Perception of airflow obstruction in patients hospitalized for acute asthma

doi:10.1016/S1081-1206(10)60117-2

Annals of Allergy, Asthma & Immunology

Volume 102, Issue 6, June 2009, Pages 455-461

https://doi.org/10.1016/S1081-1206(10)60117-2 Get rights and content

Background

Little is known about the perception of airflow obstruction in patients hospitalized for acute asthma.

Objectives

To evaluate patient perception of airflow obstruction at hospital discharge and at a 2-week follow-up visit and to determine whether symptom control and/or severity of airflow obstruction identified patients at risk for acute asthma after discharge.

Methods

In a prospective cohort study of inner-city adults hospitalized for acute asthma from April 1, 2001, through October 31, 2002, symptom control (Asthma Control Questionnaire) and airflow obstruction (forced expiratory volume in 1 second [FEV₁] percentage predicted) were evaluated at discharge and 2 weeks after discharge. We evaluated perception of airflow obstruction (symptom control vs FEV₁ percentage predicted) and perception of change in airflow obstruction (change in symptom control vs percentage change in FEV₁) between the 2 visits. Acute asthma after discharge was defined as an emergency department visit or hospitalization for asthma within 90 days of discharge.

Results

In fifty-one participants, symptom control was not significantly associated with airflow obstruction at hospital discharge (P = .30), indicating poor perception of airflow obstruction. Among the 41 participants (80.4% of those enrolled) who completed the follow-up visit, change in symptom control was not significantly associated with change in airflow obstruction (P = .20), indicating poor perception of change in airflow obstruction. Greater airflow obstruction at follow-up (P = .02) and a smaller improvement in airflow obstruction (P = .03), but not symptom control, were associated with a higher risk of acute asthma after discharge.

Conclusions

Patients hospitalized for acute asthma have poor perception of airflow obstruction and change in airflow obstruction. Objective measurements of lung function should guide treatment decisions after discharge in this population.

Section snippets

INTRODUCTION

Asthma is a chronic airway disorder characterized by variable airflow obstruction and respiratory symptoms, punctuated by periods of acute deterioration (acute asthma). Severe episodes of acute asthma result in approximately 475,000 hospitalizations per year in the United States.¹ Patients with asthma may be unable to appreciate the severity of airflow obstruction (ie, have poor perception of airflow obstruction),2, 3, 4, 5 which may contribute to delays in seeking medical attention,6, 7

METHODS

This was a prospective cohort study of adults (≥18 years old) admitted with an attending physician diagnosis of acute asthma and airflow obstruction on spirometry to 1 of 2 inner-city academic medical centers from April 1, 2001, through October 31, 2002. Participants were excluded if they had a diagnosis of another chronic respiratory disorder, had a contraindication to inhaled corticosteroids or oral corticosteroids, were discharged to locations other than home, were previous participants,

RESULTS

There were 51 participants (78% of eligible patients agreed to participate) in this study (Table 1). Most were African American women who had been diagnosed as having asthma approximately 30 years ago. More than three-quarters had an ED visit, more than half had been hospitalized for asthma within the year before enrollment, and approximately two-thirds had at least 1 episode of near-fatal asthma. The median hospital length of stay was 3 days (interquartile range, 2-5 days). Forty-one (80%) of

DISCUSSION

In this high-risk, inner-city population of adults with asthma, perception of airflow obstruction was poor at both hospital discharge and a 2-week follow-up visit. There was also evidence of poor perception of change in airflow obstruction between the 2 visits. In addition, although asthma symptom control at each visit was not predictive of subsequent episodes of acute asthma within 90 days of discharge, more severe airflow obstruction at the follow-up visit and a smaller improvement in airflow

ACKNOWLEDGMENTS

We thank Jeffery T. Charbeneau, MS, for his assistance with statistical analyses and reviewing early drafts of the manuscript.

REFERENCES (31)

GK Fritz et al.
Symptom perception in pediatric asthma: resistive loading and in vivo assessment compared
Chest
(2007)
LP Boulet et al.
Perception scoring of induced bronchoconstriction as an index of awareness of asthma symptoms
Chest
(1994)
BG Bender et al.
Factors influencing patient decisions about the use of asthma controller medication
Ann Allergy Asthma Immunol
(2007)
R Magadle et al.
The risk of hospitalization and near-fatal and fatal asthma in relation to the perception of dyspnea
Chest
(2002)
EF Juniper et al.
Measurement properties and interpretation of three shortened versions of the asthma control questionnaire
Respir Med
(2005)
MD Lougheed et al.
Dynamic hyperinflation during bronchoconstriction in asthma: implications for symptom perception
Chest
(2006)
ML Osborne et al.
Assessing future need for acute care in adult asthmatics: the profile of asthma risk study: a prospective health maintenance organization-based study
Chest
(2007)
ET Naureckas et al.
Are we closing the disparities gap? small-area analysis of asthma in Chicago
Chest
(2007)
American Lung Association
Trends in Asthma Morbidity and Mortality
(November 2007)
AL Cabral et al.
Effect of asthma severity on symptom perception in childhood asthma
Braz J Med Biol Res
(2002)

GE Hardie et al.

