Psychopathology in difficult asthma.

OBJECTIVE: Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed to predispose patients to DA or vice versa; psychopathology may develop as a consequence of DA. We reviewed the available literature on empirical findings regarding psychopathology in adult patients with DA. METHODS: Studies in English language journals using MEDLINE, Cochrane and PsycINFO databases, were retrieved by an electronic search published from 1990 till July 2014. RESULTS: Literature on psychopathology in DA is scarce. The search identified 16 articles of which only 6 articles were specifically about psychopathology in adult patients with DA. Almost half of the patients with DA had evidence of psychopathology at both syndrome and symptom level. Moreover, psychopathology appeared to be related to frequent exacerbations in patients with DA. CONCLUSIONS: This literature review suggests a high prevalence of psychopathology of patients with DA, although it remains unclear whether psychopathology occurs more often in DA compared to "stable asthma". More research is needed on a possible role of psychopathology on clinical signs and symptoms in DA.

Inaccuracy of estimating peak work rate from six-minute walk distance in patients with COPD.

INTRODUCTION: The cardiopulmonary exercise test (CPET) and the 6-minute walk test (6MWT) are used to prescribe the appropriate training load for cycling and walking exercise in patients with chronic obstructive pulmonary disease (COPD). The primary aims were: (i) to compare estimated peak work rate (Wpeak(estimated)) derived from six existing Wpeak regression equations with actual peak work rate (Wpeak(actual)); and (ii) to derive a new Wpeak regression equation using six-minute walk distance (6MWD) and conventional outcome measures in COPD patients. METHODS: In 2906 patients with COPD, existing Wpeak regression equations were used to estimate Wpeak using 6MWD and a new equation was derived after a stepwise multiple regression analysis. RESULTS: The 6 existing Wpeak regression equations were inaccurate to predict Wpeak(actual) in 82% of the COPD patients. The new Wpeak regression equation differed less between Wpeak(estimated) and Wpeak(actual) compared to existing models. Still, in 74% of COPD patients Wpeak(estimated) and Wpeak(actual) differed more than (±) 5 watts. CONCLUSION: In conclusion, estimating peak work load from 6MWD in COPD is inaccurate. We recommend assessment of Wpeak using CPET during pre-rehabilitation assessment in addition to 6MWT.

The effects of additional care by a pulmonary nurse for asthma and COPD patients at a respiratory outpatient clinic: results from a double blind, randomized clinical trial.

OBJECTIVE: To assess the effects of additional information based nursing care program in the treatment of asthma and COPD patients at a pulmonary outpatient clinic. METHODS: In a double blind, randomized clinical trial, 191 patients were allocated to an additional care group or control group. Patients in the intervention group received a protocol-based education program on individual basis by a pulmonary nurse on individual basis (average duration 60 min per patient). All patients were masked for the trial objectives. Effectiveness was expressed in terms of knowledge, inhalation technique, self-management, exacerbation rate (primary outcomes), and health-related quality of life and satisfaction with care received (secondary outcomes). The time interval between the initial and final assessments was 6 months. RESULTS: Ninety-seven patients were randomized into the additional care group and 94 into the control group, of which 157 had a complete dataset. (Un)adjusted analyses did not show differences between treatment groups in terms of knowledge, inhalation technique, self-management, health-related quality of life, and satisfaction with care. Multivariate logistic regression adjusting for baseline covariates showed a significant treatment effect with regard to exacerbation rate (odds ratio=0.35; 95% confidence limits: 0.13/0.94, p=0.04). CONCLUSION: With the exception of exacerbation rate, we could not demonstrate efficacy of additional nursing care in a broad range of outcome parameters. PRACTICE IMPLICATIONS: At present we do not recommend to implement our patient-tailored education program in daily practice.

Reliability in the assessment of videotaped inhalation technique.

