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asth.ma

Asthma Blog from the view of an asthma researcher, doctor, and mom

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#Asthma is unique at every age

The current issue of the Journal of Allergy and Clinical Immunology In practice is entitled Asthma Across the Ages.  A whole issue devoted to ASTHMA!  I had a lot of fun coordinating this issue with Paul Greenberger.

The goal of this issue is to provide an across the spectrum of life perspective on asthma in order to hopefully contribute new insights on asthma management to improve care for patients. Our editorial that accompanied the issue, entitled Asthma: Overdiagnosed, Underdiagnosed, and Ineffectively Treated, was motivated by recent data from the Centers for Disease Control (CDC) that showed that minorities, particularly black non-Hispanics and Puerto Ricans still suffer a disproportionate share of the burden of asthma. Black non-Hispanics have a 3-fold higher asthma death rate than white non-Hispanics or Hispanics.  And close to 50% of patients with current asthma had experienced at least one an asthma flare in the previous 12 months.

We still have so much work to do.

What complicates asthma treatment is we still do not have a definitive way of diagnosing asthma. So, sometimes we overdiagnose. For example, obese patients who are more likely to report shortness of breath may be overdiagnosed. 

Sometimes we underdiagnose.  Older adults are more likely to be underdiagnosed because they may be diagnosed with COPD.

And this can lead to undertreatment, which leads to asthma flares.  

We invited authors with expertise in asthma across the age spectrum to contribute articles.  Here are a few highlights. This issue is packed with articles about asthma. Guess who the titles were inspired by?

Prenatal:

In a review entitled, “As You Eat It: Effects of Prenatal Nutrition on Asthma,” Lee-Sarwar and Litonjua et al provided a summary of the literature on the effect of diet during pregnancy on risk of childhood asthma.  Vitamin D supplementation may have a protective effect on the development of childhood asthma.

School-aged children:

Naja et al reviewed asthma in school-aged children, providing an overview of racial/ethnic and socioeconomic disparities to environmental exposures to novel treatments.  Their review is “Taming Asthma in School-Aged Children: A comprehensive Review.”

Adolescents:

Being a teen these days is hard enough. Having asthma as a teen is even harder. Burg et al review real-world challenges for tens with persistent asthma in “The Tempest: Difficult to Control Asthma in Adolescence.”  How do we teach teens self-efficacy?

Adults over age 65 years:

Older individuals with asthma have unique challenges with co-existing illnesses such as heart conditions, sleep apnea, obesity or COPD.  Effectiveness of treatments may be different for older individuals and newer medicines.  Baptist and Busse review these issues in Asthma Over the Age of 65: All’s Well That Ends Well.

So, no matter what age group you care about, this is a must not miss issue for asthma!

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A new tool to help support better asthma management

Today’s blog post is from Barbara P. Yawn MD MSc, Director of Research, Olmstead Medical Center, University of Minnesota.  She writes about a recently published study on a tool she developed to help improve rates of asthma control.

Asthma burden is more than just going to the emergency room or hospital for severe asthma attacks.   Over half of people with asthma have symptoms more than 2 days or nights each week—symptoms like wheezing, coughing and shortness of breath or that keep them from doing the activities they would like to do.  We have given this a label as “out of control” asthma and score cards like the Asthma Control Test (ACT) give scores to tell clinicians or families that their asthma is out of control.

Too often, having out of control asthma results in simply giving more asthma medication.  But often that is not the best answer.   A newer tool called the Asthma APGAR helps measure the burden but goes on to assess the most common reasons for asthma being “out of control”.   Those reasons include:

·       Allergic triggers or irritants like dust mites, pets, mold, cockroaches or seasonal pollens from trees, flowers or grasses or irritants like tobacco smoke

·       Inability or concerns about taking asthma medications daily—once or twice a day

·       Incorrect inhaler technique so that the medicines from the inhalers do not get into the lungs.

The Asthma APGAR asks questions about triggers, how you talk your medications and why you do or do not take them and whether or not you think the medications help your asthma.  

