Barriers and facilitators of effective self-management in asthma: systematic review and thematic synthesis of patient and healthcare professional views

Juan Carlos Ivancevich Saturday, 16 December 2017 15:33
 

Abstract

 Self-management is an established, effective approach to controlling asthma, recommended in guidelines. However, promotion, uptake and use among patients and health-care professionals remain low. Many barriers and facilitators to effective self-management have been reported, and views and beliefs of patients and health care professionals have been explored in qualitative studies. We conducted a systematic review and thematic synthesis of qualitative research into self-management in patients, carers and health care professionals regarding self-management of asthma, to identify perceived barriers and facilitators associated with reduced effectiveness of asthma self-management interventions. Electronic databases and guidelines were searched systematically for qualitative literature that explored factors relevant to facilitators and barriers to uptake, adherence, or outcomes of self-management in patients with asthma. Thematic synthesis of the 56 included studies identified 11 themes: (1) partnership between patient and health care professional; (2) issues around medication; (3) education about asthma and its management; (4) health beliefs; (5) self-management interventions; (6) co-morbidities (7) mood disorders and anxiety; (8) social support; (9) non-pharmacological methods; (10) access to healthcare; (11) professional factors. From this, perceived barriers and facilitators were identified at the level of individuals with asthma (and carers), and health-care professionals. Future work addressing the concerns and beliefs of adults, adolescents and children (and carers) with asthma, effective communication and partnership, tailored support and education (including for ethnic minorities and at risk groups), and telehealthcare may improve how self-management is recommended by professionals and used by patients. Ultimately, this may achieve better outcomes for people with asthma.
 

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NIHR Signal Breathing exercises improve asthma and can be learned by DVD

Juan Carlos Ivancevich Saturday, 16 December 2017 10:31

 Breathing exercises taught by a physiotherapist in person or on DVD both improved the quality of life of adults with poorly controlled asthma to a small but similar extent. The DVD was the cheapest option, and it could lead to inexpensive internet delivery in the future.

This NIHR-funded trial recruited 655 UK adults with poorly controlled asthma. It showed about 63% of those receiving the breathing exercises had clinically important improvements in their asthma-related quality of life over a year, compared to 56% who improved receiving usual care.

Exercises did not improve formally measured lung function, suggesting the underlying biology of the asthma was unchanged.

The findings imply that breathing exercise programmes – currently recommended in the 2016 British guideline on the management of asthma when delivered by a physiotherapist – may be equally effective, and cheaper when delivered via DVD (or another video).

Testosterone Attenuates Group 2 Innate Lymphoid Cell-Mediated Airway Inflammation

Juan Carlos Ivancevich Friday, 01 December 2017 14:32

Volume 21, Issue 9, p2487–2499, 28 November 2017

Jacqueline-Yvonne Cephus, Matthew T. Stier, Hubaida Fuseini, Jeffrey A. Yung, Shinji Toki, Melissa H. Bloodworth, Weisong Zhou, Kasia Goleniewska, and others

Highlights

  •  The number of ILC2 is increased in women with asthma compared to men with asthma
  • Sex hormones regulate IL-2-dependent ILC2 proliferation and cytokine expression
  • Testosterone intrinsically and extrinsically attenuates ILC2 airway inflammation

 Summary

Sex hormones regulate many autoimmune and inflammatory diseases, including asthma. As adults, asthma prevalence is 2-fold greater in women compared to men. The number of group 2 innate lymphoid cells (ILC2) is increased in patients with asthma, and we investigate how testosterone attenuates ILC2 function. In patients with moderate to severe asthma, we determine that women have an increased number of circulating ILC2 compared to men. ILC2 from adult female mice have increased IL-2-mediated ILC2 proliferation versus ILC2 from adult male mice, as well as pre-pubescent females and males. Further, 5α-dihydrotestosterone, a hormone downstream of testosterone, decreases lung ILC2 numbers and IL-5 and IL-13 expression from ILC2. In vivo, testosterone attenuated Alternaria-extract-induced IL-5+ and IL-13+ ILC2 numbers and lung eosinophils by intrinsically decreasing lung ILC2 numbers, as well as by decreasing expression of IL-33 and thymic stromal lymphopoietin (TSLP), ILC2-stimulating cytokines. Collectively, these findings provide a foundational understanding of sexual dimorphism in ILC2 function.

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Inhaled magnesium sulfate in the treatment of acute asthma

Juan Carlos Ivancevich Monday, 11 December 2017 13:40

Cochrane Database Syst Rev. 2017 Nov 28;11:CD003898. doi: 10.1002/14651858.CD003898.pub6.

Rachel Knightly,  Stephen J Milan, Rodney Hughes, Jennifer A Knopp-Sihota, Brian H Rowe, Rebecca Normansell, Colin Powell

Abstract

Background

Asthma exacerbations can be frequent and range in severity from mild to life-threatening. The use of magnesium sulfate (MgSO₄) is one of numerous treatment options available during acute exacerbations. While the efficacy of intravenous MgSO₄ has been demonstrated, the role of inhaled MgSO₄ is less clear.

Objectives

To determine the efficacy and safety of inhaled MgSO₄ administered in acute asthma.

Specific aims: to quantify the effects of inhaled MgSO₄ I) in addition to combination treatment with inhaled β₂-agonist and ipratropium bromide; ii) in addition to inhaled β₂-agonist; and iii) in comparison to inhaled β₂-agonist.

