Hereditary angioedema in older adults: Understanding the patient perspective.

BACKGROUND: Hereditary angioedema (HAE) is a rare condition characterized by potentially fatal, recurrent episodes of painful swelling. Whereas there are limited studies evaluating the quality of life of individuals with HAE, none have evaluated the impact of HAE on older adults. OBJECTIVE: To evaluate the effect of HAE on older adults through qualitative methodology. METHODS: A group of 3 physicians with extensive research and clinical experience in HAE developed a focus group guidebook highlighting issues of importance to older adults. A total of 17 patients with HAE (type I or II) aged 60 years and older participated in focus groups. Three independent reviewers coded each focus group transcript using a thematic saturation approach. RESULTS: Reviewers identified 7 core themes from the focus groups. The themes identified encompassed the following: (1) challenges with securing medications and insurance concerns; (2) the experience of living with HAE before the advent of newer and more effective therapeutic options; (3) a worsening of HAE attack frequency and severity with aging; (4) the effects of comorbid conditions such as arthritis, memory loss, and irritable bowel syndrome; (5) changes in HAE with menopause; and (6) changing perspective on HAE with age, the effect of HAE on interpersonal relationships including the decision to have children, and goals for future care and research including support groups and a desire to be included in clinical trials. CONCLUSION: Older adults with HAE have specific challenges and concerns that may be unique compared with younger populations. Health care providers should address these to provide optimal care.

COVID-19 vaccine intentions and attitudes in Black American emerging adults with asthma.

BACKGROUND: Emerging adults (aged 18-29) are less likely to receive the COVID-19 vaccine than any other adult age group. Black Americans are less likely than non-Hispanic white Americans to be fully vaccinated against COVID-19. This study explored factors which affect vaccine intention and attitudes in Black American emerging adults with asthma. METHODS: Participants were recruited from an NHLBI-funded clinical trial to improve asthma control. Fifty-nine Black American emerging adults completed a Qualtrics survey that assessed asthma control, intention to vaccinate, and factors which may affect the decision to vaccinate. Twenty-five participants also completed a semi-structured interview via Zoom. Bivariate correlations and descriptive statistics, including Chi Square analyses, were run using SPSS. Interview thematic analyses were conducted via QDA Miner. RESULTS: Of the 59 Black American emerging adults with asthma who completed surveys, 32.2% responded that they were highly unlikely to receive the COVID-19 vaccine, while 50.8% responded that they were highly likely to receive it. Increased asthma control was significantly correlated with a higher likelihood to discuss the COVID-19 vaccine with their healthcare provider (ρ = 0.339, α = 0.011). Concerns about immediate (ρ= -0.261, α = 0.050) and long-term (ρ= -0.280, α = 0.035) side effects were inversely correlated with intention to vaccinate. Only 17% of the participants who were unemployed stated that they were highly likely to receive the vaccines compared to 65% of the participants who were employed; however, interview participants who were unemployed stated not needing the vaccine because they were protecting themselves by social distancing. When deciding whether to receive the vaccine, safety, efficacy, and immediate side effects were the top three factors for 91%, 54%, and 49% of the participants, respectively. Beliefs about the vaccines' safety and efficacy, information gathering, personal factors, and societal factors emerged as important themes from the interviews. CONCLUSION: Only half of the surveyed Black American emerging adults with asthma were highly likely to receive the COVID-19 vaccine. Safety and efficacy were important for the majority of the participants, regardless of vaccine intention. Greater asthma control, but not access to asthma-related healthcare, was correlated with intention to discuss the vaccine with their healthcare provider.

Assessment of mask use on oxygen saturation in adults and children with asthma.