Understanding how asthmatics perceive symptom distress during a methacholine challenge

J Asthma

(2002)

Y Kikuchi et al.

Chemosensitivity and perception of dyspnea in patients with a history of near-fatal asthma

N Engl J Med

(1994)

A Chetta et al.

Personality profiles and breathlessness perception in outpatients with different gradings of asthma

Am J Respir Crit Care Med

(1998)

TS Kwan-Gett et al.

One-year experience with an inpatient asthma clinical pathway

Arch Pediatr Adolesc Med

(1997)

R Lantner et al.

Inpatient management of asthma in the Chicago suburbs: the Suburban Asthma Management Initiative (SAMI)

J Asthma

(2005)

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Citation Excerpt :
Eradication of or a reduction in the frequency and severity of symptoms is an indicator of asthma control and a goal of asthma management.3,7,8 However, there is a poor correlation between objective measures of disease severity (eg, FEV1 and PEF) and patients’ self-reported experience of asthma symptoms.9-11 Asthma symptom severity can only be evaluated by the patients themselves and, as such, well-developed patient-reported outcome (PRO) measures are necessary for characterizing these experiences in clinical studies.
The Asthma Daytime Symptom Diary (ADSD) and the Asthma Nighttime Symptom Diary (ANSD) were developed to meet the need for standardized patient-reported measures of asthma symptoms to assess treatment trial outcomes in adults and adolescents.
To determine scoring and evaluate the measurement properties of the ADSD/ANSD.
Adolescents (12-17 years) and adults (18+ years) with asthma completed draft 8-item electronic versions of the ADSD/ANSD for 10 days alongside the Adult Asthma Symptom Daily Scales (AASDS) and a Patient Global Impression of Severity (PGIS). Using classical and modern psychometric methods, initial analyses evaluated the performance of ADSD/ANSD items to inform scoring. Subsequent analyses evaluated the reliability and validity of ADSD/ANSD scores.
A demographically and clinically diverse sample (n = 130 adolescents; n = 89 adults) was recruited. Item performance was generally strong. However, items assessing chest pressure and mucus/phlegm demonstrated redundancy and poorer performance and were removed. Principal-components analysis, confirmatory factor analysis, and item response theory supported combining items to form 6-item total ADSD/ANSD scores. Internal consistency (α = 0.94-0.95) and test-retest reliability (intraclass correlation coefficient = 0.86-0.95) were strong. Strong correlations (r = 0.72-0.80) were observed between ADSD scores and AASDS items assessing asthma symptom frequency, bother, and impact on activities. Significant differences (P < .001) in mean ADSD/ANSD scores were observed between groups categorized by asthma severity (PGIS), asthma control, inhaler use, nebulizer use, activity limitations, and nighttime awakenings.
The ADSD/ANSD items and scores demonstrated strong reliability and validity. Implementation of the measures in interventional studies will enable the evaluation of responsiveness and meaningful within-patient change.
Assessing Asthma Symptoms in Adolescents and Adults: Qualitative Research Supporting Development of the Asthma Daily Symptom Diary
2016, Value in Health
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Among the goals of asthma management (as highlighted in clinical guidelines), and an indicator of overall asthma control, is the eradication of or reduction in asthma symptoms [7–9]. Nevertheless, there is a poor correlation between the aforementioned objective measures of disease severity and patients’ experience of asthma symptoms [10–12]. To provide a holistic understanding of patient disease severity and asthma control in clinical research, there is a need for standardized ways of assessing patients’ experience of asthma symptoms.
Despite the widespread availability of patient-reported asthma questionnaires, instruments developed in accordance with present regulatory expectations are lacking. To address this gap, the Patient-Reported Outcome (PRO) Consortium’s Asthma Working Group has developed a patient-reported asthma daily symptom diary (ADSD) for use in clinical research to assess outcomes and support medical product labeling claims in adults and adolescents with asthma.
To summarize the qualitative research conducted to inform the initial development of the ADSD and to provide evidence for content validity of the instrument in accordance with the Food and Drug Administration’s PRO Guidance.
Research informing the initial development and confirming the content validity of the ADSD is summarized. This comprised a review of published qualitative research, semi-structured concept elicitation interviews (n = 55), and cognitive interviews (n = 65) with a diverse and representative sample of adults and adolescents with a clinician-confirmed diagnosis of asthma in the United States to understand the asthma symptom experience and to assess the relevance and understanding of the newly developed ADSD.
From the qualitative literature review and concept elicitation interviews, eight core asthma symptoms emerged. These were broadly categorized as breathing symptoms (difficulty breathing, shortness of breath, and wheezing), chest symptoms (chest tightness, chest pain, and pressure/weight on chest), and cough symptoms (cough and the presence of mucus/phlegm). Conceptual saturation was achieved and differences in the experience of participants according to socio-demographic or clinical characteristics were not observed. Subsequent testing of the ADSD confirmed participant relevance and understanding.
The ADSD is a new patient-reported asthma symptom diary developed in accordance with the Food and Drug Administration’s PRO Guidance. Evidence to date supports the content validity of the instrument. Item performance, reliability, and construct validity will be assessed in future quantitative research.
Asthma outcomes: Symptoms
2012, Journal of Allergy and Clinical Immunology
Citation Excerpt :
In addition, many trials employ “homemade” instruments to assess symptoms (ie, newly derived endpoints, such as asthma-free days, based on alternative analysis of the data collected by the instruments) that have neither been formally validated as an outcome measure nor described in published manuscripts, raising questions about the value of such assessments and precluding comparisons across studies. There is also limited validation of instruments in diverse populations, which is problematic given differences in symptom perception and reporting across different patient subgroups.8-10 Furthermore, evidence of minimal clinically important difference in a change in symptoms in longitudinal studies is largely lacking.
Respiratory symptoms are commonly used to assess the impact of patient-centered interventions.
At the request of National Institutes of Health (NIH) institutes and other federal agencies, an expert group was convened to propose which measurements of asthma symptoms should be used as a standardized measure in future clinical research studies.
Asthma symptom instruments were classified as daily diaries (prospectively recording symptoms between research visits) or retrospective questionnaires (completed at research visits). We conducted a systematic search in PubMed and a search for articles that cited key studies describing development of instruments. We classified outcome instruments as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at an NIH-organized workshop in March 2010 and finalized in September 2011.
Four instruments (3 daily diaries, 1 for adults and 2 for children; and 1 retrospective questionnaire for adults) were identified. Minimal clinically important differences have not been established for these instruments, and validation studies were only conducted in a limited number of patient populations. Validity of existing instruments may not be generalizable across racial-ethnic or other subgroups.
An evaluation of symptoms should be a core asthma outcome measure in clinical research. However, available instruments have limitations that preclude selection of a core instrument. The working group participants propose validation studies in diverse populations, comparisons of diaries versus retrospective questionnaires, and evaluations of symptom assessment alone versus composite scores of asthma control.
Asthma symptom perception and obesity in children
2010, Biological Psychology
This study examined the relationship between obesity and asthma symptom perception in 200 youth with asthma. Repeated subjective and objective peak flow measurements were summarized using the Asthma Risk Grid (Klein et al., 2004), resulting in Accurate, Symptom Magnification and Danger Zone scores. Analyses were stratified by age and included ethnicity.
For younger children, obesity was not significantly related to perception scores. For older children, a significant obesity-by-ethnicity interaction for Accurate Symptom Perception scores indicated that obese white children had lower accuracy than white nonobese children, while there was no difference for obese versus nonobese minority children. Obesity was also related to higher Symptom Magnification scores regardless of ethnicity for older children.
These findings suggest that obesity may complicate asthma management by interfering with the ability to accurately perceive symptoms for some patients. More remains to be learned about the role of sociodemographic factors underlying this relationship.
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Disclosures: Authors have nothing to disclose.

