The impact of dysfunctional breathing on the level of asthma control in difficult asthma.

BACKGROUND: Difficult asthma is defined as asthma requiring high dose treatment. However, systematic assessment is required to differentiate severe asthma from difficult-to-treat asthma. Dysfunctional breathing (DB) is a common comorbidity in difficult asthma, which may contribute to symptoms, but how it affects commonly used measures of symptom control is unclear. METHODS: All adult asthma patients seen in four respiratory clinics over one year were screened prospectively, and patients with possible severe asthma according to ERS/ATS criteria ('Difficult asthma': high-dose inhaled corticosteroids/oral corticosteroids), underwent systematic assessment. Symptoms of DB were assessed utilizing a symptom based subjective tool, Nijmegen questionnaire (NQ), and objective signs of DB with the Breathing Pattern Assessment Tool (BPAT). Asthma control and quality of life were evaluated with the Asthma Control Questionnaire (ACQ) and the mini Asthma Quality of Life Questionnaire (AQLQ). RESULTS: A total of 117 patients were included. Among these, 29.9% (35/117) had DB according to the NQ. Patients with DB had a poorer asthma control (ACQ: Mean (SD) 2.86 ± 1.05 vs. 1.46 ± 0.93) and lower quality of life (AQLQ score: Mean (SD) 4.2 ± 1.04 vs. 5.49 ± 0.85) compared to patients without DB. Similarly, patients with objective signs of DB according to the BPAT score had worse asthma control: BPAT >4 vs < 4: (ACQ: Mean (SD) 3.15 ± 0.93 vs 2.03 ± 1.15). CONCLUSION: DB is common among patients with difficult asthma, and is associated with significantly poorer asthma control and lower quality of life. Assessment and treatment of DB is an important part of the management of difficult asthma.

[Sentinel surveillance of risk of severe reactions associated with specific immunotherapy. A method for quality assurance of procedures with rare, but serious adverse effects]. / Sentinel overvågning af risiko for alvorlige reaktioner ved specifik immunterapi.En metode til kvalitetssikring af procedurer med sjaeldne, men alvorlige bivirkninger.

INTRODUCTION: Whether procedures are "out of control" or "in control" is a central concept in quality assurance. It is essential to stay "in control" concerning treatment. Often this is simple, when risk is known and can be discussed before treatment has been agreed upon. The situation becomes more difficult when a treatment with a well-known risk gets out of control due to an increase in side effects. This happened during 2003, when an increase in notified serious adverse events after specific allergy vaccination (SAV) was observed. MATERIALS AND METHODS: A sentinel survey was established in five allergy clinics with experience in SAV. The numbers of monthly side effects and injections were reported, and the results were returned. RESULTS: No serious reactions were observed, and therefore the maximal risk of a serious reaction was estimated. On the basis of a total of 7,538 injections, of which 44% were grass ALK 225 injections, the maximal risk was < 0.05% for all injections and < 0.1% for antigrass injections (97.5% CI). CONCLUSION: Sentinel surveillance of SAV led to the re-establishment of an "in control" situation. At present the official system for notification of side effects, the Danish Medicines Agency, and the Danish Allergy Society are not able to respond fast enough and adequately enough to gain control of the situation, and we suggest that in all high-risk and high-volume procedures sentinel surveillance should be performed by the doctors close to the patients and in charge of the procedures instead of by a centralised surveillance entity.