Retrospective observational study of asthma and chronic obstructive pulmonary disease prevalence and associated healthcare resource utilization in a large, integrated healthcare system.

Limited data exist on asthma and chronic obstructive pulmonary disease (COPD) management-major drivers of healthcare resource utilization (HCRU) in the USA. We describe prevalence and exacerbation rates, therapeutic interventions, and HCRU for asthma and/or COPD within a large, integrated healthcare system. Patients with asthma, COPD, and asthma + COPD were identified from retrospective electronic health record data (2016-2018) of >1.7 million patients. Descriptive analysis of disease prevalence and exacerbation frequencies, pharmacotherapies, and HCRU was performed. Time-to-event analysis of time to first exacerbation was performed in patients with asthma and/or COPD. Exacerbation rates, pharmacotherapies, and HCRU were examined by exploratory analysis in an outpatient subset. Overall, 149,086 unique patients (8.6%) had encounters for asthma, COPD, or asthma + COPD. Acute care utilization was high, including emergency department visits (asthma, 52.9%; COPD, 35.1%) and hospitalizations (asthma, 26.7%; COPD, 65.7%). Many patients were prescribed short-acting therapies (asthma, 45.3%; COPD, 40.0%; asthma + COPD, 54.7%). Prescription rates for maintenance therapies were low (17.1%, 20.8%, 31.7%) and annual exacerbation rates were 0.65, 0.80, and 1.33. This analysis showed a substantive prevalence of pulmonary disease, variability between documented prescriptions and pharmacotherapy guidelines, and high HCRU. Appropriate tailoring of pharmacotherapies and management of asthma and COPD over a continuum are opportunities to improve patient care.

Usefulness of harmonica playing to improve outcomes in patients with chronic obstructive pulmonary disease.

Pulmonary rehabilitation in chronic obstructive pulmonary disease (COPD) includes a multidisciplinary approach of exercise and pursed-lip diaphragmatic breathing. Pursed-lip diaphragmatic breathing reduces alveolar collapse during exhalation, and diaphragmatic breathing improves inspiratory pressures. Harmonica playing has maneuvers similar to those taught in pursed-lip diaphragmatic breathing, with diaphragmatic breathing to create musical tones. Hence, we designed a trial to determine whether patients with COPD would benefit from harmonica playing. COPD patients who completed pulmonary rehabilitation at least 6 months prior were eligible for this trial. Patients attended 12 weeks of harmonica training sessions for 2 hours a week and were encouraged to practice at home. Participants completed pre- and postspirometry testing, maximum inspired and expired pressure (PImax, PEmax) testing, and 6-minute walk tests. Eleven of the 14 participants completed the 12-week trial. PImax and PEmax increased by an average of 15.4 ± 12.0 cm H2O (P = 0.0017) and 14.4 ± 14.0 cm H2O (P = 0.0061), respectively. Additionally, 6-minute walk distance increased by approximately 60 m (61 ± 78, P = 0.03). This pilot study showed that a 12-week harmonica program significantly improved PImax, PEmax, and 6-minute walk distance in COPD patients after rehabilitation. Larger-scale harmonica studies are warranted to evaluate this program's adjunctive potential benefit to formal pulmonary rehabilitation.

Towards an assessment of perceived COPD exacerbation triggers: Initial development and validation of a questionnaire.

BACKGROUND AND OBJECTIVE: Prevention of exacerbations in chronic obstructive pulmonary disease (COPD) is important to decrease overall declines in functioning and improve quality of life. The present study sought to develop a psychometrically valid measure of perceived triggers of exacerbations in COPD patients, the COPD Exacerbation Trigger Inventory (CETI). METHODS: Participants (n = 192) were recruited through local clinics and online to complete surveys of the CETI, demographic information, disease-specific information and the COPD Assessment Test (CAT). The CETI included a free response section on patients' individual top triggers, combined with ratings of their controllability. RESULTS: Exploratory principal component analyses identified a stable 5-factor structure (33 items), from which trigger subscales for weather/climate, air pollution/irritants, exercise, infection/illness and psychological factors were formed (internal consistency Cronbach's α = 0.90-0.94). Trigger factors were associated with COPD functional status, exacerbation frequency and healthcare utilization. Participants found personal triggers related to dust, air pollution, smoking and physical activity to be the most easily controlled, whereas those related to psychological factors, climate, infection, respiratory symptoms and sleep to be more difficult to control. Greater perceived controllability of triggers was associated with lower CAT scores, indicating better health status and less impact of the disease on functioning. CONCLUSION: The CETI is a psychometrically valid measure of perceived exacerbation triggers in patients with COPD. Perceived triggers are associated with clinical outcomes. Assessment of trigger classes and their controllability may prove useful in both research and clinical settings with COPD patients and to further our knowledge in prevention and disease management.

