Showing papers by "Peter G. Gibson published in 2001"

Effect of peer led programme for asthma education in adolescents: cluster randomised controlled trial

Abstract: Objective: To determine the effect of a peer led programme for asthma education on quality of life and related morbidity in adolescents with asthma. Design: Cluster randomised controlled trial. Setting: Six high schools in rural Australia. Participants: 272 students with recent wheeze, recruited from a cohort of 1515 students from two school years (mean age 12.5 and 15.5 years); 251 (92.3%) completed the study. Intervention: A structured education programme for peers comprising three steps (the “Triple A Program”). Main outcome measures: Quality of life, school absenteeism, asthma attacks, and lung function. Results: When adjusted for year and sex, mean total quality of life scores showed significant improvement in the intervention than control group. Clinically important improvement in quality of life (>0.5 units) occurred in 25% of students with asthma in the intervention group compared with 12% in the control group (P=0.01). The number needed to treat was 8 (95% confidence interval 4.5 to 35.7). The effect of the intervention was greatest in students in year 10 and in females. Significant improvements occurred in the activities domain (41% v 28%) and in the emotions domain (39% v 19%) in males in the intervention group. School absenteeism significantly decreased in the intervention group only. Asthma attacks at school increased in the control group only. Conclusion: The triple A programme leads to a clinically relevant improvement in quality of life and related morbidity in students with asthma. Wider dissemination of this programme in schools could play an important part in reducing the burden of asthma in adolescents

Acute anti-inflammatory effects of inhaled budesonide in asthma: a randomized controlled trial.

Abstract: Corticosteroids can have acute effects on airway function and methacholine airway responsiveness in asthma as early as 6 h after dosing, suggesting there may be an acute anti-inflammatory effect of inhaled corticosteroid in asthma. This study aimed to determine the effects of a single dose of inhaled budesonide on sputum eosinophils and mast cells in adults with asthma, and to examine whether the mechanism of clearance of eosinophils was by apoptosis. A randomized, double-blind, placebo-controlled, crossover study was conducted. At the screening visit, adults with stable asthma (n = 41) ceased inhaled corticosteroid therapy for 4 d and those with significant sputum eosinophilia (> or = 7%) were randomized (n = 26) to a single dose of budesonide 2,400 microg or placebo via Turbuhaler, on two separate study days. Symptoms and lung function were followed for 6 h, then sputum was induced and airway responsiveness to hypertonic saline determined. Sputum eosinophils (mean, SE) were significantly lower 6 h after budesonide (25%, 4.5), compared with placebo (37%, 6.2, p < 0.05). There was a 2.2-fold (95% CI 1.45 to 3.33) improvement in airway responsiveness with budesonide. No significant difference was seen on mast cells, apoptotic eosinophils, symptoms, or lung function. In conclusion, a single dose of inhaled corticosteroids has beneficial effects on airway inflammation and airway hyperresponsiveness as early as 6 h after dosing. This may be clinically useful as therapy during mild exacerbations of asthma.

Oxidative stress in cystic fibrosis: dietary and metabolic factors.

Abstract: Objective: To examine oxidative stress in CF by measuring 8-iso-PGF2α and antioxidant defenses, in relation to dietary intake, immune function and clinical status.Methods: We measured total plasma concentrations of 8-iso-PGF2α and dietary antioxidants (vitamin E, vitamin C, β-carotene), erythrocyte antioxidant enzyme activities (glutathione peroxidase and superoxide dismutase), lung function and dietary intake in 21 CF subjects and 21 healthy age- and gender-matched controls.Results: Total plasma 8-iso-PGF2α concentration (median [quartile 1–quartile 3]) was significantly higher in CF subjects compared to controls (214 pg/mL (155–331) vs. 135 pg/mL (101–168), p=0.001). Neutrophil, monocyte and total white cell counts were elevated in the CF group and these correlated with 8-iso-PGF2α concentration. Despite similar dietary intake, lower plasma antioxidant concentrations were observed in the CF group (vitamin E, p < 0.001, vitamin C, p=0.004, β-carotene, p=0.001). 8-iso-PGF2α correlated negatively with plas...