Inhalation medication is essential in the treatment of asthma and chronic obstructive pulmonary disease (COPD) patients. Incorrect inhalation technique reduces the effects of medication and has been reported to range from 22% to 95% from optimal. The objective of this study was to determine inter- and intraobserver reliability in inhalation technique assessment. For interobserver reliability three observers scored after three times viewing a total of 49 video recorded inhalation demonstrations using device-specific checklists and mutually agreed scoring rules. Intraobserver reliability was assessed for two observers after 8 months by scoring inhalation demonstrations a second time. Both inter- and intraobserver reliability were expressed by mean percent agreement and mean Kappa scores. All inhaler devices revealed a high mean percent agreement and a substantial or almost perfect Kappa scoring for both inter- and intraobserver reliability. Only one item, "exhale to residual volume," showed poor intraobserver reliability. Assessment of video recorded inhalation technique using device-specific checklists, triple viewing, and mutual agreed scoring rules is reliable. This method enables blind observation of inhalation technique.

Unrecognised psychopathology in patients with difficult asthma: major mental and personality disorders.

BACKGROUND: Difficult asthma is a severe subgroup of asthma in which the main feature is uncontrollability of symptoms. Psychopathology is suggested to be prominent in patients with difficult asthma and considered important in its treatment; however, the evidence is scarce. AIMS: To describe psychopathology in difficult asthma, both major mental and personality disorders, based on diagnostic interviews. METHOD: This study was conducted in a specialised asthma care centre. A total of 51 patients with difficult asthma were diagnosed at the start of the treatment programme using two structured clinical interviews for both major mental (SCID-I) and personality disorders (SCID-II) according to DSM-IV-TR. RESULTS: About 55% of the patients with difficult asthma had a psychiatric disorder of which 89% was undiagnosed and untreated before being interviewed. About 49% had a minimum of one major mental disorder of which the cluster of anxiety disorders was the most common cluster of major mental disorders, followed by somatoform disorders. About 20% were diagnosed with a personality disorder. Of the 10 patients with a personality disorder, 9 had an obsessive-compulsive personality disorder. CONCLUSIONS: This study demonstrates that more than half of patients with difficult asthma had a psychiatric disorder of which 89% was unrecognised. This study highlights the importance of offering patients with difficult asthma a psychiatric diagnostic interview and/or a psychiatric consultation as part of their routine medical examination and provision of appropriate psychiatric treatment. Moreover, it highlights the urgency of further research into the role of psychopathology in the development of difficult asthma. DECLARATION OF INTEREST: None. COPYRIGHT AND USAGE: © The Royal College of Psychiatrists 2015. This is an open access article distributed under the terms of the Creative Commons Non-Commercial, No Derivatives (CC BY-NC-ND) licence.

Predictors of incorrect inhalation technique in patients with asthma or COPD: a study using a validated videotaped scoring method.

BACKGROUND: Inadequate technique reduces the effects of inhalation medication. Errors in inhalation technique have been reported to range up to 85%. Not only various patients' characteristics but also the device has an effect on correct inhalation technique. The purpose of this study was to determine the effect of patients' characteristics and type of inhaler device on inhalation technique in patient with asthma or chronic obstructive pulmonary disease (COPD). METHODS: A validated scoring method was used that consisted of triple viewing of video-recorded inhalations, using device-specific checklists. The following patient characteristics were investigated: gender, age, education level, diagnosis, treatment by a pulmonary physician, previously received inhalation instruction, exacerbation frequency, knowledge, self-management competence, pulmonary function, and use of multiple inhaler devices. Chi-square statistics were used for univariate associations between potential determinants and correctness of inhalation technique. Relevant determinants were entered into a multivariate logistic regression model. Moreover, inhalation technique errors were examined for six inhaler devices: three prefilled dry powder inhalers, one single-dose dry powder inhaler, a pressurized metered-dose inhaler (pMDI) and a pMDI with a spacer. RESULTS: Overall, 40% of the patients made at least one essential mistake in their inhalation technique. Patients who never received inhalation instruction and patients who used more than one inhaler device made significantly more errors (odds ratio both 2.2). Comparison between devices showed that a correct inhalation technique most likely occurred with the use of prefilled dry powder devices. CONCLUSION: Incorrect inhalation technique is common among asthma and COPD patients in a pulmonary outpatient clinic. Our study suggests that the use of prefilled dry powder inhalers as well as inhalation instruction increases correct inhalation technique. Simultaneous use of different types of inhalation devices has to be discouraged.