Effects of Immunoglobulin Replacement on Asthma Exacerbation in Adult Asthmatics with IgG Subclass Deficiency

PURPOSE: Recurrent respiratory tract infection is a common manifestation of primary immunodeficiency disease, and respiratory viruses or bacteria are important triggers of asthma exacerbations. Asthma often coexists with humoral immunodeficiency in adults, and some asthmatics with immunoglobulin (Ig) G subclass deficiency (IgGSCD) suffer from recurrent exacerbations. Although some studies suggest a benefit from Ig replacement, others have failed to support its use. This study aimed to assess the effect of Ig replacement on asthma exacerbation caused by respiratory infection as well as the asthma control status of adult asthmatics with IgGSCD. METHODS: This is a multi-center, open-label study of adult asthmatics with IgGSCD. All patients received monthly intravenous immunoglobulin (IVIG) for 6 months and were evaluated regarding asthma exacerbation related to infection, asthma control status, quality of life, and lung function before and after IVIG infusion. RESULTS: A total of 30 patients were enrolled, and 24 completed the study. Most of the patients had a moderate degree of asthma severity with partly (52%) or uncontrolled (41%) status at baseline. IVIG significantly reduced the proportion of patients with asthma exacerbations, lowered the number of respiratory infections, and improved asthma control status, compared to the baseline values (P<0.001). The mean asthma-specific quality of life and asthma control test scores were improved significantly (P=0.009 and P=0.053, respectively); however, there were no significant changes in lung function. CONCLUSIONS: IVIG reduced the frequency of asthma exacerbations and improved asthma control status in adult asthmatics with IgGSCD, suggesting that IVIG could be an effective treatment option in this population.

A Case of Sorafenib-induced DRESS Syndrome in Hepatocelluar Carcinoma / 대한소화기학회지

Sorafenib is currently the only targeted therapy available for advanced stage hepatocellular carcinoma (HCC). Cutaneous adverse events associated with sorafenib treatment include hand-foot skin reaction, but there has been no report of drug reaction (or rash) with eosinophilia and systemic symptoms (DRESS) syndrome. Here, we report a case of 72-year-old man with HCC and alcoholic liver cirrhosis who developed skin eruptions, fever, eosinophilia, and deteriorated hepatic and renal function under sorafenib treatment. He has since successfully recovered with conservative care.

DRESS syndrome with acute interstitial nephritis caused by quinolone and non-steroidal anti-inflammatory drugs / 영남의대학술지

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and severe drug-induced hypersensitivity syndrome characterized by hematological abnormalities and multiorgan involvement. Liver involvement is the most common visceral manifestation. However, renal failure has been rarely described. The common culprit drugs are anticonvulsants and allopurinol. We experienced a patient with DRESS syndrome with acute interstitial nephritis caused by concomitant administration of quinolone and non-steroidal anti-inflammatory drugs (NSAIDs). A 41-year-old man presented with a diffuse erythematous rash and fever which developed after administration of quinolone and NSAIDs for a month due to prostatitis. He was diagnosed with DRESS syndrome. Skin rash, fever, eosinophilia, and elevations of liver enzymes improved with conservative treatment and discontinuation of the causative drugs. However, deterioration of his renal function occurred on day 8 of admission. The levels of blood urea nitrogen and serum creatinine increased and oliguria, proteinuria and urinary eosinophils were observed. Ultrasonography showed diffuse renal enlargement. The clinical features were compatible with acute interstitial nephritis. Despite intravenous rehydration and diuretics, renal function did not improve. After hemodialysis, his renal function recovered completely within 2 weeks without administration of systemic corticosteroid.

