treatment options

According to  Global Initiative for Asthma (GINA) guidelines , initial therapy includes low-dose ICS and an as-needed short-acting beta2-agonist (SABA) such as albuterol. 5

Dr. L was advised that while high-dose ICS can place asthma patients at risk for osteopenia and cataracts, both asthma therapies are relatively safe. 5  She was also advised that a spacer is recommended with hydrofluoroalkane inhalers and that she needs to rinse her mouth after each ICS use. 5  She received asthma education and was provided an asthma action plan to help her manage her asthma. A follow-up appointment is set for 4 weeks in order to assess the efficacy of the treatment regimen and the need for stepping up therapy (ie, adding a long-acting beta2-agonist [LABA] to the ICS). 5

Additionally, GERD therapy is recommended to control heartburn and reflux symptoms, and she was advised to stop and avoid HRT. 5  A weight reduction plan is put into place; advice is given about the management of exercise-induced bronchoconstriction. 5

Treatment outcome

Dr. L returns 4 weeks later to the chest clinic for follow-up. She reports partial improvement in her dyspnea and exercise intolerance. However, she continues to report cough, wheezing, and dyspnea on exertion more than twice a week requiring rescue albuterol. She has been compliant with therapy and has been using her inhalers with a spacer routinely. She also reports losing 3 lb since her last visit and says that her heartburn has been controlled with therapy. Her peak flow measurement improved from an average of 250 to 350 L/min. A repeated office spirometry demonstrated a baseline percent predicted FEV1 of 72%. Since her asthma was not fully controlled, a LABA was added to her treatment regimen. She was advised to continue measuring peak flow and to return in 1 to 3 months to assess asthma control and response to therapy.

Although there are a wide variety of asthma phenotypes, treatment is uniformly applied to all patients in a stepped-care approach. 5-8  However, the morbidities and costs associated with the overtreatment and/or undertreatment of this common disease provide a rationale for precision medicine, particularly for older asthmatics (age 30 and older), who comprise a heterogeneous group of patients.

Aging and menopause Older asthmatics tend to have multiple comorbidities, such as GERD, rhinosinusitis, and obstructive sleep apnea, which may contribute to more severe asthma. 5  In addition, data suggest that older asthma patients have a greater risk of treatment failure, particularly for ICS, compared with younger adult patients; this finding was observed in a recent study based on data from ten Asthma Clinical Research Network trials. 4

Importantly, lung aging occurs over the course of life. 2  In a cross-sectional study of patients enrolled in NHLBI-SARP, the risk of severe asthma increased by 7% each year until age 45. 2  Asthma was more likely to be severe in older adult patients (older than age 45 versus age 18-45) independent of asthma duration or age-related comorbidities. 2  After age 45, the risk of severe asthma continued to increase with age in men but not women. 2  These data, along with other reports, suggest that asthma may improve with menopausal transition, when sex hormones wane. 9,10

Overview of comorbidities and factors affecting asthma relevant to this case

HRT Postmenopausal HRT may be disadvantageous and worsen asthma severity in menopausal women. 11  HRT was also shown to be associated with an increased risk of asthma diagnoses in postmenopausal women in the prospective Nurses' Health Study and in the prospective  French E3N study ; there was also an increased prevalence of asthma in perimenopausal women using HRT in the population-based, cross-sectional  Respiratory Health in Northern Europe study . 9,12,13  This finding regarding HRT emphasizes the importance of reviewing the medications asthma patients take.

GERD The most common digestive system disorder in the United States, GERD affects nearly one third of Americans and has been reported in 40% to 80% of asthma patients. 14  GERD may cause bronchoconstriction through microaspiration into airways or through effects on the vagus nerve. 14  Asthma may also favor the development of GERD. 14  A meta-analysis on the effects of proton pump inhibitor (PPI) therapy on asthma in adults found that PPI therapy yielded a small but significant improvement in morning PEF rate, with a larger benefit in morning PEF rate in patients with GERD than in those without. 14  However, other objective and subjective outcomes were not significantly altered by PPI treatment. 14  The authors concluded that the benefit from GERD treatment is unlikely to be clinically significant and there is not enough evidence to support the use of PPIs to treat asthma in adults. 14

Obesity Asthma is more severe in obese compared with nonoverweight patients. 15  In the  National Asthma Survey , obese respondents more often reported symptoms all of the time, missed more work days, and were more likely to use SABA and ICS treatments. 15  When classified according to the GINA guidelines, obese respondents were also more likely to use controller medications, less likely to be in remission, and more likely to have persistent and/or severe persistent asthma. 15

Asthma is also more difficult to control in obesity. 16,17  In a  post-hoc study of four placebo-controlled trials , the effect of an ICS on the number of asthma control days decreased with increasing body mass index. 17  Similarly, in  another pooled analysis , fewer obese individuals achieved asthma control with an ICS + LABA or an ICS alone compared with nonobese patients. 16

Importantly, the Global Initiative for Asthma guidelines recommend including a weight reduction program in the treatment of obese patients with asthma. 5  A randomized trial studying the effects of weight loss by dietary intervention, exercise intervention, or both on clinical asthma outcomes in overweight and obese men and women found that a 5% to 10% weight loss improved measures of lung function, asthma control, and quality of life. 18  Weight loss greater than 10% further improved lung function, but not asthma control or quality of life. 18

The treatment of older asthma patients may be complicated by the presence of comorbidities, such as GERD and obesity, and by the use of HRT in postmenopausal women. Addressing all of these factors in a personalized, precision medicine approach is essential to providing optimal care to older asthma patients and ensuring the best outcomes.

Published: April 16, 2018

• 1. Centers for Disease Control and Prevention. The State of Aging and Health in America 2013.
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• 11. Bønnelykke K, Raaschou-Nielsen O, Bisgaard H, et al. Postmenopausal hormone replacement therapy is associated with increased risk of asthma hospitalization. Eur Respir J . 2011;38(suppl 55):P4111.
• 12. Romieu I, Fabre A, Fournier A, et al. Postmenopausal hormone therapy and asthma onset in the E3N cohort. Thorax . 2010;65:292-297.
• 13. Gómez Real F, Svanes C, Björnsson EH, et al. Hormone replacement therapy, body mass index and asthma in perimenopausal women: a cross sectional survey. Thorax . 2006;61:34-40.
• 14. Chan WW, Chiou E, Obstein KL, et al. The efficacy of proton pump inhibitors for the treatment of asthma in adults: a meta-analysis. Arch Intern Med . 2011;171:620-629.
• 15. Taylor B, Mannino D, Brown C, et al. Body mass index and asthma severity in the National Asthma Survey. Thorax . 2008;63:14-20.
• 16. Boulet LP, Franssen E. Influence of obesity on response to fluticasone with or without salmeterol in moderate asthma. Respir Med . 2007;101:2240-2247.
• 17. Peters-Golden M, Swern A, Bird SS, et al. Influence of body mass index on the response to asthma controller agents. Eur Respir J . 2006;27:495-503.
• 18. Scott HA, Gibson PG, Garg ML, et al. Dietary restriction and exercise improve airway inflammation and clinical outcomes in overweight and obese asthma: a randomized trial. Clin Exp Allergy . 2013;43:36-49.

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Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Cathy Benninger, RN, MS, CNP

The Ohio State University

Columbus, OH

John Mastronarde, MD

Submit your comments to the author(s).

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

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

Physical Exam

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

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

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

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

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

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

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

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

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

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

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• Volume 62, Issue 5
• Asthma exacerbations · 5: Assessment and management of severe asthma in adults in hospital
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• Sarah Aldington 1 ,
• Richard Beasley 1 , 2
• 1 Medical Research Institute of New Zealand, Wellington, New Zealand
• 2 Wellington Hospital, Capital and Coast District Health Board, Wellington, New Zealand
• Correspondence to: Professor Richard Beasley Medical Research Institute of New Zealand, P O Box 10055, Wellington, New Zealand; richard.beasley{at}mrinz.ac.nz

It is difficult to understand why there is such a huge discrepancy between the management of severe asthma recommended by evidence-based guidelines and that observed in clinical practice. The recommendations are relatively straightforward and have been widely promoted both in guidelines and reviews. Specialist physicians need to be more proactive in their implementation of such guidelines through the use of locally derived protocols and assessment sheets, reinforced by audit. The common occurrence of severe asthma and its considerable burden to the community would support such an approach.

• CPAP, continuous positive airway pressure
• FEV 1 , forced expiratory volume in 1 s
• HDU, high dependency unit
• ICU, intensive care unit
• NIPPV, non-invasive positive pressure ventilation
• Pa o 2 , Pa co 2 , arterial oxygen and carbon dioxide tension
• PEF, peak expiratory flow
• PVCD, paradoxical vocal cord dysfunction
• Sp o 2 , oxygen saturation

https://doi.org/10.1136/thx.2005.045203

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Over the last two decades, British guidelines on the management of asthma have provided evidence-based recommendations for the assessment and management of severe asthma in hospitals. 1– 3 Practical assessment and management algorithms have been provided, supported by clear advice regarding their implementation. Despite their availability and widespread promotion, repeated audits have indicated that there is a major discrepancy between the standard of current medical management of severe asthma in hospitals and that recommended in the guidelines. 4– 6 Common problems include inadequate assessment and recognition of severity, confusion over the use and interpretation of investigations, insufficient use of systemic steroids, over-reliance on bronchodilators, delayed specialist or intensivist referral and poor follow-up arrangements including communication with the general practitioner (GP) (table 1).

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 Hospital management of severe asthma: the problems

Recognition of these problems provides a good basis for determining priorities for the hospital care of patients with severe asthma (table 2). In this review we focus on these issues and the clinical approaches that might be used to improve the management of severe asthma in adults in hospital. We also highlight the use of assessment sheets and treatment protocols in the emergency department to illustrate how the guidelines can be implemented in a simple and practical manner. The review also raises issues of clinical uncertainty that need to be considered in updated versions of the guidelines and where further research is required.

 Hospital management of severe asthma: the priorities

A brief history can be obtained while the patient is being initially examined as part of the clinical assessment. The priority is to identify quickly the patient at increased risk of serious morbidity and mortality from asthma, and this can be achieved by asking a few questions to determine the background chronic asthma severity and the severity of the acute attack (table 3). Among the markers of an increased baseline risk of death that have been identified, a hospital admission in the previous 12 months is the most reliable and easily ascertained, with the occurrence of multiple hospital admissions for asthma signifying a greatly increased risk. 7– 9 The amount of β-agonist regularly used by the patient is also informative, based on epidemiological evidence that increasing use is associated with a progressively greater likelihood of a hospital admission and/or risk of death. 10 For example, the Saskatchewan study reported that the risk of death increased markedly with the use of more than two β-agonist inhalers per month. 10 The factor which identifies patients at greatest long-term risk of death is a previous life-threatening attack (ever), which is most easily documented by obtaining a history of a previous intensive care unit (ICU) admission for asthma. 11

 Markers of risk of an adverse outcome in asthma

The amount of inhaled β-agonist self-administered during the exacerbation is a good marker of the severity of the acute attack and risk of a poor outcome. It also gives the attending doctor an indication of the likelihood of a response to further inhaled β-agonist treatment and requirement for systemic steroid treatment. In a study of adult patients admitted to hospital with severe asthma, 12 about half had used at least 30 doses from their β-agonist inhaler in the 24 h before presentation and about 20% had used over 60 doses. Most patients who had access to both an inhaler and nebuliser had used the nebuliser more than four times, as well as at least 20 doses of their inhaler during the 24 h period before admission. The likely poor response to further inhaled bronchodilator and the requirement for hospital admission and systemic steroid treatment could be predicted from such heavy prior β-agonist use.

For those patients who have monitored their peak flow during the attack, marked variability in peak flow with falls of >50% from baseline is a marker of risk of sudden death. 13, 14

The perceived speed of onset of the attack is also informative for recognising asthmatic patients with “precipitate attacks” who are likely to present with more severe asthma but have a greater improvement with treatment. 15– 17 Overall precipitate attacks are uncommon, representing around one in eight presentations at the emergency department when defined as an onset of symptoms within 3 h of presentation. The more common presentation is that of a gradual deterioration over many days before a more rapid worsening just before presentation.

Additional history will be required, including markers of poor long-term control (such as nocturnal wakening) and precipitating factors, of which viral upper respiratory tract infections are most common. In cases of precipitate asthma, allergen exposure, use of non-steroidal anti-inflammatory drugs and psychological stress are important factors to consider. 15– 17 In addition to documentation of the routine medications (including compliance with inhaled corticosteroid therapy), consideration of other issues such as continuity of primary care, adverse behavioural or psychosocial problems and the presence of comorbid conditions is required. 18

It is also informative to ask the patient to describe the sequence of events in the 24 h period before admission to establish if there was a significant delay in the recognition of the severity of the attack and whether earlier medical review should have occurred. This provides the opportunity to discuss “what should have happened in this attack” and recommend what steps might be taken to ensure a better outcome in the next attack. This advice may also serve as the basis for implementing a self-assessment and management plan prior to discharge.

Consideration should also be given to other disorders which may mimic or coexist with asthma. Particular consideration should be given to paradoxical vocal cord dysfunction (PVCD), 19, 20 which is normally recognised by patients attending the emergency room frequently with poorly reproducible lung function measurements and predominant wheezing during both expiration and inspiration originating from the larynx rather than the chest. Other distinctive features include a predominance in women, a background of psychological or psychiatric problems, and a lack of response to standard asthma management. Careful elicitation of symptoms and signs of PVCD at presentation may be helpful in its subsequent investigation, which is based on laryngoscopy and flow-volume loops. This is important not only because PVCD is amenable to treatment, but also because it can reduce the risk of substantial morbidity with intensive treatment including long-term oral corticosteroids.