The tool also includes a list of questions for you or your doctor, nurse or physician assistant to discuss that can help bring out more details about your activities and how they may have changed due to your asthma, more about triggers that seem to make your asthma worse and reasons why you find it difficult or uncomfortable to take asthma medications.

The control score (first 3 questions) and the other responses are linked to a care flow chart or algorithm that can guide next steps in your care.  It is color coded—red is for an acute asthma attack that requires immediately attention usually with additional medication or even oxygen.  Yellow is for people with out of control scores—2 or higher on the Asthma APBGAR. And green is for times when the asthma seems to be in control and not bothering your usual activities.

For the yellow times, the algorithm reminds you and your clinician to not just prescribe more medicine but to explore reasons for the problems including making sure they have explained and watched you use each of your inhalers.  Different inhalers require slightly different techniques (see box below).  

By circling any of the triggers that you think may make your or your child’s asthma worse, you can help guide an allergy assessment.  Over 90% of children and about 70% of adults have some allergy sensitivities.   Without identifying and either avoiding those triggers or treating those problems, it may be very hard to control asthma symptoms.   Allergic sensitivities can be assessed by a blood test that includes 10 to 12 of the most common allergies in your geographic area, by allergy skin tests or by exposing you to the triggers and watching for symptoms—like noticing that your asthma gets worse every time to visit your friend or neighbor with a cat.   Dust mites are very common problems that don’t mean you are a poor housekeeper—they are in many households except those above 3,000 feet in altitude where dust mites don’t like to live.  Mold and even cockroaches can be common in warm humid climates and require care but often can be removed.   Other allergies may be seasonal and respond to increased asthma and allergy medications.   Some allergies require immunotherapy—either as asthma allergy “shots” usually given by an allergist or for some allergens, sub-lingual drops you can use at home after a few doses given in a clinic.

Reasons for not taking medications as prescribed—labeled adherence—are many but often include:

·       Not understanding why, when or how the medications are to be used.  Remember that most people with asthma have 2 kinds of medicine—one for quick relief when symptoms get worse and one or more they need to take daily called maintenance medicines like inhaled corticosteroids.

·       Having a very busy life that makes it difficult to remember things regularly.  Putting the medicines in an obvious but safe place where you will notice them—like near your bed if you use medicine morning and evening can help.   Using a calendar on the refrigerator to check them off daily or an app on your smart phone can also work.

·       Not being able to pay for the medicine or pay the co-pays can make it difficult to have what you need.   If this is a problem, it is better to ask your doctor or nurse or people in the clinic about any programs that could help and to make sure you are only taking medicines that you need.   Simply taking less medicine on your own often does not work.

Ok, that is a lot of information available from one tool.  Does it work?  YES.   In a study of over 1200 people with asthma (ages 5 to 45 years of age) who were cared for in primary care offices scattered around the country, using the Asthma APGAR system led to improved rates of asthma control and to a 50% decrease in asthma visits to the emergency room or hospital in the group using the Asthma APGAR compared to patients in clinics not using the Asthma APGAR.

The Asthma APGAR can be put on your refrigerator to allow you to follow how things are going.   If you mark several of the triggers, ask your doctor, nurse or physician’s assistant to do more evaluation to see what can be done if you have allergies.   Sharing any problems, concerns or fears about taking the medications and making sure you know which is for what purpose as well as asking them to watch you use your inhalers lets you guide your care.

For children, the Asthma APGAR can be shared with the school nurse or even the day care center to help them learn more about asthma and let you know what is happening while your child is in day care or at school.

The Asthma APGAR system works to support better outcomes for patients.  It is one of the only control scores that has been tested to show how it affects asthma care and it is the only one that helps busy primary care clinicians next steps.

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Does #obesity cause #asthma, or does asthma cause obesity?