Management of Anaphylaxis / 대한내과학회지

Anaphylaxis is a life-threatening systemic hypersensitivity reaction with a rapid onset. All healthcare professionals should be familiar with its recognition and management. The clinical diagnosis is important. It involves the sudden onset of characteristic symptoms and signs within minutes to hours after exposure to a known or potential trigger, often followed by rapid progression over hours. Symptoms usually involve two or more body systems, including the skin and mucous membranes, and respiratory, gastrointestinal, cardiovascular, and central nervous systems. Prompt initial basic treatment with intramuscular epinephrine in the mid-anterolateral thigh can be life-saving. Simultaneously, it is important to place the patient in a supine position, call for help when indicated, provide supplemental oxygen, start intravenous fluid, and provide cardiopulmonary resuscitation as required, while monitoring the patient's vital signs and oxygenation status. Antihistamines and glucocorticoids are not initial treatments of choice. For self-management, patients at risk of anaphylaxis should carry epinephrine auto-injectors, have personalized emergency action plans, and follow-up with a physician about preventing anaphylaxis recurrence. Patient and caregiver training and education are essential in the management of anaphylaxis.

Immunologic Evaluation of Patients with Cefotetan-Induced Anaphylaxis

Cefotetan is a commonly prescribed second-generation cephalosporin that acts against a wide range of bacteria. However, cefotetan-induced hypersensitivity has rarely been reported. We report 2 cases of cefotetan-induced anaphylaxis with immunologic evaluation. The first case was a 70-year-old asthmatic woman who had dyspnea and hypotension during administration of cefotetan, in which high serum-specific IgE to cefotetan-human serum albumin (HSA) conjugate was detected by enzyme-linked immunosorbent assay. The second case was a 63-year-old asthmatic woman who complained of chest tightness and dyspnea during cefotetan infusion, in which high serum-specific IgG1 and IgG4 with no serum specific IgE to cefotetan-HSA conjugate was detected. The basophil activation test using basophils from the patient showed a significant up-regulation of CD63 with the addition of anti-IgG4 antibody compared with that in non-atopic healthy controls. In conclusion, cefotetan can induce anaphylaxis, which may involve both IgE- and IgG4-mediated responses in the pathogenic mechanism.

Seasonal and regional variations in the causes of anaphylaxis in Korean adults

PURPOSE: To investigate whether causes of anaphylaxis vary according to regions and seasons in Korean adults. METHODS: Based on previous retrospective studies of anaphylaxis between 2007 and 2011 at the 15 university hospitals. Regions were classified into 4 groups: region I, Seoul; region II, Gyeonggi; region III, Chungcheong; and region IV, Chonnam and Busan. The cases induced by 5 major allergens including drugs, food, bee sting, radiocontrast media, and exercise, were analyzed in the present study. RESULTS: Among a total of 1,661 cases reported (53% male, 45.9+/-16.0 years), 367 (22.2%), 706 (42.5%), 319 (19.2%), and 269 cases (16.2%) were enrolled in regions I, II, III, and IV, respectively. Of the 5 major allergens, drugs (37.3%) were the most frequently reported, followed by food (25.7%), bee sting (17.9%), radiocontrast media (12.9%), and exercise (6.2%). There was no significant difference in the total occurrence of anaphylaxis in 4 seasons (374 in spring, 460 in summer, 460 in autumn, and 367 in winter). Multiple logistic regression analysis revealed that drug-induced anaphylaxis was significantly associated with the winter season (odds ratio [OR] 1.0 vs. OR 0.597, P<0.05 for spring; OR 1.0 vs. OR 0.481, P<0.01 for summer; OR 1.0 vs. OR 0.653, P<0.05 for autumn). Food-associated anaphylaxis was mainly reported in region I, whereas the frequency of insect sting was relatively higher in regions II, III, and IV than in region I. Older age and female gender were significantly associated with drug-induced anaphylaxis. CONCLUSION: Specific causative allergens of anaphylaxis in adults may vary according to age, gender, region, and season in Korea.

