The actions of dopamine on the airways.

Velasco M.

Department of Physiology and Pharmacology, Jose M Vargas Medical School, Central University of Venezuela, Caracas, Venezuela. gcabezas reacciun.ve

BACKGROUND: Dopamine exerts inhibitory and excitatory effects on different systems. In the lungs, dopamine modulates respiratory functions through carotid bodies and modulates pulmonary blood vessel tone, alveolar liquids, and bronchial exchange, and possibly participates in the regulation of airways diameter. It has been reported that dopamine has no acute effect on human airways in normal subjects or those with asthma background. However, inhaled or infused dopamine decreased histamine-induced bronchoconstriction in both normal and asthmatic subjects. We have examined the possible modulating effect of dopamine on bronchial diameter by administering inhaled dopamine and the DA2 dopaminergic blocker metoclopramide to subjects with various degrees of bronchial tone. METHODS: We examined 56 volunteers. Arterial blood pressure and heart rate were determined in every subject. By means of spirometry, we measured forced vital capacity, forced expiratory volume in the first second, maximal forced expiratory flow, and forced expiratory flow at 50% of vital capacity, before and after each treatment. By inhalation with a nebulizer, we administered dopamine (0.5 microg/kg/min) to 10 healthy subjects, 10 subjects with asthma without acute bronchospasm, and 16 subjects with acute asthma attack; intravenous metoclopramide (7 microg/kg/min) was administered to 10 healthy subjects and 10 subjects with asthma without acute bronchospasm. For ethical reasons, metoclopramide was not used in subjects with acute asthma attack. Statistics: non-parametric Wilcoxon tests for paired samples, ANOVA tests, and Bonferroni multiple comparison tests were performed. RESULTS: Inhaled dopamine increased forced expiratory volume in the first second, forced vital capacity, maximal forced expiratory flow, and forced expiratory flow at 50% of vital capacity in the acute asthma attack group, but there were no modifications in the healthy group or in the asthma without acute bronchospasm group. Metoclopramide did not induce changes in respiratory parameters in healthy individuals or in those with asthma without acute bronchospasm. CONCLUSIONS: Inhaled dopamine was able to induce bronchodilatation when the bronchial tone was already increased by acute asthma attack, but it did not modify the resting bronchial tone in normals or in asthmatics without acute bronchospasm. DA2 blockade with metoclopramide did not modify resting bronchial tone either. We suggest that dopamine exerts a modulatory effect on bronchial tone of human airways depending on the degree of existing basal tone.

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Asthma, body mass index, and C-reactive protein among US adults.

Ford ES.

Division of Environmental Hazards and Health Effects, National Center for Environmental Health, Centers for Disease Control and Prevention, Atlanta, Georgia 30333, USA. esf2 cdc.gov

Obesity, a state that may be characterized by a low-grade inflammation, has been associated with asthma. C-reactive protein, an acute phase reactant, is elevated in obese people. However, little is known about how asthma affects C-reactive protein concentrations. Using data from 14,224 participants of the Third National Health and Nutrition Examination Survey (1988-1994), the author examined C-reactive protein concentrations among participants with current asthma (n = 651), who formerly had asthma (n = 303), and who never had asthma (n = 13,270). Compared with 21% of participants with current asthma, 11% with former asthma (P < .001) and 15% without asthma (P = .018) had C-reactive protein concentrations > or = 85th percentile of the sex-specific distribution. Compared with participants without asthma, the age-adjusted odds ratios for having an elevated C-reactive protein concentration was 1.49 (95% confidence interval [CI]: 1.11, 2.00) for persons with current asthma. After adjusting for age, sex, race or ethnicity, years of education, cotinine concentration, body mass index, waist-hip ratio, physical activity level, aspirin use, oral corticosteroid use, and inhaled corticosteroid use, the odds ratio decreased to 1.15 (95% CI: 0.83, 1.59). Body mass index was the main reason for the attenuation of the odds ratio. Whether the inflammatory activity associated with body mass index contributes to the pathophysiology of asthma is unknown.

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Association between outpatient follow-up and pediatric emergency department asthma visits.

Clark NM.

Child Health Evaluation and Research Unit, Division of General Pediatrics, University of Michigan Health Care System, Ann Arbor, Michigan 48109-0456, USA. mcabana med.umich.edu

BACKGROUND: The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. OBJECTIVE: To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. DESIGN: We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from January 1998 to October 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. RESULTS: A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. CONCLUSIONS: Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits.

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The relationship of asthma and anxiety disorders.

McCauley E.

