Engaging stakeholders to level up COPD care in LMICs: lessons learned from the "Breathe Well" programme in Brazil, China, Georgia, and North Macedonia.

BACKGROUND: Effective stakeholder engagement in health research is increasingly being recognised and promoted as an important pathway to closing the gap between knowledge production and its use in health systems. However, little is known about its process and impacts, particularly in low-and middle-income countries. This opinion piece draws on the stakeholder engagement experiences from a global health research programme on Chronic Obstructive Pulmonary Disease (COPD) led by clinician researchers in Brazil, China, Georgia and North Macedonia, and presents the process, outcomes and lessons learned. MAIN BODY: Each country team was supported with an overarching engagement protocol and mentored to develop a tailored plan. Patient involvement in research was previously limited in all countries, requiring intensive efforts through personal communication, meetings, advisory groups and social media. Accredited training programmes were effective incentives for participation from healthcare providers; and aligning research findings with competing policy priorities enabled interest and dialogue with decision-makers. The COVID-19 pandemic severely limited possibilities for planned engagement, although remote methods were used where possible. Planned and persistent engagement contributed to shared knowledge and commitment to change, including raised patient and public awareness about COPD, improved skills and practice of healthcare providers, increased interest and support from clinical leaders, and dialogue for integrating COPD services into national policy and practice. CONCLUSION: Stakeholder engagement enabled relevant local actors to produce and utilise knowledge for small wins such as improving day-to-day practice and for long-term goals of equitable access to COPD care. For it to be successful and sustained, stakeholder engagement needs to be valued and integrated throughout the research and knowledge generation process, complete with dedicated resources, contextualised and flexible planning, and commitment.

Association between illness perception and clinical control, quality of life, physical activity, and psychosocial status in subjects with moderate to severe asthma: a cluster analysis.

Background: Illness perception (IP) is a psychosocial factor involved in several chronic diseases and is associated with relevant clinical outcomes. However, the relationship between IP and health-related quality of life (HRQoL), psychosocial status, and physical activity in daily life (PADL) in subjects with asthma is poorly understood.Objective: To identify groups of subjects with asthma based on their IPs and to assess their association with clinical control, HRQoL, psychosocial disturbances, and PADL.Methods: This cross-sectional study included 149 subjects with moderate to severe asthma. IP, anthropometric data, Asthma Control Questionnaire-7, Asthma Quality of Life Questionnaire, Hospital Anxiety and Depression Scale, PADL (accelerometry), and general self-efficacy (GSE) were assessed. Cluster analysis was performed to identify clusters with similar profiles and investigate their characteristics and differences. Pearson's correlation coefficient was used to test the associations between IP and other variables.Results: Statistical analyses identified two clusters of subjects with asthma based on IP. Cluster 1 presented worse IP in seven out of eight domains than Cluster 2. Cluster 1 had more negative consequences of the disease, worse understanding, and a high emotional representation of the disease than Cluster 2. Cluster 1 also had a greater extent of asthma symptoms, poor clinical control, worse HRQoL, and more symptoms of anxiety and depression. No difference between clusters was found for PADL or self-efficacy.Conclusion: Subjects with asthma who have worse IP have more negative symptoms, worse clinical control, HRQoL, and symptoms of anxiety and depression.

Randomised controlled trial testing effectiveness of feedback about lung age or exhaled CO combined with very brief advice for smoking cessation compared to very brief advice alone in North Macedonia: findings from the Breathe Well group.