CLINICAL EXAMINATION

The priority of the clinical examination is to confirm the diagnosis of asthma quickly and to assess its severity. The general appearance of the patient, including difficulty in talking, respiratory rate and heart rate form the basis of the clinical assessment of severity. 21, 22 Increasing pulse rate has a close correlation with worsening asthma severity, and it is incorrect to assume that the tachycardia is due to β-agonist treatment. Studies of the response to high-dose β-agonist treatment in severe asthma have shown that the heart rate falls in association with the bronchodilator response. 21, 23

While it is generally well recognised that some patients may have a poor perception of the severity of their asthma, 24, 25 it is less well appreciated that such patients may also appear deceptively well, despite the presence of severe airflow obstruction. 26 These factors contribute both to delay in seeking medical help by the patient and a tendency for the doctor not to appreciate the severity when the patient does present. This underlies the importance of lung function measurements in severe asthma, as well as eliciting other clinical signs such as the difficulty a patient may have in talking, 21 blood pressure paradox, accessory muscle use and tracheal tug. In acute severe asthma, the marked hyperinflation and associated greater inspiratory muscle effort is responsible for the patient’s perception that the difficulty in breathing is predominantly inspiratory rather than expiratory. 27 The inspiratory muscle work may increase up to tenfold in patients with severe asthma in whom the FEV 1 is <50% of baseline. 28

In clinical practice, signs such as a “quiet chest” and blood pressure paradox (>15 mm Hg) should alert the doctor to the presence of a severe attack. 21, 29 Although difficulties in their interpretation and wide observer variability have led to a reduced emphasis on their use, these clinical examination features are informative when carefully elicited, and clinicians are encouraged to develop and maintain these clinical examination skills. Other clinical signs which indicate life-threatening asthma include patients assuming the upright position (or an inability to lie supine), cyanosis and sweating. 21 Confusion or a reduced level of consciousness may be a premorbid sign, although many patients remain fully conscious until immediately before a fatal cardiac arrest.

The clinical severity markers that should alert the assessing doctor to the presence of a life-threatening attack are outlined in table 4. While these criteria appear practical and simple to apply, they have inherent limitations. 26 First, the clinical symptoms and signs of severe asthma often do not correlate with the severity of physiological impairment and, as a result, their absence is not necessarily reassuring. Another limitation is that the components do not develop simultaneously or at unique levels of impairment. It is recommended that it is wise to base management on the “worst” abnormality and not be reassured because another feature does not fall within the definition of severe. 18 In this way, some patients may be admitted unnecessarily or be overtreated, but some “preventable” deaths from asthma can be avoided.

 Levels of severity of acute asthma exacerbations

Lung function tests

Lung function tests are the basis for assessment of the severity of the asthmatic attack (table 4). 3, 18, 22 Preferably, this should be undertaken by spirometry with measurement of the forced expiratory volume in 1 s (FEV 1 ) expressed as a percentage of predicted normal values. The National Health and Nutrition Examination Survey (NHANES) reference prediction equations should be used rather than the traditional European Coal and Steel normal values which are now acknowledged to be out of date and underestimate normal reference values by about 15%. 30

Measurement of the peak expiratory flow (PEF), with values expressed as predicted normal values, represents an alternative if spirometry is not available. The normal reference values sourced from the Nunn and Gregg nomogram are recommended for the calculation of “percent predicted” PEF values. 31 Contrary to current dogma, the PEF and FEV 1 are not equivalent when expressed as a percentage of predicted values, with the FEV 1 being on average 5–10 percentage points lower than the PEF (ie, FEV 1 of 30% predicted is equivalent to PEF of 35–40%). 32, 33 There is also marked intra-patient variability in the relationship, with 95% confidence intervals of around 50 percentage points. This means that major differences in the classification of asthma severity may occur (and the treatment recommended on the basis of this classification), depending on the lung function measurement used. This caution particularly applies to the assessment and management of life-threatening asthma in which FEV 1 values are 4–10% lower than the PEF across the FEV 1 range of 20–33% predicted. 34, 35

While recognising the poor correlation between clinical signs and physiological measures, an FEV 1 of <30% predicted is likely to be present in a patient who is unable to speak more than a few words with an arterial carbon dioxide tension (Pa co 2 ) of >5.3 kPa (40 mm Hg), a quiet chest with the absence of audible wheezing, respiratory rate >30/min or pulsus paradoxus >20 mm Hg. 21, 36, 37

Importantly, the magnitude of the improvement in lung function following initial bronchodilator treatment represents the most informative measure of severity of the acute episode and likely requirement for hospital admission. 38 As a result, severity may be best defined in terms of outcome rather than the patient’s initial presentation. 26

If one accepts that the FEV 1 is the “gold standard” method of assessing airflow obstruction in asthma, and that lung function measurements are essential in the assessment of asthma, a strong case can be made for the provision of spirometers in all hospital emergency departments. This case is further strengthened when one considers the use of spirometry in the assessment of other respiratory disorders and the costs and relative benefits of other medical equipment used in emergency departments. Peak flow measurements are preferred for monitoring lung function following admission to the ward.

While the measurement of the magnitude of hyperinflation is not indicated in the acute setting, it is informative to be aware that, in severe asthma, the residual volume can approach 400% and functional residual volume can be double the expected values. 37

Oxygen assessment and other tests

Measurement of oxygen saturation by pulse oximetry should be undertaken in all patients with severe asthma presenting to hospital. In the absence of oxygen therapy, arterial desaturation and hypercarbia occur concurrently and normally only develop in life-threatening asthma. 37 As a result, pulse oximetry is a suitable means for the routine assessment of ventilatory status. Analysis of arterial blood gases can be selectively reserved for those patients with oxygen saturations on room air of <92% 39 or those who do not respond to initial treatment, with the FEV 1 remaining <30%. 38

In the interpretation of arterial blood gases, attention focuses primarily on the Pa co 2 with a normal value in a breathless asthmatic being a warning sign of impending hypoventilation and values above 6 kPa (45 mm Hg) indicating a life-threatening attack and probable need for transfer to a high dependency unit (HDU) or intensive care unit (ICU, table 4). Fortunately, arterial oxygen tensions <6.7 kPa (50 mm Hg) or carbon dioxide tensions >6 kPa (45 mm Hg) occur infrequently, being present in less than 10% of patients attending the emergency department with severe asthma. 26, 36

A chest radiograph is not routinely needed in an adult asthmatic attending the emergency department, being reserved for those who do not respond to initial treatment or in whom an alternative diagnosis such as pneumothorax or pneumonia is suspected. 40, 41 The serum potassium concentration should be measured, particularly in patients with prior corticosteroid or diuretic treatment. Hypokalaemia caused primarily by high-dose β-agonist therapy is not uncommon in severe asthma and may require potassium supplementation. Other investigations include a full blood count and electrocardiography in older patients. Microbiological investigations are seldom required, although purulent sputum should be cultured if present.

The mainstay of treatment during the acute attack is supplementary oxygen, repeated inhaled bronchodilator and systemic corticosteroids (table 5).

 Treatment for severe asthma

Oxygen therapy

Although it is recommended that high-flow oxygen is administered to all patients presenting with severe asthma, there is some evidence to suggest that this approach should be modified. First, best practice indicates that oxygen should be prescribed in the dose required to relieve hypoxaemia, guided by measurements of oxygen saturation obtained by oximetry and/or arterial blood gases and not prescribed at high flow to all patients with respiratory difficulties regardless of need. The administration of excessive oxygen is not without potential risks, including atelectasis and increased intrapulmonary shunting, and a reduction in cardiac output and coronary blood flow. 42 Although carbon dioxide retention associated with high-flow oxygen therapy is not considered to occur in asthma, one small study raised the possibility that the administration of 100% oxygen to acutely ill asthmatics can induce or worsen carbon dioxide retention, particularly in patients with severe airway obstruction. 43 Another concern which is not widely recognised is that the use of high-flow oxygen has the potential to lead to a delay in recognising deteriorating respiratory function. 44, 45 This delay is caused by the patient maintaining 100% oxygen saturations despite progressive clinical deterioration so that, when the oxygen saturations begin to fall, the deterioration is recognised late and the opportunity to “buy time” by increasing the oxygen concentration is not available. As a result, supplementary oxygen should only be prescribed in severe asthma if the patient is hypoxic with the flow adjusted to achieve saturations greater than 92%.

Heliox is a mixture of helium and oxygen which has been used in the treatment of severe asthma. The rationale is that its lower density results in increased airflow and reduced work of breathing. Some studies, 46, 47 but not all, 48 have reported benefits in patients with severe asthma. However, systematic reviews 49, 50 suggest that there is not yet sufficient evidence to recommend heliox as a routine treatment for severe asthma in the emergency department, perhaps to be reserved for those with refractory attacks.

Non-invasive positive pressure ventilation (NIPPV)

While non-invasive ventilation has a well established role in the management of exacerbations of chronic obstructive pulmonary disease, its role in the management of severe asthma is less clearly defined. Although early reports are encouraging, 51, 52 NIPPV does not yet have a place in current management guidelines. It has been suggested, however, that it may be useful in those patients with hypercapnic respiratory failure as long as they are protecting their own airways and are able to tolerate the face mask. For those patients who are able to tolerate the positive pressures, NIPPV can reduce the work of breathing and respiratory muscle fatigue, thereby buying time for transfer to an ICU/HDU and for pharmacological intervention to take effect. There is also some evidence to suggest that it might decrease airways resistance, re-expand atelectatic areas of the lung and decrease the adverse haemodynamic effects of the large negative inspiratory pleural pressures. 52 Although it may prevent invasive ventilation in some patients, there is concern that it may delay timely intubation in deteriorating patients. For those in whom it is indicated and tolerated, bilevel NIPPV should be started with 5 cm H 2 O continuous positive airway pressure (CPAP) and 10 cm H 2 O pressure support (equivalent to inspiratory positive airway pressure of 15 cm H 2 O) with the inspired oxygen titrated to achieve an oxygen saturation >92%. Adjustments should be made to optimise patient comfort.

Inhaled bronchodilators

Inhaled β-agonists are the mainstay of bronchodilator therapy, with the dose and frequency determined by the severity of the asthma attack and the response to treatment. With respect to bronchodilator treatment, the key points are:

In addition to increasing the total dose of β-agonist administered, increasing the frequency of administration also leads to a greater bronchodilator efficacy. However, there is no advantage to the repeat administration of doses of nebulised salbutamol of >2.5 mg every 20 min. 53 This regime has equivalent bronchodilator efficacy to 7.5 mg salbutamol every 20 min in acute severe asthma. If there is an inadequate response to this regime, the best option is to proceed to continuous β-agonist nebulisation. 23, 54

Metered dose inhalers with a holding chamber (spacer) produce outcomes that are at least equivalent to nebuliser therapy in severe asthma. 55– 57 This finding includes those with life-threatening asthma, with an FEV 1 <30% predicted on presentation. As a guide, 400 µg salbutamol via a spacer can be considered equivalent to a 2.5 mg dose of salbutamol via nebuliser. It is suggested that the β-agonist should be actuated into a spacer in individual puffs, inhaled by tidal breathing or single breaths. The frequency of treatments is adjusted to the individual patient response, as occurs with nebuliser therapy. The previous British recommendation of 50 puffs of β-agonist via a metered dose inhaler and spacer in a life-threatening attack of asthma can be considered excessive. 1

The addition of ipratropium bromide to inhaled β-agonist therapy provides an increase in the bronchodilator response in severe asthma. 58, 59 This additional bronchodilation has now been shown with multiple dose regimes (as well as the administration of single doses), leading to both an improvement in lung function and a reduction in the requirement for hospital admission. In the absence of an established dose-response relationship in severe asthma, a 500 µg dose can be administered by nebulisation if there is a poor initial response to inhaled β-agonist therapy, repeated after 60 min if there is minimal interval improvement. The standard dose of nebulised ipratropium bromide is 500 µg 6-hourly. The absolute benefit of ipratropium bromide in combination with a β-agonist is achieved in patients with the most severe airflow obstruction. One important indication for the use of anticholinergic bronchodilators is as first-line treatment for β-blocker induced attacks. 60

Bronchodilator nebuliser solutions should be administered from preservative-free sterile unit dose vials. 61 The use of multidose nebuliser solutions with the preservative benzalkonium chloride should be avoided as such preparations have the potential to reduce the magnitude of bronchodilation or cause paradoxical bronchoconstriction. 62, 63

There is preliminary evidence to suggest that salbutamol nebuliser solution administered with isotonic magnesium sulphate results in a greater bronchodilator response than the standard isotonic salbutamol solution. 64, 65 The greatest efficacy with the adjuvant magnesium solution occurs in those with life-threatening asthma, defined by a baseline FEV 1 of <30% predicted. Further research is now needed to determine whether salbutamol nebuliser solution with adjuvant magnesium should become the preferred agent for the treatment of severe asthma. Regrettably, there is no commercially available salbutamol solution which incorporates isotonic magnesium for use.

In life-threatening asthma the greatest bronchodilator response to nebulised β-agonist is achieved with continuous administration. For example, 2.5 mg at 30 min intervals for 2 h results in a lesser degree of bronchodilation than the same dose (10 mg in 70 ml) administered continuously over the 2 h period in those with life-threatening asthma. 66 There appears to be no benefit in nebulising higher concentrations continuously. 54

In view of the theoretical risk of oxygen desaturation while using air-driven compressors to nebulise β-agonists, oxygen-driven nebulisers are the preferred method of delivery. The absence of supplemental oxygen should not prevent nebulised therapy from being administered. 67

One regimen which incorporates these features is the administration of 2.5 mg salbutamol via nebulisation every 20 min for 1 h (or 400 µg salbutamol by metered dose inhaler with spacer) as the initial bronchodilator treatment for severe asthma, with the frequency of further administration and the use of ipratropium bromide and/or intravenous magnesium determined by the response to treatment. In patients with life-threatening asthma, continuous nebulised salbutamol should be undertaken with the co-administration of nebulised ipratropium bromide every 60 min.

Intravenous bronchodilators

It is with the intravenous administration of bronchodilators that the major changes in management have occurred over the last decade.