Department of Psychiatry and Behavioral Sciences, University of Washington, Seattle, Washington 98195-6560, USA. wkaton u.washington.edu

OBJECTIVE: This article reviewed the child and adult medical literature on the prevalence of comorbid anxiety disorders in patients with asthma. Theoretical ideas regarding the relatively high comorbidity rates are presented along with a model describing putative interactions between anxiety disorders and asthma. METHOD: A search of the literature from the last 2 decades using MEDLINE by pairing the word, "asthma," with the following words: "anxiety," "depression," "panic," and "psychological disorders." We located additional research by screening the bibliographies of articles retrieved in the MEDLINE search. RESULTS: Both adult and child/adolescent populations with asthma appear to have a high prevalence of anxiety disorders. In child/adolescent populations with asthma, up to one third may meet criteria for comorbid anxiety disorders. In adult populations with asthma, the estimated rate of panic disorder ranges from 6.5% to 24%. However, most studies are limited by small samples, nonrepresentative populations, self-reported asthma status, and lack of controlling for important potential confounders such as smoking and asthma medications. There are also limited data on the impact of anxiety comorbidity in patients with asthma on symptom burden, self-care regimens (such as monitoring peak expiratory flow, taking medication, and quitting smoking), functional status, and medical costs. CONCLUSIONS: There appears to be a high comorbidity of anxiety disorders in patients with asthma. The prevalence and longitudinal impact of anxiety comorbidity needs to be examined in a large population-based sample of children, adolescents, and adults with asthma. If a high prevalence of comorbid anxiety disorder is documented and if this comorbidity adversely affects the self-efficacy and self-care, symptom burden, and functioning in persons with asthma, then it will be important to develop treatment trials.

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Predictors of poor asthma control in European adults.

Vermeire PA.

Worldwide Epidemiology, GlaxoSmithKline Research and Development, Greenford, Middlesex, UK. joan.b.soriano gsk.com

Asthmatics in the community suffer morbidity due to poor asthma control. The Global Initiative for Asthma (GINA) guidelines established minimum goals for the management of asthma. Our objective was to quantify the demographic and clinical factors associated with asthma control in adult asthmatics. A population sample of asthmatics 16 years and older was obtained by random digit dialing in seven European countries (France, Germany, Italy, The Netherlands, Spain, Sweden, and United Kingdom), and asthma control was quantified according to daytime and nighttime symptoms, severe episodes, and limits on daily activities due to asthma. Among the 2050 adult current asthmatics surveyed, 35% had good asthma control (0 or 1 GINA goals failed), 40% had moderate asthma control (2 or 3 GINA goals failed), and 25% had poor asthma control (4 or 5 GINA goals failed). Fewer subjects with poor than those with good asthma control had ever received a lung function test, and significantly fewer patients with poor asthma control had been taught by a doctor or nurse how to use their peak flow meter. When questioned about the underlying cause of asthma, only 7.8% of asthmatics mentioned airway inflammation, and only 17.6% stated that inhaled corticosteroids were the most effective medication for reducing airway inflammation. There was more use of quick relief bronchodilator medications in the past 4 weeks among patients with poor asthma control. Asthma management practices and the knowledge, attitudes, and behavior of adult asthmatics in the general population are associated with the degree of asthma control.

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The use of complementary therapies in inner-city asthmatic children.

Sharif I.

Department of Pediatrics, Albert Einstein College of Medicine/Children's Hospital at Montefiore, Bronx, New York 10467, USA. sandrafb juno.com

Use of complementary/alternative medicine (CAM) has been increasing, especially among patients with a chronic illness. Although asthma is the most common chronic illness affecting children in the United States, very little is known about the use of CAM in children with asthma. Our objective was to determine the prevalence and correlates of CAM use among inner-city children with asthma. A cross-sectional survey of parents of children with asthma attending an urban health center was performed. Parents were surveyed regarding CAM use over the past year, perceived efficacy of CAM, severity of child's asthma symptoms and demographic information. Differences in proportions were tested by chi-square or Fisher's exact test as appropriate. Three hundred ten parents participated, of whom 61% were Hispanic and 37% were African American. Parental mean age was 33 years and the mean age of the child was 7.2 years; 89% of parents had treated their child in the past year with some form of CAM. However, only 18% had informed a physician of doing so. The most common forms of CAM used were as follows: prayers (53%), rubs (53%), and massage (45%). Of those who used CAM, 59% perceived it to be at least as effective as pharmacotherapy, and 44% used CAM as first treatment of an asthma attack. Mild and moderate persistent asthmatics had significantly higher rates of CAM use than did mild intermittent and severe persistent asthmatics. We found a very high rate of CAM use among children with asthma in this inner-city population. Most importantly, a very high proportion of parents perceived the therapies to be effective, used them as first treatment of an acute exacerbation, and did not inform a physician of doing so. These findings have implications for the care of asthmatic children by pediatricians practicing in urban settings.