How often I’ve been told by a parent that their child’s obesity was because he or she couldn’t exercise because of asthma. But I’ve never been told that a child’s obesity caused the child’s asthma. Or that a child’s obesity made her asthma worse.  We know that asthma and obesity are related. But which comes first? It turns out it could be both. A recent article in the Journal of Allergy and Clinical Immunology by Ubong Peters PhD et al reviews this topic.  

 So, it turns out:

  • Obese subjects are more likely to have asthma.

  • Obese asthmatic individuals are more likely to have symptoms, more frequent and severe flares, and poorer response to asthma medications, and decreased quality of life.

  • Both asthma and obesity are common in children and adults.  In the U.S., 9% of children have asthma and 17% are obese (with another 15% being overweight).  In adults, 7% of lean adults have asthma while 11% of obese adults have asthma.

  • In children, asthma can lead to obesity.

  • But most studies suggest obesity changes asthma by increasing asthma severity, leading to poorer control and lower quality of life.

  • In adults, obese adults have a much higher risk of being hospitalized than lean adults with asthma.

  • In children and adults, obesity has a significant effect on lung function.

  • Diet may play a role.  Obesity is associated with low circulating vitamin D levels, and multiple studies have suggested that vitamin D deficiency may be linked to asthma exacerbations.  Furthermore, diets that are high in saturated fatty acids that promote obesity also are associated with asthma. On the flip side, breastfeeding is associated with lower risks of both asthma and obesity.  Beverages containing high sugar levels are risk factors for asthma and obesity.

  • Diet also affects the gut microbiome (microorganisms in the gut), and the Western dietary pattern is known to alter the gut microbiome to promote obesity. This might also affect development of allergic airway disease.

  • Weight loss interventions appear to improve asthma outcomes

What does all this mean?

  • Obesity is an important risk factor for asthma and symptoms related to asthma in both children and adults.

  • Even though there are commonalities between adults and children, there are different characteristics between age groups.

  • Potential underlying mechanisms for asthma and obesity include:

    • Shared genetic component

    • Dietary and nutritional factors

    • Alterations in the gut microbiome

    • Systemic inflammation

    • Metabolic abnormalities

    • Changes in lung anatomy and function

So, asthma and obesity are definitely related, but much is still unknown, including:

  • How to classify obese and non-obese asthma

  • Whether new treatments might be better for individuals with obesity and asthma

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Who invented the stethoscope?

It’s one of the most defining items for doctors.  1 year old patients will imitate how to use mine by putting it behind their necks.  5 year old patients will ask to try to take a listen to their hearts beat. It’s the one item I’m lost without in clinic.   It’s the basis of diagnosing asthma.

The stethoscope. 

So, who invented it?  A recent essay by Professor Goran Wennergren tells us that Rene Laennec invented the stethoscope over 200 years ago.

The stethoscope was invented in 1816 while Dr. Laennec was a physician in Paris.  The Laennec stethoscope was a wooden cylinder, but in the beginning, Laennec used tightly rolled sheets of paper as his stethoscope.

He tried multiple materials for the stethoscope before deciding that wood was the best.  The name “stethoscope” comes from the Greek words stethos for chest and skopein for look.

Before the invention of the stethoscope, physicians placed their ears on the patients’ chests.

The modern stethoscopes that we are familiar with now, with two ear pieces, were invented in 1851 by Arthur Leared, an Irish physician.

A photo of one of the first stethoscopes.

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And here’s a picture of Rene Leannec.

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No need to increase inhaled steroids at first sign of #asthma symptoms

Earlier this month, the New England Journal of Medicine published a study called “Quintupling Inhaled Glucocorticoids to Prevent Childhood Asthma Exacerbations.”  Now that many have had a chance to read and think about this, I’m hoping this post opens up a dialogue on how this study is influencing practice.

Details are below.  Briefly, the study found that in children with persistent asthma who were on daily inhaled corticosteroids, quintupling the dose of inhaled steroids for 7 days at early signs of loss of asthma control did not improve asthma outcomes.