Current evidence does not support the use of intravenous β-agonists in patients with severe asthma as its use does not result in greater benefit than repeat nebulised β-agonist. 68– 70 The role of intravenous β-agonist in addition to nebulised β-agonist has not been adequately studied, nor has its role in ventilated patients. As a result, its use should be restricted to patients with refractory life-threatening asthma as an adjunct to conventional intensive treatment. The recommended dose of salbutamol when administered by intravenous dose infusion is 200 µg over 10 min, followed by an infusion of 0.1–0.2 µg/kg/min with the rate of the infusion adjusted according to the therapeutic response.

Adding intravenous theophylline to repeated administration of β-agonist via a nebuliser does not increase the efficacy but does increase the risk of side effects. 71 No subgroups in which aminophylline might be more effective have been identified. As with the use of intravenous β-agonists, its use should be restricted to patients with refractory life-threatening asthma as an adjunct to conventional intensive treatment. Intravenous aminophylline is given in a dose of 6 mg/kg over 30 min, then infused in the dose range 0.5–0.9 mg/kg/h. A loading dose should not be given to patients who are already receiving oral theophylline. The maintenance infusion rate is altered according to plasma theophylline levels, which should be measured within 24 h. For the continuous infusion, lower doses may be required in patients with liver disease or cardiac failure and those taking cimetidine, ciprofloxacin or erythromycin. Higher doses may be required in smokers.

The use of intravenous magnesium can now be recommended in patients with life-threatening attacks. 72 Its use leads to an improvement in lung function and a reduction in hospital admissions in those who respond poorly to initial treatment, but not those with less severe asthma responding to initial treatment. Currently, the evidence relates to a single dose (2 g MgSO 4 diluted in 50 ml 0.9% normal saline administered over 30 min) and the efficacy of a continuous infusion or repeated dose has yet to be determined. As a result of these studies, if an intravenous bronchodilator is to be administered, current evidence favours the use of intravenous magnesium rather than intravenous β-agonist or aminophylline.

Systemic corticosteroids

Systemic corticosteroids administered on presentation to the emergency department markedly reduce the need for hospital admission in patients with severe asthma. 73 The benefits are greatest in patients with life-threatening asthma and those not currently receiving steroids. Significant benefit with systemic steroid therapy is observed within 4 h of administration.

The major issue that has been clarified over recent years is the optimal dose and route of administration. It has been shown that there is no benefit in using very high intravenous doses in severe asthmatics needing hospital admission. 74 In this meta-analysis, no additional benefit was observed with doses of >50 mg prednisolone or 200 mg hydrocortisone per day. In terms of lower doses, the most informative double-blind randomised study has shown that intravenous hydrocortisone 50 mg four times a day for two days, followed by prednisone 20 mg daily, is as effective in resolving acute severe asthma as either hydrocortisone 200 mg or 500 mg four times daily followed by prednisone 40 or 60 mg daily, respectively. 75 These findings apply to the situation of life-threatening asthma, as the presentation FEV 1 was 19% predicted and similar efficacy between the three treatment groups was observed in the subgroup whose FEV 1 after initial bronchodilator treatment remained <30% predicted.

Several studies have shown a similar efficacy with oral and intravenous steroids in severe asthma, suggesting that intravenous treatment is often unnecessary. 76, 77 This is because of the rapid absorption of prednisolone and its high bioavailability. When the added costs and potential minor complications of intravenous treatment are considered, these results support the initial use of oral steroids, except in patients who are vomiting or too breathless to swallow or in those in whom an intravenous line is already in place or is required. Thus, initial treatment with intravenous hydrocortisone 100 mg stat and/or 30–60 mg prednisone is likely to be adequate with subsequent treatment determined by the response.

Inhaled corticosteroids

One issue that has not been resolved is the role of high-dose inhaled corticosteroids as an adjunct to—or in place of—systemic corticosteroids in asthma. 78 It has been shown that a 2 week course of high-dose inhaled corticosteroid (eg, fluticasone 2000 µg/day) may be as effective as a course of oral steroids (prednisolone starting at 40 mg and reducing by 5 mg every other day) in the treatment of mild to moderate exacerbations not requiring hospital admission (presentation PEF >60%). 79

However, it has recently been reported that, in adults with severe asthma, the use of repeated high doses of inhaled corticosteroids (fluticasone propionate 3000 µg/h administered by metered dose inhaler and spacer for 3 h) was more effective than intravenous hydrocortisone (500 mg). 80 This therapeutic benefit was evident within 90 min of presentation at the emergency department and was particularly marked in those patients with more severe airways obstruction in which there was a significant reduction in hospitalisation rate. It was proposed that the beneficial effect may be related to vasoconstriction and possibly mucosal decongestion rather than modulation of gene expression because of the time course of the benefit.

It has yet to be determined whether inhaled corticosteroid treatment provides additional benefit when used in combination with standard systemic steroids for severe asthma. However, it may be worthwhile following a pragmatic approach of administering high-dose inhaled corticosteroids in addition to systemic steroids in patients with life-threatening asthma who respond poorly to conventional treatment.

RESPONSE TO TREATMENT

The response to treatment determines both the further treatment requirements and the need for hospital admission. 38, 81 Assessment of the response is based on repeat clinical examination, lung function tests and oximetry. Of these, the magnitude of improvements in FEV 1 and absolute FEV 1 values following bronchodilator treatment are the best indicators of requirement for admission and likely relapse at discharge. The initial FEV 1 , clinical signs or laboratory parameters such as arterial blood gas measurements are less reliable as predictive indices than post-bronchodilator FEV 1 . In part this is because small improvements in the degree of airflow obstruction in severe asthma may produce substantial changes in clinical signs and symptoms, with dyspnoea normally resolving once the FEV 1 reaches only 50% of the predicted normal value. 37 As a result, severity may be best measured as the response in lung function to high-dose inhaled bronchodilator therapy rather than in terms of the patient’s initial presentation.

ICU TRANSFER

Patients with features of potentially life-threatening asthma who are not responding to treatment, or those with features suggesting that they are at imminent risk of death, should be admitted to an ICU or HDU if adequate facilities are available (table 4). Transfer to such units will ensure that these patients are intensively monitored and can be ventilated without delay should the need arise. Early referral, before the need for ventilation arises, usually makes the process easier. The intensive care management of life-threatening asthma including invasive ventilation is beyond the scope of this review, but it has been reviewed elsewhere. 82, 83

WARD ADMISSION

If repeated bronchodilator treatment does not increase the FEV 1 to >50–60% predicted, or if clinical features of severe asthma persist, admission is recommended. Patients may also require admission if, despite achieving an FEV 1 >60%, there are other concerns, as outlined in table 6. 3 Depending on resources, admission to a respiratory ward is preferable as this is likely to lead to a higher standard of care and better outcome than admission to a general medical ward. 84

 Criteria for admission

A doctor and/or nurse should remain with the patient after initial treatment has started, or at least until clear improvement is seen. The patient should be assessed regularly, with measurement of lung function and heart rate. The frequency of these measurements will be dictated by the response—at least every 15 min initially. Once improvement has occurred, a suitable regimen would be to monitor these measurements before and after bronchodilator treatment. Patients who are stable can be transferred to a medical ward where oxygen can be continued if hypoxic and nebulised β-agonists given every 2–4 h. There is no major advantage in continuing inhaled ipratropium bromide treatment beyond the initial 12–24 h period. 85

Oral steroids should be continued throughout the admission. A single morning dose of steroid may not adequately protect the circadian narrowing of the airways experienced at night. The peak effect of oral steroids occurs at around 9 h and then declines and, as a result, may not provide sufficient effect throughout the 24 h dosing interval. 86 The clinical significance of this time course of effect is suggested by a small study in which a small dose of prednisolone given at 15:00 hours was shown to be more effective in protecting against nocturnal bronchoconstriction than an 08:00 or 20:00 hours dosing regime. 87 To overcome this problem, the preferred dosing regime in hospital is twice daily, in contrast to the once morning regime routinely used as an outpatient. As discussed, the effective daily dose of oral prednisolone is between 30 and 50 mg. 88

On average, it takes 7–10 days for symptoms and lung function to stabilise after an asthma exacerbation and, for this reason, a 10–14 day course is usually recommended. Unless the patient is on maintenance oral steroids, tapering the dose at the end of the course is unnecessary. Studies comparing abrupt cessation with a tapering regime found no difference in lung function or relapse rate between the two groups. 89, 90 Suppression of the hypothalamic pituitary axis is not clinically significant after a short course in a patient who is not on maintenance steroids.

Treatment with inhaled corticosteroids should be continued throughout the admission as there is evidence that it may have efficacy in this situation 79, 80 and to reinforce the importance of this long-term treatment to patients.

The prescription of sedatives has been associated with sudden death due to their effect in reducing respiratory drive and alertness, and they are therefore contraindicated outside the ICU. 13, 14 Percussive physiotherapy is likely to distress a severely ill asthmatic patient and is contraindicated in the initial stages, although relaxation techniques to achieve control over the rate, depth and pattern of breathing may be helpful in the recovery phase.

Antibiotics should not be routinely prescribed as bacterial infections seldom provoke exacerbations (in contrast to viral respiratory tract infections), and their routine prescription does not influence outcome in exacerbations of asthma. 91 Consideration may need to be given to use of a macrolide if chronic Mycoplasma or Chlamydia pneumoniae infection are suspected in chronic unstable disease; however, data to support this approach are not yet conclusive. 92

It is difficult to determine the optimal duration of hospital stay for an admission for severe asthma. Because of the widespread under-resourcing of medical inpatient beds, there is often considerable management pressure to discharge patients early. However, in the case of asthma, this approach is not without risk, not least because there is an increased risk of early relapse and readmission in the two to three months after admission. 93 Perhaps the best predictor of outcome is the PEF variability in the 24 h before discharge, for which it has been shown that a diurnal variation in PEF of >20% is associated with an increased risk of further severe attacks requiring repeat hospital admission. 94

One approach which facilitates early discharge is the use of nebulised β-agonist treatment according to an “as required” regime rather than a regular 4-hourly regime from 24 h after hospital admission. 95 Implementation of this “as required” regime has similar efficacy but results in an average reduction in the length of hospital stay of about 1 day. This outcome is achieved with about half the total dose of β-agonist administered, a reduced incidence of side effects and a strong patient preference for this regime. At least 24 h before scheduled discharge, the patient should be changed from nebulised to their routine aerosol or dry powdered metered dose inhaler to ensure that clinical stability is maintained on this lower dose of β-agonist.

As improvement is achieved, the emphasis shifts to investigation of the causes and circumstances of the severe attack, and arrangements are made for management following discharge, long term treatment, the institution of a self-management plan and appropriate follow-up arrangements.

DISCHARGE ARRANGEMENTS

Whether the discharge occurs from the emergency department or hospital ward, it is crucial that doctors address the problems that may have led to the hospital admission. Patients admitted to hospital with asthma and those who make frequent attendances at the emergency department are recognised as a particularly high-risk group of patients who have poor self-management skills and often have inadequate medical follow-up in the community. For this reason, doctors should ensure that patients are prescribed regular inhaled corticosteroids and that their inhaler technique is checked before discharge. It is also worthwhile to provide simple advice on what to do if their asthma worsens again. This can be achieved by giving patients a peak flow meter with instructions concerning the level at which to seek medical care either from their GP or, if necessary, the emergency department. Doctors are also encouraged to prescribe a course of oral steroids, based on the evidence that in this situation it greatly improves outcome with a fourfold reduction in relapse rate in the following week. 96 This recent systematic review reported that about 15 patients need to be treated to prevent relapse requiring medical care after discharge from the emergency department with an exacerbation of asthma. 96

Written communication with the GP via letter or email concerning the details of the ED attendance and/or hospital admission is essential to help address the problem of discontinuity of care. Alternatively, it may be advisable to phone if there is a delay in letters being typed and sent out, due to the high rate of relapse in the first week following discharge. Arrangements need to be made for medical follow-up both with the GP and with the respiratory specialist in the case of life-threatening asthma. An open access self-admission service should be considered in patients who have experienced a life-threatening or precipitate attack. The advantages of such a service, which may require prior arrangement with the ambulance service, have been shown. 97

ASSESSMENT SHEETS AND TREATMENT PROTOCOLS

One approach which has been used to facilitate clinical practice in accordance with guidelines is the implementation of assessment sheets and treatment protocols. 98, 99, 100, 101, 102, 103 When used in the emergency department, they have been shown to identify rapidly individuals at risk of an adverse outcome, ensure a high standard of management, facilitate the appropriate referral to respiratory wards and medical ICU and improve outcomes such as length of stay and number of subsequent return visits. Treatment protocols are traditionally limited to algorithm-based flow charts, but the addition of an assessment sheet facilitates their implementation. This is particularly the case with severe asthma in which management is determined by asthma severity and in which doctors seem to have major difficulties in following this approach.

A guideline-based asthma assessment and associated treatment algorithm is shown in figs 1 and 2. The assessment sheet is designed to encourage a quick focused history to identify baseline and acute risk, an objective assessment of asthma severity, and repeat clinical examination and measures of FEV 1 . The response to treatment can thus be assessed and a decision made on whether the patient requires admission or can be discharged. In this case, a structured approach is provided to address issues relating to long-term care and advice on when the patient should present again if their asthma deteriorates further.

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 Asthma Assessment Sheet currently in use in the Wellington Hospital Emergency Department, Wellington, New Zealand. FEV 1 , forced expiratory volume in 1 s; ICU, intensive care unit; VC, vital capacity; Pa co 2 , arterial carbon dioxide tension; Pa o 2 , arterial oxygen tension; PEF, peak expiratory flow.

 (A) Asthma management protocol and (B) Information Sheet currently in use in the Wellington Hospital Emergency Department, Wellington, New Zealand.

The management of asthma in the emergency department can be improved through the use of simple assessment and treatment protocols.