Comparison of skin prick test and serum specific IgE measured by ImmunoCAP system for various inhalant allergens

PURPOSE: It appears that much of the discordance between skin prick test (SPT) and ImmunoCAP in clinical practice. We investigated the comparison and correlation between SPT and ImmunoCAP for inhalant allergens. METHODS: A total of 1,400 patients who were tested SPT and ImmunoCAP were recruited from June 2011 to May 2014 in Dong-A University Hospital, and the results of two assays were compared for 17 inhalant allergens. For SPT, mean wheal size> or =3 mm or allergen/histamine> or =1 at 15 minutes, and the result of ImmunoCAP of > or =0.35 kU/L was considered positive, respectively. RESULTS: Of the study subjects, bronchial asthma was 29.3%, rhinitis 36.8%, atopic dermatitis 0.6%, and chronic urticaria 4.3%. The agreement rate of between two assays was 77.4%. When ImmunoCAP was compared with SPT as the reference, the sensitivity, specificity was 75.5% and 80.0%, respectively. Significant correlation was observed (r=0.59), and birch, mugwort, Japanese hop, house dust mites, and cockroach showed very strong correlation (r>0.7). CONCLUSION: The agreement, sensitivity, and specificity between SPT and ImmunoCAP was various according to allergens. We should determine the clinical relevance of the allergen sensitization using both SPT and ImmunoCAP not alone with combination of clinical symptoms.

Predictors of the Severity and Serious Outcomes of Anaphylaxis in Korean Adults: A Multicenter Retrospective Case Study

PURPOSE: Differences in definitions of the condition, relevant triggers, and the geographical locations of study centers, cause estimates of the prevalence of anaphylaxis to vary. Recent epidemiological data indicate that the incidence of anaphylaxis is rising. METHODS: To investigate the causes and clinical features of anaphylaxis in Korean adults, factors associated with the severity of the condition, and serious outcomes, a retrospective medical record review was performed on adult patients diagnosed with anaphylaxis between 2007 and 2011 in 15 University Hospitals of South Korea. RESULTS: A total of 1,806 cases (52% male, age 16-86 years) were reported. Cutaneous symptoms (84.0%), combined with respiratory (53.9%) and/or cardiovascular (55.4%) symptoms, were the most frequent presentations. Using a recognized grading system, 1,776 cases could be classified as either mild, 340; moderate, 690; or severe, 746. Although eliciting factors varied significantly by age, gender, and regional and seasonal factors, drugs (46.5%; including nonsteroidal anti-inflammatory drugs, antibiotics, and radiocontrast media) were the most common cause of anaphylaxis, followed by foods (24.2%), insect stings (16.4%), exercise (5.9%), and unknown etiology (7.0%). All of age, multi-organ involvement, a history of allergic disease, and drug-induced anaphylaxis, were significant predictors of serious outcomes requiring hospital admission or prolongation of hospital stay. Epinephrine auto-injectors were prescribed for 7.4% of reported cases. CONCLUSIONS: The principal causes of anaphylaxis in Korean adults were drugs, food, and insect stings. Drug-associated anaphylaxis, a history of allergic disease, multi-organ involvement, and older age, were identified as predictors of serious outcomes.

Predictors of Asthma Control by Stepwise Treatment in Elderly Asthmatic Patients

The geriatric population is increasing, and asthma severity increases with age. We determined the predictors of asthma control, exacerbation, and the factors that affect asthma-specific quality of life (A-QOL) in elderly asthmatic patients. This was a prospective, multicenter, real-life study for 6 months with stepwise pharmacologic treatment based on the Global Initiative for Asthma (GINA) guideline. A total of 296 asthmatic patients aged > or = 60 yr were recruited from 5 university centers in Korea. The improved-asthma control group was defined as the group of patients who maintained well-controlled or improved disease and the not-improved asthma control group was defined as the remaining patients. Fewer number of medications for comorbidities (2.8 +/- 3.3 in the improved vs. 4.5 +/- 4.4 in the control) and higher physical functioning (PF) scale (89.8 +/- 14.2 in the improved vs. 82.0 +/- 16.4 in the control) were significant predictors in the improved-asthma control group (OR = 0.863, P = 0.004 and OR = 1.028, P = 0.018, respectively). An asthma control test (ACT) score of < or = 19 at baseline was a significant predictor of asthma exacerbation (OR = 3.938, P = 0.048). Asthma duration (F = 5.656, P = 0.018), ACT score (F = 12.237, P = 0.001) at baseline, and the presence of asthma exacerbation (F = 5.565, P = 0.019) were significant determinants of changes in A-QOL. The number of medications for comorbidities and performance status determined by the PF scale may be important parameters for assessing asthma control in elderly asthmatic patients.