INTRODUCTION: In 2019, smoking prevalence in North Macedonia was one of the world's highest at around 46% in adults. However, access to smoking cessation treatment is limited and no co-ordinated smoking cessation programmes are provided in primary care. METHODS: We conducted a three parallel-armed randomised controlled trial (n = 1368) to investigate effectiveness and cost-effectiveness of lung age (LA) or exhaled carbon monoxide (CO) feedback combined with very brief advice (VBA) to prompt smoking cessation compared with VBA alone, delivered by GPs in primary care in North Macedonia. All participants who decided to attempt to quit smoking were advised about accessing smoking cessation medications and were also offered behavioural support as part of the "ACT" component of VBA. Participants were aged ≥ 35 years, smoked ≥ 10 cigarettes per day, were recruited from 31 GP practices regardless of motivation to quit and were randomised (1:1:1) using a sequence generated before the start of recruitment. The primary outcome was biochemically validated 7-day point prevalence abstinence at 4 weeks (wks). Participants and GPs were not blinded to allocation after randomisation, however outcome assessors were blind to treatment allocation. RESULTS: There was no evidence of a difference in biochemically confirmed quitting between intervention and control at 4wks (VBA + LA RR 0.90 (97.5%CI: 0.35, 2.27); VBA + CO RR 1.04 (97.5%CI: 0.44, 2.44)), however the absolute number of quitters was small (VBA + LA 1.6%, VBA + CO 1.8%, VBA 1.8%). A similar lack of effect was observed at 12 and 26wks, apart from in the VBA + LA arm where the point estimate was significant but the confidence intervals were very wide. In both treatment arms, a larger proportion reported a reduction in cigarettes smoked per day at 4wks (VBA + LA 1.30 (1.10, 1.54); VBA + CO 1.23 (1.03, 1.49)) compared with VBA. The point estimates indicated a similar direction of effect at 12wks and 26wks, but differences were not statistically significant. Quantitative process measures indicated high fidelity to the intervention delivery protocols, but low uptake of behavioural and pharmacological support. VBA was the dominant intervention in the health economic analyses. CONCLUSION: Overall, there was no evidence that adding LA or CO to VBA increased quit rates. However, a small effect cannot be ruled out as the proportion quitting was low and therefore estimates were imprecise. There was some evidence that participants in the intervention arms were more likely to reduce the amount smoked, at least in the short term. More research is needed to find effective ways to support quitting in settings like North Macedonia where a strong smoking culture persists. TRIAL REGISTRATION: The trial was registered at http://www.isrctn.com (ISRCTN54228638) on the 07/09/2018.

Work-related asthma consequences on socioeconomic, asthma control, quality of life, and psychological status compared with non-work-related asthma: A cross-sectional study in an upper-middle-income country.

BACKGROUND: Work-related asthma (WRA) is the most prevalent occupational respiratory disease, and it has negative effects on socioeconomic standing, asthma control, quality of life, and mental health status. Most of the studies on WRA consequences are from high-income countries; there is a lack of information on these effects in Latin America and in middle-income countries. METHODS: This study compared socioeconomic, asthma control, quality of life, and psychological outcomes among individuals diagnosed with WRA and non-work-related asthma (NWRA) in a middle-income country. Patients with asthma, related and not related to work, were interviewed using a structured questionnaire to assess their occupational history and socioeconomic conditions, and with questionnaires to assess asthma control (Asthma Control Test and Asthma Control Questionnaire-6), quality of life (Juniper's Asthma Quality of Life Questionnaire), and presence of anxiety and depression symptoms (Hospital Anxiety and Depression Scale). Each patient's medical record was reviewed for exams and use of medication, and comparisons were made between individuals with WRA and NWRA. RESULTS: The study included 132 patients with WRA and 130 with NWRA. Individuals with WRA had worse socioeconomic outcomes, worse asthma control, more quality-of-life impairment, and a higher prevalence of anxiety and depression than individuals with NWRA. Among individuals with WRA, those who had been removed from occupational exposure had a worse socioeconomic impact. CONCLUSIONS: Consequences on socioeconomic, asthma control, quality of life, and psychological status are worse for WRA individuals when compared with NWRA.

Identification of asthma phenotypes based on extrapulmonary treatable traits.