Medical treatment for reflux oesophagitis does not consistently improve asthma control: a systematic review

Abstract: BACKGROUND—A systematic literature review was conducted to assess the effect of treating reflux oesophagitis on asthma outcomes. METHODS—Randomised controlled trials of reflux oesophagitis treatment in adults or children that reported asthma health outcomes were included and assessed in accordance with the standard Cochrane systematic review process. Patients were typically adults with asthma and concurrent symptomatic gastro-oesophageal reflux who received interventions that included pharmacological therapy, conservative management, and surgery. The following outcome measures were assessed: lung function, peak expiratory flow, asthma symptoms, asthma medications, and nocturnal asthma. RESULTS—From 22 potentially relevant published and unpublished randomised controlled trials, 12 were included. Treatment duration ranged from 1 week to 6 months. Eight trials reported that treatment improved at least one asthma outcome, but these outcomes differed between trials. Overall, treatment of reflux oesophagitis did not consistently improve forced expiratory volume in one second (FEV1), peak expiratory flow rate, asthma symptoms, nocturnal asthma symptoms, or use of asthma medications in asthmatic subjects. Significant improvement in wheeze was reported in two studies. CONCLUSIONS—The published literature does not consistently support treatment of reflux oesophagitis as a means of controlling asthma. Further large randomised controlled trials in subjects with a demonstrated temporal relationship between gastro-oesophageal reflux and asthma are needed. These trials should be conducted over at least 6 months to allow adequate time to observe a treatment effect.

Interventions for educating children who have attended the emergency room for asthma.

Abstract: BACKGROUND: Asthma is one of the most common reasons for paediatric admissions to hospital, with substantial cost to the community There is some evidence to suggest that many hospital admissions could be prevented with effective education about asthma and its management OBJECTIVES: To conduct a systematic review of the literature in order to identify whether asthma education leads to improved health outcomes in children who have attended the emergency department for asthma SEARCH STRATEGY: We searched the Cochrane Airways Group trials register, including Medline, Embase, and Cinahl databases, and reference lists of trials and review articles SELECTION CRITERIA: Randomised controlled trials or controlled clinical trials of asthma education for children who had attended the emergency department for asthma, with or without hospitalisation, within the previous 12 months DATA COLLECTION AND ANALYSIS: Two reviewers independently assessed trial quality and extracted data Study authors were contacted for additional information MAIN RESULTS: Eight trials involving 1407 patients were included, in all the education was provided by nurses or researchers Compared to control (usual care or lower intensity education) education did not reduce subsequent emergency department (ED) visits [4 trials; relative risk (RR)= 087, 95% confidence interval (CI) 037 to 208], hospital admissions [5 trials; RR=074, 95% CI 038 to 146] and unscheduled doctor visits [5 trials; RR= 074, 95% CI 049 to 112) Each analysis showed evidence of heterogeneity among the studies (P<001) Subgroup analyses by the overall difference in scale of intervention between treatment and control groups (comprehensive programme versus information only) or the timing of the intervention/recruitment (early versus delayed) gave similar results to the main analysis and still revealed significant heterogeneity between trials REVIEWER'S CONCLUSIONS: On the basis of the published trials, there is no firm evidence to support the use of asthma education for children who have attended the emergency department for asthma as a means of reducing subsequent ED visits, hospital admissions or unscheduled doctor visits Some trials appeared to show clear evidence of benefit, but reasons for differences between these and the negative studies is not clear More research is required

Alterations of placental vascular function in asthmatic pregnancies.

Abstract: Asthma during pregnancy is associated with low-birthweight neonates at term but the mechanisms that cause this outcome are presently unknown. Changes in placental vascular function resulting from asthma or its treatment could contribute to altered fetal growth. We have prospectively followed women with asthma and a control group of women without asthma during their pregnancies, classified them based on asthma severity and glucocorticoid intake, and monitored fetal development and placental blood flow using Doppler ultrasound at 18 and 30 wk gestation. The placentae from these women were collected after delivery and vascular responses to dilator and constrictor agonists assessed using an in vitro placental perfusion method. At 18 wk gestation, umbilical artery flow velocity waveforms were significantly reduced in the moderate and severe asthmatic groups and in those women using high-dose inhaled glucocorticoid for the treatment of their asthma (ANOVA, p 0.05). Corticotropin-releasing hormone (CRH), a potent vasodilator that acts via the nitric oxide pathway, caused a dose-dependent vasodilatory response in all placentae in vitro. However, CRH-induced dilation was significantly reduced in moderate and severe asthmatics (ANOVA, p < 0.05). Vasoconstrictor responses to potassium chloride and prostaglandin F(2alpha) were reduced in placentae from moderate and severe asthmatic women (ANOVA, p < 0.05). These studies demonstrate significant differences in placental vascular function in pregnancies complicated by asthma, which may relate directly to the asthma or be a consequence of the associated glucocorticoid treatment. These changes in vascular function in asthmatic pregnancies may contribute to the low-birthweight outcome observed in this condition.