Prevalence and Risk Factors for Depression in Korean Adult Patients with Asthma: Is There a Difference between Elderly and Non-Elderly Patients?

Depression is an important comorbidity of asthma. However, little information is available about depression and its potential impact on asthma control in Korean adult asthma patients. We aimed to estimate the prevalence and risk factors for depression in Korean adults with persistent asthma. The 127 non-elderly (20-64 yr) and 75 elderly (> or =65 yr) patients with asthma were recruited. Demographic and clinical data were extracted, and the patients completed the Asthma Specific Quality of Life (AQOL) questionnaire and asthma control test (ACT). Depression status was defined using the Korean version of the Patient Health Questionnaire-9 (PHQ-9). Depression was more prevalent in non-elderly (18.9%) than in elderly patients with asthma (13.3%). Patients with depression were significantly younger, had lower economic status, shorter disease duration, poorer asthma control, and worse AQOL scores (P<0.05). Within the non-elderly group, younger age and shorter disease duration were significantly associated with depression (P<0.05). Within the elderly group, a higher body mass index and current smoking status were significantly associated with depression (P<0.05). The PHQ-9 score was significantly correlated with worse ACT and AQOL scores in both groups. In conclusion, depression is strongly associated with poor asthma control and quality of life in Korean adult asthma patients. Our results provide important clues that used to target modifiable factors which contribute to development of depression in asthma patients.

Cefepime-induced encephalopathy without renal impairment

Cefepime is an extended-spectrum, fourth-generation cephalosporin that has been widely used for approved indications such as febrile neutropenia. Common adverse events of cefepime include headache, skin rash, gastrointestinal problems, and fever. However, encephalopathathy caused by cefepime has been sporadically reported worldwide over the last decade. We experienced a rare case of cefepime-induced encephalopathy. A 75-year-old man with a 30-year history of chronic obstructive pulmonary disease was admitted to the medical intensive care unit under a diagnosis of pneumonia. Initial antibiotic therapy was started with piperacillin/sulbactam and ciprofloxacin. His condition was improved with this treatment. About 2 months later, his condition was aggravated again, with mild fever and purulent sputum. Intravenous cefepime was selected on the basis of antibiotic susceptibility to Pseudomonas aeruginosa isolated from his sputum. However, his mentality became drowsy 48 hours after cefepime adminstration. He showed tremors and right facial paralysis. Neurologic examination for motor power and sensory function revealed normal findings. Laboratory tests, including serum electrolytes, glucose, osmolality, and ammonia, gave normal results. Brain magnetic resonance imaging showed chronic ischemic and atropic changes, and an electroencephalography revealed triphasic waves. The administration of cefepime was stopped, and his symptoms started to improve within 48 hours. Electroencephalography results became normalized, and he completely recovered within 48 hours after discontinuation of cefepime.