Asthma is a heterogeneous and complex disease, and a description of asthma phenotypes based on extrapulmonary treatable traits has not been previously reported.The objective of this study was to identify and characterise clusters based on clinical, functional, anthropometrical and psychological characteristics in participants with moderate-to-severe asthma.This was a cross-sectional multicentre study involving centres from Brazil and Australia. Participants (n=296) with moderate-to-severe asthma were consecutively recruited. Physical activity and sedentary time, clinical asthma control, anthropometric data, pulmonary function and psychological and health status were evaluated. Participants were classified by hierarchical cluster analysis and the clusters compared using ANOVA, Kruskal--Wallis and Chi-squared tests. Multiple logistic and linear regression models were performed to evaluate the association between variables.We identified four clusters: 1) participants with controlled asthma who were physically active; 2) participants with uncontrolled asthma who were physically inactive and more sedentary; 3) participants with uncontrolled asthma and low physical activity, who were also obese and experienced anxiety and/or depression symptoms; and 4) participants with very uncontrolled asthma who were physically inactive, more sedentary, obese and experienced anxiety and/or depression symptoms. Higher levels of sedentary time, female sex and anxiety symptoms were associated with increased odds of exacerbation risk, while being more active showed a protective factor for hospitalisation. Asthma control was associated with sex, the occurrence of exacerbation, physical activity and health status.Physical inactivity, obesity and symptoms of anxiety and/or depression were associated with worse asthma outcomes, and closely and inextricably associated with asthma control. This cluster analysis highlights the importance of assessing extrapulmonary traits to improve personalised management and outcomes for people with moderate and severe asthma.

The relationship between heart rate and VO2 in moderate-to-severe asthmatics.

Objective: The main purpose of this study was to evaluate whether the %HRR-%VO2R relationship and %HRR-VO2peak relationship are affected in patients with moderate or severe asthma and whether airway obstruction and aerobic capacity influence these relationships.Methods: A linear regression was calculated using the paired %VO2R-%HRR and %VO2peak-%HRR for 93 subjects with asthma. The mean slope and y-intercept were calculated and compared with the line of identity (y-intercept = 0, slope = 1) for all patients and subgroups for the following conditions: low and normal VO2peak and low and normal FEV1.Results: The slope and intercepts of %VO2R-%HRR were similar to the line of identity for all groups (p > 0.05), and the regressions between %HRR and %VO2peak did not coincide with the line of identity for all groups (p < 0.05). There were no associations between the intercepts of the %HRR-VO2peak and the %HRR-%VO2R relationship with the VO2peak (p > 0.05) or FEV1 (p > 0.05).Conclusions: This is the first study to confirm a constant equivalence between %HRR and %VO2R in outpatients with moderate or severe asthma. Our data also suggest that the relationship between %HRR and %VO2peak is unreliable. These results support the use of %HRR in relation to %VO2R to estimate exercise intensity in this population, independently of the pulmonary function and fitness level.

Quality of Life Questionnaire-Bronchiectasis: a study of the psychometric properties of the Brazilian Portuguese version.

OBJECTIVE: To evaluate the psychometric properties of the Brazilian Portuguese version of the Quality of Life Questionnaire-Bronchiectasis. DESIGN: Cross-sectional study. SETTING: Outpatient clinic. SUBJECTS: Clinically stable individuals with a diagnosis of bronchiectasis. MEASURES: The evaluations performed were spirometry, incremental shuttle walk test, Saint George's Respiratory Questionnaire, and the modified Medical Research Council dyspnea scale. The Quality of Life Questionnaire-Bronchiectasis was administered twice (seven to 14 days apart). Psychometric analyses were performed as follows: reliability, construct validity, criterion validity, and interpretability. RESULTS: In total, 108 individuals (48 ± 14 years, 61 women) participated in the study. Internal consistency was considered adequate (Cronbach's alpha ⩾ 0.70) for the majority of scales (from 0.58 to 0.93). Test-retest coefficients were moderate to excellent (intraclass correlation coefficients from 0.70 to 0.93). In the construct validity, 35 of 37 items correlated more strongly with their assigned scale than a competing scale. The convergent validity showed significant correlations between scales of the Quality of Life Questionnaire-Bronchiectasis with modified Medical Research Council dyspnea scale, and incremental shuttle walk test (r from 0.20 to 0.59). A low to moderate correlations was revealed between all scales of the Quality of Life Questionnaire-Bronchiectasis and the Saint George's Respiratory Questionnaire domains (r from 0.26 to 0.70). The standard error of measurement was acceptable. Ceiling effects were found for the Social Functioning and Treatment Burden scales. CONCLUSIONS: The Quality of Life Questionnaire-Bronchiectasis is a reliable, valid instrument with adequate internal consistency for the evaluation of the impact of bronchiectasis on the health-related quality of life of Brazilian adults.