Assessment of asthma severity should be based primarily on the measurement of FEV 1 , expressed as the percentage of normal predicted values.

For most patients, initial treatment with high-flow oxygen, nebulised β-agonist and oral corticosteroids is sufficient.

Currently available evidence does not support the routine use of intravenous theophylline or intravenous β-agonist treatment in acute asthma; magnesium is the preferred intravenous bronchodilator in life-threatening asthma.

Patients with any feature of a severe attack persisting after initial treatment should be admitted; patient circumstances should also be considered.

For patients who are discharged, long-term management should be reviewed and medical follow-up arranged.

The algorithm recommended in the British guidelines, based on peak flow, is shown in fig 3. Modification of the current protocols and assessment sheets for use in general practice is encouraged, where similar problems in the assessment and management of severe asthma may also be encountered. 104

 Management of acute severe asthma in adults in A&E (reproduced from the British Guideline on the Management of Asthma). 3

CONCLUSIONS

It is difficult to understand why there is such a huge discrepancy between the management of severe asthma recommended by evidence-based guidelines and that observed in clinical practice. The recommendations are relatively straightforward and have been widely promoted both in guidelines 1– 3 and reviews. 18, 22, 26, 105 It is likely that the problems are related in part to the inexperience of the junior medical staff who are commonly delegated responsibility for the hospital care of patients with severe asthma, and to inadequate senior medical supervision. Specialist physicians need to be more proactive in their implementation of such guidelines through the use of locally derived protocols and assessment sheets, reinforced by audit.

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Funding: None

Competing interests: None.

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Case of Acute Severe Asthma

Kane guthrie.

• Dec 2, 2022

A 25-year-old lady Miss. Poor Compliance is rushed into your Emergency Department as a Priority 1. She is a brittle asthmatic and has been given 3x 5mg salbutamol nebs, and 0.5mg of adrenaline IM prehospital. On arrival Miss PC is sitting forward in the tripod position , using her accessory muscles to breath. She is tachypnoeic, agitated and unable to talk.

Vital signs: Pulse 143, BP 138/95, RR 42, Sp02 91% on neb, GCS 14/15.

Past Medical and Medication History

• Smoker. Severe asthmatic. Intubated twice in past 2 years
• Currently taking seritide 250/50mg, salbutamol MDI PRN and prednisolone 50mg PRN

Asthma Epidemiology

• Over 2.2 million Australians have currently diagnosed asthma
• 406 deaths attributed to asthma in 2006
• Highest risk of dying from asthma is in the elderly over 70
• The emergency clinician’s goal in treating acute severe asthma is preventing intubation
• Severe/Critical asthma is a life threatening condition

Asthma Pathophysiology

• Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role, in particular, mast cells, eosinophils, T lymphocytes, macrophages, neutrophils, and epithelial cells.
• Smooth muscle hypertrophy and hyperplasia
• Inflammatory cell infiltration and oedema
• Goblet cell and mucous gland hyperplasia with mucous hypersecretion
• Protein deposition including collagen
• Epithelial desquamation
• Most common, responsible for 80-85% of all fatal events is characterised by eosinophilic inflammation associated with gradual deterioration over days-weeks occurring in patients with severe or poorly controlled asthma, and is slow to respond to therapy.
• The second phenotype, with neutrophilic inflammation, has both rapid onset and response to therapy.

Markers of severe asthma:

• Inability to speak in full sentences
• Use of accessory muscles or tracheal tugging
• Cyanosis and sweating
• Pulsus paradoxus (>15mmHg decreased with inspiration). With severe muscle fatigue might be absent
• Quiet chest on auscultation (The “Silent Chest”)
• Confusion or decreased level of consciousness
• Hypotension or bradycardia
• FEV 1<40% predicted
• PEF <40% of predicted or best (<25% in life threatening asthma)
• Oxygen saturation <90-92%
• PaO2 <60mmHg
• PaCO2 >45mmHg

Complications of Asthma :

• Pneumothorax, Pneumomediastinum, Pneumopericardium and Pneumoretroperitoneum
• Cardiac Arrhythmias, Myocardial ischaemia or infarction
• Electrolyte disturbances (hypokalaemia, hypomagnesaemia, hypophosphataemia)
• Lactic Acidosis
• Hyperglycaemia

Conditions that may mimic acute asthma:

• Upper airway obstruction
• Foreign-body aspiration
• Vocal cord dysfunction syndrome
• Pulmonary oedema
• Acute exacerbations of COPD
• Hysterical conversion reaction
• Munchausen syndrome

Diagnostic Test:

• Hyperinflation 5-10%
• Infiltrate 5%
• Pneumothorax <1%
• Pneumomediastinum <1%
• Respiratory alkalosis typical
• Inaccurate predictor of outcome
• Will seldom alter your treatment plan
• An objective measure of lung function
• Useful to assess response to treatment
• Impossible to obtain in the dying patient
• <25% Severe
• 25-50% Moderate
• 50-70% Mild
• >70% Discharge Goal
• Simple, and less painful than ABG
• Provides continuous oxygenation measurements
• Needs to placed on well-perfused site, difficult to obtain readings if global hypoperfusion or peripheral vasoconstriction present.
• Aim to keep sp02 >92%

Management of Acute Severe Asthma

• Hypoxia is the main cause of death in asthma
• Oxygen should be given to keep Sp02 above 92%
• A slight Pco2 rise may occur with oxygen therapy but this is of no clinical significance.

Beta-agonists:

• Rapid acting inhaled beta-agonists (bronchodilators) are the first line therapy for acute asthma.
• Nebulisers should generally be used in acute severe asthma, as provide easier delivery of medication to patient, multi dose inhalers have a role in mild to moderate asthma.
• IV salbutamol gives you the advantage of hitting the beta 2 receptors from the back door, while continuing nebulizer treatment, and should be trialed in patients not responding to nebulisers.
• Continuous nebuliser therapy appears to be more effective than intermittent nebulisers for delivering beta-agonist drugs to relieve airway spasm in acute severe asthma.  (Cochrane Review, 2009)
• Salbutamol toxicity can caused a lactic acidosis which is often unrecognized in asthma patients, the lactic acidosis has been hypothesized to adversely affect ventilation by increasing ventilatory demand, increasing dead space ventilation, worsening dynamic hyperinflation and intrinsic PEEP. Management is to discontinue salbutamol at the earliest opportunity.
• Dose:  Salbutamol Nebuliser Ampoule 5mg
• Dose: Salbutamol IV 5mg in 500mL of 0.9% sodium chloride or 5% dextrose start at 30mL/hr titrating up to 120mL/hr

Anticholinergics:

• Anticholinergics agents block muscarinic receptors in airway smooth muscles, inhibit vagal cholinergic tone and result in bronchodilation.
• Dose: Ipratropium bromide (Atrovent) 500ug to second dose of salbutamol via neb, can be repeated every 4hours
• Use of corticosteroids within 1 hour of presentation to an ED significantly reduces the need for hospital admission in patients with acute asthma. Benefits appear greatest in patients with more severe asthma, and those not currently receiving steroids
• Dose: Prednisolone 50mg PO
• Dose: IV Hydrocortisone 100-200mg
• Note: Parenteral route is indicated in ventilated patient or patient unable to swallow, eg. Vomiting

Adrenaline:

• Can be give either intravenously or via nebulizer
• Bronchoconstriction is the major pathology in asthma; airway oedema might also make a significant contribution. Both the a-agonist and B-agonist effects of adrenaline might be beneficial, with the alpha effect decreasing oedema and the beta effect responsible for bronchodilation.
• Dose:  IV 6mg in 100mls 5% dextrose start at 1-15mLs/hour
• Dose: Nebulizer 1mg in 3ml normal saline

Aminophylline:

• The popularity of aminophylline in asthma exacerbations has diminished in recent years.
• Systematic reviews have shown that IV aminophylline in severe acute asthma does not produce additional bronchodilation above that achieved with beta-agonist and corticosteroids.
• Side effects; cardiac arrhythmia’s, vomiting, toxicity.
• Dose : 5mg/kg over 20min followed by infusion of 500mg aminophyline n 500mL of 5% dextrose at 0.5mg/kg per hour

Magnesium Sulphate:

• Magnesium potential role is asthma may involve a combination of smooth muscle relaxation, inhibition of histamine release and acetylcholine release from nerve endings.
• Most evidence to support the use of magnesium in asthma is in the acute severe asthmatic were it has been shown to be safe and beneficial.
• Dose : IV 2-4g over 30-60mins
• Heliox Mixture 80% helium/20% oxygen
• There is evidence that helium and oxygen mixtures (heliox) may provide additional benefits to patients with acute asthma.
• Heliox mixtures have the potential to decrease airway resistance, and therefore decrease the work of breathing for the severe acute asthma patient.

Antibiotics:

• Antibiotics are not indicated in the management of severe acute asthma.
• Antibiotics should only be used in the setting of an underlying pneumonia, respiratory tract infection or to aid in the prevention of ventilator-associated pneumonia in ICU.

Airway Management

Non-Invasive Positive Pressure Ventilation:

Good quality evidence and trails to support the use of NPPV in asthma are lacking, however it is worth trying when intubation is not immediately indicated. Remember the goal of the emergency clinician’s in treating asthma is to prevent intubation.

• Positive pressure is generally less than 15cmH2O
• Benefit between CPAP vs BiPAP is unknown
• Tachypnea caused by severe asthma can make it difficult for the patient to coordinate they’re breathing with machine making BiPAP uncomfortable
• Need a large randomised control trial to determine the effectives properly of NIV, in acute severe asthma.

“Asthmatic on BiPAP before being Intubated”

Mechanical Ventilation:

1-3% of acute severe asthma requires intubation. Prevention of intubation and mechanical ventilation are the goals of managing acute severe asthma, this can be achieved by maximising pre-intubation therapy, however you don’t want to wait too long or let the severe asthmatic tire before trying to intubate them. Once an asthmatic is intubated and ventilated their morbidity and mortality increasing dramatically, and it can be difficult to wean from the ventilator.

Criteria for Intubation:

• Cardiac or Respiratory arrest
• Altered mental status
• Progressive exhaustion
• Severe hypoxia despite maximal oxygen delivery
• Failure to reverse severe respiratory acidosis despite intensive therapy
• pH <7.2, carbon dioxide pressure increasing by more than 5mmHg/hr or greater than 55 to 70mm/Hg, or oxygen pressure of less than 60mm/Hg.

Challenges:

• Effective pre-oxygenation impossible
• No margin for error or delay
• Need to be intubated by most experienced person available
• High intrathoracic pressure after RSI

Recommendations:

• Fluid bolus before intubation if possible
• RSI preferred
• Ketamine for bronchodilator effects
• Permissive hypercapnea essential

Initial Ventilator settings in paralysed patients:

• FiO2 1.0, then titrate to keep SpO2 >94%
• Tidal Volume 5-6ml/kg
• Ventilator rate 6-8 breaths/min
• Long expiratory time (I:E ratio >1:2)
• Minimal PEEP < 5cmH2O
• Limit peak inspiratory pressure to <40cmH2O
• Target plateau pressure <20cmH2O
• Ensure effective humidification
• Brenner, B. Corbridge, T. & Kazzi, A. (2009). Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. The Journal of Emergency Medicine. 37(2s), s23-s34.
• Camargo, C. Rachelefsky, G. & Schatz, M. (2009). Managing Asthma Exacerbation in the Emergency Department: Summary of the National Asthma Education and Prevention Program Expert Panel Report 3 Guidelines for the Management of Asthma Exacerbation.The Journal of Emergency Medicine. 37 (2S), S6-S17.
• Camargo, C. Spooner, C. & Rowe, B. (2009). Continuous versus intermittent beta-agonist for acute asthma (Review). http://www.thecochranelibrary.com.
• Chua, F. & Lai, D. (2007). Acute severe asthma: Triage, treatment and thereafter. Current Anaesthesia & Critical Care. 18, 61-68.
• Creagh-Brown, B. & Ball, J. (2007). An under-recognized complication of treatment of acute severe asthma. American Journal of Emergency Medicine. 26, 513-515.
• Hodder, R. et al. (2009). Management of acute asthma in adults in the emergency department: nonventilatory management.  CMAJ. 182(2), E55-E67.
• Holley, A. & Boots, R.(2009). Review article: Management of acute severe and near-fatal asthma. Emergency Medicine Australasia, (21) 259-268.
• Jones, L. & Goodacre, S. (2009). Magnesium sulphate in the treatment of acute asthma: evaluation of current practice in adult emergency departments. Emergency Medicine Journal. 26, 783-785.
• Melnick, E. & Cottral, J. (2010). Current Guidelines for Management of Asthma in the Emergency Department.  http://www.ebmedicine.net. 2(2). 1-13.
• Morris, F. & Fletcher, A. (Ed). (2009). ABC of Emergency Differential Diagnosis. Oxford: Blackwell Publishing
• National Asthma Council of Australia. Asthma management handbook: 2006. Accessed http://www.nationalasthma.org.au/cms/images/stories/amh2006_web_5.pdf, 12/02/2010
• Nowak, R. Corbridge, T. & Brenner, B. (2009). Noninvasive Ventilation. The Journal of Emergency Medicine. 37(2S), S18-S22.
• Peters, S. (2007). Continuous Bronchodilator Therapy. Chest. 131(1),1-5.
• Phipps, P. & Garrard, C. (2003). The pulmonary physician in critical care. 12: Acute severe asthma in the intensive care unit. Thorax. 58, 81-88.
• Ram, F. Wellington, S. Rowe, B. & Wedzicha, J. (2009). Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma (Review)
• Rodrigo, G. Pollack, C. Rodrigo, C. Rowe, B. (2010). Heliox for non-intubated acute asthma patents (Review).
• Rowe, B. Spooner, C. Ducharme, F. Bretzlaff, J. Bota, G. (2008). Early emergency department treatment of acute asthma with systemic corticosteroids (Review). http://www.thecochranelibrary.com.
• Rowe, B. et al. (2009). Magnesium sulfate for treating exacerbations of acute asthma in the emergency department (Review). http://www.thecochranelibrary.com.