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Exhaled nitric oxide continues to reflect airway hyperresponsiveness and disease activity in inhaled corticosteroid-treated adult asthmatic patients.

Walters EH.

Department of Respiratory Medicine and Monash University Medical School, Alfred Hospital, Melbourne, Victoria, Australia. David.Reid med.monash.edu.au

OBJECTIVE: Exhaled nitric oxide (eNO) has been used as a surrogate of airway inflammation in mild asthma. However, whether eNO levels reflect disease activity in symptomatic asthmatics receiving moderate doses of inhaled corticosteroid (ICS) is more uncertain. METHODOLOGY: To examine the relationship between eNO levels, sputum and blood eosinophils (SpE and PbE), PD(20) methacholine as a marker of airway hyperresponsiveness (AHR) and clinical status in 28 ICS-treated asthmatic subjects with persistent asthma compared to that in 25 symptomatic asthmatics managed with beta2-agonists alone. RESULTS: As expected, eNO levels were normalized in ICS-treated subjects and significantly elevated in the beta2-agonist only group (P < 0.001). SpE, PbE and PD20M did not differ between asthmatic groups but FEV1 was significantly worse in ICS-treated subjects (P < 0.01). Exhaled NO levels correlated with PbE within both asthmatic groups (P < 0.005), but with SpE only in ICS-untreated subjects (r(s) = 0.6, P < 0.05). In contrast, PD20M was negatively correlated with eNO and PbE in ICS-treated subjects only (r(s) = - 0.4, r(s) = - 0.4, respectively, P < 0.05). SpE and PbE were strongly correlated in both asthmatic groups (r(s) = 0.8, r(s) = 0.7, respectively, P < 0.005). Exhaled NO levels, SpE and PbE were all positively associated with increased nocturnal awakenings ( P < 0.05) in ICS-treated subjects, but not in ICS-untreated subjects. CONCLUSIONS: In ICS-treated asthma, eNO reflects clinical activity, PbE and AHR but not eosinophilic airway inflammation. Exhaled NO levels are quantitatively and relationally different in asthmatic subjects treated with ICS and continue to have potential for use as a surrogate of asthma pathophysiology in this group.

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[Asthma management in adult emergency departments in Israel in comparison to asthma guidelines]

[Article in Hebrew]

Varsano S.

Asthma Care and Education Unit, Pulmonary Medicine Department, Sapir Medical Center Meir Hospital, Kfar Saba Sackler Faculty of Medicine, Tel Aviv University, Israel.

BACKGROUND: Asthma management is in focus all over the world. It is constantly updated, including aspects of Emergency Department (ED) care, on the basis of global and national evidence-based clinical guidelines. Despite the existence of these guidelines, the management of asthma, including management in the ED, is lagging behind. AIM: This study strives to evaluate various aspects of asthma management in the EDs in Israel. METHOD: A questionnaire was sent to each Head or Deputy Head of all the adult EDs in Israel. The questionnaires were collected within 16 days in December 2000. Ninety-six percent of all adult EDs in Israel responded. The mean response of each ED to all the questions was 99.5%. RESULTS: Oximetry on admission is performed for every patient in a third of the EDs although an oximeter is available in every ED. Measurements of airway obstruction severity by PEFRm or FEV1 in more than 50% of patients before hospital admission or discharge is only conducted in 9% of the EDs and in 52% of them it is not measured at all. Inhalation of a short beta-agonist combined with anticholinergic is performed in 84% of EDs. Corticosteroids are given to more than 80% of the arriving patients in only 54% of EDs and on discharge it is continued in all or almost all patients in 63% of EDs. A written time interval for the next medical visit after discharge from ED is not specified in 50% of EDs. In contrast to these findings, there is almost complete accordance among EDs (88%) that asthma management in the ED should follow formal guidelines and that common guidelines for asthma management should be adopted by all EDs in Israel (71%). CONCLUSIONS: The discrepancies between the existing clinical guidelines for asthma management in the ED and its actual use on the one hand, and the agreement among EDs on the importance of the guidelines on the other hand, are raising the necessity for common guidelines for asthma management in the EDs in Israel. Perhaps, more importantly, it highlights the urgent need for new effective and creative ways to implement asthma guidelines into routine ED practice.

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