Airway Eosinophilia Is Associated with Wheeze But Is Uncommon in Children with Persistent Cough and Frequent Chest Colds

Abstract: The role of eosinophilic airway inflammation in the variant asthma syndromes of cough and chest colds is not well defined. We tested the hypothesis that children with persistent cough and chest colds have increased sputum eosinophils, similar to those with wheeze. The parents of 390 primary school children completed a symptoms questionnaire. Children with wheeze (n = 28), cough (n = 12), recurrent chest colds (n = 17), and no symptoms (control subjects, n = 26), underwent allergy skin prick tests, spirometry, hypertonic saline inhalation challenge, and sputum induction, and then completed a peak expiratory flow (PEF) and symptoms diary over a 2-mo period. Children with wheeze had significantly reduced PEF (p = 0.001) and higher sputum eosinophils when compared with the cough, chest cold, and control groups (3.1% versus 0.5%, 0%, 0%; p = 0.03). The prevalence of eosinophilic bronchitis (sputum eosinophils > 2.5%) was 45% in the wheeze group, which was significantly higher than the control group (9.35%, p = 0.04). Eosinophilic bronchitis was present in two children with cough (20%) and two with chest colds (15%, p > 0.05 versus control). In these groups, eosinophilic bronchitis was not associated with airway hyperresponsiveness (AHR) to hypertonic saline (p > 0.05). Children with cough and chest colds reported greater exposure to environmental tobacco smoke. In conclusion, this community-based survey of children with chronic respiratory symptoms has shown that wheeze is a good discriminator for the presence of eosinophilic bronchitis, and that persistent cough and recurrent chest colds without wheeze should not be considered a variant of asthma. Eosinophilic bronchitis did occur in a significant minority of these "variant asthma" syndromes.

Allergic bronchopulmonary aspergillosis: new concepts of pathogenesis and treatment.

Abstract: Allergic bronchopulmonary aspergillosis (ABPA) is a condition that results from a hypersensitivity reaction to the fungus Aspergillus fumigatus. The purpose of the present review is to examine the pathogenesis of this condition and the evidence for treatments available. Allergic bronchopulmonary aspergillosis is characterized by an intense airway inflammation with eosinophils and the formation of mucus plugs. Clinically, there are periods of exacerbation and remission that may lead to proximal bronchiectasis and fibrotic lung disease. New evidence confirms the role of intense airway inflammation with eosinophils, but also suggests a role for interleukin (IL)-8/neutrophil-mediated inflammation in this process, and the potential deficiency of anti-inflammatory cytokines such as reduced IL-10. Treatment for ABPA has so far focused on corticosteroids to suppress eosinophilic airway inflammation. An expanding knowledge of the pathology of ABPA also suggests other therapies may be of potential benefit, particularly the use of azole antifungal agents. Allergic bronchopulmonary aspergillosis is itself an important complication of asthma and cystic fibrosis. A greater understanding of the condition is required to improve management and well-designed clinical trials need to be carried out to critically assess new and current treatments. In addition, the information gained from the studies of its pathogenesis has the potential to benefit our understanding of the disease processes in asthma and bronchiectasis.

The tolerability, safety, and success of sputum induction and combined hypertonic saline challenge in children.

Abstract: Induced sputum using hypertonic saline (HS) is a useful research tool to study airway inflammation (AI). HS provocation testing can also be used to measure airway hyperresponsiveness (AHR). A combined HS challenge and sputum induction procedure has been developed to permit assessment of AI and AHR in a single test. The aim of this study is to report the success and tolerability of sputum induction alone, and in combination with a HS bronchial provocation challenge. Sputum induction alone was performed with β2-agonist pretreatment. In the combined challenge, no β2-agonist pretreatment was used. A high-output ultrasonic nebulizer with valve box and tubing were used to deliver 4.5% saline in doubling time periods from 0.5 s to 4 min. Outcomes assessed were completion of the test protocol, adequacy of sputum samples, decrease in FEV1, and adverse effects during the procedure. Fifty-three children who underwent a sputum induction alone, and 182 children who underwent a combined sputum induction and bronchial p...

Safety of sputum induction with isotonic saline in adults with acute severe asthma.