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Clinical case study - asthma, clinical case study - asthma, resource information.

• Disease management

• Open access
• Published: 03 April 2020

Determinants of Acute Asthma Attack among adult asthmatic patients visiting hospitals of Tigray, Ethiopia, 2019: case control study

• Melaku Negash 1 ,
• Hagos Tsegabrhan 2 ,
• Teklit Meles 3 ,
• Degena Bahrey Tadesse 1 ,
• Gebreamlak Gidey 4 ,
• Yemane Berhane 5 ,
• Kibrom Berhanu 6 &
• Tsgalem Haylemaryam 7  

Asthma Research and Practice volume  6 , Article number:  1 ( 2020 ) Cite this article

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Introduction

Acute asthma attack is one of the most common causes of visits to hospital emergency departments in all age groups of the population and accounts for the greater part of healthcare burden from the disease. Despite, Acute asthma attack is an important public health problem that affects not only the patients, but also to the family, health professionals, health care institutions and development of the nation, little is known about the risk factors of acute asthma attack.

Therefore, this study is aimed to investigate the determinants of acute asthma attack among.

The aim of this study was to assess the determinant factors of acute asthma attack among adult asthmatic patients visiting general hospitals of central zone, Tigray, Ethiopia, 2019.

Hospital based unmatched case control study design was conducted in general hospitals of central zone of Tigray, Ethiopia 2019. Data were collected using pretested interviewer administered questionnaire. A total of 289 study subjects (96 cases &193 controls) were selected by systematic random sampling. Data were entered to Epi data version 3.1 then exported to SPSS version 23 for analysis. Bivariate logistic regression was employed to examine the statistical association between dependent and independent variables. Variables with p value < 0.25 in binary logistic regression were entered to multivariable logistic regression model and variables with p value < 0.05 was taken as significant determinants of the outcome variable.

A total of 96 adult asthmatic patients who have acute asthma attack (cases) and 193 adult asthmatic patients without attack (controls)) with 100% response rate were participated in this study. Upper Respiratory tract Infection [AOR = 6.835,95% CI = 3.285,14.222], Season [AOR =2.204,95% CI = 1.011,4.805] kitchen smoke [AOR = 2.307,95%CI1.010,5.272]& sleep apnea [AOR = 9.254, 5%CI =3.563,25.460] were significantly associated with acute asthma exacerbation.

Asthma is a long-term inflammatory disease of the respiratory system which is characterized by wheezing, shortness of breath, chest tightness. Globally it affects approximately 300 million people and is estimated to rise to 400 million by 2025 globally [ 1 , 2 ]. And it is ranked 16th among the leading causes of disability and 28th among the leading causes of burden of disease, as measured by disability adjusted life years (DALYs) [ 3 ].

According to Croatian medical journal 2013, an estimate of asthma prevalence in Africa, was 49.7 million in the age of < 15 years (13.9%), < 45 years 102.9 million (13.8%), and in total population 119.3 million (12.8%) in 2010 [ 4 ].

Asthma exacerbation is defined as a worsening of shortness of breath, cough, wheezing, or chest tightness. If not treated immediately there will be increase in flow resistance causing increased work of breathing, gas exchange inefficiency, respiratory muscle tiredness and finally hypercapnic and hypoxemic respiratory failure [ 5 ]. This implies that acute asthma attack is a significant public health problem that affects patients with their parents or families and the community through labor and school loss, frequent emergency clinic visits, a poor quality of life hospitalizations and finally death [ 6 ]. According to Centers for Disease Control and prevention (CDC) report, More than 11 million people reported having an acute asthma attack [ 7 ].

Despite, in Ethiopia little is known about how risk factors are associated with exacerbation, according to asthma severity and the relative importance of the risk factors. This may be the reason for no policy and strategy to ascertain and acting out of effective intervention in order to reduce the burden of acute asthma attack [ 8 ]. Therefore, this study is aimed to full fill this gap.

Study setting and study design

Hospital based unmatched case control study was conducted in the selected general Hospitals of Central zone of Tigray from November 2018 to July 2019.

Study population and sample size determination

Source population.

All adult asthmatic patients visited to emergency unit who have acute asthma attack.

All adult patients diagnosed as asthma but without acute asthmatic attack who visited the OPD and the regular follow-up unit during the data collection period.

Study population

All selected adult asthmatic patients visited to emergency unit who have acute asthma attack during the data collection period.

All selected adult patients diagnosed as asthma but without acute asthmatic attack who visited the OPD and the regular follow-up unit during the data collection period.

Eligibility criteria

Inclusion criteria.

Adult asthmatic patients who have acute asthma attack during the data collection period.

Adult asthmatic patient without acute asthma attack during the data collection period.

Exclusion criteria

Patients with any history of pulmonary embolism, chronic obstructive pulmonary disease, active pulmonary TB, known congestive heart failure and known mechanical obstruction.

Sample size determination

Sample size was calculated from Previous study conducted in Uganda [ 9 ],using Epi info version 7. sample size was determined based on the assumption of confidence level = 95%; Power = 80%; Odds ratio = 2.132 with case to control ratio = 1:2, proportion of among controls 37.2%, proportion of among cases = 55.8%.

Therefore, the required sample size for cases was =92 where as for the controls =183 and the overall sample size was = 275 then after adding 5% non-response rate, the total sample size was 289. Finally, a sample size for cases was 96 and for controls 193.

Sampling technique and procedure

The total sample size was allocated to each hospital proportionally based on the number of patients who attend in the selected hospitals. A total number of 585(case 165, control.420) patients attended at the selected Hospitals with in 2 months of the previous year (April 1 to May 30–2018). Systematic random sampling method was applied in each hospital to select 289 participants.

Study Variables

Dependent variable.

Acute asthma attack.

Independent variables

Socio-demographic variables.

Age, Gender, Marital status, Residence, Educational level, Employment status and Occupational status.

Behavioral factors

Exercise, vigorous activity Smoking cigarette.

Environmental factors

Humidity, Kitchen smoke, dust, Season.

Medical and Clinical characteristics

URTI, Sleep apnea, Missing follow-up / appointments,

Operational definitions

Those who present with cough, wheezing and difficulty of breathing and diagnosed asthma by physician [ 10 ].

Acute Asthma Attack

Those who present with worsening of wheezing, shortness of breath, cough, chest tightness and diagnosed as acute asthma attack by physician [ 10 ].

Smoker:( daily smoker and non-daily smoker) those who currently smokes or those who quit smoking less than 1 year before the assessment [ 10 ].

Passive smoker: Smoke inhaled involuntarily by non-smokers [ 11 ].

Nonsmoker: Respondents who report never smoke those who quit smoking greater than 1 year before the assessment.

Vigorous activity: participants doing activity more than 10 min continuously, that increases breathing, like carrying or lifting heavy loads, digging or construction work, cutting fire wood [ 11 ].

Data collection tool

Structured questionnaire was used to collect the data which was adapted from different literatures [ 9 , 12 , 13 , 14 ]. The questionnaire contains four parts: socio-demographic, environmental factors, behavioral factors, and Medical &Clinical characteristics.

Data collection procedures

Data were collected from cases and controls using structured questionnaire and checklists through face-to-face interview and from patients chart review respectively.

Twelve BSc nurses as data collectors and three senior nurse supervisors were recruited for the data collection, Then data from cases were collected after they take all the necessary medical care and they recover from their attack whereas from the controls data were collected after they have completed their assessment by physician and at the last record reviews from their chart. Participants were identified as having upper respiratory tract infection and Obstructive sleep apnea from their medical charts which was diagnosed by senior physicians. This is to mean that, it was just suspected clinically by the time of the acute event. The reason we obeyed to use clinically diagnosis for obstructive sleep apnea is that, there is no accesses of modern diagnostic modality like polysomnography in the study area which was Tigray regional state not only in the study area but also in the country Ethiopia as a whole. The evaluation protocol that we use were a single evaluation visit for each case and even those who have follow-up and developed acute asthma attack were included .

Data quality control techniques

Data quality was ensured by training of data collectors and supervisors before data collection period. 5% of the questionnaire was pre-tested in Shire Hospital which was not included in the actual data collection. Based on the findings of the pre-test, questionnaire was modified. The filled questionnaire was checked for completeness and accuracy by data collectors, supervisors and principal investigator each day.. The questionnaire was translated into Tigrigna language for better understanding to both the data collectors and respondents and then back translated into English by another expert to ensure accuracy and consistency.

Data analysis procedures

Data were entered in to Epi data version 3.1 and analyzed using SPSS version 23.0. The degree of association between independent and dependent variables were assessed using adjusted odds ratio with 95% confidence interval. Variables < 0.25 p -value in binary logistic regression were entered to multivariable logistic regression model to control the potential confounding variables. Variables with p-value less than 0.05 in multivariable logistic regression model were taken as significantly associated factors. Variance inflation factor (VIF) was used to assess Multicollinearity between the independent variables. Hosmer and Lemeshow goodness fit model were used to check model fitness.

Ethical consideration

Ethical clearance was obtained from Mekelle University College of health sciences institutional review board (IRB). A subsequent permission was also obtained from Tigray teaching hospitals. Respondents were informed about the purpose of the study and the interview was conducted after receiving the written consent from participants. Confidentiality of the data/information was secured and was not used for other purposes.

Sociodemographic characteristic of study participants

Among the participants, 67.7% (65) of the cases and 60.6% (117) of the controls were females. The median ages of participants were 43 years with interquartile range (IQR) of 26.5 years among cases and 43 median ages with interquartile range (IQR) of 22 for control.

The educational status, one third 33.3% (32) of the cases and 24.9% (48) of the controls were collage and above, where as 14.6% (14) of the cases and 16.6% (32) of the controls were unable to read and write. The majority of the cases 63.5% (61) and 60.1% (116) of the controls were married (Table  1 ).

Behavioral characteristics of study participants

Among the participants, 2.1% (2) of the cases and 1.1% (6) of the controls were smokers.in parallel with this 3.1% of the cases and 4.7% of the control were passive smokers. Regarding vigorous activity 37.5% (36) of the cases and 23.8% (46) of the controls were do vigorous activity. Majority of the participants 72.9% (70) of the cases and 58% (112) of the controls were doing exercise.

Medical & clinical characteristics of study participants

Among the participants, 44.8% (43) of the cases and 13.5% (26) of the controls had Upper Respiratory Tract Infections (URTI) and 29.2% (28) of the cases and few of the controls 5.2% (10) had obstructive sleep apnea.

Among the participants, 31.3% (30) of the cases and 20.7% (40) of the controls had Missing follow up.

Environmental characteristics of study participants

Regarding the seasons of a year, spring season (April, May, June) were the season with high percentage 37.7% (109) of acute asthma attack than the autumn season. Majority of the participants 79.5% (230) were open their window/door while they were cooking. Concerning the kitchen of the participants 32.3% (31) of the cases and 20.2% (39) of the control’s kitchen have no kitchen smoke (chimney) (Table  2 ).

Unmatched case control study with 96 cases and 193 controls was conducted to show the determinants of acute asthma attack among adult asthmatic patients visiting general hospitals of central zone, Tigray, Ethiopia.

Having URTI increases the occurrence of acute asthma attack 6.8 times [AOR = 6.835,95% CI = 3.285,14.222] than those who have not upper respiratory tract infection (URTI) (Table 3 ).

This is consistent with the studies conducted in Gondar, Uganda and Ireland [ 9 , 12 , 15 ].

The association might be due to the mechanism of airway inflammation,mucus hyper secretion, and bronchial hyper responsiveness [ 16 ]. In contrast to this study upper respiratory tract infections was no risk factor for acute asthma exacerbation on the study conduct in Pretoria and New Zealand [ 14 , 17 ]. This difference might be due to difference in health care seeking behavior of the participants in this study.

This study revealed that, sleep apnea was strongly associated with the occurrence of acute asthma exacerbation. Those who have sleep apnea are 9.5 times more likely to run in to acute asthma exacerbation than those who have not sleep apnea [AOR = 9.524, 95% CI = 3.563, 25.460].

This findings is comparable with a study done in Gondar and USA [ 12 , 18 ].

The possible reason is the fact that sleep apnea lead to the worsening of asthma control in patients with concomitant sleep apnea secondary to bronchoconstriction as a result of increase vagal tone while sleeping [ 19 ].

The result of this study shows that the odds of having acute asthma in Spring season was 2.2 times higher than the odds of having acute asthma attack in the autumn season [AOR = 2.204,95% CI = 1.011,4.805]. This is consistent with a study conducted in Canada in which spring season was triggering factor for asthma exacerbation [ 20 ]. Seasonal variation is the risk factors for acute asthma attack especially pollens appearing seasons like spring season exacerbates acute asthma attack. This may be due to the reason that during the spring, tree pollen, mold spores and grass have the power to inflame and narrow the air passages of people who have asthma [ 21 ].

The result of this study was different from a study conducted in Spain which was resulting winter season as higher risk of developing acute asthma attack [ 22 ]. The difference could be arisen from seasonal variation between the study areas, due to the influence of temperature and humidity.

In this study, Kitchen smoke (chimney) is highly associated with risk of acute asthma exacerbation.

Those who have no kitchen smoke in their kitchen were 2.3 times at risk to develop acute asthma exacerbation [AOR = 2.307,95%CI = 1.010,5.2725] than those who have kitchen smoke. This finding is comparable with the study conducted in India [ 13 ]. This is due to the fact that kitchen smoke (chimney) is a way that helps in removing the smokes and fumes from the kitchen and making it clean and smoke free which result in reduction of indoor air pollution and prevents acute asthma exacerbation [ 23 ]. Inhaling harmful smoke can inflame lungs and airway, causing them to swell and block oxygen. This can lead to acute asthma exacerbation [ 24 ]

In this study the determinant factors of acute asthma attack were spring season, presence of upper respiratory tract infection (URTI), having no Kitchen smoke in their kitchen and having obstructive sleep apnea.