Funding Sources: Dr Davis was supported at the time of analysis and manuscript preparation and Dr Stein is supported currently by National Institutes of Health Training Grant HL007605. At the time of data collection, Dr Krishnan was supported by National Institutes of Health grant HL67850.

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Original Articles: Asthma, Lower Airway DiseasesPerception of airflow obstruction in patients hospitalized for acute asthma

Background

Objectives

Methods

Results

Conclusions

Section snippets

INTRODUCTION

METHODS

RESULTS

DISCUSSION

ACKNOWLEDGMENTS

Chest

Chest

Ann Allergy Asthma Immunol

Chest

Respir Med

Chest

Chest

Chest

Trends in Asthma Morbidity and Mortality

Effect of asthma severity on symptom perception in childhood asthma

Braz J Med Biol Res

Understanding how asthmatics perceive symptom distress during a methacholine challenge

J Asthma

Chemosensitivity and perception of dyspnea in patients with a history of near-fatal asthma

N Engl J Med

Personality profiles and breathlessness perception in outpatients with different gradings of asthma

Am J Respir Crit Care Med

One-year experience with an inpatient asthma clinical pathway

Arch Pediatr Adolesc Med

Inpatient management of asthma in the Chicago suburbs: the Suburban Asthma Management Initiative (SAMI)

J Asthma

Original Articles: Asthma, Lower Airway Diseases
Perception of airflow obstruction in patients hospitalized for acute asthma