Mobile technology offers novel insights into the control and treatment of allergic rhinitis: The MASK study.

BACKGROUND: Mobile health can be used to generate innovative insights into optimizing treatment to improve allergic rhinitis (AR) control. OBJECTIVES: A cross-sectional real-world observational study was undertaken in 22 countries to complement a pilot study and provide novel information on medication use, disease control, and work productivity in the everyday life of patients with AR. METHODS: A mobile phone app (Allergy Diary, which is freely available on Google Play and Apple stores) was used to collect the data of daily visual analogue scale (VAS) scores for (1) overall allergic symptoms; (2) nasal, ocular, and asthma symptoms; (3) work; and (4) medication use by using a treatment scroll list including all allergy medications (prescribed and over-the-counter) customized for 22 countries. The 4 most common intranasal medications containing intranasal corticosteroids and 8 oral H1-antihistamines were studied. RESULTS: Nine thousand one hundred twenty-two users filled in 112,054 days of VASs in 2016 and 2017. Assessment of days was informative. Control of days with rhinitis differed between no (best control), single (good control for intranasal corticosteroid-treated days), or multiple (worst control) treatments. Users with the worst control increased the range of treatments being used. The same trend was found for asthma, eye symptoms, and work productivity. Differences between oral H1-antihistamines were found. CONCLUSIONS: This study confirms the usefulness of the Allergy Diary in accessing and assessing behavior in patients with AR. This observational study using a very simple assessment tool (VAS) on a mobile phone had the potential to answer questions previously thought infeasible.

Seasonal changes influence the improvement in asthma symptoms by exercise training in subjects with asthma*.

OBJECTIVE: To investigate whether patients with moderate-to-severe asthma who commence an exercise training program in winter or summer show differences in exercise capacity, health-related quality of life (HRQoL) and asthma symptoms. METHODS: Forty-two consecutive subjects visiting the outpatient clinic were enrolled in the 17-week rehabilitation program. One group of patients received the intervention from summer to winter (SWG, n = 21), and the other group participated from winter to summer (WSG, n = 21). Before and after the exercise training program, all patients were evaluated by cardiopulmonary exercise test, pulmonary function test, quality of life questionnaire and a daily diary that evaluated clinical asthma symptoms. RESULTS: After the training period, both groups improved similarly in health-related quality of life (HRQoL) and aerobic capacity. The WSG patients had a greater increase that those in the SWG in asthma symptom-free days (p < 0.05). CONCLUSIONS: Our results indicate that seasonal variations affect the improvement in asthma symptoms after an exercise training program but have no effect on health-related quality of life, exercise capacity or pulmonary function.

Greater Access to Long Acting Beta2 Agonists Is Associated with Less Hospital Admissions Due to COPD: A Longitudinal Nation-Wide Study.