Background: Mask use is recommended to reduce the transmission of severe acute respiratory syndrome coronavirus 2. The safety of mask use in adults and children with asthma is unknown. Objective: The objective of this study is to evaluate the effect of mask use on peripheral oxygen saturation (SpO2) in those with and those without asthma. Methods: A two-stage cross-sectional study was performed. In the first stage, the SpO2 concentration in adults and children with and without asthma was measured with the adults and children at rest during mask use. In the second stage, children years 6-17 performed a 6-minute walk test while wearing masks. The SpO2 concentration was measured before the exercise and at 3 and 6 minutes into exercise. Subjective dyspnea was evaluated by using the Pediatric Dyspnea Scale (PDS). Results: In the first stage, SpO2 levels in 393 subjects were analyzed. In the second stage, 50 pediatric subjects were included, 25 with and 25 without asthma. There was no difference in SpO2 levels between those with and those without asthma in adults and children wearing masks while at rest, with median SpO2 98% in both groups. There was no difference in oxygen saturation or reported level of dyspnea between the children with asthma and children without asthma performing the 6-minute walk test while wearing masks. Median SpO2 levels were at or near 99% in the asthma and non-asthma groups at all time points. Median PDS scores were similar between the asthma and non-asthma groups. Conclusion: Mask use did not affect SpO2 in adults and children at rest or in children performing low-to-moderate intensity exercise. These findings were consistent in those with and without asthma.

Breathing exercises in older adults with asthma: a blinded, randomized, placebo-controlled trial.

OBJECTIVE: Breathing exercises have been found to benefit patients with some respiratory disorders, but can take a significant amount of time to complete. The effects of a breathing exercise program are unknown. The aim of this study was to evaluate the effectiveness of a short multi-component exercise program for older adults with asthma. METHODS: To be included, subjects were age 65 years or older with persistent asthma. 90 subjects with predominantly moderate to severe asthma were randomized, 45 each, into either the exercise or control groups. After in person training at the initial visit, those in the exercise group performed a short three-part exercise program twice per day at home for one month. Those in the control group performed 2 breaths with the incentive spirometer twice per day. At the initial visit patients completed baseline questionnaires assessing demographic information, asthma control (Asthma Control Test - ACT) and quality of life (mini-Asthma Quality of Life Questionnaire - mini-AQLQ) as well as spirometry. After the one-month period at the follow-up visit the ACT, mini-AQLQ, and spirometry were repeated. RESULTS: Subjects in the intervention felt that breathing exercises were helpful, and 87% would recommend them to a friend. Although both groups had improvement in ACT and mini-AQLQ, there were no differences between groups. FEV1 was lower in both groups. CONCLUSION: Although a short breathing exercise program was acceptable for older adults with asthma, it did not produce meaningful improvements in asthma outcomes. A longer program may be necessary.

Asthma care during COVID-19: differences in attitudes and expectations between physicians and patients.

OBJECTIVE: The aim of this study was to explore differences in attitudes, behaviors and expectations related to COVID-19 between physicians and patients with asthma. METHODS: An anonymous survey was distributed through email and social media to adult patients with asthma during a three-week period in April-May 2020. A separate survey was sent to physicians. The surveys asked about demographic information, specific challenges and concerns due to COVID-19, and attitudes/behaviors during this time. RESULTS: A total of 1171 patients and 225 physicians completed the surveys. Overall, patients with asthma and physicians had large differences in expectations related to COVID-19. Patients were more likely than physicians to believe that individuals with asthma are at a higher risk to get COVID-19 (37.5% vs. 12.0%, p < 0.001), have increased anxiety due to COVID-19 (79.6% vs 70.0%, p = 0.002), and should not go to work (62.7% vs 11.9%, p < 0.001). Neither patients nor physicians felt confident they could distinguish COVID-19 symptoms from asthma (61.2% and 74.5% did not feel confident, respectively). Patients with severe asthma were significantly more impacted by the pandemic (e.g., became unemployed [OR 2.15], had difficulty getting asthma medications [OR 2.37]) compared to those with nonsevere asthma. CONCLUSION: Patients with asthma and their physicians have markedly different attitudes and opinions regarding care during the COVID-19 pandemic. Such differences have important implications when providing patient-centered care.Supplemental data for this article can be accessed at publisher's website.

Understanding the Updates in the Asthma Guidelines.

Asthma is a chronic inflammatory lung disease that affects millions of Americans, with variable symptoms of bronchospasm and obstruction among individuals over time. The National Heart, Lung, and Blood Institute (NHLBI) published the 2020 Focused Updates to the Asthma Management Guidelines based on the latest research since the 2007 Expert Panel Report-3 (EPR-3). The following article reviews the 21 new recommendations on the six core topics in asthma: use of intermittent inhaled corticosteroids, long-acting muscarinic antagonist therapy, use of the fractional exhaled nitric oxide test in asthma diagnosis and monitoring, indoor allergen mitigation, immunotherapy, and bronchial thermoplasty. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to rate recommendations as strong or conditional based on the evidence. The recommendations were based on systematic reviews of the literature and focused on patient-centered critical outcomes of asthma exacerbations, asthma control, and asthma-related quality of life. Understanding the recommendations with consideration of individual values through shared decision-making may improve asthma outcomes.

