Nouveautés en pneumologie et en allergologie pédiatriques

Asthma and other allergic conditions are priority research subjects because they are major public health problems world-wide. The management of severe allergic asthma has benefited from the development of a new class of drugs, anti-IgE antibodies (omalizumab). Other molecules being studied in adult asthmatics include monoclonal antibodies and fusion proteins whose action is to block bronchial inflammation at different levels. Considerable progress has been made in the understanding of the genesis of asthma and allergy. It appears that the early years of life have a fundamental importance in the natural history of allergic diseases and, in particular, of asthma; this makes it important to act early on the process, that is, from the earliest age possible. Specific immunotherapy, by injection or sublingually, may have a positive effect on the natural history of allergy, making it possible to predict the development of new sensitivities and reduce the risk of developing asthma. The coming years will probably reveal which therapeutic measures will be effective in preserving the respiratory capital of the asthmatic infant.     

‘You have to learn to live with it’: a qualitative and quantitative study of older people with asthma

Introduction: Asthma mortality has declined overall because of a range of public health initiatives. In western countries, the majority of asthma deaths now occur in people over the age of 50. The reasons for the poorer response of older age groups to public health asthma initiatives are not known. Objectives: We undertook a study to investigate the disease perspectives of older people with asthma and barriers which may exist and prevent optimal asthma care. Methods: Fifty‐five participants (16 male and 39 female) aged over 50 from an inner city, suburban area and a rural region were recruited. Lung function was measured, and questionnaire data on asthma symptoms, knowledge and control, medication use and respiratory health were collected. Participants were also interviewed in‐depth, and the quantitative and qualitative data were triangulated. Results: Participants with a duration of asthma for >30 years reported significantly fewer symptoms and better quality of life irrespective of asthma severity, indicating less appreciation of symptoms in those with a long asthma duration. Interviews revealed this was related to previous asthma management strategies when treatment options were limited. Participants with a recent diagnosis sought understanding of asthma and the reason for their illness. Initiatives to improve asthma care in older people need to reflect these findings. Conclusions: Self‐management strategies for older people need to be tailored according to the time of disease onset and the duration of disease. Please cite this paper as: Goeman DP, O’Hehir RE, Jenkins C, Scharf SL and Douglass JA. ‘You have to learn to live with it’: a qualitative and quantitative study of older people with asthma. The Clinical Respiratory Journal 2007; 1:99–105.     

Chronic airflow limitation in developing countries: burden and priorities

Respiratory disease has never received priority in relation to its impact on health. Estimated DALYs lost in 2002 were 12% globally (similar for industrialized and developing countries). Chronic airflow limitation (due mainly to asthma and COPD) alone affects more than 100 million persons in the world and the majority of them live in developing countries. International guidelines for management of asthma (GINA) and COPD (GOLD) have been adopted and their cost-effectiveness demonstrated in industrialized countries. As resources are scarce in developing countries, adaptation of these guidelines using only essential drugs is required. It remains for governments to set priorities. To make these choices, a set of criteria have been proposed. It is vital that the results of scientific investigations are presented in these terms to facilitate their use by decision-makers. To respond to this emerging public health problem in developing countries, WHO has developed 2 initiatives: “Practical Approach to Lung Health (PAL)” and the Global Alliance Against Chronic Respiratory Diseases (GARD)”, and the International Union Against Tuberculosis and Lung Diseases (The Union) has launched a new initiative to increase affordability of essential asthma drugs for patients in developing countries termed the “Asthma Drug Facility” (ADF), which could facilitate the care of patients living in these parts of the world.     

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.     

Rational oral corticosteroid use in adult severe asthma: A narrative review

OCS play an important role in the management of asthma. However, steroid‐related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25–60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add‐on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCS‐sparing interventions, such as improving guideline adherence and add‐on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS‐weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker‐based strategies.     

Respiratory health and lung research in New Zealand

This article summarizes the recent history of respiratory research in New Zealand which was triggered by an epidemic of asthma mortality in the 1980s and which led to the rapid emergence of quality research groups. This unique event led to major initiatives to improve the standards of care for people with asthma in New Zealand. Perspectives on other lung health issues including tobacco control, the COPD epidemic and the emergence of bronchiectasis as a serious respiratory disease are also provided.     

Influenza and COVID‐19: What does co‐existence mean?