Serotonin syndrome associated with linezolid

Serotonin syndrome (SS) is a potentially life-threatening drug reaction characterized by mental status change, increased neuromuscular tone, and autonomic instability. Linezolid, an oxazolidinone antibacterial agent, is widely used in general hospitals; however, it interacts with some serotonin agonists and may cause SS. We report a case of SS caused by linezolid, without the concomitant use of serotonin agonist. A 72-year-old patient was admitted due to recurrent wound infection of his left ankle. He developed fever, skin rash, and renal function deterioration, and blood eosinophils and liver enzymes increased after administration of vancomycin. The antibiotic was changed to linezolid against methicillin-resistant Staphylococcus aureus. Four days later, he developed agitation, fever, increased blood pressure, and tachycardia. There were no abnormal findings in laboratory and image tests, including brain and chest computed tomography suggesting the cause of his symptoms. He had not taken any serotonin agonists, including serotonin uptake inhibitors and monoamineoxidase-inhibiting antidepressants. When administration of linezolid was stopped, his symptoms improved within 24 hours and fully recovered within 2 days without additional treatments.

Epidemiological Aspects of Pertussis among Adults and Adolescents in a Korean Outpatient Setting: A Multicenter, PCR-Based Study

Epidemiological data of Bordetella pertussis infection among adolescents and adults are limited in Korea. Patients (> or = 11 yr of age) with a bothersome cough for less than 30 days were enrolled during a 1-yr period at 22 hospitals in Korea. Nasopharyngeal swabs were collected for polymerase chain reaction (PCR) and for bacteriologic culture. In total, 490 patients were finally enrolled, and 34 (6.9%) patients tested positive for B. pertussis; cough duration (14.0 days [7.0-21.0 days]) and age distribution were diverse. The incidence was the highest in secondary referral hospitals, compared to primary care clinics or tertiary referral hospitals (24/226 [10.6%] vs. 3/88 [3.4%] vs. 7/176 [4.0%], P = 0.012), and the peak incidence was observed in February and August (15.8% and 15.9%), with no confirmed cases between March and June. In the multivariate analysis, post-tussive vomiting was significantly associated with pertussis (odds ratio, 2.508; 95% confidence interval, 1.146-5.486) and secondary referral hospital showed a borderline significance. In conclusion, using a PCR-based method, 6.9% of adolescent and adult patients with an acute cough illness had pertussis infection in an outpatient setting. However, hospital levels and seasonal trends must be taken into account to develop a better strategy for controlling pertussis.

Relationships between serum vitamin D levels and clinical characteristics of drug reaction with eosinophilia and systemic symptoms syndrome

PURPOSE: Vitamin D deficiency (VDD) is widely spread and on the increase throughout the world. Although vitamin D is essential for skeletal mineralization, VDD or vitamin D insufficiency (VDI) has been associated with nonskeletal disorders including cardiovascular disease, cancer, allergic disease and skin disease. However, a few reports showed the association of vitamin D and drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. Thereafter, we evaluated the association between vitamin D and DRESS syndrome. METHODS: We conducted a retrospective study on 45 patients with DRESS syndrome. Four hundred and ninty-eight healthy people who visited the health screening center were enrolled in the study as a control group. We investigated the clinical characteristics, the causative drugs and treatments in the patients with DRESS syndrome, and also analyzed the associations with serum 25-hydroxyvitamin D (25(OH)D3). RESULTS: Forty-four patients (97.8%) had low serum vitamin D levels; 21 patients were VDD (serum 25(OH)D3 <10 ng/mL), and 23 patients were VDI (serum 25(OH)D3 10 to 30 ng/mL). There were no significant differences in clinical parameters between two groups. Serum 25(OH)D3 level of the study patients was significantly lower that of the controls (12.3+/-9.6 ng/mL vs. 17.3+/-5.5 ng/mL, P<0.001). Serum 25(OH)D3 level showed a significant negative correlation with admission days (r=-0.377, P=0.011). CONCLUSION: The majority of the patients with DRESS syndrome showed low vitamin D levels. Serum 25(OH)D3 was inversely correlated with admission days.