The role of aspirin desensitization followed by oral aspirin therapy in managing patients with aspirin-exacerbated respiratory disease: A Work Group Report from the Rhinitis, Rhinosinusitis and Ocular Allergy Committee of the American Academy of Allergy, Asthma & Immunology.

Aspirin-exacerbated respiratory disease (AERD) is characterized by the clinical triad of chronic rhinosinusitis with nasal polyps, asthma, and an intolerance to medications that inhibit the cycloxgenase-1 enzyme. Patients with AERD on average have more severe respiratory disease compared with patients with chronic rhinosinusitis with nasal polyps and/or asthma alone. Although patients with AERD traditionally develop significant upper and lower respiratory tract symptoms on ingestion of cycloxgenase-1 inhibitors, most of these same patients report clinical benefit when desensitized to aspirin and maintained on daily aspirin therapy. This Work Group Report provides a comprehensive review of aspirin challenges, aspirin desensitizations, and maintenance aspirin therapy in patients with AERD. Identification of appropriate candidates, indications and contraindications, medical and surgical optimization strategies, protocols, medical management during the desensitization, and recommendations for maintenance aspirin therapy following desensitization are reviewed. Also included is a summary of studies evaluating the clinical efficacy of aspirin therapy after desensitization as well as a discussion on the possible cellular and molecular mechanisms explaining how this therapy provides unique benefit to patients with AERD.

2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group.

The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality's (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.

A behavioral intervention can decrease asthma exacerbations in older adults.

BACKGROUND: Older adults have higher rates of asthma morbidity and mortality compared with younger age groups. Few interventions are tailored to this population. OBJECTIVE: To evaluate a self-management asthma intervention in older adults. METHODS: Adults age 55 and older with persistent asthma were enrolled into blinded, randomized controlled trial of a 6-session asthma self-management intervention. This educational intervention was conducted in group sessions and through individual telephone calls. Outcomes including asthma exacerbations (defined as unscheduled office visits, emergency department visits, or hospitalizations for asthma), spirometric values, FeNO, asthma control, asthma quality of life, and asthma self-management were assessed at 3, 6, and 12 months. RESULTS: One hundred eighty-nine subjects were enrolled, 172 were randomized and received at least 1 treatment dose, and 145 (84%) were analyzed at 12 months. On a modified intent-to-treat analysis, those in the intervention group were less likely to have an asthma exacerbation (26.9% vs 47.1%, P = .01), had a lower asthma exacerbation rate (0.8 vs 1.9, P = .02), had better asthma control (19.9 vs 18.6, P = .08), and had a higher asthma self-management score (8.9 vs 8.4, P = .03). After a mixed-model analysis to control for confounding factors, a decrease in asthma exacerbations (P = .02), as well as a decreased asthma exacerbation rate (P = .04), remained statistically significant, whereas asthma control and self-management did not. No other significant outcome differences were found. CONCLUSION: A 6-session asthma self-management intervention can successfully decrease asthma exacerbations among older adults.

Asthma in the older adult.

Objective: The older adult population is increasing worldwide, and a significant percentage has asthma. This review will discuss the challenges to diagnosis and management of asthma in older adults. Data Sources: PubMed was searched for multiple terms in various combinations, including asthma, older adult, elderly, comorbid conditions, asthma diagnosis, asthma treatment, biologics and medication side effects, and adverse events. From the search, the data sources that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Study Selections: Study selections that were utilized included peer reviewed scholarly review articles, peer reviewed scientific research articles, and peer reviewed book chapters. Results: Asthma in older adults is frequently underdiagnosed and has higher morbidity and mortality rates compared to their younger counterparts. A detailed history and physical examination as well as judicious testing are essential to establish the asthma diagnosis and exclude alternative ones. Medical comorbidities, such as cardiovascular disease, cognitive impairment, depression, arthritis, gastroesophageal reflux disease (GERD), rhinitis, and sinusitis are common in this population and should also be assessed and treated. Non-pharmacologic management, including asthma education on inhaler technique and self-monitoring, is vital. Pharmacologic management includes standard asthma therapies such as inhaled corticosteroids (ICS), inhaled corticosteroid-long acting ß-agonist combinations (ICS-LABA), leukotriene antagonists, long acting muscarinic antagonists (LAMA), and short acting bronchodilators (SABA). Newly approved biologic agents may also be utilized. Older adults are more vulnerable to polypharmacy and medication adverse events, and this should be taken into account when selecting the appropriate asthma treatment. Conclusions: The diagnosis and management of asthma in older adults has certain challenges, but if the clinician is aware of them, the morbidity and mortality of this condition can be improved in this growing population.