PURPOSE: Long Acting Beta2 Agonists (LABA) prevent COPD exacerbations in strictly standardized clinical trials. Our aim was to evaluate the relationship between the amount of LABA provided by the government and the trend in COPD hospital admission (HA) rate in Brazil. METHODS: This is a longitudinal large-scale real-life study. We calculated COPD HA rate and the number of subjects per 105 inhabitant who received LABA supplied by the government in each Brazilian municipality, between years 2004 and 2013. We used Poisson Multilevel Regression analysis to calculate the rate ratio between LABA dispensation rate and COPD HA rate. RESULTS: In Brazil, COPD HA rate reduced 59% among subjects between 40 and 59 years of age and 60% among subjects older than 59 years of age. Most of the 5506 Brazilian municipalities reduced COPD HA rate [4149 (75%) municipalities & 1357 (25%) municipalities]. The dispensation of LABA was greater among municipalities that reduced COPD HA rate. In the 40-59 age group, the gap in LABA dispensation between the two groups of municipalities increased during the study period from 90.40 to 614.28 subjects per 105 inhabitants. In the > 59 age group, the gap in LABA dispensation increased from 35.87 to 912.99 subjects per 105 inhabitants. For each one hundred subjects who received LABA there was less one HA (RR 0.99, 95 CI 0.99-0.99). CONCLUSIONS: COPD HA rate reduced in Brazil. LABA dispensation growth was associated with COPD HA rate reduction.

The Role of Exercise in a Weight-Loss Program on Clinical Control in Obese Adults with Asthma. A Randomized Controlled Trial.

RATIONALE: Clinical control is difficult to achieve in obese patients with asthma. Bariatric surgery has been recommended for weight loss and to improve asthma control; however, the benefits of nonsurgical interventions have been poorly investigated. OBJECTIVES: To examine the effect of exercise training in a weight-loss program on asthma control, quality of life, inflammatory biomarkers, and lung function. METHODS: Fifty-five obese patients with asthma were randomly assigned to either a weight-loss program plus exercise (WL + E group, n = 28) or a weight-loss program plus sham (WL + S group, n = 27), where the weight-loss program included nutrition (caloric restriction) and psychological therapies. The WL + E group incorporated aerobic and resistance muscle training, whereas the WL + S group incorporated breathing and stretching exercises. MEASUREMENTS AND MAIN RESULTS: The primary outcome was clinical improvement in asthma control over 3 months. Secondary outcomes included quality of life, lung function, body composition, aerobic capacity, muscle strength, and inflammatory/antiinflammatory biomarkers. After 3 months, 51 patients were analyzed. Compared with the WL + S group, the WL + E group demonstrated improved clinical control scores (median [25th to 75th percentile], -0.7 [-1.3 to -0.3] vs. -0.3 [-0.9 to 0.4]; P = 0.01) and greater weight loss (mean ± SD, -6.8% ± 3.5 vs. -3.1% ± 2.6; P < 0.001) and aerobic capacity (median [25th to 75th percentile], 3.0 [2.4 to 4.0] vs. 0.9 [-0.3 to 1.3] ml O2 × kg-1 × min-1; P < 0.001). These improvements in the WL + E group were also accompanied by improvements in lung function, antiinflammatory biomarkers, and vitamin D levels, as well as reductions in airway and systemic inflammation. CONCLUSIONS: Adding exercise to a short-term weight-loss program should be considered as a useful strategy for achieving clinical control of asthma in obese patients. Clinical trial registered with www.clinicaltrials.gov (NCT 02188940).

COPD Assessment Test (CAT) is a Valid and Simple Tool to Measure the Impact of Bronchiectasis on Affected Patients.

The COPD assessment test (CAT) is a short questionnaire developed to help patients and clinicians to assess the impact of symptoms in routine clinical practice. We aimed to validate and to test the reproducibility of CAT in patients with bronchiectasis and correlate with the severity of dyspnea, aerobic and functional capacity, and physical activity in daily life. This is a cross-sectional study, patients with bronchiectasis underwent spirometry, cardiopulmonary exercise test (CPET), incremental shuttle walk test (ISWT), Saint George`s Respiratory Questionnaire (SGRQ), and received pedometer. CAT was applied twice (CAT-1 and CAT-2, 7 to 10 days apart). The severity of bronchiectasis was assessed by E-FACED and bronchiectasis severity index (BSI). A total of 100 patients were evaluated (48 ± 14 years, 59 women, FVC: 67 ± 22% pred, FEV1: 52 ± 25% pred). According to CAT, 14% patients presented low, 40% medium, 32% high, and 14% very high impact. The higher the CAT, the worse the severity of bronchiectasis, dyspnea, quality of life, performance on the CPET, and smaller the distance walked (DW) on the ISWT and number of steps (NS) per day. There was significant correlation between CAT and SGRQ, E-FACED, BSI, NS, ISWT, oxygen uptake, and workload at CPET. CAT-1 and CAT-2 presented similar values: 21 (13-26) and 19 (13-26), respectively. The CAT is a valid and reproducible instrument in patients with bronchiectasis presenting good correlation with clinical, functional, and quality of life measurements. This easy-to-use, easy-to-understand, quick, and useful tool may play an important role to assess the impact of bronchiectasis on both daily medical practice and clinical trial settings.