Some of the questions I’ve received are:

·      Does this mean we should go right to combination inhaled corticosteroids/long acting beta agonists (such as Advair, Symbicort), rather than increasing the dose of inhaled steroids to control asthma?

·      The study found that children who received the quintupled dose of inhaled steroids had decreased height. Would it be better or worse to give oral steroids?

Many of the best asthma providers recommend that patients increase the dose of inhaled steroids at the first sign of asthma symptoms.  Still, many providers don’t believe increasing the dose of inhaled steroids makes a difference. 

First, some more details about the study:

Why did the authors conduct the study?

Children with persistent asthma are often prescribed inhaled corticosteroids as a preventive medicine, to prevent symptoms.  Many clinicians increase the doses of inhaled steroids at the first signs of symptoms, at early signs of loss of control of asthma.

The recommendation to increase the dose of inhaled corticosteroids is recommended in GINA (Global Initiative for Asthma) guidelines, but not in U.S. National guidelines.  According to the GINA guidelines 2018, For patients taking conventional maintenance inhaled steroid-containing treatment, this should generally be increased when there is a clinically important change from the patient’s usual level of asthma control…”  The reference for this recommendation is a study by Gibson and Powell in 2004 on written action plans for asthma.

Gibson and Powell conducted a review of 26 randomized clinical trials that compared action plans to usual care.  The focus of their review was on whether written action plans helped improve asthma outcomes. Thirteen of the trials increased both inhaled steroids and oral steroids.  Four trials recommended use of oral steroids alone but these studies had insufficient data. None of the studies only increased the inhaled steroid dose.  So, all of the studies analyzed recommended inhaled steroids and oral steroids at the start of symptoms and they found an improvement in asthma when inhaled steroids and oral steroids were recommended.

But was it the increase in inhaled steroids or addition of oral steroids that improved asthma outcomes? This part was unclear, making this recommendation uncertain.

Another review in 2016 by Kew et al looked at 8 randomized trials (3 pediatric and 5 adult) and found that current evidence does not support increasing the dose of ICS at the start of symptoms.   Given the uncertainty of these findings, a definitive trial is needed.

 How did the authors conduct their study?

·      They studied 254 children, ages 5 to 11 years who had mild to moderate persistent asthma

·      All children had at least one asthma flare treated with oral steroids in the prior year

·      Children were treated for 48 weeks on low dose inhaled steroids

·      These children were randomly assigned to continue on the same low dose or use a quintupled dose of inhaled steroids for 7 days at the early signs of loss of asthma control (yellow zone).  

Yellow zone refers to the three zones of an Asthma Action Plan. When people are in the green zone, they are doing well without asthma symptoms, and they take their daily controller medicine if prescribed. When they are in the yellow zone, they are starting to have symptoms, and usually start taking their rescue medicine (albuterol). At this point, many clinicians recommend that patients increase their dose of inhaled steroids. When they are in the red zone, they are requiring more frequent albuterol use and need to call their clinician or go to the ED.

What did the authors find?

·      The rate of severe asthma exacerbations (defined as requiring systemic steroids) was not significantly different between the two groups.

·      The total steroid exposure was 16% higher in the group that received quintupling of inhaled steroids at the first sign of symptoms.

·      The difference in linear growth between the group receiving the quintupling dose and the regular dose groups was -0.23cm/year, but this was not statistically significant (although the trend was there).

What does this mean?

·      Increasing the dose of inhaled steroids four-fold during the early signs of an asthma flare did not reduce the rate of severe asthma exacerbations or other asthma outcomes.

·      Quintupling the dose may be associated with decreased linear growth.

So, how has this study changed your practice? Or how has this changed your self-management?

Filed under medications sideeffects

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DNA changes in cells of the immune system in childhood asthma

Today’s guest blog post is from Erik Melén, an Associate Professor at the Institutet of Environmental Medicine, Karolinska Institutet. He writes about a new study, just published in The Lancet Respiratory Medicine.  He writes…

Why did we conduct our study?