Asthmatic granulomatosis as a rare variant of uncontrolled severe asthma.

Asthmatic granulomatosis (AG) is a variant of severe asthma, first described in 2012, that consists of small airway changes compatible with asthma as well as interstitial nonnecrotizing granulomas. Treatment of AG requires immunosuppression as opposed to the traditional asthma therapy of inhaled steroids. We describe a 5-year course of a patient with AG that has shown no improvement with immunosuppression or other standards of therapy.

Controlling asthma by training of Capnometry-Assisted Hypoventilation (CATCH) vs slow breathing: a randomized controlled trial.

BACKGROUND: Hyperventilation has been associated with adverse effects on lung function, symptoms, and well-being in asthma. We examined whether raising end-tidal CO2 levels (ie, Pco2) compared with slow breathing is associated with improvements in asthma control, including peak flow variability. METHODS: One hundred twenty patients with asthma were randomly assigned to capnometry-assisted respiratory training (CART) for raising Pco2 or slow breathing and awareness training (SLOW) for slowing respiratory rate. Patients received five weekly sessions and completed bid homework exercises over 4 weeks. Blinded assessments at baseline, posttreatment, 1- and 6-month follow-up of asthma control, Pco2, and diurnal peak flow variability were primary outcome measures. Additionally, we measured pulmonary function (spirometry, forced oscillation, exhaled nitric oxide, and methacholine challenge), symptoms, quality of life, and bronchodilator use. Because the control group received active treatment, we expected improvements in asthma control in both groups but more pronounced benefits from CART. RESULTS: Improvements were seen in 17 of 21 clinical indexes (81.0%) in both interventions, including the primary outcome variables asthma control (d = 0.81), peak flow variability (d = 0.54), quality of life, bronchodilator use, lung function, and airway hyperreactivity. Most improvements were sustained across the 6-month follow-up. Compared with slow breathing, CART showed greater increases in Pco2 (d = 1.45 vs 0.64 for CART vs SLOW, respectively) and greater reductions in respiratory impedance during treatment, less distress during methacholine challenge, and greater reduction in asthma symptoms at follow-up (P < .05). CONCLUSIONS: Brief interventions aimed at raising Pco2 or slowing respiratory rate provide significant, sustained, and clinically meaningful improvements in asthma control. Raising Pco2 was associated with greater benefits in aspects of lung function and long-term symptoms. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00975273; URL: www.clinicaltrials.gov.

Discrepancies between lung function and asthma control: asthma perception and association with demographics and anxiety.

Understanding asthma symptom perception is necessary for reducing unnecessary costs both for asthma sufferers and society and will contribute to improving asthma management. The primary aim of this study was to develop and test a standardized method for classification of asthma perceiver categories into under-, normal, and overperceiver groups based on the comparison between self-report and lung function components of asthma control. Additionally, the degree to which demographic variables and anxiety contributed to the classification of patients into perceiver groups was examined. Patients underwent methacholine or reversibility testing to confirm asthma diagnosis. Next, participants completed lung function testing over 3 days before their next appointment. Finally, patients filled out demographic and self-report measures including the Asthma Control Test (ACT). Each self-report category of control assessed by the ACT (interference, shortness of breath, nighttime awakenings, rescue inhaler usage, and a composite total score) was compared with lung function measurements using a modified version of the asthma risk grid. Using the modified asthma risk grid to determine perceiver categorization, this sample included 14 underperceivers, 29 normal perceivers, and 36 overperceivers. A discriminant analysis was performed that indicated that a majority of underperceivers were characterized by being African American and having low asthma-specific anxiety. Normal perceivers in this sample tended to be older. Overperceivers tended to be female. Our findings encourage further research using the reported method of classifying asthma patients into perceiver categories.