Effects of periodontal treatment on exacerbation frequency and lung function in patients with chronic periodontitis: study protocol of a 1-year randomized controlled trial.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) has been associated with periodontal disease (PD), and periodontal treatment (PT) has been connected to reduction of lung disease exacerbations. Bronchiectasis has many clinical similarities with COPD but, although it is also a chronic lung disease, to date it has not been studied with relation to PD. The aim of this study is to evaluate whether PT associated with photodynamic therapy (PDT) reduces the number of exacerbations, improves pulmonary function, periodontal clinical parameters and quality of life after 1 year of periodontal treatment follow-up. METHODS: Bronchiectasis patients will undergo medical anamnesis and periodontal examination. Participants with periodontitis will be divided into two groups and PT will be performed as G1 control group (n = 32) - OHO (oral hygiene orientation) + supragingival treatment + simulation of using photodynamic therapy (PDT); G2 experimental (n = 32) - scaling and root planing + PDT + OHO. Lung function will be assessed both at baseline and after 1 year by spirometry, exacerbation history will be analyzed through clinical records monitoring. Three instruments for quality of life assessment will also be applied - Saint George's Respiratory Questionnaire and Impact Profile Analysis Oral health (OHIP-14). It is expected that periodontal treatment can improve the analyzed parameters after 1 year. DISCUSSION: Although only one study evaluates exacerbation in COPD after 1 year of PT, bronchiectasis has not been studied in the dentistry field to date. TRIAL REGISTRATION: NCT02514226. Version #1. This study protocol receives grant from FAPESP (São Paulo Research Foundation) #2015/20535-1. First received: July 22, 2015, 1st version. This protocol has been approved by the Research Ethics Committee of Nove de Julho University.

Can severe asthmatic patients achieve asthma control? A systematic approach in patients with difficult to control asthma followed in a specialized clinic.

BACKGROUND: Despite advances in asthma treatment, severe asthma (SA) still results in high morbidity and use of health resources. Our hypothesis was that SA patients would achieve adequate control with a systematic protocol, including oral corticosteroids, budesonide/formoterol maintenance and reliever therapy and a multidisciplinary approach to improve adherence. METHODS: Non-controlled (NC) SA patients were enrolled to receive 2 weeks of oral corticosteroids and 12 weeks of formoterol + budesonide. Assessments included asthma control questionnaire (ACQ), asthma control test (ACT), daily symptom diary, lung function and health-related quality of life (HRQoL) questionnaires. RESULTS: Of 51 patients, 13 (25.5%) achieved control. NC patients had higher utilization of health resources and higher exacerbation rates. Both controlled (C) and NC patients had significantly reduced ACQ scores after oral corticosteroid treatment. After 12 weeks, C patients continued improving. NC patients did not have significant changes. A similar pattern was found regarding lung function, use of rescue medication, and days free of symptoms. After 2 weeks of oral corticosteroids, an increase occurred in those who achieved the ACQ cut off; however, 53.8% of C patients had an ACQ < 1.57 versus 21.1% of NC patients (p = 0.03). Both groups had low HRQoL at baseline with improvement after intervention. CONCLUSIONS: Despite rigorous, optimized follow-up treatment, 75% of SA patients did not achieve adequate symptom control and presented with impaired quality of life. Conversely, application of a low-cost, easy to implement systematic protocol can prevent up to 25% of SA patients from up-titrating to new and complex therapies, thus reducing costs and morbidity. TRIAL REGISTRATION: Retrospectively registered at ClinicalTrial.gov on 22 February 2010 ( NCT01089322 ).

