Early thickening of the reticular basement membrane in children with difficult asthma.

Jeffery PK.

Department of Paediatrics, Imperial College at the Royal Brompton Hospital, London, United Kingdom.

Remodeling of the airway wall occurs in adults with asthma, and reticular basement membrane (RBM) thickening is pathognomonic of the asthma process. To investigate whether RBM thickening is present in children with difficult asthma and comparable to that seen in adults with asthma, we used light microscopy to measure RBM thickness in plastic-embedded endobronchial biopsy sections from 19 children with difficult asthma who were prescribed 1,600 microg/day or more of inhaled steroids (age range, 6-16 years), 10 children without asthma (7-16 years), and three adult groups: 8 healthy control subjects (21-42 years), 10 mild steroid-naive subjects with asthma (18-41 years), and 6 adults (3 steroid naive and 3 on inhaled steroids) intubated after a life-threatening attack of asthma (20-64 years). RBM thickness in the children with asthma was similar to that in adults with either mild or life-threatening asthma (median 8.2 [range 5.4-11.1] versus 8.1 [5.8-10.0] and 7.2 [2.8-10.0] microm, respectively) and greater than either adult or pediatric control subjects (8.2 [5.4-11.1] versus 4.4 [3.2-6.3] microm, p < 0.01, and 4.9 [3.7-8.3] microm, p < 0.01). We conclude that RBM thickening is already present in children with difficult asthma and to a similar extent to that seen in adults with asthma. In addition, we find no association with age, symptom duration, lung function, or concurrent eosinophilic airway inflammation.

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Eosinophilic inflammation in sputum of poorly controlled asthmatics.

Chanez P.

Clinique des Maladies Respiratoires, Institut National de la Sante et de la recherche medicale U454, Centre Hospitalier Universitaire-Montpellier, Hopital Arnaud de Villeneuve, Montpellier, France.

Despite full effective treatment, asthmatic patients often present with poorly controlled asthma. Airway eosinophilia is associated with asthma, but its relationship with asthma control is still undetermined. To investigate the relationship between airway eosinophilia and asthma control, cellular and biochemical markers of airway inflammation were measured in 19 subjects with poorly controlled asthma, 16 subjects with asthma under control and eight normal volunteers. The severity of asthma was mild-to-moderate persistent in 23 patients (14 poorly controlled) and severe prednisone-dependent in 12 subjects (five poorly controlled). Induced sputum was analysed for total and differential cell counts, leukotriene E4 (LTE4), eosinophil cationic protein (ECP), regulated on activation, normal T-cell expressed and secreted (RANTES), and interleukin (IL)-8. Sputum eosinophils, LTE4, ECP and RANTES levels (but not IL-8) were significantly higher in patients with poorly controlled asthma as compared to patients with controlled asthma. By contrast, sputum cells and sputum inflammatory markers were not different among groups of patients with different severity of asthma. These results suggest that sputum eosinophilia is associated with poorly controlled asthma rather than with the severity of asthma.

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Bronchodilators and corticosteroids in the treatment of asthma.

Martin RJ.

Department of Medicine, National Jewish Medical and Research Center, Denver, Colorado 80206, USA.

Despite advancements in treatment, the incidence of asthma, asthma-related deaths and hospitalizations for asthma have increased significantly during the past decade. Although asthma mortality may now be decreasing, reasons for the worsening of morbidity and mortality in asthma remain unclear. These unexpected changes in asthma severity have sparked renewed interest in research into the pathogenesis and treatment of the condition. Beta(2)-Adrenergic agonists are the most commonly used class of drugs for the treatment of asthma. Recent concerns about safety issues for beta-agonists caused reevaluation of prescribing practices, and using them on an as-needed basis is now more frequently accepted and recommended. In acute asthma, a beta(2)-adrenergic agonist is still the medication of choice. Long-acting salmeterol and formoterol, administered only twice daily, can decrease symptoms of asthma during day and nighttime. On the other hand, the role of tolerance to their bronchodilator and bronchoprotective effects is still to be determined in the treatment of asthma. Theophylline, whose use has been limited by the potential for serious toxicity, may regain an important position in asthma treatment with the development of the knowledge about its antiinflammatory actions. Dosing theophylline on a time- related basis also improves the risk/benefit ratio and makes it a useful drug for nocturnal asthma. Ipratropium bromide, an anticholinergic drug, still awaits a defined role in the treatment of asthma. Studies on its use for acute asthma have not achieved consensus and, for nocturnal asthma, the short duration of effect limits the benefits. Corticosteroids, including inhaled steroids, have measurable effects on symptoms, lung function, bronchial responsiveness and inflammation associated with asthma. Side effects of chronic use limit systemic, but not inhaled administration. Newer preparations, like budesonide, flunisolide and fluticasone, decrease the incidence of possible side effects related to inhaled steroids by having better ratio of topical to systemic potency. Daily doses up to 1600 micro g of beclomethasone (or equivalent) are considered safe and higher doses should be reserved for patients with moderate to severe asthma. Although future trials are necessary to clarify many issues related to dosing of inhaled steroids, chronotherapy studies have shown that single administration between 3 and 5:30 p.m. may be as effective as 4 times a day dosing. (c) 1998 Prous Science. All rights reserved.