Electronic cigarettes: How confident and effective are allergists, pulmonologists, and primary care physicians in their practice behavior?

Background: There has been a striking increase in electronic cigarette (EC) use in the United States. The beliefs and practices toward ECs among physicians are unknown. Objective: The purpose of this study was to investigate EC practice patterns among allergists, pulmonologists, and primary care physicians. Methods: An anonymous survey was sent to physicians. The survey contained 32 questions and addressed issues related to demographics, cessation counseling behaviors, personal use, and knowledge and beliefs about ECs. Statistical analysis was performed by using analysis of variance, the Pearson χ² test, Fisher exact test, and logistic regression. Results: A total of 291 physicians completed the survey (222 primary care physicians, 33 pulmonologists, and 36 allergists) for a response rate of 46%. The allergists asked about tobacco cigarette use as frequently as did the pulmonologists and more than the primary care physicians (p < 0.001), but they rarely asked about EC use. The pulmonologists scored highest on self-reported knowledge on ECs, although all the groups answered <40% of the questions correctly. The allergists did not feel as comfortable about providing EC cessation counseling as did the pulmonologists and primary care physicians (p < 0.001). All three groups were equally unlikely to recommend ECs as a cessation tool for tobacco cigarette users. Conclusion: Allergists lacked knowledge and confidence in providing education and cessation counseling for EC users. As the number of patients who use these products continues to increase, there is an urgent need for all physicians to be comfortable and knowledgeable with counseling about ECs.

Are primary care physicians following National Institute of Allergy and Infectious Disease guidelines for the prevention of peanut allergy? A survey-based study.

Background: The 2017 addendum to the National Institute of Allergy and Infectious Diseases (NIAID) guidelines on peanut allergy prevention significantly altered recommendations for patients at risk of developing peanut allergies. It is unknown if primary care physicians are aware of or are following these guidelines. Objective: To assess the knowledge and practice of the NIAID guidelines among primary care physicians. Methods: A survey was developed to assess the knowledge, awareness, and practice behaviors of the NIAID guidelines. It was distributed to pediatric, family medicine, and medicine-pediatric residents and attending physicians at two large academic centers. Responses were analyzed with binary logistic regression. Results: The survey was distributed to 605 providers, with a response rate of 35% (n = 210). The average score was 4.8 of seven questions answered correctly. Of the participants, 53% incorrectly recommended at-home peanut introduction in patients with egg allergy. In addition, 40% of the participants incorrectly believed that the earliest age for peanut introduction was >1 year of age. More than half of the participants were unaware of the new guidelines. On logistic regression, factors associated with adequate knowledge assessment scores were awareness of the guidelines (odds ratio [OR] 2.98 [confidence interval {CI}, 1.34-6.60]), graduation from residency within 5 years (OR 3.60 [95% CI, 1.14-11.35]), and affiliation with the medicine-pediatrics department (OR 4.59 [95% CI, 1.07-19.65]). Conclusion: The primary care providers incorrectly answer one-third of the questions related to the prevention of peanut allergy. Increasing awareness of the 2017 NIAID guidelines may provide an opportunity to improve patient outcomes. There is an urgent need to develop innovative education strategies to publicize these guidelines.

Factors correlated with repeated aspirin dosing during aspirin desensitization.