Asthma is a respiratory disease caused by a chronic inflammation of the airways. An estimated 800,000 people have asthma in Sweden, about 50,000 of whom suffer so seriously that their everyday functioning is impaired. It is thought that asthma is caused by a combination of hereditary and environmental factors, but there are still many knowledge gaps to be filled. Epigenetics is an emerging research field that is focused on analyses of chemical modifications of the DNA. Epigenetics governs where and when different genes are active and DNA methylation is one of its most common regulatory mechanisms. In this study, we show that children with asthma have epigenetic DNA changes in certain cells of their immune system.  

How did we conduct our study?

Collaborating with Professor Gerard Koppelman at the Groningen University in the Netherlands and others, we have conducted an extensive study of the epigenetic changes that can be related to asthma. The study included over 5,000 children from 10 European cohorts, including the Swedish birth cohort BAMSE, which is led by Erik Melén. The research is the result of a longer-standing collaboration with European researchers in the EU MeDALL (Mechanisms of the Development of Allergy) programme.  In this project, we conducted an epigenome-wide association study (EWAS), which means that methylation levels at thousands of different loci across the genome was analyzed.

What did we find?

Our study shows that asthmatics have a lower degree of DNA methylation in certain immune cells than healthy controls, particularly in what are known as eosinophils, which play a critical part in the asthmatic inflammation. We identified DNA changes in 14 gene regions linked to children’s asthma, but these changes were not present at birth.

What do our findings mean?

We believe that our findings are key to understanding the disease mechanisms, even if we’ve not yet been able to show that the epigenetic changes actually cause asthma. Our results suggest that the lower DNA methylation in asthmatics increases activation of the immune cells, which play a central part in the development of asthma.

This is the largest epigenetic asthma study to date and we hope that our discoveries will give rise to better diagnostics and treatment possibilities. Influencing epigenetic regulation could be a new and interesting therapeutic strategy. We believe our findings can one day lead to improved diagnostics and treatment.

The study was primarily financed by the EU (the MeDALL project).

Link to the publication:
http://www.thelancet.com/journals/lanres/article/PIIS2213-2600(18)30052-3/fulltext?elsca1=tlxpr

Filed under research innovations

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My visit to AAFA, leading organization for people with asthma and allergies

If you have asthma, you should know about AAFA. Last week, I had the opportunity to visit the Asthma and Allergy Foundation of America.  AAFA is the leading organization for people with asthma and allergies.

I visited their office in Landover, Maryland, but they also have regional chapters in Alaska, Michigan, New England, and St. Louis.  I had the opportunity to visit with AAFA’s new CEO, Kenny Mendez, who was on day 9 of his new job.

AAFA provides education for patients, caregivers, healthcare providers. They have online materials, printed materials, tools in Spanish, and so much more. The AAFA website is worth visiting.

·      One education project of AAFA is Asthma Capitals. Every year, they rank the most challenging places to live in the U.S. for individuals with asthma by looking at 13 important factors.

·      Another educational project is the State Honor Roll of Asthma and Allergy Policies for Schools, which ranks the states with the best public policies for people with asthma food allergies, anaphylaxis, and related allergic diseases in U.S. schools. Check out the interactive map to see how your state ranks!

AAFA provides advocacy for and support for public policies that will benefit people with asthma and allergies.  For example, AAFA promotes access to affordable treatment and management of asthma and allergies. 

AAFA conducts multiple research studies for asthma and allergic diseases including:

·      Asthma Inhaler Design Survey where they invited over adult patients and parents of children with asthma to take an online survey.  They found that 50% of relief inhalers were expired, 48% of relief inhalers were found to be empty.  Adding a dose counter for inhalers would improve satisfaction with quick-relief inhalers (and these are now available).

·      My Life With Asthma was an online survey that examined the challenges and experiences of those living with severe asthma.  They found that 97% reported that asthma limited their everyday tasks, 83% reported that asthma affects their personal relationships, 48% used their quick-relief inhaler more than once a day, and 41% said they believed their asthma was so severe that there are no medicines that can make it better.