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The efficacy of a management protocol in reducing emergency visits and hospitalizations in chronic asthmatics.

Alamoudi OS.

Department of Medicine, King Abdul-Aziz University Hospital, PO Box 80215, Jeddah 21589, Kingdom of Saudi Arabia. Tel. +966 (2) 6408246. Fax. +966 (2) 6408315. E-mail: dramoudi yahoo.com

OBJECTIVE: To assess whether a simple protocol used in the outpatient's asthma clinic was effective in reducing emergency room (ER) visits and hospitalizations in chronic asthmatics during a year of follow-up, and to evaluate which type of asthmatics, according to severity of asthma, may benefit more from the protocol. METHODS: Prospective assessment of a simple protocol (consisted of combined medical and educational aspects in the form of corticosteroids inhalation as a monotherapy and correction of the pitfalls of inhalation technique) in reducing ER visits, and hospitalization in chronic asthmatics. It was performed in the outpatients asthma clinic at King Abdul-Aziz University Hospital, Jeddah, Kingdom of Saudi Arabia. A total of 128 chronic asthmatics were evaluated and followed up for one year between January 1999 and March 2000. RESULTS: Between January 1999 and March 2000 the total number of ER visits, and hospitalizations in 128 chronic asthmatics in the year before the protocol were 269 and 85. This was reduced to 116 ER visits and 27 hospitalizations a year after the protocol, a 55.4%, and 68.2% reduction. While only 25% never attended ER before the protocol, almost 58.6% did not attend ER after the protocol. The proportion that visited ER more frequently (at least 3 times/year) decreased from 50.8-18%, a 65% reduction. Similarly, patients who did not require hospitalization increased from 62.5% up to 85.2%. Moreover, the proportion that was hospitalized more frequently (at least 3 times/year) decreased from 10.2% to as low as 0.8%. Mean paired differences for ER visits were -1.16 1.42 with 95% confidence interval extending from -1.412 to - 0.916 with a P value <0.001. Mean paired differences for hospitalization were -0.453 0.955 with 95% confidence interval extending from -0.620 to -0.286 with a P value <0.001. CONCLUSION: A simple protocol in outpatient's asthma clinic can significantly reduce ER visits and hospitalizations in chronic asthmatics. All asthmatics, irrespective of severity benefited significantly from the protocol.

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An assessment of the role of exhaled carbon monoxide in acute asthmatic exacerbations in hospitalised patients.

Wang YT.

Department of Respiratory Medicine, Tan Tock Seng Hospital, 11 Jalan Tan Tock Seng Singapore 308433. po_marn_kong ttsh.com.sg

Exhaled carbon monoxide is a useful marker of airway inflammation in untreated asthma. Whether exhaled CO is clinically useful in steroid treated patients in a hospital setting is uncertain. We therefore studied exhaled CO as a marker of asthma severity in clinical practice. Non-smoking "acute" asthmatics (hospitalised; n=33), "stable" asthmatics (n=35), and healthy controls (n=22) were recruited. Exhaled CO, peak expiratory flow (PEF) and FEV1 were measured daily (hospitalised cases) or once only (stable outpatients). Inpatients were managed without knowledge of the results. Exhaled CO levels in acute asthmatics (initial levels), stable asthmatics and controls were similar (median=2.0 ppm, h=5.05, p=0.08). In acute asthmatics, initial exhaled CO did not correlate with duration of hospitalisation, doses of intravenous corticosteroids, doses of nebulised salbutamol, PEF (% predicted) or FEV1 (% predicted). In stable asthmatics, exhaled CO did not correlate with corticosteroid dosage, PEF (% predicted) or FEV1 (% predicted). In the setting of acute hospitalised asthma patients, exhaled CO may not add any further to clinical management. This may in part be due to prior treatment with corticosteroids.