Clinical Manifestations of 6 Cases of Septic Pulmonary Embolism at Increased Risk Recently / 고신대학교의과대학학술지

OBJECTIVES: The aim of this study was to investigate the clinico-radiologic features and microbiologic data of patients with SPE in a tertiary care hospital in Busan. METHODS: We retrospectively analyzed clinical and radiologic features of 6 cases with septic pulmonary embolism that occurred from March 2009 to March 2011 in Dong-A university medical center. RESULTS: The mean age of the study population was 58 years, and two men and four women were included. Clinical symptoms included general weakness (5 patients), febrile sensation (4 patients) and pleuritic chest pain (2 patients). Underlying conditions were chemoport infection (4 patients), dental abscess (1 patients), and cellulitis of hip (1 patient). Chest computed tomography revealed bilateral multiple nodular opacities in most patients, and cavitation, central necrosis, feeding vessels were identified. All patients received parenteral antimicrobial therapy with or without central catheter removal, drainage of the extrapulmonary infection. Causative organisms were Pseudomonas aeruginosa (2 patients), Candida albicans (1 patient), Bacillus species (1 patient), and Klebsiella pneumonia (1 patient). CONCLUSIONS: Clinical and radiologic features of septic pulmonary embolism were various and nonspecific. The diagnosis was usually suggested by the presence of a predisposing factor of septic pulmonary embolism and CT findings of bilateral multiple nodular opacities in patients with infectious signs and symptoms. Most important underlying condition was intravascular device infection.

Management of Severe Refractory Asthma / 대한내과학회지

Most patients with asthma have mild to moderate disease and are well controlled by regular use of inhaled corticosteroids with or without long-acting beta2-agonists. However, about 5-10% patients with severe asthma remain poorly controlled despite optimal treatment, and these patients have greater morbidity and mortality than mild to moderate asthmatics. Patients with severe refractory asthma (SRA) often require regular systemic corticosteroid use, which increase risk of steroid-related adverse events and require more health care support. A systematic approach is necessary to establish a correct diagnosis, identify coexisting disorders, and evaluate aggravating factors. The management of SRA remains extremely challenging, and many clinical studies are currently in progress. Anti-IgE antibody (omalizumab) and bronchial thermoplasty may be alternative treatment for SRA approved by US Food and Drug Administration. SRA is a heterogeneous disease, which is classified in to distinct clinical phenotypes. A better understanding of these subtypes may lead to improved treatment of SRA.

MDA-7/IL-24 Expression and Its Relation with Clinicopathologic Factors in Lung Adenocarcinomas of 3 cm or Less in Diameter

PURPOSE: The melanoma differentiation-associated gene-7 (MDA-7) protein, also known as interleukin 24 (IL-24), is a novel candidate of tumor suppressor that has been found to experimentally induce apoptosis and growth inhibition in a variety of human malignant cells. However, there have been few studies about its role in lung adenocarcinoma. Even at the same stage and with similar pathologic characteristics, lung adenocarcinomas with a diameter of 3 cm or less can have a variable prognosis depending on their biologic characteristics. The purpose of this study is to define the relationship between MDA-7/IL-24 expression and the progression of small-sized lung adenocarcinomas. MATERIALS AND METHODS: We performed immunohistochemical detection of MDA-7/IL-24 in forty-seven tissue samples from primary lung adenocarcinomas of 2 cm or < or =3 cm in diameter. A statistically significant association was found between MDA-7/IL-24 expression and tumor size (p=0.03). Although this difference did not reach statistical significance, tumors with a negative MDA-7/IL-24 expression tended to more frequently show lymph node metastasis (p=0.07). There were no significant associations for other clinicopathologic characteristics. CONCLUSION: These results suggest the possible involvement of MDA-7/IL-24 in the growth and progression of small-sized lung adenocarcinoma. MDA-7/IL-24 immunoreactivity could be used to identify a subset of adenocarcinomas of the lung of 3 cm or less in diameter that have different biologic behavior.