Approaches to chronic disease management for asthma and chronic obstructive pulmonary disease: strategies through the continuum of care.

Investigator-initiated research in both asthma and chronic obstructive pulmonary disease conducted at the Baylor Martha Foster Lung Care Center has sought to improve management throughout the continuum of respiratory care using a multidisciplinary approach. Respiratory care therapists employed in the primary care setting were shown to improve the quality of asthma care: rescue inhaler use decreased by 75% and respiratory symptom score decreased by 49% in patients who were seen by this midlevel specialty provider. In addition to similar results in a geriatric population, patients' diagnosis was changed in 48% of cases and treatment was changed in 76% of cases after the intervention. For pulmonary rehabilitation, an activity of daily living assessment form was created, and rehabilitation-whether traditional or water-based-was shown to improve patients' ability to perform activities of daily living and improve quality of life scores. The Rules of Two((R)), developed by Baylor University Medical Center at Dallas to simplify understanding of good asthma control, continues to be taught, and patient education has also been offered through asthma summer camps for children. Finally, a multidisciplinary team worked to develop a protocol for treatment of asthma patients in the emergency department and, through this effort, was able to reduce length of stay from an average of 278 minutes to an average of 168 minutes. These efforts aim to overcome the gap between recommended care and actual practice, so that patients benefit from evidence-based medicine and continuing refinements to diagnosis and treatment.

Children with asthma miss more school: fact or fiction?

BACKGROUND: It is widely believed that children with asthma miss considerably more school than children without asthma. Previous surveys have indicated that 49% of children with asthma miss school (Asthma in America, 1998), but only a few studies have attempted to quantify the amount of school missed. Understanding the role of asthma in school attendance will help direct limited health-care resources to the children who need them most. METHODS: We investigated school absence rates in fourth- through sixth-grade students in 19 inner-city schools in the Dallas Independent School District (DISD). The sample consisted of 353 students who were identified as possibly having asthma based on responses to a modified Brief Pediatric Screen instrument and who underwent spirometry and/or exercise challenge (EC) testing to confirm the diagnosis of asthma: 25 students were excluded for FEV(1) < 70% and without bronchodilator response, while 157 students had EC-positive test results, and 171 students had EC-negative test results. We compared yearly absences for these students with each other, with all fourth- through sixth-grade students in the 19 study schools, and with all fourth- through sixth-grade students in the district. We also tabulated data from a separate database that included asthma patients identified by the school registered nurse (RN). Absence data by school and by grade level were provided by the school district for the 2002-2003 school year. RESULTS: Absence rates were as follows: 2.54% (EC positive), 2.12% (EC negative), 2.59% (abnormal FEV(1)), 2.86% (RN identified), 2.85% (all fourth- through sixth-grade students in study schools), and 2.95% (all fourth- through sixth-grade students in the DISD). CONCLUSION: Students with asthma in the DISD miss no more school their classmates without asthma.

Quality of life and physical performance in land- and water-based pulmonary rehabilitation.

PURPOSE: Traditional land-based pulmonary rehabilitation (PR) has been shown to provide improvement in physical performance and quality of life in patients with chronic obstructive pulmonary disease (COPD). The training effects of a water environment in pulmonary patients have only been briefly investigated. The purpose of this retrospective study was to compare quality of life and physical performance in land- and water-based PR. METHODS: The study included participants of a land- or water-based PR program. Twenty land- and water-based participants with stable COPD disease were retrospectively matched within 20 mL of their forced expiratory ventilation in 1 second. A multivariate analysis of variance was performed on each group's 6-minute walk test distance; 6-repetition maximum strength tests for the knee, hip, and shoulder; and mental and physical health summary scores of the Medical Outcomes Short-form 36. RESULTS: Each group significantly improved in all outcome measurements, but there was no difference found in the improvements between the land- or water-based groups. CONCLUSION: Clinicians can consider water-based PR exercise program as another treatment option, if available, for patients with COPD and expect similar benefits to traditional land-based PR programs including improved walk distances, strength, and perception of well-being.