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The prognosis of bronchial asthma in childhood in Hungary: a long-term follow-up.

Cserhati E.

1st Department of Paediatrics, Semmelweis University, Budapest, Hungary. cser gyer1.sote.hu

The aim of this study was to determine the prognosis of bronchial asthma in childhood in Hungary. One hundred and forty five adults (96 men and 49 women) with a clinical history of childhood bronchial asthma were examined at the age of 28 years or above (mean age 37.6, SD 5.9 years). The patients completed questionnaires concerning their asthmatic and accompanying allergic symptoms in childhood, at the age of 18 and at present. They were all prick-tested with 12 inhalant allergens. The results showed that 42.8% of the patients had become symptom-free, but 57.2% still had intermittent or persisting asthmatic symptoms in adulthood. More patients had intermittent day-time (59%) and night-time (67%) asthmatic symptoms than persistent symptoms (41% and 33%). Accompanying allergic diseases (rhinitis, conjunctivitis, dermal and gastrointestinal diseases, and drug andfood allergies) in childhood did not definitely affect the prognosis of the bronchial asthma. The proportion of females with allergic diseases increased, and among patients with skin diseases it was significantly higher than the proportion of affected males. At the age of 18, allergic rhinitis was more frequent than in childhood. The frequencies of other allergic disorders did not change significantly. In the patients with asthmatic symptoms, molds and cat-hair allergies were more frequent than in the symptom-free group. The long-term prognosis of bronchial asthma in childhood in Hungary is relatively good, but fewer than half of the patients became symptom-free. The complaints of most of the patients were mild, but one in seven of all the adults suffered from moderate or serious bronchial asthma. Household allergens may contribute to the persistence of asthmatic symptoms.

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Asthma knowledge and medication compliance among parents of asthmatic children in Nanjing, China.

Bauman A.

Asthma knowledge and medication compliance among parents of 150 asthmatic children in Nanjing were assessed using a self-administered questionnaire. The results showed that 54.7% of parents had poor knowledge of asthma and its management. Parental compliance with medication was also suboptimal as only 43.3% of parents reported adherence with prescribed anti-asthmatic medication for their children. Reasons for non-compliance included fear of medication side-effects and tolerance, and forgetting to give the child's medication. Education and occupation were found to be associated with asthma knowledge, however there was no association between age or income with knowledge. Income was associated with compliance with asthma medication, however no association was found between parents' age, education, occupation, or asthma knowledge with compliance. This study has identified the need for accurate and up-to-date information on asthma for parents of asthmatic children as well as programs aimed at teaching parents skills in managing their child's asthma. There is also the need for strategies aimed at improving communication between the health provider and parents of asthmatic children.

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Comparison of atopic cough with cough variant asthma: is atopic cough a precursor of asthma?

Nishi K.

Third Department of Internal Medicine, Kanazawa University School of Medicine, Kanazawa, Japan. fujimura med3.m.kanazawa-u.ac.jp

BACKGROUND: We have described a group of patients who present with isolated chronic bronchodilator resistant non-productive cough with an atopic constitution, eosinophilic tracheobronchitis, and airway cough receptor hypersensitivity without bronchial hyperresponsiveness, which we have termed "atopic cough". Although cough variant asthma (in which the cough responds to bronchodilators) is recognised as a precursor of typical asthma, it is not known whether atopic cough is also a precursor of asthma. METHODS: Eighty two patients with atopic cough were retrospectively examined for onset of typical asthma and compared with 55 patients with cough variant asthma (20 untreated patients and 35 treated with long term inhaled beclomethasone dipropionate (BDP), 218-467 micro g/day). The median follow up period for patients with atopic cough and cough variant asthma was 4.8 (1-11.5) years and 3.7 (1-12.4) years, respectively. RESULTS: Onset of typical asthma occurred in only one of the patients with atopic cough. In patients with cough variant asthma, typical asthma developed in two of 35 patients taking BDP and six of 20 untreated patients (difference 24.3%, 95% CI 2.8 to 45.8, p<0.02). CONCLUSIONS: These findings suggest that cough variant asthma is a precursor of typical asthma but that atopic cough is not. Treatment with inhaled steroids may prevent the transformation of cough variant asthma into typical asthma.

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