Vocal cord dysfunction diagnosis may be improved by a screening check list.

BACKGROUND: Many patients with vocal cord dysfunction (VCD), with or without asthma, receive inappropriate treatment because they are misdiagnosed as having difficult-to-control asthma alone. We developed a clinical screening check list designed to aid the diagnosis of VCD. METHODS: A prospective observational study involving 80 patients aged ≥18 years, diagnosed with severe asthma. After anamnesis and physical examination, physicians completed a check list with 6 questions to identify VCD, for which the answer "yes" counted one point. Then patients underwent spirometry and laryngoscopy. On the basis of the laryngoscopic findings, we created three patient groups: VCD (vocal cord adduction during inspiration, n = 14); unconfirmed VCD (inconclusive findings, n = 29); and control (normal findings, n = 37). We attempted to determine whether any of those groups were associated with the responses to individual questions or sets of questions on the check list. RESULTS: The proportion of affirmative answers to the question "Does pulmonary auscultation reveal wheezing, predominantly in the cervical region, and/or stridor?" was significantly higher for the VCD group than for the other two groups (P = 0.006), notably in elderly patients. The variable "4 or more affirmative answers" was more common in VCD and unconfirmed VCD groups in comparison to controls (P = 0.022). CONCLUSIONS: A finding of wheezing or stridor on auscultation of the cervical region is suggestive of vocal cord dysfunction, especially in elderly patients, and such dysfunction can be confirmed through laryngoscopy. Our VCD screening check list proved to be useful in the screening of VCD among patients with severe asthma.

Aerobic training decreases bronchial hyperresponsiveness and systemic inflammation in patients with moderate or severe asthma: a randomised controlled trial.

BACKGROUND: The benefits of aerobic training for the main features of asthma, such as bronchial hyperresponsiveness (BHR) and inflammation, are poorly understood. We investigated the effects of aerobic training on BHR (primary outcome), serum inflammatory cytokines (secondary outcome), clinical control and asthma quality of life (Asthma Quality of Life Questionnaire (AQLQ)) (tertiary outcomes). METHODS: Fifty-eight patients were randomly assigned to either the control group (CG) or the aerobic training group (TG). Patients in the CG (educational programme+breathing exercises (sham)) and the TG (same as the CG+aerobic training) were followed for 3 months. BHR, serum cytokine, clinical control, AQLQ, induced sputum and fractional exhaled nitric oxide (FeNO) were evaluated before and after the intervention. RESULTS: After 12 weeks, 43 patients (21 CG/22 TG) completed the study and were analysed. The TG improved in BHR by 1 doubling dose (dd) (95% CI 0.3 to 1.7 dd), and they experienced reduced interleukin 6 (IL-6) and monocyte chemoattractant protein 1 (MCP-1) and improved AQLQ and asthma exacerbation (p<0.05). No effects were seen for IL-5, IL-8, IL-10, sputum cellularity, FeNO or Asthma Control Questionnaire 7 (ACQ-7; p>0.05). A within-group difference was found in the ACQ-6 for patients with non-well-controlled asthma and in sputum eosinophil and FeNO in patients in the TG who had worse airway inflammation. CONCLUSIONS: Aerobic training reduced BHR and serum proinflammatory cytokines and improved quality of life and asthma exacerbation in patients with moderate or severe asthma. These results suggest that adding exercise as an adjunct therapy to pharmacological treatment could improve the main features of asthma. TRIAL REGISTRATION NUMBER: NCT02033122.

The effects of exercise training in a weight loss lifestyle intervention on asthma control, quality of life and psychosocial symptoms in adult obese asthmatics: protocol of a randomized controlled trial.