BACKGROUND: Aspirin desensitization is an appropriate procedure for many patients with aspirin-exacerbated respiratory disease (AERD). Patients can require aspirin re-dosing, which prolongs the desensitization process. The frequency of this is not widely reported, nor is it known which patients will require multiple re-dosing. OBJECTIVE: To determine the frequency of and factors associated with repeat aspirin re-dosing during desensitization. METHODS: Charts of aspirin desensitization procedures from 2011 to 2016 at the University of Michigan Allergy/Immunology Clinic were reviewed. Reactions with provoking doses and number of dose repetitions were characterized. Previous AERD history, medical history, medications, and baseline spirometry were also recorded. Bivariate correlation and multivariate logistic regression were used to analyze associations between patient characteristics and need for repeated dosing of aspirin. RESULTS: A total of 84 positive-reacting patients during desensitization were identified. Of these patients, 33% required 2 or more aspirin dose repetitions during desensitization. Requiring 2 or more repeat doses during desensitization was associated with male gender (odds ratio = 6.194, P = .008), forced expiratory volume in 1 second (FEV1) decrease during desensitization (odds ratio = 1.075 per percent point drop, P = .021), and initial aspirin provoking dose during desensitization of 81 mg or lower (odds ratio = 11.111, P = .003). No association was found with pre-desensitization medications, asthma severity, AERD duration, or number/character of reported previous aspirin reactions. CONCLUSION: During aspirin desensitization for AERD, approximately one third of our patients require multiple repeat doses. Risk factors for multiple repeated doses include male gender, drop in FEV1, and lower aspirin provoking doses during desensitization. This information can help inform which patients may require multiple re-dosing for desensitization.

Risk factors and clinical outcomes associated with fixed airflow obstruction in older adults with asthma.

BACKGROUND: Asthma in older adults is associated with increased morbidity and mortality compared with asthma in younger patients. Fixed airflow obstruction (FAO) is associated with decreased survival in younger patients, but its significance remains unclear in older adults with asthma. OBJECTIVE: To identify risk factors and outcomes related to FAO in older adults with asthma. METHODS: Subjects older than 55 years with a physician diagnosis of persistent asthma were evaluated. Collected data included participant demographic information, medications, asthma exacerbations, Asthma Control Test (ACT) score, Asthma Quality of Life (AQLQ) score, comorbidities, spirometry, atopic status, and fractional exhaled nitric oxide. Clinical characteristics and outcomes associated with FAO (defined as post-bronchodilator ratio of forced expiratory volume in 1 second to forced vital capacity ≤70%) were assessed. RESULTS: A total of 186 participants were analyzed (48 men and 138 women, mean age 66 years). FAO was demonstrated in 30% of participants. Using regression analysis, predictors of FAO included advanced age, African American race, male sex, and longer duration of asthma. In outcomes analysis, FAO was associated with worsened ACT and AQLQ scores; however, after controlling for confounding factors, logistic regression showed no association. No significant association was found between FAO and exacerbations, fractional exhaled nitric oxide, atopy, rhinitis, education level, depression, smoking, or body mass index. CONCLUSION: Risk factors associated with FAO in older adults with asthma include advanced age, African American race, increased asthma duration, and male sex. Unlike younger patients, FAO is not independently associated with worsened asthma control, quality of life, or exacerbations in older patients with asthma. TRIAL REGISTRATION: ClinicalTrials.gov identifier: NCT01979055.

The impact of patient autonomy on older adults with asthma.

BACKGROUND: Understanding patient preferences and desire for involvement in making medical decisions is important when managing chronic conditions. Previous studies have used the Autonomy Preference Index (API) in younger patients with asthma to evaluate these preferences. OBJECTIVE: To identify factors associated with autonomy and to determine whether autonomy is related to asthma outcomes among older adults. METHODS: A total of 189 older adults (>55 years old) with persistent asthma were included. Preferences for autonomy were assessed using the API, with a higher score indicating higher desire for autonomy. Scores were separated into 2 domains of information-seeking and decision-making preferences. The separated scores were correlated with asthma outcomes and demographic variables. To control for confounding factors, a linear regression analysis was performed. RESULTS: Higher decision-making preference scores correlated with female sex (P = .007), higher educational level (P = .01), and lower depression scores (P = .04). Regarding outcomes, decision-making scores positively correlated with Mini Asthma Quality of Life Questionnaire (Mini-AQLQ) scores (P = .01). On linear regression analysis, the Mini-AQLQ score remained significantly associated with decision-making preference scores (P = .03). There was no association with asthma control test scores, spirometry values, and health care use. Information-seeking preference scores correlated with educational level (P = .03), but there was no correlation with asthma outcomes. CONCLUSION: Older adults with asthma and a greater desire for involvement in decision making have better asthma-related quality of life. Future studies with the intention to increase patient autonomy may help establish a causal relationship.