The COVID‐19 pandemic caused by the novel coronavirus SARS‐CoV‐2 continues to have a major impact on healthcare and social systems throughout the world. As the clinical and epidemiological features of COVID‐19 have many parallels with influenza, it is important to ensure optimal management of both respiratory diseases as we anticipate their continued co‐circulation. In particular, there is a need to ensure that effective surveillance and diagnostic capacities are in place to monitor these and other respiratory viruses, as this will underpin decisions on the appropriate clinical management of the respective diseases. As such, we propose a series of key recommendations for stakeholders, public health authorities, primary care physicians and surveillance bodies that will help mitigate the combined risks of concurrent influenza epidemics and the COVID‐19 pandemic. We advocate the judicious use of influenza vaccines and antivirals, particularly among groups at high risk of complications, with healthcare workers also considered a priority for vaccination. It is likely that the increased use of emerging technologies such as telemedicine and contact tracing will permanently change our approach to managing infectious disease. The use of these technologies, alongside existing pharmaceutical strategies, will ensure that we achieve a holistic approach to the global public health measures needed to deal with the combined threat of influenza and COVID‐19. Ensuring that this approach is optimal will be key as we move from a reactive pandemic response towards preparing for the long‐term management of the remarkable clinical burden associated with these respiratory pathogens.     

City tuberculosis control coordinators' perspectives of patient adherence to DOT in S?o Paulo State, Brazil, 2005.

SETTING: Thirty-six priority cities in S?o Paulo State, Brazil, with a high incidence of tuberculosis (TB) cases, deaths and treatment default. OBJECTIVE: To identify the perspectives of city TB control coordinators regarding the most important components of adherence strategies adopted by health care teams to ensure patient adherence in 36 priority cities in the State of S?o Paulo, Brazil. DESIGN: Qualitative research with semi-structured interviews conducted with the coordinators of the National TB Control Programme involved in the management of TB treatment services in the public sector. RESULTS: The main issues thought to influence adherence to directly observed treatment (DOT) by coordinators include incentives and benefits delivered to patients, patient-health care worker bonding and comprehensive care, the encouragement given by others to follow treatment (family, neighbours and health professionals), and help provided by health professionals for patients to recover their self-esteem. CONCLUSION: The main aspects mentioned by city TB control coordinators regarding patient adherence to treatment and to DOT in S?o Paulo are improvements in communications, relationships based on trust, a humane approach and including the patients in the decision-making process concerning their health.     

Air pollution and chronic airway diseases: what should people know and do?

The health effects of air pollution remain a public health concern worldwide. Exposure to air pollution has many substantial adverse effects on human health. Globally, seven million deaths were attributable to the joint effects of household and ambient air pollution. Subjects with chronic respiratory diseases such as chronic obstructive pulmonary disease (COPD) and asthma are especially vulnerable to the detrimental effects of air pollutants. Air pollution can induce the acute exacerbation of COPD and onset of asthma, increase the respiratory morbidity and mortality. The health effects of air pollution depend on the components and sources of pollutants, which varied with countries, seasons, and times. Combustion of solid fuels is a major source of air pollutants in developing countries. To reduce the detrimental effects of air pollution, people especially those with COPD or asthma should be aware of the air quality and take extra measures such as reducing the time outdoor and wearing masks when necessary. For reducing the air pollutants indoor, people should use clean fuels and improve the stoves so as to burn fuel more efficiently and vent emissions to the outside. Air cleaners that can improve the air quality efficiently are recommended.     

Crosscultural communication in those with airway diseases

Transcultural consultations are becoming commonplace. Such consultations arise because patients from ethnic groups consult doctors, but also because patients consult doctors from other ethnic backgrounds. Such consultations require a cultural awareness and sensitivity which may be particularly necessary when concerning those with respiratory illnesses which are often long-term and about which there may be considerable stigma. The prevalence of respiratory disease can vary between ethnic groups, most noticeably in tuberculosis and smoking; and in diseases such as asthma, health service usage and treatment can vary significantly with ethnicity. Some of this may represent cultural, rather than disease specific differences. Good communication is essential throughout medical practice, but in transcultural consultations it is especially important that the doctor pays appropriate attention to likely patient beliefs and approaches to shared decision making. Usual negotiation regarding goals and outcomes first requires the clinician to understand how a patient's understanding of illness may vary from a traditional western scientific approach. Special attention needs to be paid to the optimal way of using interpreters and more time is often needed for crosscultural consultations. Specific training is necessary for health practitioners to enable them to acquire the skills for crosscultural care and this involves learning about other cultures and an appreciation of how a change in attitude often needs to be incorporated into the clinical approach. Acquiring these skills and understandings to facilitate optimal transcultural consultation enables transfer of these skills to other similar clinical scenarios such as the approach to those with disability. The global burden of long-term respiratory disease, both infectious and noncommunicable, coupled with increased migration and geographical mobility means that a successful crosscultural approach is now a priority area for attention.     