·      The AFFORD (Asthma in Families Facing Out-of-Pocket Requirements with Deductibles) Study is the reason I was visiting AAFA. The principal investigator, Alison Galbraith, and I went to present some of our preliminary findings. The goal of this study is to better understand how different types of health insurance plans affect the experiences of people with asthma and their families.

As I said at the start, if you have asthma, you should know about AAFA.

Some photos of our visit…

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Filed under clinical

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#Asthma flares decreasing in U.S. children

This week, the CDC published its report “Vital Signs: Asthma in Children – United States, 2001-2016.”  The positive news is the percentage of U.S. children having asthma attacks decreased from 2016 to 2001 (see figure).  But still, about half of children with asthma had one attack in 2016. So we still have a ways to go.

The below figure shows the percentage of asthma attacks among children aged 0–17 years with current asthma, by year — National Health Interview Survey, 2001–2016 

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How did the researchers conduct their study?

They analyzed asthma data from the 2001-2016 National Health Interview Survey for children aged 0-17 years.  The survey asked information about health outcomes, health care use, asthma care and management.

There were 11,107 respondents who were aged 0–17 years, and 960 (8.3%) had current asthma.

What did they find?

  • One in 12 children aged 0–17 years had asthma in 2016.
  • Asthma was more common among boys, non-Hispanic black children, children of Puerto Rican descent, and children from low-income households.
  • The percentage of children with asthma who had an asthma attack during the preceding year declined from 2001 to 2016. Even so, approximately half of children with diagnosed asthma had one or more asthma attack in 2016.
  • Children with asthma had fewer missed school days and hospitalizations in 2013 compared with 2003.
  • Approximately 55% children with asthma were taking asthma control prescription medicines during the preceding 3 months. Among children who were taking asthma control medicines, only 54.5% of them were taking control medicines regularly as prescribed, which was significantly lower than during 2003.

What does this mean?

Asthma is still an important public health and medical problem.

The health of children with asthma can be further improved by promoting asthma control strategies, including asthma trigger reduction, appropriate guidelines-based medical management, and asthma education for children, parents, and others involved in asthma care.

Filed under epidemiology

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#Housing as a vaccine against #asthma

The parents of a 3 year old boy asked me in clinic if the cockroaches in their hotel room, their homeless shelter, could be contributing to his asthma flare.  It was hard to keep the cockroaches away with only a mini bar and no kitchen.  After all, the family of 4 still needed to eat.

A mother of a 4 year old girl with asthma asked if I could write a letter to her homeless shelter stating that the child needed to stay at her grandmother’s house for a few days.  It was too hard to give the child her albuterol nebulizer treatments in their room.  But if the mother and child did not stay in the shelter, they risked losing their coveted placement.

So, a recent article in JAMA entitled “Housing as Health” got me thinking.  In this article, Howard Koh and Robert Restuccia argue that even though health and housing seem to be separate issues, “housing as a vaccine” could prevent illness and disability.  

Many efforts currently try to improve health through housing.  Initiatives exist to help children whose asthma is triggered by suboptimal housing conditions.  Clinicians are encouraged to ask about possible issues with housing with their patients.  The authors argue that cutting HUD’s (US Department of Housing and Urban Development) budget would only weaken affordable housing efforts.  And health will suffer.

What do we know about homelessness and health? I’ll focus on homelessness and asthma.

·        Multiple studies have shown that children living in a shelter were consistently two to three more likely to have asthma.

·        Increased asthma could be from increased exposure to risk factors such as pollution, mold, moisture, rodent, insect droppings, tobacco smoke.

·        Or the increased rates could be from increased respiratory infections in early life or due to chronic stress early in life.

·        Children with asthma who lived in shelters used more health care services—they went to the doctors more.

·        Children with asthma in shelters had more trouble making friends at school compared to their peers who lived in shelters but did not have asthma.

·        In a study of adults, having worries about housing was associated with 1.5 increased risk of asthma.

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