Absence of Hyper-Responsiveness to Methacholine after Specific Bronchial Provocation Tests in a Worker With Hydroxyapatite-Induced Occupational Asthma

Hydroxyapatite is commonly used as a filler to replace amputated bone or as a coating to promote bone ingrowth into prosthetic implants. Many modern implants, such as hip replacements and dental implants, are coated with hydroxyapatite. We report a patient with occupational asthma due to hydroxyapatite, proven by a specific inhalation challenge, who experienced an early asthmatic reaction after exposure to hydroxyapatite, without increased airway responsiveness to methacholine despite an increased eosinophil count in the peripheral blood. A 38-year-old male dental implant worker visited our allergy department for the evaluation of occupational asthma. He had treated dental implant titanium surfaces with hydroxyapatite for 1.5 years. One year after starting his employment, he noticed symptoms of rhinorrhea, paroxysmal cough, and chest tightness. His symptoms were aggravated during and shortly after work and subsided several hours after work. When he stopped working for 2 months because of his chest symptoms, he became asymptomatic. After restarting his work, his symptoms reappeared and were aggravated. A methacholine bronchial challenge test had a negative response. The following day, a specific bronchial provocation test with wheat powder was negative. On the third day, a specific bronchial provocation test with hydroxyapatite powder produced an early asthmatic response. On the fourth day, a methacholine bronchial challenge test was negative. Further studies are needed to evaluate the exact pathogenetic mechanism of hydroxyapatite-induced occupational asthma.

Stepwise Approach Update to the Asthma Treatment / 대한내과학회지

Asthma is a chronic inflammatory disorder of the airways in which many cells and cellular elements play a role. Chronic inflammation is associated with airway hyper-responsiveness, which leads to various airway symptoms. Approaches to asthma treatment have been changing because our knowledge about the pathogenesis and treatment of asthma is continually evolving. Until recently, the stepwise approach to the treatment of asthma was based on a patient's asthma severity. However, new international guidelines have recommended that treatment should be adjusted in a continuous cycle driven by the patient's asthma-control status. If asthma is not controlled on the current treatment regimen, treatment should be stepped up until control is achieved. When control is maintained for at least 3 months, treatment can be stepped down. Ongoing monitoring is essential to maintain control and to establish the lowest step and dose of treatment to minimize cost and maximize safety. However, the stepwise approach and recommended treatments are meant to assist, not replace, the clinical decision making necessary to determine the most appropriate treatment to meet the individual patient's needs and circumstances. This article is a review of the stepwise approach to the treatment of asthma recommended by the Global Initiative for Asthma 2009 and Expert Panel Report 3 of National Heart, Lung, and Blood Institute 2007.

Skills in Handling Turbuhaler, Diskus, and Pressurized Metered-Dose Inhaler in Korean Asthmatic Patients

PURPOSE: The objective of this study was to evaluate skills in handling inhalers and factors associated with these skills among patients with asthma who had undergone treatment at special asthma and allergy clinics in Korea. METHODS: We enrolled 78 subjects who used Turbuhaler and 145 who used Diskus for asthma control at special clinics in 10 university hospitals and visually assessed their skills in handling these inhalers. We also evaluated skills in 137 subjects who had used pressurized metered-dose inhalers (pMDIs) for symptom relief. Age, sex, duration of asthma and inhaler use, smoking status, monthly income, highest grade completed in school and previous instruction for handling inhalers were also measured to evaluate their association with overall inhaler skills. RESULTS: Performance grade was inadequate for 12.8% of participants using Turbuhaler, 6.2% for Diskus, and 23.4% for pMDIs. The success rates for each step in handling the inhalers were relatively high except for the "exhale slowly to residual volume" step, in which success rates ranged from 24.2% to 28.5%. Older age, male sex, lower educational grade, and absence of previous instruction for handling inhalers were associated with inadequate inhaler technique in univariate analysis; however, only older age and absence of previous instruction remained significant independent risk factors in multivariate analysis. CONCLUSIONS: Among Korean asthmatic patients in special asthma and allergy clinics, skills in handling their inhalers were mostly excellent; meanwhile, older age and absence of previous instruction for handling inhalers were associated with inadequate techniques.