Frequency and severity of reactions to a 325-mg aspirin dose during desensitization.

BACKGROUND: The frequency with which patients with aspirin-exacerbated respiratory disease (AERD) react to 325 mg of aspirin during aspirin desensitization, or fail to react at all, is not fully known. OBJECTIVE: To determine the rate and type of reaction at 325 mg of aspirin during desensitization. METHODS: A retrospective study of 104 patients who underwent aspirin desensitization from 2010 to 2016 was performed. A standard desensitization protocol (starting at 20-40 mg, progressing through 325 mg, and extinguishing reactions by dose repetition) was used. Reactions were defined by upper respiratory tract symptoms, lower respiratory tract symptoms, and/or forced expiratory volume in 1 second decrease of 15% or greater. Patients who did and did not react were compared by logistic regression. RESULTS: Eighty-four patients reacted (81%) and 20 did not (19%). Seventy-seven patients who had a provoking reaction at 162 mg of aspirin or less subsequently extinguished their reactions before they reached a dose of 325 mg and had no problems at that dose; one subsequent 325-mg reaction occurred during a protocol violation. One initial provoking reaction to 325 mg occurred. Both 325-mg reactions were mild, and neither met the forced expiratory volume in 1 second criterion for a clinically meaningful change. The remaining 5 patients could not complete the protocol because of persistent reactions or social reasons. Reactors were more likely to have had asthma for more than 10 years than nonreactors (odds ratio, 3.2; 95% confidence interval, 1.0-10.3; P = .05). CONCLUSION: During aspirin desensitization for AERD, provoking reactions at the 325-mg dose are rare (1%) and mild. Patients who react at 162 mg or less and extinguish their reactions may be able to administer the 325-mg dose at home.

A modified breathing exercise program for asthma is easy to perform and effective.

OBJECTIVES: Breathing exercises are used by some asthmatic patients, yet are often difficult to perform and time-consuming. This study evaluated a simple, modified breathing exercise program regarding ease to perform and effectiveness as an adjunctive therapy. METHODS: Subjects age 18 to 65 with a current diagnosis of persistent asthma were enrolled. A program that incorporated three different breathing exercises (yoga pranayama techniques, diaphragmatic breathing and pursed lip breathing) was taught to subjects. The program was designed to be completed in less than 10 minutes per day. Subjects completed the Asthma Control Test (ACT) and mini-Asthma Quality of Life Questionnaire (AQLQ) at baseline and at 1-month follow-up. They also completed a survey that asked them to rate the effectiveness and difficulty of the exercises, and whether they would recommend them in the future. RESULTS: A total of 74 subjects were enrolled in this study. The intervention improved breathing for 52.9% of the subjects, while 67.6% felt that their daily activity was improved and 66.1% noted that the exercises allowed decreased use of a rescue inhaler. Most subjects (80.9%) recommended breathing exercises as a complementary therapy for asthma and 79.4% of the subjects stated the exercises took less than 10 minutes per day total. Overall, ACT scores improved significantly (p = 0.002) with a statistically non-significant improvement in AQLQ scores. CONCLUSION: A simple program of breathing exercises was found to be effective and could be completed in less than 10 minutes per day. Furthermore, there was a statistically significant improvement in ACT scores post-exercise.

Effects of pediatric asthma care coordination in underserved communities on parent perceptions of care and asthma-management confidence.

OBJECTIVE: Disparities by race and socioeconomic status persist in pediatric asthma morbidity, mortality, and treatment. Improving parent/provider communication and parents' asthma-management confidence may result in better asthma control in vulnerable populations. The Merck Childhood Asthma Network, Inc. funded an initiative to implement medical-social care coordination to improve asthma outcomes at sites in four low-income, urban communities (Los Angeles, CA; Philadelphia, PA; Chicago, IL; and San Juan, PR.) As part of a cross-site evaluation of this effort, pre- post-program changes in parents' reports of asthma care and management were assessed. METHODS: Across sites, 805 parents or other caregivers responded to a baseline survey that was repeated one year later following their child's participation in care coordination. Parents' asthma-management confidence, as well as their perceptions of provider access, trust, and communication, were measured with Likert scales. Linear mixed models were used to assess improvement in these variables, across and within sites, adjusting for sociodemographics. RESULTS: Pooled across sites, the adjusted mean estimate for all outcomes showed a significant improvement (p <.05) from baseline to follow-up. Knowledge and Between-Provider Communication improved significantly (p <.05) within all four sites; Access improved significantly in Chicago, Philadelphia, and Puerto Rico; Trust improved significantly in Chicago, Los Angeles, and Philadelphia; and Patient-Provider Communication improved significantly in Philadelphia only. CONCLUSION: Pediatric asthma care coordination, as implemented variously in diverse settings, was associated with improvement in parents' perceptions of asthma care and self-reported asthma-management knowledge and confidence. This positive impact on parents may help sustain care coordination's impact on children.