Abstract: BACKGROUND Sputum induction is a safe and effective technique to study airway inflammation in stable asthma. However, it has the potential to induce bronchospasm and the safety and efficacy of the technique in acute asthma has not been determined. OBJECTIVE The objective of this study was to evaluate the safety and efficacy of a protocol to induce sputum using isotonic saline in adults with acute exacerbations of asthma. METHODS Adults (n = 47) presenting to the emergency room with acute asthma and an FEV1 > 1.0 L underwent supervised sputum induction with 0.9% saline delivered by an ultrasonic nebuliser. Induction was ceased if there was a fall of 20% or greater from baseline FEV1. RESULTS Subjects had moderate to severe exacerbations of acute asthma. An adequate sputum sample was obtained in 87% of subjects. Four subjects ceased induction because of symptom distress. There was a fall > or = 20% in 28% of subjects. Bronchoconstriction was successfully reversed by salbutamol in all subjects. Predictors of significant bronchoconstriction were older age, use of ingested corticosteroids, and a requirement for high-dose nebulized salbutamol for the exacerbation. Maintenance long-acting beta2-agonist therapy protected against bronchoconstriction during sputum induction. CONCLUSIONS Sputum induction in acute asthma using isotonic saline is highly efficacious in obtaining an adequate sputum sample. There is the potential for significant bronchoconstriction to occur but this can be managed safely with minimal discomfort to subjects.

Exacerbations of asthma: addressing the triggers and treatments.

Abstract: Airway inflammation is known to play a crucial role in chronic asthma and has led to the effective use of anti-inflammatory treatments to control chronic asthma. Despite these improvements exacerbations of asthma continue to occur in subjects with stable disease compliant with treatment. Viral respiratory tract infections have been found to be associated with the majority of asthma exacerbations in both children and adults. Evidence is emerging that viral infections may alter the inflammatory infiltrate present in chronic asthma with a more heterogenous neutrophil/eosinophil infiltrate. The implications are that the pathogenesis of acute asthma may differ from that present in chronic asthma in important ways that may influence the effectiveness of treatment. Inhaled corticosteroids are effective in controlling chronic airway inflammation in asthma but appear not to be as effective in acute asthma. This may mean that new directions will be needed to target specifically the airway inflammation in virus-induced acute asthma.

Implementing evidence-based guidelines.

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Evaluation of an asthma education programme delivered in an antenatal clinic

Abstract: Severe and poorly controlled asthma may lead to adverse outcomes for mothers and their babies. An asthma management and education programme was established in the Antenatal Clinic (ANC) of John Hunter Hospital to optimise asthma management in pregnant women with asthma. Aim: The aim of this study was to evaluate the effect of the Asthma Management Service in the John Hunter Hospital ANC. Design: Longitudinal analytic survey. Method: Women were enrolled in their first trimester and underwent an initial assessment of asthma severity, treatment and management skills. Deficits were corrected by skills education, medical assessment and treatment. Records were reviewed of pregnant women with asthma who attended the Asthma Management Service between January 1998 and December 1999. Results: 83 women were enrolled and 72 patients attended between 2 and 8 visits during pregnancy, depending upon asthma severity. Conclusion: After structured asthma education, there were significant improvements in asthma knowledge and management skills. The antenatal clinic is a opportune setting for asthma education among pregnant women with asthma. Asthma Control Visit 1 After Education p Value Night Symptoms 53% 42% 0.15 Morning Symptoms 66% 46% 0.01 Activity Limitation 35% 30% 0.65 Asthma Skills pMDI: Inadequate 13% 0% 0.001 Spacer: Inadequate 2% 0% 0.50 Medication Knowledge 47% 88% 0.0001 Action Plan 13% 78% 0.0001 Peak Flow Monitoring 8% 78% 0.0001.

Management of chronic obstructive pulmonary disease (COPD)

Abstract: SYNOPSIS The expiratory airflow obstruction that characterises chronic obstructive pulmonary disease is usually progressive over time and caused by emphysema, obliterative bronchiolitis, and mucus hypersecretion. Stopping smoking is the only measure that slows the progression of chronic obstructive pulmonary disease, and smokers should be encouraged to stop at all stages of the disease. The effects of medication are limited, and need to be balanced against cost and adverse effects. Bronchodilators, given by puffer and spacer rather than by nebuliser, are effective. Avoid inhaled corticosteroids unless there is associated asthma. Pulmonary rehabilitation leads to important improvements in quality of life. Influenza vaccination is helpful. Comorbidity from cardiac disease and sleep disordered breathing are common and can be effectively treated. New therapies under evaluation include lung volume reduction surgery, non-invasive ventilation, and anti-inflammatory drugs.

Outcomes of the Cochrane Airways Group International Conference

Abstract: The Cochrane Airways Group and the Commonwealth Department of Health and Aged Care held a meeting in Newcastle in...