Prevention in liver disease

Prevention has become an important component of medical therapy for a variety of diseases. Preventive strategies in liver disease are relatively underdeveloped and have focused mainly on specific complications of chronic liver disease and vaccination for viral hepatitis. Although public health initiatives designed to prevent certain forms of liver disease are in place, they seem to be underutilized and their utility has not been evaluated. The development of a comprehensive approach using public health initiatives in conjunction with strategies by health care providers is important because of the potential for decreasing the human and health care costs associated with hepatic dysfunction. This article reviews the available literature regarding prevention for health care providers, includes a summary of ongoing public health initiatives, and suggests an approach to prevention in liver disease. It is intended to raise awareness and encourage implementation of preventive strategies in hepatology.     

Global Alliance against Chronic Respiratory Diseases.

Hundreds of millions of people of all ages suffer from chronic respiratory diseases which include asthma and respiratory allergies, chronic obstructive pulmonary disease, occupational lung diseases and pulmonary hypertension. More than 500 million patients live in developing countries or in deprived populations. Chronic respiratory diseases are increasing in prevalence. Although the cost of inaction is clear and unacceptable, chronic respiratory diseases and their risk factors receive insufficient attention from the healthcare community, government officials, media, patients and families. The Fifty-Third World Health Assembly recognised the enormous human suffering caused by chronic diseases and requested the World Health Organization (WHO) Director General to give priority to the prevention and control of chronic diseases, with special emphasis on developing countries. This led to the formation of the WHO Global Alliance against Chronic Respiratory Diseases (GARD). GARD is a voluntary alliance of organisations, institutions and agencies working towards a common vision to improve global lung health according to local needs. GARD is developed in a stepwise approach using the following three planning steps: estimate population need and advocate action; formulate and adopt policy; and identify policy implementation steps.     

Management of the child with cough or difficult breathing.

Childhood respiratory disease creates considerable morbidity and mortality, especially amongst children living in low-income countries. Of the more than 10 million children who die annually from preventable diseases, pneumonia is responsible for 18.1%, while in low-income countries this percentage rises to 26%. It is calculated that 90% of these deaths from preventable diseases occur in 42 countries. Even in the face of the human immunodeficiency virus (HIV) epidemic, pneumonia is still responsible for 21% of deaths. HIV-infected children are at greatest risk for developing and dying from pneumonia. By the introduction of low cost standardised case management strategies for the management of pneumonia, increasing immunisation, reducing risk factors such as poor nutrition and environmental smoking and promoting breast-feeding, it is estimated that the death rate from pneumonia can be reduced by 50%. In this series the epidemiology of childhood acute respiratory infections (ARI) and the recognition and management of childhood pneumonia in resource-poor settings will be highlighted as well as the scientific justification for the standard case management of childhood pneumonia. As cases of pneumonia are better managed, other childhood respiratory diseases such as asthma and tuberculosis (TB) will be discovered, which also require a standard approach to management. The management of asthma and TB in resource-poor settings will also be discussed.     

The effect of passive smoking on respiratory health in children and adults.

Passive smoking, or environmental tobacco smoke (ETS), has been found to be causally associated with a large number of diseases in various organs although the evidence is sometimes conflicting. This review summarises the effects of passive smoking on respiratory symptoms, lung function and asthma in children and adults. In children, prenatal exposure to ETS is associated with impaired lung function and increased risk of developing asthma, while postnatal exposure mainly acts as a trigger factor for respiratory symptoms and asthma attacks. In adults, ETS exposure is associated with respiratory symptoms, asthma, a small but significant impairment of lung function and increased bronchial responsiveness. The consequence of workplace exposure seems to be more serious than domestic exposure. Legislative measures banning smoking at work have positive health effects in non-smokers and increase the quitting rate in smokers. Measures aimed at reducing childhood exposure to ETS should have high priority. Smoke cessation programmes for pregnant women attending antenatal clinics and for parents at the time of child hospitalisation for respiratory illness seem to have a fairly high success rate. Passive smoking is a widespread, important and avoidable risk factor for respiratory symptoms in both children and adults. Reducing passive smoking in the community will have a large positive effect on respiratory health.     

Case management of childhood pneumonia in developing countries: recent relevant research and current initiatives.

Acute respiratory infections (ARI), mostly pneumonia, are one of the leading causes of death in young children in developing countries, accounting for 28% of childhood mortality. This paper provides a summary of the research and technical development efforts made in the last 15 years which contributed to improving the effectiveness of the case management strategy to reduce mortality from pneumonia in children in developing countries. Community intervention studies provided strong evidence that the strategy was feasible and effective in producing a substantial impact on pneumonia mortality. Clinical studies provided the rationale for improving the sensitivity and specificity of key signs of pneumonia, and for enhancing the therapeutic efficacy of standard home treatment. Research also provided data to deal with the problem of the clinical overlap of pneumonia and malaria in children. Technological initiatives succeeded in making appropriate diagnostic and therapeutic devices available. An important body of socio-cultural knowledge about family practices regarding pneumonia and ARI in children was built up and provided orientation on effective communication between health workers and families about home care of children with ARI. Health systems research focused on methods for surveillance of bacterial drug resistance and methodologies for evaluating the control programmes. Despite advances in the development of vaccines against respiratory bacteria and in the prevention of risk factors for pneumonia in children, case management will continue to be a central strategy for preventing mortality. Current international research initiatives are looking into measures that can improve the referral of severe pneumonia and effective management of severe pneumonia at first level hospitals.     