IL-17RB+ granulocytes are associated with airflow obstruction in asthma.

BACKGROUND: Interleukin (IL)-25 (IL-17E) is a proinflammatory cytokine that plays an important role in the T-helper type 2 cell pathway. The effects of IL-25 are mediated by its specific receptor, IL-17RB. Previous studies have defined an IL-17RB+ granulocyte population known as type 2 myeloid (T2M) cells that express T-helper type 2 cell cytokines. The correlation of IL-17RB+ granulocytes, T2M cells, and asthma parameters is unknown. OBJECTIVE: To investigate the relation of IL-17RB+ granulocytes (and its subset, T2M cells) in patients with asthma with clinical parameters including spirometric values and the Asthma Control Test (ACT). METHODS: Peripheral blood from subjects with asthma and healthy controls was collected and analyzed by flow cytometry. Granulocytes were gated for IL-17RB+, T2M (CD11b+CD16+CD177+IL-17RB+), and eosinophil (CD16-) populations. Spirometry testing was performed on subjects with asthma. ACT scores and medical histories were collected by questionnaire and chart review. Correlations of IL-17RB+ cells and T2M cells with spirometry and ACT score were analyzed. RESULTS: Percentages of IL-17RB+ granulocytes and T2M cells were larger in subjects with asthma than in controls. Furthermore, percentages of the 2 cell populations were negatively correlated with degree of airway obstruction as measured by the ratio of percentage-predicted forced expiratory volume in 1 second to force vital capacity (r = -0.17, P = .043 for IL-17RB+ granulocytes; r = -0.32, P = .03 for T2M cells). There was no correlation with ACT score. The percentage of eosinophils was increased in subjects with asthma. However, IL-17RB+ eosinophil percentages were similar between subjects with asthma and controls and did not correlate with any clinical parameter. CONCLUSION: IL-17RB+ granulocytes and T2M cells from peripheral blood were increased in subjects with asthma, and the 2 cell types correlated with degree of airflow obstruction.

Characteristics of Complementary and Alternative Medicine (CAM) use among older adults with asthma.

OBJECTIVE: A growing number of asthma patients are using Complementary and Alternative Medicine (CAM). Prior studies have not examined CAM use among the older adult population. METHODS: Data from the 2011 Behavioral Risk Factor Surveillance Survey (BRFSS), a national telephone survey, and the Asthma Call-Back survey (ACBS), a survey conducted among BRFSS individuals reporting asthma, were used for the analyses. The study population consisted of 7685 individuals aged 55 years or older with current asthma. The relationship of CAM use with demographic and asthma outcomes was analyzed using logistic regression. RESULTS: CAM use was reported by 39% (3030). Breathing techniques were the most commonly reported CAM therapy. Demographic factors associated with CAM use include female gender (OR 1.36, p < 0.002), having at least a college education (OR 1.76, p < 0.001), cost barrier to healthcare (OR 1.43, p < 0.001), and living in the West (OR 1.31, p < 0.01). An inverse relationship was noted between income and CAM use. Those who had received an asthma action plan (OR 1.29, p < 0.005), current smokers (OR 1.35, p < 0.02), or impaired asthma control (as defined by symptoms affecting sleep, symptoms limiting activities, and rescue medication use) were more likely to use CAM (OR 1.37, p < 0.001; OR 1.38, p < 0.001; and OR 1.2, p < 0.046, respectively). CONCLUSIONS: A large proportion of asthmatic older adults use CAM. In addition, older adults with asthma who use CAM have decreased asthma control, and further studies are needed to determine a causal role.