Limitations

The diagnosis of respiratory tract infections and sleep apnea was empirical (without laboratory) and all measures used were based on self-reporting, this might end up with social desirability bias. This study may have recall bias, since some of the information was based on the recall of the study participants. Unavailability of studies on acute asthma exacerbation.

Availability of data and materials

The datasets used and analyzed during the current study are presented within the manuscript and available from the corresponding author on reasonable request.

Abbreviations

Adjusted Odds Ratio

Confidence Interval

Crude Odds Ratio

Central Statistical Agency

Interquartile Range

National Health Interview Survey

Out Patient Department

Tigray Region Health Development Agency

Upper Respiratory Tract Infection

Variance Inflation Factor

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Acknowledgments

Authors thanks to public general hospitals of central zone Tigray, Ethiopia for their co-operation, to data collectors, supervisors, for the health staffs of the hospitals and to the study participants for their valuable information.

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Melaku Negash & Degena Bahrey Tadesse

Department of Psychiatric, Mekelle University, Mekelle, Ethiopia

Hagos Tsegabrhan

Adwa General Hospital, Adwa, Ethiopia

Teklit Meles

Department of midwifery, Aksum University, Aksum, Ethiopia

Gebreamlak Gidey

college of medicine and health science, Adigrat university, Adigrat, Ethiopia

Yemane Berhane

Maternity and reproductive health nursing, Mekelle University, Mekelle, Ethiopia

Kibrom Berhanu

Department of Emergency and critical care nursing, Mekelle University, Mekelle, Ethiopia

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Contributions

MN: was made substantially contributions to conceived and designed the study, analysis the data, methodology, data interpretation and wrote the final manuscript.TM, DB, GG,YB, had equally contributed to analysis and interpretation of the data. Whereas HT, TH and KB substantial contribution in reviewing overall the study in analysis, interpretation of data, have drafted the manuscript and substantively revised the work. All authors read and approved the final manuscript.

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Correspondence to Melaku Negash .

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Ethics approval and consent to participate.

Ethical clearance was obtained from Mekelle University College of health sciences institutional review board (IRB). Official supportive letters were obtained from Regional Health Bureau (TRHB) and central zone health office. Respondents were informed about the purpose of the study and the interview was conducted after receiving the written consent from participants. The right of participants to withdraw from the study at any time, without any precondition were secured and participants were informed. Confidentiality of the data/information was secured and was not used for other purposes. No personal identifiers was used on the questionnaire. To maintain confidentiality, data collector was recruited from the study unit.

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Supplementary information

Additional file 1..

Annex I: English version structured interview questionnaire.

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Negash, M., Tsegabrhan, H., Meles, T. et al. Determinants of Acute Asthma Attack among adult asthmatic patients visiting hospitals of Tigray, Ethiopia, 2019: case control study. asthma res and pract 6 , 1 (2020). https://doi.org/10.1186/s40733-020-00054-w

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DOI : https://doi.org/10.1186/s40733-020-00054-w

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Case Report

Conundrum in an asthma exacerbation.

A 66-year-old man, an asthmatic, presented with symptoms suggestive of an acute exacerbation of asthma. His arterial blood gas revealed type 1 respiratory failure (PaO 2 <8 kPa or 60 mm Hg with normal or low PaCO 2 ) with a compensated lactic acidosis. He was treated for an asthma exacerbation and sepsis. Despite treatment, his respiratory rate remained elevated although his hypoxaemia improved. There was progressive worsening of the lactic acidosis. Treatment for sepsis was augmented. Peak flow measurements were not used to assess the severity of his exacerbation nor his response to treatment. An alternate diagnosis of acute coronary syndrome with acute pulmonary oedema was made and his asthma treatment was stopped. This coincided with a decline in his serum lactate. A diagnosis of salbutamol-induced lactic acidosis (SILA) was made. SILA is a relatively common complication of salbutamol therapy in moderate/severe asthma exacerbations. It is caused by a mechanism different from the lactataemia that is associated with septic shock and life-threatening asthma.

Elevated lactate is a marker of severe sepsis and systemic shock. It is also seen in life-threatening asthma when respiratory fatigue and hypoxaemia become overwhelming. However, these are not the only causes. Repeated treatment with nebulised β-2 agonists in otherwise healthy patients can result in hyperlactataemia during a moderate/severe asthma exacerbation.

Acute asthma exacerbations are common medical presentations. Failure to recognise the described scenario can lead to unnecessary escalation of treatment and paradoxical worsening of symptoms ( figure 1 ). Prompt recognition and management lead to dramatic improvement, reducing the risk of iatrogenic harm and prolonged hospital admission.

Flow chart depicting the sequence of events with likely explanations.

Case presentation

The patient, a 66-year-old asthmatic man, had a 3-day history of worsening cough, wheeze and shortness of breath that was not relieved by his salbutamol inhaler. He had purulent sputum but neither fever, chest pain nor haemoptysis. He had been diagnosed with asthma many years ago, but was only treated with a salbutamol inhaler, which he used infrequently. He did not measure his peak flow. He had an admission for an asthma exacerbation 15 years prior, but had never required admission to intensive care. His other comorbidities were atrial fibrillation (AF) and a deep vein thrombosis many years earlier. He had never smoked. He was a retired accountant. He took warfarin in addition to his salbutamol.

On examination, he was able to complete sentences, but was using his accessory muscles to aid respiration. He had a respiratory rate of 23 breaths/min and required 2 L/min of oxygen by nasal cannula to saturate at 94%. His heart rate was 104 bpm and he was normotensive and euvolaemic. Auscultation of the chest revealed a bilateral polyphonic wheeze. The remainder of the examination was normal. A clinical diagnosis of acute infective exacerbation of bronchial asthma was made.

Investigations

The patient's chest radiograph was normal. The white cell count was 11.3 (neutrophils 7.8, eosinophils 0.03×10 9 /L) and C reactive protein was 6 mg/dL. Renal function, serum electrolytes and liver enzymes were normal. Troponin was 8 ng/L. International normalized ratio was 2.2. Arterial blood gas (ABG) at admission ( table 1 ) revealed type 1 respiratory failure and a compensated metabolic acidosis, with a serum lactate of 5.6 mmol/L. Peak flow measurements were not taken. ECG showed AF with a controlled ventricular rate.

Table 1

Timeline of first 10 h of admission, detailing ABG results and medication administration (units and normal ranges for blood gas values given in parenthesis)

ABG, arterial blood gas; BE, base excess; FM, face mask; GTN, glyceryl trinitrate; IV, intravenous; NC, nasal cannula.

Differential diagnosis

Treatment and course.

The patient received repeated doses of 5 mg nebulised salbutamol provided by the ambulance crew. In the emergency department, he received nebulised bronchodilators, parenteral steroids and magnesium. A sepsis care bundle was instituted (intravenous co-amoxiclav, intravenous fluids, blood culture, hourly urine output) because of the lactataemia and he was moved to a monitored bed in the acute medical unit, with instructions to staff to carry out overnight medical review.

He was reviewed 4 h and 6 h after admission. His respiratory rate remained elevated at 24/min but his oxygen saturations had improved to 99%. His heart rate was 105 bpm and he remained normotensive. Urine output was over 150 mL/h. Repeat ABGs revealed worsening lactataemia and metabolic decompensation ( table 1 ). Peak flows were not recorded. Aminophylline infusion was prescribed and intravenous fluids were sped up. Nebulised salbutamol was continued.

After a further 2 h, he developed orthopnoea and worsening hypoxaemia but his wheeze had improved. Clinically, he was thought to have pulmonary oedema, probably precipitated by an acute coronary syndrome. Repeat ECG showed sinus tachycardia without ST changes. Repeat troponin was 40 ng/L. His chest radiograph was unchanged. Aminophylline and salbutamol were stopped. He was treated with fondaparinux, clopidogrel and a glyceryl trinitrate infusion.

At 10 h after admission, the patient showed signs of clinical improvement. His lactate had fallen to 5.9. Over the next few hours, his oxygen was weaned off and a serum lactate level was recorded at 3.3 mmol/L. A diagnosis of salbutamol-induced lactic acidosis and acute exacerbation of asthma was made. He was given prednisolone and a corticosteroid/long-acting β-2 agonist inhaler. Troponin fell to 24 ng/L and treatment for acute coronary syndrome was stopped. Echocardiogram showed a left ventricular ejection fraction of 65%, no regional wall motion abnormalities and no valvular pathology. He was discharged after 24 h.

Outcome and follow-up

At 3-month outpatient follow-up, the patient was well. He had no further asthma exacerbations. He required only infrequent inhaled salbutamol in addition to his salmeterol and fluticasone preventer medication. Infrequent salbutamol usage is not associated with lactic acidosis in otherwise healthy people.

Hyperlactataemia represents a disruption in the homeostatic control of lactate metabolism. It is caused either by increased lactate production or diminished lactate utilisation and clearance. The commonest cause of a raised serum lactate level is type ‘A’ lactic acidosis. This is associated with tissue hypoxia, anaerobic metabolism and increased lactate production. It is seen in profound shock, severe sepsis and life-threatening asthma. However, there are a number of other causes of hyperlactataemia and these are unrelated to tissue hypoxia. Type ‘B’ lactic acidosis has a number of different causes. This topic has been extensively reviewed recently. 1 Table 2 summarises the main causes of lactic acidosis.

Table 2

Causes of lactic acidosis (adapted from Kraut JA et al 1 )

Salbutamol is a selective short acting β-2 agonist that has been used in the treatment of asthma exacerbations since the early 1970's. It has a systemic effect and is recognised as a cause of type ‘B’ lactic acidosis. 2 Intravenous salbutamol is most likely to cause this effect, but it is recognised with nebulised therapy 2 3 and large inhaled doses from a metre-dosed inhaler. 4 5

Since the late 1990s, it has been accepted that adrenergic stimulation of gluconeogenesis, glycogenolysis and glycolysis causes an increased production of lactate, resulting in lactic acidosis. 5 This is not unique to asthma exacerbations and has been reported in acute exacerbations of chronic obstructive pulmonary disease. 2

Figure 1 summarises the physiological response to salbutamol therapy and how this was misinterpreted. The patient took a high frequency of inhaled salbutamol from a metre-dosed inhaler at home and had nebulised treatment before his first ABG, resulting in the high initial value ( table 1 ). He was clinically stable, without signs of sepsis, making type A lactataemia unlikely. His repeat gases at 4 and 5.5 h showed a significantly improved A-a gradient, likely due to an improvement in his asthma. His persistently elevated respiratory rate was compensation for the lactataemia. It is at this point that peak flow measurements are crucial. If, as expected, they showed improvement, it would make it very unlikely that the situation was caused by a worsening of his asthma. Peak flow assessment remains a cornerstone of the assessment of asthma exacerbations. 6 Instead, in this case, the decision was taken to escalate treatment ( table 1 ), leading to further metabolic derangement, confusion over the diagnosis and potential harm to the patient ( figure 1 ).

Increase in lactate secondary to inhaled β agonist therapy is more common than generally recognised. In a prospective study 7 of 18 patients with acute exacerbation of asthma, attending the emergency department, the change in lactate levels after administering 1200 µg of inhaled salbutamol over 120 min was assessed. Fifty per cent of patients had increased lactate levels of over 2.5 mmol/L, and were over 4 mmol/L in four of these. However, none of these patients had acidosis.

Patient's perspective

• I was admitted with a severe asthma attack and was advised that I suffered a small heart attack. This aggravated my asthma problem but I have since learnt that this was a side effect of the nebuliser use.

Learning points

• if there are no signs of shock or hypoperfusion;
• if the lactate rises rapidly after salbutamol therapy;
• if the lactate level rise is associated with an objective improvement in hypoxaemia and peak flow (or forced expiratory volume in 1 s (FEV 1 )).
• Treatment of salbutamol-induced lactic acidosis is to reduce the salbutamol frequency.
• Peak flow or FEV 1 measurement by a peak flow metre or a bedside spirometer is an essential bedside tool that should be used to monitor response to treatment in an asthma exacerbation.

Contributors: Authors BTJI and JS initiated the idea. Author BTJI primarily wrote up the manuscript. All the authors were involved in the care of the patient and helped in the literature search. The manuscript was checked and edited by all the authors and all of them approved the final submission. Author TM was actively involved in rewriting the article during the revision process.

Competing interests: None declared.

Patient consent: Obtained.

Provenance and peer review: Not commissioned; externally peer reviewed.

• Open access
• Published: 09 April 2024

Association of endometriosis with asthma: a study of the NHANES database in 1999–2006

• Guangxin Pan 1 , 2   na1 ,
• Pei Zhang 1 , 2   na1 ,
• Sha Li 1 , 2 ,
• Lanlan Cao 1 , 2 &
• Changqun Yang 1 , 2  

Journal of Health, Population and Nutrition volume  43 , Article number:  50 ( 2024 ) Cite this article

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Asthma is a chronic inflammatory disease of the airways with a gender differences in the prevalence after puberty. Recent studies have reported a relationship between asthma and endometriosis, possibly related to the immune response mechanisms, but the evidences are limited and inconsistent. Herein, this research aimed to investigate the association of endometriosis with asthma based on the representative population in the United States (U.S.) to provide some reference for further exploration on mechanism of gender difference in asthma.

In this cross-sectional study, data of women aged ≥ 20 years old were extracted from the National Health and Nutrition Examination Survey (NHANES) database in 1999–2006. Weighted univariate and multivariate logistic regression analyses were utilized to explore the association of endometriosis with asthma. The multivariate models adjusted for covariates including age, race, education level, marital status, poverty income ratio (PIR), body mass index (BMI), waist circumference, smoking, estrogen and progesterone hormones use, uterine fibroids, at least one ovary removed, and birth control pills intake. The evaluation indexes were odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age, race, BMI, and pregnancy history were also performed.

