NPJ Primary Care Respiratory Medicine最新文献

Asthma is the most common chronic respiratory disease among school-going adolescents worldwide. However, the burden of severe asthma is highest in Sub-Saharan Africa. This study aimed to explore teachers' perceptions of asthma care across six African countries. We conducted focus group discussions (FGDs) using a semi-structured interview guide. Interviews were audio-recorded, transcribed verbatim and analysed thematically. FGDs were conducted in Kumasi(Ghana), Blantyre (Malawi), Lagos (Nigeria), Durban (South Africa), Kampala (Uganda), and Harare (Zimbabwe) between 01 November 2020 and 30 June 2021. We identified two key themes related to asthma care; barriers to asthma care and suggestions to improve the care of adolescents with asthma. Barriers reported by teachers included a lack of knowledge and skills among themselves, adolescents, and caregivers. In addition, some traditional beliefs of teachers on asthma exacerbated challenges with asthma care in schools. Regarding suggestions, most teachers identified a need for all-inclusive asthma training programmes for teachers, adolescents and caregivers, focusing on acute episodes and mitigating triggers. Utilising teachers with personal experiences with asthma to advocate and support these initiatives was suggested. Further suggestions included the need for annual screening to enable early identification of adolescents with asthma and clarify restrictions on teachers administering asthma medications. Teachers across African schools identify multiple barriers to asthma care. Structured school education programs and annual asthma screening are key to addressing some barriers to care.

This cross-sectional study of 136 patients with chronic obstructive pulmonary disease (COPD) investigated the mechanism underlying overlap syndrome, defined as coexisting COPD and obstructive sleep apnea (OSA). OSA was defined as a respiratory event index (REI) ≥ 5 events/h, determined using type-3 portable monitors. The mean REI was 12.8 events/h. Most participants (60.1%) had mild OSA (REI: 5-15 events/h). The REI was positively correlated with forced expiratory volume in one second (%FEV₁) (r = 0.33, p < 0.001), body mass index (BMI) (r = 0.24, p = 0.005), and fat-free mass index (r = 0.31, p = 0.005), and negatively correlated with residual volume divided by total lung capacity (r = -0.27, p = 0.003). Receiver-operating characteristic curve analysis revealed an optimal BMI cutoff of 21.96 kg/m² for predicting moderate/severe OSA. A BMI ≥ 21.96 kg/m² was associated with OSA among participants with %FEV₁ ≥ 50%, but not those with %FEV₁ < 50%. This study revealed an interaction between airflow limitation and hyperinflation, nutritional status, and OSA.

Chronic comorbid conditions are common in adults with asthma, and some may influence a patient's asthma exacerbation risk. We explored associations between eighteen chronic comorbid conditions and asthma exacerbation occurrence in adults with asthma in a cross-sectional study nested within a cohort study using data from the two-yearly US National Health and Nutrition Examination Survey (NHANES) program. Data of 2387 adults with self-reported doctor-diagnosed current asthma from the 2007 to 2018 NHANES surveys were selected. Investigated chronic comorbidities were: angina pectoris; congestive heart failure; coronary heart disease; depression; diabetes mellitus; soft and hard drug use; gastroesophageal reflux; gout; history of heart attack; history of stroke; hypercholesterolemia; hypertension; kidney failure; liver conditions; obesity; rheumatoid arthritis; and thyroid problems. Outcome was defined as asthma exacerbation category: no, moderate, or severe exacerbation(s) in the past year. Ordinal logistic regression analysis with correction for potential confounders was used to estimate odds ratios (OR) for moderate or severe exacerbations. Observed associations with increased severe asthma exacerbation occurrence were: obesity (OR = 1.67; 95% confidence interval 1.24, 2.26), and rheumatoid arthritis (OR = 1.55; 1.04, 2.30). History of stroke (OR = 1.95; 1.22, 3.11) and rheumatoid arthritis (OR = 1.33; 1.00, 1.75) showed associations with increased moderate exacerbation occurrence. Age-stratified analysis showed soft drug use, obesity, depression, thyroid problems, and rheumatoid arthritis to be associated with moderate and/or severe exacerbation occurrence in one or more 10-year age strata. In conclusion, several chronic comorbid conditions were associated with asthma exacerbation occurrence, which confirms but also complements previous studies. Our observations contribute to understanding exacerbation risk estimation and, ultimately, personalized asthma management.