Asthma and Rhinitis in the Workplace

Accumulating evidence indicates that the workplace environment substantially contributes to the global burden of asthma and rhinitis. Work-related asthma and rhinitis represent a public health concern due to their health and socioeconomic impacts. This article summarizes the scientific evidence on sensitizer-induced occupational asthma and rhinitis that has been published during the past 5 years. The review addresses the strategies for diagnosing and managing these highly prevalent occupational diseases.     

A workshop on asthma management programs and centers in Brazil: reviewing and explaining concepts

Objective:

To report the results of a workshop regarding asthma management programs and centers (AMPCs) in Brazil, so that they can be used as a tool for the improvement and advancement of current and future AMPCs.

Methods:

The workshop consisted of five presentations and the corresponding group discussions. The working groups discussed the following themes: implementation of asthma management strategies; human resources needed for AMPCs; financial resources needed for AMPCs; and operational maintenance of AMPCs.

Results:

The workshop involved 39 participants, from all regions of the country, representing associations of asthma patients (n = 3), universities (n = 7), and AMPCs (n = 29). We found a direct relationship between a lack of planning and the failure of AMPCs. Based on the experiences reported during the workshop, the common assumptions about AMPCs in Brazil were the importance of raising awareness of managers; greater community participation; interdependence between primary care and specialized care; awareness of regionalization; and use of medications available in the public health system.

Conclusions:

Brazil already has a core of experience in the area of asthma management programs. The implementation of strategies for the management of chronic respiratory disease and their incorporation into health care system protocols would seem to be a natural progression. However, there is minimal experience in this area. Joint efforts by individuals with expertise in AMPCs could promote the implementation of asthma management strategies, thus speeding the creation of treatment networks, which might have a multiplier effect, precluding the need for isolated centers to start from zero.     

Generation of political priority for global health initiatives: a framework and case study of maternal mortality

Why do some global health initiatives receive priority from international and national political leaders whereas others receive little attention? To analyse this question we propose a framework consisting of four categories: the strength of the actors involved in the initiative, the power of the ideas they use to portray the issue, the nature of the political contexts in which they operate, and characteristics of the issue itself. We apply this framework to the case of a global initiative to reduce maternal mortality, which was launched in 1987. We undertook archival research and interviewed people connected with the initiative, using a process-tracing method that is commonly employed in qualitative research. We report that despite two decades of effort the initiative remains in an early phase of development, hampered by difficulties in all these categories. However, the initiative's 20th year, 2007, presents opportunities to build political momentum. To generate political priority, advocates will need to address several challenges, including the creation of effective institutions to guide the initiative and the development of a public positioning of the issue to convince political leaders to act. We use the framework and case study to suggest areas for future research on the determinants of political priority for global health initiatives, which is a subject that has attracted much speculation but little scholarship.     

Dissemination and implementation of guidelines for the treatment of asthma.

Asthma remains a serious global health problem that affects people of all ages. Many asthma management guidelines, both national and international, are available, but they are seldom implemented. The implementation of guidelines remains a challenge worldwide, as barriers exist at several levels. These barriers are generic, such as poverty, inadequate resources and poor infrastructure, or specific, such as organisational, health care provider and patient factors. The barriers are, however, potentially correctable, and the goal of guideline implementation is to translate evidence-based asthma management recommendations into real-life practice to improve patient health. This state of the art article reviews the challenges and current status of and strategies for asthma dissemination and implementation globally, and highlights the specific strategies for such improvement in developing countries.     

Asthma in Urban Children: Epidemiology,Environmental Risk Factors,and the Public Health Domain

Asthma is the most commonly reported chronic condition of childhood in developed countries, with 6.5 million children affected in the USA. A disparate burden of childhood asthma is seen among socioeconomically disadvantaged youth, often concentrated in urban areas with high poverty rates. Host factors that predispose a child to asthma include atopy, male gender, parental history of asthma, and also race, ethnicity, and genetic and epigenetic susceptibilities. Environmental factors, such as improved hygiene, ambient air pollution, and early life exposures to microbes and aeroallergens, also influence the development of asthma. With greater than 90 % of time spent indoors, home exposures (such as cockroach, rodent, and indoor air pollution) are highly relevant for urban asthma. Morbidity reduction may require focused public health initiatives for environmental intervention in high priority risk groups and the addition of immune modulatory agents in children with poorly controlled disease.