Among 5,556 eligible women, 782 had asthma, and 380 had endometriosis. The average age of participants was 37.19 years old, and more than half of them were non-Hispanic White (68.44%). After adjusting for covariates, endometriosis was associated with higher odds of asthma compared with non-endometriosis [OR = 1.48, 95%CI: (1.10–1.99)]. This relationship was also found in 40–49 years old [OR = 2.26, 95%CI: (1.21–4.23)], BMI of 25-29.9 kg/m 2 [OR = 2.87, 95%CI: (1.52–5.44)], and pregnancy history [OR = 1.44, 95%CI: (1.01–2.06)] subgroups.

Endometriosis had a positive association with asthma in adult women. Females aged 40–49 years old, with BMI of 25-29.9 kg/m 2 and had a history of pregnancy should take care about monitoring endometriosis to reduce the potential risk of asthma. Further studies are still needed to clarify the causal association between endometriosis and asthma.

Introduction

As a chronic inflammatory disease of the airways, asthma can bring about wheezing, chest tightness, shortness of breath, and coughing [ 1 ]. Epidemiological data on the prevalence, incidence, and severity of asthma appear to suggest gender differences in the risk of developing asthma [ 2 ]. Basing on the United States (U.S.) Centers for Disease Control and Prevention (CDC), 25 million persons suffer from asthma, in which 12 million were female adults and 7.3 million were male adults [ 3 ]. Among European countries, Japan, and the U.S., the prevalence of asthma after puberty in females is higher than that in males [ 4 , 5 ]. Although sex hormones ratio in women to those in men may play an important role in etiology, pathogenesis, and clinical manifestations of asthma, evidences connecting sex hormones with asthma remain equivocal [ 6 , 7 , 8 ].

Endometriosis affects about 190 million females especially at reproductive age worldwide, which is an inflammatory and chronic gynecologic disease, and is characterized by endometrial-like tissue presenting outside the uterus [ 9 , 10 ]. Patients with endometriosis seem to have higher risks of multisite pain, infertility, as well as other comorbidities [ 11 ]. Recent studies have reported the comorbidity of asthma and endometriosis, but the corresponding evidences are limited and inconsistent [ 12 , 13 ]. Sinaii et al. [ 14 ] found that comparing with the published occurrence rates of allergies and asthma in general female populations in the U.S., they are higher in female adults with endometriosis, about 12%. Peng et al. [ 15 ] suggested that women of reproductive age who have asthma are at higher risk of developing endometriosis comparing with those who do not have asthma. Differently, Ferrero et al. [ 6 ] conducted a case-control study, showing a similar prevalence of asthma in females with and without endometriosis. Additionally, the biological mechanisms underpinning this relationship remains elusive. Up to now, the most widely accepted theory is that development of endometrial lesion is related to the dysfunction of the immune system, which affects the expression of particular cytokines [ 16 ]. The immune responses involving T helper (Th) 1/Th2 and Th17/regulatory T cells (Treg) have been reported to be associated with endometriosis [ 17 , 18 ]. Besides, Th2 cells overproducing Th cytokines plays a key role in asthma’s pathophysiology [ 19 ].

Given the mechanistic link between endometriosis and asthma, as well as the inconsistency of existing epidemiological studies, this research aimed to discuss the association of endometriosis with asthma based on the representative population in the U.S. We hope our findings may provide some reference for further exploration of mechanism of the gender difference in asthma.

Study population

In this cross-sectional study, data of women were extracted from the National Health and Nutrition Examination Survey (NHANES) database in 1999–2006. The NHANES is conducted by the National Center for Health Statistics (NCHS) and the Centers for Disease Control and Prevention (CDC) jointly with the aim of assessing nutritional and health status of noninstitutionalized population in the U.S. The database includes a complex, multistage and stratified probability sample on the basis of selected counties, blocks, households, and persons within households. Information was collected through interviews conducted by the NCHS well-trained professionals in participants’ homes, and extensive physical examinations performed at mobile exam centers (MECs). Details were shown elsewhere https://www.cdc.gov/nchs/nhanes/index.htm .

Initially, 41,474 adult women (aged ≥ 20 years old) in the database were included. After excluding those without information on endometriosis ( n  = 35,917) or asthma ( n  = 1), 5,556 adult women were eligible. The NHANES is approved by the Institutional Review Board (IRB) of NCHS. Since the data are de-identified and publicly available, ethical approval has been waived by the IRB of The Central Hospital of Wuhan.

Assessment of endometriosis and asthma

According to the NHANES, assessments of endometriosis and asthma were using the Reproductive Health (RHQ_D) and the Medical Conditions (MCQ), respectively. Endometriosis was identified by a positive answer to the question “Has a doctor or other health professional ever told you that you had endometriosis? (Endometriosis is a disease in which the tissue that forms the lining of the uterus/womb attaches to other places, such as the ovaries, fallopian tubes, etc.)” [ 20 ] Asthma is defined by the positive answers to the question “Has a doctor or other health professional ever told you that you have asthma?” [ 21 ].

Data collection

In the NHANES, demographic variables, including age, race, education level, marital status, and family poverty income ratio (PIR), were collected through questionnaires. Body mass index (BMI) (kg/m 2 ) of all candidates were recorded at the mobile examination center (MEC) by a trained examiner. The variable of cigarette smoking, and other tobacco use was defined by smoking ≥ 100 cigarettes in their entire life. Data on whether individuals had sexual intercourse was also included. In addition, several clinical data were also collected through questionnaires in the NHANES. Using estrogen and progesterone hormones was that participants ever used or was using these female hormones (any forms of estrogen and progesterone hormones, for example, pills, patch, cream, and injectables, but except birth control methods or use for infertility). Participants were asked if they had uterine fibroids by the following question “Has a doctor or other health professional ever told you that you had uterine fibroids? (Yes or no)”. Uterine fibroids are benign (not cancerous) tumors growing in various locations on or within the uterus/womb. Variables of pregnancy history, ovary remove, and birth control pills were assessed by the question “have you ever been pregnant, had at least one of your ovaries removed, and ever taken birth control pills for any reason? (Yes or no)”. Information on “whether the participant is currently pregnant” was also collected.

Statistical analysis

Continuous variables were expressed as mean ± standard error (S.E), and weighted t test was employed for the comparation between two groups. Categorical variables were expressed by frequency and constituent ratio [n (%)], and weighted chi-square test ( 𝜒 2 ) was used for comparation. All NHANES analyses were weighted, as recommended, to represent the U.S. population [ 22 ]. In brief, the NHANES full sample 4 years MEC exam weight (WTMEC4YR) and WTMEC2YR were used for analyses in the current study. The calculation of sample weight for combining data in 1999–2002 was 1/2 × WTMEC4YR, and that for combining data in 2003–2006 was 1/2 × WTMEC2YR.

Weighted univariate logistic regression was utilized to screen potential confounders. Then we used weighted univariate and multivariate logistic regression analyses to investigate the association of endometriosis with asthma. Model 1 only adjusted for age. Model 2 adjusted for demographic variables, including age, race, education level, marital status, PIR, BMI, and waist circumference. Model 3 adjusted for all the covariates selected through weighted univariate logistic regression analysis ( P  < 0.05), including age, race, education level, marital status, PIR, BMI, waist circumference, cigarettes smoking, estrogen and progesterone hormones use, uterine fibroids, at least one ovary removed, and birth control pills use [ 20 , 23 , 24 ]. Subgroup analyses of age, race, BMI, and pregnancy history were also performed to assess the above relationship. The standards of classification for age subgroup and race subgroup were according to menopause or not, and the NHANES criteria, respectively.

The evaluation indexes were odds ratios (ORs) and 95% confidence intervals (CIs). Statistical significance was recognized when P  < 0.05. Analyses were conducted using SAS v. 9.4 (SAS Institute, Cary, North Carolina). Variables with missing data were shown in Supplementary Tables 1 , and were interpolated using multiple imputation method.

Characteristics of adult women

Among 5,556 eligible women, 782 had asthma. The characteristics of eligible women were shown in the Table  1 . The mean age of total participants was 37.19 years old, in which 1,869 (26.89%) participants were under 30 years old, 1,560 (28.78%) between 30 and 39 years old, 1,463 (30.53%) between 40 and 49 years old, and 664 (13.80%) older than 50. The majority of females were non-Hispanic White [2,567 (68.44%)], followed by Mexican American [1,314 (7.91%)], other Hispanic [1,151 (12.28%)], non-Hispanic Black [271 (5.87%)], and other races [253 (5.50%)]. The mean BMI was 28.19 kg/m 2 . A total of 380 (9.02%) females had endometriosis, whereas 5,176 (90.98%) did not. In addition, PIR, weight, waist circumference, cigarettes smoking, estrogen and progesterone hormones use, uterine fibroids, ovary removed, and birth control pills use were also significantly different between the asthma group and non-asthma group (all P  < 0.05).

Association of endometriosis with asthma

We first screened the covariates associated with asthma (Table  2 ). The results showed that race, education level, marital status, PIR, BMI, waist circumference, cigarettes smoking, estrogen and progesterone hormones use, uterine fibroids, ovary removed, and birth control pills were respectively associated with asthma in adult women (all P  < 0.05).

After adjusting for the selected covariates as well as age, women who had endometriosis seemed to have higher odds of asthma compared to those who without endometriosis [OR = 1.48, 95%CI: (1.10–1.99)]. Similarly, in the analysis of data before multiple imputation, this positive association between endometriosis and asthma was still significant [OR = 1.54, 95%CI: (1.13–2.10)], indicating this result was relatively reliable (Table  3 ).

Association between endometriosis and asthma in age, race, BMI, and pregnancy history subgroups

The association between endometriosis and asthma was further assessed in different subgroups. As shown in the Table  4 , endometriosis was also linked to higher odds of asthma in women aged 40–49 years old [OR = 2.26, 95%CI: (1.21–4.23)], with BMI of 25-29.9 kg/m 2 [OR = 2.87, 95%CI: (1.52–5.44)], or had pregnancy history [OR = 1.44, 95%CI: (1.01–2.06)].

In the current research, we explored the relationship of endometriosis with asthma. The study results showed that women with endometriosis seemed to have higher odds of asthma. According to the subgroup analyses, the positive association between endometriosis and asthma was also observed in 40–49 years old, BMI of 25-29.9 kg/m 2 , and having pregnancy history subgroups.

At present, evidences on the relationship between endometriosis and asthma in women are limited and inconsistent. Tempest et al. [ 25 ] retrospectively collected information on females aged 16–30 years from the Liverpool Women’s Hospital, finding that women with endometriosis who underwent laparoscopy were observed to have higher odds of asthma than women without endometriosis. Similarly, in the present study, we found a positive association between endometriosis and asthma in a representative population of the U.S., after adjusting for relevant covariates. A previous study based on the U.S. population showed asthma in women with endometriosis was more common than that in the general U.S. population [ 14 ], but these findings were from a control group of the general population without adjustment for potential confounders [ 6 ]. Differently, according to the study conducted by Ferrero et al. [ 6 ], a similar prevalence of asthma was observed in women who underwent surgery for benign gynecological disorders between endometriosis and non-endometriosis groups. We speculated that a possible explanation for this difference may be that Ferrero’s findings are limited to a study population only including females who have undergone gynecologic surgery, so that these findings may not be applicable to the general population. Therefore, further prospective cohort studies are still needed to clarify the causal association of endometriosis with asthma.

Although the exact pathophysiology for the relationship between endometriosis and asthma is unclear, existing studies have provide some plausible speculations for this association. There are abundant evidences that asthma is linked to Th2-type inflammatory responses induced by allergic stimuli, and the expression of interleukin (IL)-4 is crucial for the development of Th2 immune responses [ 26 , 27 ]. The relationship of endometriosis with major Th2 cytokine immune responses has been reported in previous studies [ 28 , 29 ]. In addition, asthma is related to the airways’ persistent inflammation, and for example, tumor necrosis factor-α, IL-4, transforming growth factor-β, IL-6, and vascular endothelial cell growth factor are all involved in the inflammatory response of asthmatic lungs as well as airway remodeling [ 27 , 30 , 31 ]. Inflammatory responses have also been observed to play important roles in the pathogenesis of endometriosis in several studies [ 15 , 32 ], finding that women with endometriosis had higher levels of inflammatory cytokines in the peritoneum or serum than those without endometriosis [ 33 , 34 ]. Both endometriosis and asthma were related to inflammatory and immunity response, indicating that women who had endometriosis may be potential high-risk population to develop asthma, and for them, asthma-related indicators should be focused on monitoring, and immunity should be improved to reduce the odds of asthma.

The subgroup analyses results showed the positive association of endometriosis with asthma was also observed in women aged 40–49 years old, with BMI of 25-29.9 kg/m 2 , and had pregnancy history. Age played an important role in adult asthma. In 2005–2018, in the U.S., the overall prevalence of asthma in youngers, adults, middle-aged adults, and elderly adults was 8.30%, 8.41%, 8.70%, and 7.92%, respectively [ 35 ]. For adult females, especially menopausal women aged 50 to 60 years old, there is a drop in asthma severity compared to men [ 36 ]. As sex hormones levels decrease with menopause, the age-adjusted risk of asthma may drop in postmenopausal compared to premenopausal women [ 37 , 38 ]. According to our findings, peri-menopausal women who had endometriosis may be at higher risk of asthma. Tempest et al. [ 25 ] suggested the mean of BMI was little higher in the women with endometriosis than females without endometriosis. In a retrospective cohort study exploring the relationship of weight change patterns in adulthood with the incidence of asthma, overweight participants seemed to have a significantly higher risk of developing asthma than those had normal weight [ 39 ]. Similarly, we observed the association between endometriosis and asthma in women with BMI of 25-29.9 kg/m 2 that is at the overweight status. In fact, compared with normal weight, both obesity and underweight had adverse effects on asthma control [ 40 ]. Although this relationship was not significant in BMI < 18.5 kg/m 2 or ≥ 30 kg/m 2 subgroup, it may be meaningful to recommended women who are underweight or obese to keep a healthy BMI through following healthy eating patterns and increasing physical activity levels suitably, and follow the routine physical examination, thereby reducing the potential risk of asthma [ 41 ]. Besides, no studies have discussed the association between endometriosis and asthma in women with or without a history of pregnancy. We speculated a possible mechanism that pregnancy may influence this association could be epigenetic regulation, as a previous study reported alterations in placental DNAm in women with antenatal asthma, compared with women without a history of asthma.