Inhaled corticosteroids (ICS) are the mainstay of treatment for asthma, but their role in chronic obstructive pulmonary disease (COPD) is debated. Recent randomised controlled trials (RCTs) conducted in patients with COPD and frequent or severe exacerbations demonstrated a significant reduction (~25%) in exacerbations with ICS in combination with dual bronchodilator therapy (triple therapy). However, the suggestion of a mortality benefit associated with ICS in these trials has since been rejected by the European Medicines Agency and US Food and Drug Administration. Observational evidence from routine clinical practice demonstrates that dual bronchodilation is associated with better clinical outcomes than triple therapy in a broad population of patients with COPD and infrequent exacerbations. This reinforces guideline recommendations that ICS-containing maintenance therapy should be reserved for patients with frequent or severe exacerbations and high blood eosinophils (~10% of the COPD population), or those with concomitant asthma. However, data from routine clinical practice indicate ICS overuse, with up to 50-80% of patients prescribed ICS. Prescription of ICS in patients not fulfilling guideline criteria puts patients at unnecessary risk of pneumonia and other long-term adverse events and also has cost implications, without any clear benefit in disease control. In this article, we review the benefits and risks of ICS use in COPD, drawing on evidence from RCTs and observational studies conducted in primary care. We also provide a practical guide to prescribing ICS, based on the latest global treatment guidelines, to help primary care providers identify patients for whom the benefits of ICS outweigh the risks.

Several questionnaires are used to measure asthma control in children. The most appropriate tool for use in primary care is not defined. In this systematic review, we evaluated questionnaires used to measure asthma control in children in primary care and determined their usefulness in asthma management. Searches were performed in the MEDLINE, Embase, Web of Science, Google Scholar and Cochrane databases with end date 24 June 2022. The study population comprised children aged 5-18 years with asthma. Three reviewers independently screened studies and extracted data. The methodological quality of the studies was assessed, using the COSMIN criteria for the measurement properties of health status questionnaires. Studies conducted in primary care were included if a minimum of two questionnaires were compared. Studies in secondary or tertiary care and studies of quality-of-life questionnaires were excluded. Heterogeneity precluded meta-analysis. Five publications were included: four observational studies and one sub-study of a randomized controlled trial. A total of 806 children were included (aged 5-18 years). We evaluated the Asthma Control Test (ACT), childhood Asthma Control Test (c-ACT), Asthma APGAR system, NAEPP criteria and Royal College of Physicians' '3 questions' (RCP3Q). These questionnaires assess different symptoms and domains. The quality of most of the studies was rated 'intermediate' or 'poor'. The majority of the evaluated questionnaires do not show substantial agreement with one another, which makes a comparison challenging. Based on the current review, we suggest that the Asthma APGAR system seems promising as a questionnaire for determining asthma control in children in primary care.

Spirometry should be used to confirm a diagnosis of chronic obstructive pulmonary disease (COPD). This test is not always performed, leading to possible misdiagnosis. We investigated whether the proportion of patients with diagnostic spirometry has increased over time as well as factors associated with omitted or incorrectly interpreted spirometry. Data from medical reviews and a questionnaire from primary and secondary care patients with a doctors' diagnosis of COPD between 2004 and 2010 were collected. Data were compared with a COPD cohort diagnosed between 2000 and 2003. Among 703 patients with a first diagnosis of COPD between 2004 and 2010, 88% had a diagnostic spirometry, compared with 59% (p < 0.001) in the previous cohort. Factors associated with not having diagnostic spirometry were current smoking (OR 2.21; 95% CI 1.36-3.60), low educational level (OR 1.81; 1.09-3.02) and management in primary care (OR 2.28; 1.02-5.14). The correct interpretation of spirometry results increased (75% vs 82%; p = 0.010). Among patients with a repeated spirometry, 94% had a persistent FEV₁/FVC or FEV₁/VC ratio <0.70.

Smart inhalers are electronic monitoring devices which are promising in increasing medication adherence and maintaining asthma control. A multi-stakeholder capacity and needs assessment is recommended prior to implementation in healthcare systems. This study aimed to explore perceptions of stakeholders and to identify anticipated facilitators and barriers associated with the implementation of smart digital inhalers in the Dutch healthcare system. Data were collected through focus group discussions with female patients with asthma (n = 9) and healthcare professionals (n = 7) and through individual semi-structured interviews with policy makers (n = 4) and smart inhaler developers (n = 4). Data were analysed using the Framework method. Five themes were identified: (i) perceived benefits, (ii) usability, (iii) feasibility, (iv) payment and reimbursement, and (v) data safety and ownership. In total, 14 barriers and 32 facilitators were found among all stakeholders. The results of this study could contribute to the design of a tailored implementation strategy for smart inhalers in daily practice.