BACKGROUND: Asthma and obesity are public health problems with increasing prevalence worldwide. Clinical and epidemiologic studies have demonstrated that obese asthmatics have worse clinical control and health related quality of life (HRQL) despite an optimized medical treatment. Bariatric surgery is successful to weight-loss and improves asthma control; however, the benefits of nonsurgical interventions remain unknown. METHODS/DESIGN: This is a randomized controlled trial with 2-arms parallel. Fifty-five moderate or severe asthmatics with grade II obesity (BMI ≥ 35 kg/m(2)) under optimized medication will be randomly assigned into either weight-loss program + sham (WL + S group) or weight-loss program + exercise (WL + E group). The weight loss program will be the same for both groups including nutrition and psychological therapies (every 15 days, total of 6 sessions, 60 min each). Exercise program will include aerobic and resistance muscle training while sham treatment will include a breathing and stretching program (both programs twice a week, 3 months, 60 min each session). The primary outcome variable will be asthma clinical control. Secondary outcomes include HRQL, levels of depression and anxiety, lung function, daily life physical activity, body composition, maximal aerobic capacity, strength muscle and sleep disorders. Potential mechanism (changes in lung mechanical and airway/systemic inflammation) will also be examined to explain the benefits in both groups. DISCUSSION: This study will bring a significant contribution to the literature evaluating the effects of exercise conditioning in a weight loss intervention in obese asthmatics as well as will evaluate possible involved mechanisms. TRIAL REGISTRATION: NCT02188940.

Effects of weight loss on asthma control in obese patients with severe asthma.

Studies on the effects of weight loss in patients with asthma are scarce. No studies have been performed in patients with severe asthma. Therefore, the aim of the present study was to assess the impact of weight loss in patients with severe asthma associated with obesity. This was an open, prospective, randomised study of two parallel groups, in patients with severe uncontrolled asthma and moderate obesity. The primary outcome was the level of asthma control 6 months after initiation of the weight reduction programme, quantified using the Asthma Control Questionnaire (ACQ). We evaluated clinical parameters, lung function, markers of airway inflammation and circulating cytokines. 22 patients were randomised to undergo treatment for obesity and 11 to the control group. The weight reduction programme was associated with significant improvements in asthma control (mean ± se ACQ score 3.02 ± 0.19 to 2.25 ± 0.28 in the treatment group versus 2.91 ± 0.25 to 2.90 ± 0.16 in the controls, p=0.001). This improvement was not accompanied by changes in markers of airway inflammation or bronchial reactivity, but by an increase in forced vital capacity. Our results suggest that weight reduction in obese patients with severe asthma improves asthma outcomes by mechanisms not related to airway inflammation.

Age is not associated with hospital admission or uncontrolled symptoms of asthma if proper treatment is offered.

BACKGROUND: Aging modifies immune response and respiratory physiology. Few studies evaluate the effect of age on asthma. The aim of our study was to evaluate whether age is associated with uncontrolled symptoms and hospital admissions due to asthma in a setting where patients were receiving proper treatment. METHODS: We enrolled 401 patients with uncontrolled asthma who were inhaled corticosteroid-naive. The follow-up period was 1 year. They received medications for asthma, performed spirometry, a symptoms questionnaire, and all emergency room visits and hospital admissions due to asthma were reported. The primary end point was hospital admission during the follow-up period. RESULTS: Baseline data demonstrated that subjects >55 years of age had a later onset of asthma and a longer duration of symptoms. Adjusted logistic regression models demonstrated that older age at enrollment did not predict asthma control in the follow-up: hospital admission due to asthma [odds ratio (OR) 1.7 and 95% confidence interval (CI) 0.6-4.7], symptoms score (OR 0.6 and 95% CI 0.3-1.1) and emergency room visits due to asthma (OR 0.9 and 95% CI 0.6-1.3). Older age was associated with worse lung function (OR 1.8 and 95% CI 1.1-3.3). CONCLUSION: This study allows us to conclude that older age is associated with a later onset of asthma and a longer duration of symptoms. Age does not predict hospital admissions or poor control of asthma symptoms if proper treatment is offered. It does, however, predict worse lung function.