Search methods

We identified randomised controlled trials (RCTs) from the Cochrane Airways Group register of trials and online trials registries in September 2017. We supplemented these with searches of the reference lists of published studies and by contact with trialists.

Selection criteria

RCTs including adults or children with acute asthma were eligible for inclusion in the review. We included studies if patients were treated with nebulised MgSO₄ alone or in combination with β₂-agonist or ipratropium bromide or both, and were compared with the same co-intervention alone or inactive control.

Data collection and analysis

Two review authors independently assessed trial selection, data extraction and risk of bias. We made efforts to collect missing data from authors. We present results, with their 95% confidence intervals (CIs), as mean differences (MDs) or standardised mean differences (SMDs) for pulmonary function, clinical severity scores and vital signs; and risk ratios (RRs) for hospital admission. We used risk differences (RDs) to analyse adverse events because events were rare.

Main results

Twenty-five trials (43 references) of varying methodological quality were eligible; they included 2907 randomised patients (2777 patients completed). Nine of the 25 included studies involved adults; four included adult and paediatric patients; eight studies enrolled paediatric patients; and in the remaining four studies the age of participants was not stated. The design, definitions, intervention and outcomes were different in all 25 studies; this heterogeneity made direct comparisons difficult. The quality of the evidence presented ranged from high to very low, with most outcomes graded as low or very low. This was largely due to concerns about the methodological quality of the included studies and imprecision in the pooled effect estimates.

Inhaled magnesium sulfate in addition to inhaled β-agonist and ipratropium

We included seven studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, results were inconsistent overall and the largest study reporting this outcome found no between-group difference at 60 minutes (MD −0.3 % predicted peak expiratory flow rate (PEFR), 95% CI −2.71% to 2.11%). Admissions to hospital at initial presentation may be reduced by the addition of inhaled magnesium sulfate (RR 0.95, 95% CI 0.91 to 1.00; participants = 1308; studies = 4; I² = 52%) but no difference was detected for re-admissions or escalation of care to ITU/HDU. Serious adverse events during admission were rare. There was no difference between groups for all adverse events during admission (RD 0.01, 95% CI −0.03 to 0.05; participants = 1197; studies = 2).

Inhaled magnesium sulfate in addition to inhaled β-agonist

We included 13 studies in this comparison. Although some individual studies reported improvement in lung function indices favouring the intervention group, none of the pooled results showed a conclusive benefit as measured by FEV1 or PEFR. Pooled results for hospital admission showed a point estimate that favoured the combination of MgSO₄ and β₂-agonist, but the confidence interval includes the possibility of admissions increasing in the intervention group (RR 0.78, 95% CI 0.52 to 1.15; participants = 375; studies = 6; I² = 0%). There were no serious adverse events reported by any of the included studies and no between-group difference for all adverse events (RD −0.01, 95% CI −0.05 to 0.03; participants = 694; studies = 5).

Inhaled magnesium sulfate versus inhaled β-agonist

We included four studies in this comparison. The evidence for the efficacy of β₂-agonists in acute asthma is well-established and therefore this could be considered a historical comparison. Two studies reported a benefit of β₂-agonist over MgSO₄ alone for PEFR and two studies reported no difference; we did not pool these results. Admissions to hospital were only reported by one small study and events were rare, leading to an uncertain result. No serious adverse events were reported in any of the studies in this comparison; one small study reported mild to moderate adverse events but the result is imprecise.

Authors' conclusions

Treatment with nebulised MgSO₄ may result in modest additional benefits for lung function and hospital admission when added to inhaled β₂-agonists and ipratropium bromide, but our confidence in the evidence is low and there remains substantial uncertainty. The recent large, well-designed trials have generally not demonstrated clinically important benefits. Nebulised MgSO₄ does not appear to be associated with an increase in serious adverse events. Individual studies suggest that those with more severe attacks and attacks of shorter duration may experience a greater benefit but further research into subgroups is warranted.

Despite including 24 trials in this review update we were unable to pool data for all outcomes of interest and this has limited the strength of the conclusions reached. A core outcomes set for studies in acute asthma is needed. This is particularly important in paediatric studies where measuring lung function at the time of an exacerbation may not be possible. Placebo-controlled trials in patients not responding to standard maximal treatment, including inhaled β₂-agonists and ipratropium bromide and systemic steroids, may help establish if nebulised MgSO₄ has a role in acute asthma. However, the accumulating evidence suggests that a substantial benefit may be unlikely.

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Asthma: diagnosis, monitoring and chronic asthma management

Juan Carlos Ivancevich Thursday, 30 November 2017 11:45

National Institute for Health and Care Excellence (NICE)

Guidance
Tools and resources
Information for the public
Evidence
History

Guidance

This guideline covers diagnosing, monitoring and managing asthma in adults, young people and children. It aims to improve the accuracy of diagnosis, help people to control their asthma and reduce the risk of asthma attacks. It does not cover managing severe asthma or acute asthma attacks. The investment and training required to implement the guideline will take time. In the meantime, primary care services should implement what they can of the recommendations, using currently available approaches to diagnosis until the infrastructure for objective testing is in place.

Recommendations

This guideline includes recommendations on:

Who is it for?

  • GPs and practice nurses
  • Healthcare professionals in secondary care and tertiary asthma services
  • Commissioners and providers
  • People with suspected or diagnosed asthma, their families and carers

Implementation statement

We recognise that implementing the new approach to diagnosis in this guideline will need a big change in practice. See putting this guideline into practice.

Guideline development process

How we develop NICE guidelines

Next review: November 2019

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