This study based on the NHANES database to explore the correlation between endometriosis and asthma, the study population is the relative representative population in the U.S. Also, we conducted subgroup analyses to further assesse the relationship between endometriosis and asthma in different age, race, BMI, and pregnancy history populations. However, there were some limitations in the current study. First, because of the observational nature of this research, it is hard to conclude a causal association of endometriosis with asthma. Second, due to the limitation of the database, both diagnoses of endometriosis and asthma were self-reported through questionnaires, and women without information on these two diseases were excluded, which may result in a selection bias. Third, this study only included the U.S. general population, further studies are needed to investigate the association of endometriosis with asthma in individuals with different races. In addition, information on endometriosis was only collected by the NHANES database in 1999–2006, and therefore, future prospective researches with larger samples and updated data are needed to explore the causal association of endometriosis with asthma.

Women with endometriosis had potential risk of asthma. Monitoring asthma-related indicators in women who aged 40–49 years old, with BMI of 25-29.9 kg/m2, or having pregnancy history may be beneficial to reduce the odds of asthma. However, the causal association of endometriosis with asthma in adult women was needed to be further clarified.

Data availability

No datasets were generated or analysed during the current study.

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Guangxin Pan, Pei Zhang, Sha Li, Lanlan Cao & Changqun Yang

Key Laboratory for Molecular Diagnosis of Hubei Province, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, P. R. China

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Pan, G., Zhang, P., Li, S. et al. Association of endometriosis with asthma: a study of the NHANES database in 1999–2006. J Health Popul Nutr 43 , 50 (2024). https://doi.org/10.1186/s41043-024-00541-3

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Study finds no evidence COVID-19 causes childhood asthma

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A study today in Pediatrics says there is no evidence that COVID-19 infections lead to asthma in children.

The study, conducted by researchers at the Children's Hospital of Philadelphia (CHOP), included 27,423 patients ages 1 to 16 years who received polymerase chain reaction (PCR) testing for SARS-COV-2 from March 1, 2020, to February 28, 2021.  

Patients were followed up for 18 months, with the main outcome the likelihood of receiving a new asthma diagnosis. Medical records from 1 year before inclusion in the study were also included to establish asthma-naive status among participants.  

"During the early days of the pandemic, we could isolate the effects of COVID-19 from other viruses and follow these patients long enough to observe the onset of asthma," said first study author James Senter, MD, MPH, an attending physician at CHOP, in a press release from the hospital. "We were also testing so frequently that we had a built-in control group to compare asthma symptoms and whether COVID-19 was a critical factor."

During the early days of the pandemic, we could isolate the effects of COVID-19 from other viruses and follow these patients long enough to observe the onset of asthma.

Asthma tied to race, allergies

Instead of finding that COVID-19 infection raised the risk of childhood asthma, the researchers found that kids who were prone to developing asthma were more likely to test positive for COVID-19 during the 18-month study period. Known risk factors for asthma included race, food allergies, allergic rhinitis (or hay fever), and preterm birth  

In total, 3,147 children (11.5%) were in the SARS-CoV-2–positive group and 24,276 (88.5%) were in the SARS-CoV-2–negative group, and 573 total received an asthma diagnosis during the 18 months.

SARS-CoV-2 positivity on PCR had no significant effect on the hazard of new asthma diagnosis (hazard ratio [HR], 0.96; 95% confidence interval [CI]: 0.73 to 1.27).

What did have an effect on asthma diagnosis was Black race (HR, 1.49; 95% CI, 1.13 to 1.95), food allergy (HR, 1.26; 95% CI, 1.03 to 1.55), and allergic rhinitis (hay fever; HR, 2.30; 95% CI, 1.93 to 2.74).

Secondary analysis finds similar results

In a secondary analysis that required two asthma medical codes, 418 participants received and maintained an asthma diagnosis in the 18-month follow-up period. Of those, 1.12% (35) of SARS-CoV-2 – positive children were diagnosed as having asthma, compared with 1.59% (383) of SARS-CoV-2 – negative children.

" SARS-CoV-2 PCR positivity was not associated with a new asthma diagnosis using this stricter definition. However, Black race, atopic comorbidities, and age were again associated with new asthma diagnosis when using the secondary asthma definition, " the authors wrote.  

"This well-powered study reaffirms risk factors we know contribute to asthma development and provides clinically useful information to pediatricians and providers on the absence of risk of developing asthma as a result of COVID-19," said senior author David A. Hill, MD, PhD , a physician in the Division of Allergy and Immunology at CHOP. "We are hopeful that this study will put to rest an outstanding question on the minds of many their families."

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Association of endometriosis with asthma: a study of the NHANES database in 1999-2006

Affiliations.

• 1 Department of Obstetrics and Gynecology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, No 26. Shengli Street, Jiang'an District, Wuhan, 430014, Hubei Province, P. R. China.
• 2 Key Laboratory for Molecular Diagnosis of Hubei Province, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, P. R. China.
• 3 Department of Obstetrics and Gynecology, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, No 26. Shengli Street, Jiang'an District, Wuhan, 430014, Hubei Province, P. R. China. [email protected].
• 4 Key Laboratory for Molecular Diagnosis of Hubei Province, Tongji Medical College, The Central Hospital of Wuhan, Huazhong University of Science and Technology, Wuhan, 430014, P. R. China. [email protected].
• PMID: 38594768
• PMCID: PMC11003178
• DOI: 10.1186/s41043-024-00541-3

Objective: Asthma is a chronic inflammatory disease of the airways with a gender differences in the prevalence after puberty. Recent studies have reported a relationship between asthma and endometriosis, possibly related to the immune response mechanisms, but the evidences are limited and inconsistent. Herein, this research aimed to investigate the association of endometriosis with asthma based on the representative population in the United States (U.S.) to provide some reference for further exploration on mechanism of gender difference in asthma.

Methods: In this cross-sectional study, data of women aged ≥ 20 years old were extracted from the National Health and Nutrition Examination Survey (NHANES) database in 1999-2006. Weighted univariate and multivariate logistic regression analyses were utilized to explore the association of endometriosis with asthma. The multivariate models adjusted for covariates including age, race, education level, marital status, poverty income ratio (PIR), body mass index (BMI), waist circumference, smoking, estrogen and progesterone hormones use, uterine fibroids, at least one ovary removed, and birth control pills intake. The evaluation indexes were odds ratios (ORs) and 95% confidence intervals (CIs). Subgroup analyses of age, race, BMI, and pregnancy history were also performed.

Results: Among 5,556 eligible women, 782 had asthma, and 380 had endometriosis. The average age of participants was 37.19 years old, and more than half of them were non-Hispanic White (68.44%). After adjusting for covariates, endometriosis was associated with higher odds of asthma compared with non-endometriosis [OR = 1.48, 95%CI: (1.10-1.99)]. This relationship was also found in 40-49 years old [OR = 2.26, 95%CI: (1.21-4.23)], BMI of 25-29.9 kg/m 2 [OR = 2.87, 95%CI: (1.52-5.44)], and pregnancy history [OR = 1.44, 95%CI: (1.01-2.06)] subgroups.

Conclusion: Endometriosis had a positive association with asthma in adult women. Females aged 40-49 years old, with BMI of 25-29.9 kg/m 2 and had a history of pregnancy should take care about monitoring endometriosis to reduce the potential risk of asthma. Further studies are still needed to clarify the causal association between endometriosis and asthma.

Keywords: Adult women; Asthma; Cross-sectional study; Endometriosis; NHANES database.

© 2024. The Author(s).

• Asthma* / complications
• Asthma* / epidemiology
• Body Mass Index
• Cross-Sectional Studies
• Endometriosis* / complications
• Endometriosis* / epidemiology
• Middle Aged
• Nutrition Surveys
• United States / epidemiology
• Young Adult

Unfavorable social factors may raise heart disease risk factors in Asian American adults

Having more unfavorable social determinants of health, such as being unemployed, uninsured or not having education beyond high school, was associated with an increased likelihood of having risk factors for cardiovascular disease among Asian American adults, according to new research published today in the Journal of the American Heart Association , an open access, peer-reviewed journal of the American Heart Association.

The investigation also noted that the link between these unfavorable social determinants of health variables and cardiovascular disease risk factors varied widely among people in different Asian American subgroups in this study. An association does not mean that social determinants of health directly caused the risk factor.

"Despite the perception that Asian Americans may be less impacted by social determinants of health compared to people in other racial/ethnic groups, our findings indicate unfavorable social factors are associated with higher prevalence of cardiovascular risk factors among Asian American adults," said lead study author Eugene Yang, M.D., a professor of medicine at the University of Washington School of Medicine in Seattle.

"The Asian American population is the fastest growing racial/ethnic group in the United States," Yang said. "People of South Asian heritage have higher rates of premature heart disease globally, and they recently have been found to have higher cardiovascular mortality than non-Hispanic white people. Better understanding of why differences in cardiovascular risk exist among Asian subgroups is vital to reducing risk and improving outcomes."

Researchers examined data from the National Health Interview Survey conducted in the U.S. from 2013 to 2018, which included 6,395 adults who self-identified as Asian.

Researchers rated 27 social determinants of health factors as favorable or unfavorable in six areas: economic stability (which included employment and income status); neighborhood and social cohesion (which gauged neighborhood trust and whether homes were owned or rented); psychological distress; food security; education; and health care utilization.

The analysis found a significant relationship between unfavorable social determinants of health and cardiovascular disease risk factors. This relationship varied among people in different Asian American subgroups. Among the findings:

• For all Asian groups included in the data, a higher unfavorable social determinants of health score by one standardized unit was associated with a 14% greater risk of high blood pressure; a 17% greater risk of poor sleep; and a 24% greater risk of Type 2 diabetes -- all of which increase the risk for developing cardiovascular disease.
• a 45% greater likelihood of Type 2 diabetes among Chinese adults and a 24% greater likelihood among Filipino adults;
• a 28% greater risk of high blood pressure among Filipino adults;
• a 42% increased likelihood of insufficient physical activity among Asian Indian adults, a 58% increased likelihood among Chinese adults and a 24% increased likelihood among Filipino adults;
• a 20% likelihood of suboptimal sleep among Asian Indian adults; and
• a 56% and 50% likelihood of nicotine exposure among Chinese adults and Filipino adults, respectively.
• Compared with other Asian American subgroups, adults who identified as Filipino reported the highest prevalence -- 4 out of 7 -- cardiovascular risk factors: poor sleep, high cholesterol, high blood pressure and obesity.

Yang said many social determinants of health are often interconnected, such as neighborhood cohesion, economic stability and use of the health care system.

"It is important to understand how different Asian subgroups are affected," he said. "When Asian people are lumped together, higher risk groups like South Asian people may not be treated aggressively enough, while groups with lower risk, like people of Korean and Japanese descent, may be overtreated for blood pressure or cholesterol."

Study background and details:

• The large, cross-sectional study reviewed data from 2013-2018 National Health Interview Surveys -- annual, nationally representative surveys of U.S. adults.
• Of the 6,395 Asian adults in the survey, about 22% self-identified as Filipino adults; 22% as Asian Indian adults; 21% as Chinese adults; and 36% as other Asian.
• The sample size of Asian American individuals in the national survey was too small to analyze several major Asian populations, including Japanese, Korean and Vietnamese people, as well as other smaller Asian subgroups.
• Nearly 56% of the group were women, and nearly 52% were between the ages of 18 and 44. About 77% of the participants were born outside the United States.
• Participants were assigned scores for social determinants of health by categorizing 27 variables as favorable or unfavorable.
• The cardiovascular risk factors were self-reported and were similar to the American Heart Association's Life's Essential 8 -- eight lifestyle metrics assessing ideal cardiovascular health. These eight metrics include: following a healthy diet, maintaining a healthy weight, getting regular exercise and enough quality sleep, avoiding nicotine exposure and maintaining healthy levels of blood pressure, glucose and cholesterol. However, healthy diet was not measured in this study. Reaching optimal levels of these eight metrics improves heart health and reduces the risk for heart disease and stroke.

Limitations of the study include that its small sample size did not allow for analysis of some Asian subgroups (Japanese, Korean, Vietnamese and other Asian people). In addition, it examined self-reported survey data on social factors and cardiovascular risk factors at a single point in time. Therefore, the analysis could not assess long-term social determinants of health patterns, and it could not prove that unfavorable social factors caused the development of cardiovascular disease risk factors. Furthermore, language barriers may have been a factor for some participants because the National Heath Interview Surveys were only conducted in English and Spanish.

Study authors noted that it is vital to include more Asian Americans in national surveys to reveal potential differences in optimal social determinants of health profiles and cardiovascular risk factor prevalence and outcomes.

• Heart Disease
• Cholesterol
• Mental Health Research
• Hypertension
• Diseases and Conditions
• Chronic Illness
• Health Policy
• Epidemiology
• Athletic training
• Public health
• Environmental impact assessment
• Personalized medicine
• Premature birth

Story Source:

Materials provided by American Heart Association . Note: Content may be edited for style and length.

Journal Reference :

• Alicia L. Zhu, Austin D. Le, Yuemeng Li, Latha P. Palaniappan, Malathi Srinivasan, Nilay S. Shah, Sally S. Wong, Javier Valero‐Elizondo, Tali Elfassy, Eugene Yang. Social Determinants of Cardiovascular Risk Factors Among Asian American Subgroups . Journal of the American Heart Association , 2024; DOI: 10.1161/JAHA.123.032509

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