The Science Journal of the American Association for Respiratory Care

1997 OPEN FORUM Abstracts

Impact on Quality of Life: Recent Advances in Asthma Management

Andrew P Greening, MBCHB, Tuesday, December 9, 1997.

An important goal of asthma management is to improve patients' everyday functioning and subjective well-being, often referred to as "quality of life" (QOL). Improvement in QOL can be achieved through improvement in respiratory function and reduction of symptoms and exacerbations. Objective assessment of QOL in asthma has not always been readily determined. Within the past five to ten years, however, a number of asthma-specific quality of life measures and questionnaires have been developed (1-6). No questionnaire is necessarily the answer, and each requires ongoing assessment in different countries and populations. Sometimes it is helpful to apply more than one to a particular clinical circumstance (7).

Symptoms and provoking factors. Airway narrowing plays an important part in the causation of symptoms. The trigger factors for this are many but may be considered, broadly, as allergic, infective and non-specific. Allergens are widespread and of major importance. House dust mite, pollens, animals and moulds are common allergens. Infections, particularly the many viral upper respiratory tract infections, seem to play an important role, especially in children. Non-specific factors include exercise, dusts, temperature changes, chemicals, drugs, laughter and emotion. Guidelines recommend avoidance of provoking or trigger factors as an ideal means towards asthma control (8). This is not always easy to achieve while maintaining patients' perceived QOL.

Psychosocial influences. In the UK, patients with severe, troublesome asthma form a major "core" of the hospital specialist asthma clinics. When time is spent talking to these patients rather than simply modifying their drug therapy it is evident that they have substantial personal, family or social problems. These influence their perception of the severity of their asthma (9), leading to greater use of medications and time off work. Conversely, we must recognize the consequences of inadequate therapy for asthma. Persistent asthma symptoms and reduced activity lead to increased anxiety and depression levels. It is easy to see how vicious circles may be established with poorly controlled asthma leading to anxiety and depression, leading to worsening perception of asthma and so on. The clinician must establish simple but effective therapy for asthma control but to be alert to life events that may influence patients' asthma, particularly when a patient's asthma, previously well controlled, becomes increasingly difficult to manage.

Drug therapy. The developments of better and more potent inhaled steroids and of the long-acting inhaled ß_{2}-agonists have allowed greater potential for effective drug therapy in asthma management. There is good evidence for the efficacy of fluticasone propionate in reducing asthma exacerbation rates and reducing the need for systemic steroid therapy. At the same time there is evidence of improved quality of life (10). The long-acting inhaled ß_{2}-agonist, salmeterol, has been shown in several studies to be very effective at improving lung function and reducing the need for rescue medication (11,12). Other studies have shown significant benefit with quality of life, but particularly related to symptom control (7, 13, 14).

References. (1) Respir Med 1991; 85 (suppl); 13-16; (2) J Psychosom Res 1991 1991; 35: 99-110; (3) J Clin Epidemiol 1992; 45: 461-472; (4) J Asthma 1992; 29: 393-399; (5) Am J Respir Dis 1992; 145: 1321-1327; (6) Thorax 1992; 47: 76-83; (7) Eur Respir J 1995; 8: 888-898; (8) Clin Exp Allergy 1992: 22 (suppl): 1-72; (9) J Asthma 1993; 30: 5-21; (10) Am J Respir Crit Care Med 1995; 152: 1467-1473; (11) Lancet 1994; 344: 219-24; (12) Am J Respir Crit Care Med, 1996; 153: 1481-88; (13) Am J Respir Crit Care Med, 1995; 151: 66-70; (14) Am J Respir Crit Care Med, 1997; 155: 104-108.

AARC 50th Anniversary, December 6 - 9, 1997, New Orleans, Louisiana.

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