The Annals of Respiratory Medicine (AoRM), Vol 1 Issue 1

Managing Asthma in Real Life: Defining What Really Matters

Dekhuijzen PNR, Kneussl M, Bateman E, Partridge M, Lavorini F, Virchow JC, Stowasser S, Steinkamp G. Managing Asthma in Real Life: Defining What Really Matters.  Annals of Respiratory Medicine, February 2010; 1(1):3-10

Review article

Richard Dekhuijzen¹, Meinhard Kneussl², Eric D Bateman³, Martyn R Partridge⁴, Federico Lavorini⁵, Christian Virchow⁶, S Stowasser⁷ and G Steinkamp⁸

Affiliations: ¹Radboud University Nijmegen Medical Centre, The Netherlands; ²Wilhelminenspital Vienna, Medical University Vienna, Austria; ³University of Cape Town, South Africa; ⁴Imperial College London, NHLI at Charing Cross Hospital, UK; ⁵University of Florence, Italy; ⁶University of Rostock, Germany; ⁷TEVA Pharmaceuticals Europe B.V., The Netherlands and ⁸Clinical Research and Medical Writing, Schwerin, Germany


ABSTRACT

Asthma control has become a focus in the treatment and follow‐up of patients. Division into good, partial, and poor control is operational and can be applied in daily practice, with support from validated questionnaires. Well‐controlled asthma can be achieved in a majority of patients in clinical trials, whereas epidemiological studies suggest that results may be different in “real life” settings. In health surveys, about half of patients with asthma were classified as uncontrolled, and many subjects were not receiving appropriate medication. Most major treatment studies are performed on highly selected groups and, as a result, represent only a small proportion of “real‐life” patients. A pragmatic approach to patients with inadequate asthma control is abbreviated by the acronym A‐B‐C‐D‐E: Is it really and only asthma? Are all bronchial triggers known? Is compliance optimal? Can the patient handle the device? Is every small airway reached? This scheme addresses the most frequent reasons for uncontrolled asthma and helps to explore possible underlying factors. With respect to compliance, physicians should elicit their patients’ information needs and concerns, involve patients in treatments decisions, support their self‐management, and provide patient‐centered care. Inhalation devices should be matched to the patient, and physicians should train patients in how to use the inhaler correctly. Because asthma is a disease of both large and small airways, targeting all airways more homogeneously with an extra‐fine HFA‐BDP formulation might improve asthma control and reduce asthma exacerbations in “real‐life” patients.

Keywords: Asthma control, Real life, Compliance, Inhalers, Small airways, Extra‐fine HFA‐BDP
Correspondence: Prof.P. N. Richard Dekhuijzen, Head, Dept. of Pulmonary Diseases (454), Radboud University Nijmegen Medical Centre, PO Box 9101, 6500 HB Nijmegen, The Netherlands. Tel: +31 (0)243614579; e‐mail: R.Dekhuijzen@LONG.umcn.nl

Vaccinating High‐risk Patients Against Influenza: Doing More to Protect Patients With Asthma

Rohde G, Wisnivesky J, van Essen GA, Ompad D, Barnes P. Vaccinating High-risk Patients Against Influenza: Doing More to Protect Patients With Asthma.  Annals of Respiratory Medicine, February 2010; 1(1):11-17

Review Article

Gernot Rohde ¹, Juan Wisnivesky ³, GA (Ted) van Essen ⁴, C Danielle Ompad ⁵ and J Peter Barnes ²
Affiliations: ¹University Hospital Bergmannsheil, Bochum, Germany; ²National Heart & Lung Institute, Imperial College London, UK; ³Division of General Internal Medicine, Department of Medicine, Mount Sinai School of Medicine, New York, USA; ⁴Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, The Netherlands and ⁵Center for Urban Epidemiologic Studies, New York Academy of Medicine, New York, USA

ABSTRACT

Globally, asthma is a significant source of both morbidity and mortality. Patients with asthma frequently experience episodes of exacerbation that necessitate the utilization of substantial healthcare resources. Viral infections of the respiratory tract in asthmatic patients have been associated with an increase in acute exacerbations; in particular, infection with influenza virus leads to a rise in severe asthma exacerbations that require hospitalization.

Many influenza‐triggered respiratory complications are unnecessary and can potentially be avoided by vaccination. Vaccination against influenza has been established as an effective way of reducing general practitioner consultations, exacerbations, hospitalizations and deaths in asthma patients. For these reasons, major international healthcare organizations and national authorities recommend annual vaccination against influenza for patients with high‐risk medical conditions, including the subpopulation of asthmatic patients.

Despite the availability of safe and effective vaccines against influenza, vaccination rates remain lower than desirable, even among targeted high‐risk populations, depriving these patients of protection against influenza and unnecessarily exposing them to influenza‐related complications. Proactive strategies based on prevailing evidence‐based international guidelines therefore need to be implemented to overcome barriers to vaccination and to extend protection against influenza to all high‐risk patients, particularly those with asthma. Healthcare providers play a pivotal role in ensuring adherence to vaccination guidelines, thereby ensuring that these evidence‐based recommendations are translated into improved outcomes for asthma patients.

Keywords: Asthma, Exacerbation, Guidelines, High‐risk, Influenza, Patients, Protect, Vaccination
Correspondence: Gernot Rohde, Medizinische Klinik III – Pneumologie, Allergologie, Schlaf‐ und Beatmungsmedizin, Berufsgenossenschaftliches Universitätsklinikum Bergmannsheil GmbH, Haus 3 (Neubau), Raum 03.‐1.007, Bürkle‐de‐la‐Camp‐Platz 1, 44789 Bochum, Germany. Tel: +49 (0)234 302 3532; Fax: +49 (0)234 302 6420; e‐mail: gernot.rohde@ruhr‐uni‐bochum.de

Managing Asthma in Real Life: A pragmatic approach to the patient with inadequate asthma control

Dekhuijzen PNR. Managing Asthma in Real Life: A pragmatic approach to the patient with inadequate asthma control.  Annals of Respiratory Medicine, February 2010; 1(1):1-2

Meeting Summary


PN Richard Dekhuijzen
Affiliation: Radboud University Nijmegen Medical Centre, The Netherlands


The goal of asthma treatment is to achieve and maintain clinical control of the disease. In the past, the terms “asthma severity” and “asthma control” were often used to describe a patient’s baseline status and their response to treatment. A task force from the American and European respiratory societies, ATS and ERS, respectively, has recently standardized these terms [1]. In addition, experts have provided separate conceptual frameworks on asthma severity and control.

Detection of Epidermal Growth Factor Receptor Mutations in Samples obtained with Endobronchial Ultrasound‐Guided Transbronchial Needle Aspiration: A Short Review

Garcia-Olive I, Sanz-Santoz J, Andreo F, Monso E. Detection Of Epidermal Growth Factor Receptor Mutations In Samples Obtained With Endobronchial Ultrasound-Guided Transbronchial Needle Aspiration: A Short Review. Annals of Respiratory Medicine, February 2010; 1(1):85-88

Review Article

Ignasi Garcia‐Olivé ^{1 2}, José Sanz‐Santos ¹, Felipe Andreo ^{1 3} and Eduard Monsó ^{1 3}
Affiliations: ¹Respiratory Service, Hospital Universitari Germans Trias i Pujol, Badalona, Catalunya, Spain; ²Departament de Medicina, Universitat Auto`noma de Barcelona, Spain and ³Ciber de Enfermedades Respiratorias—CibeRes, Bunyola, Spain


ABSTRACT

The presence of somatic mutations of the tyrosine kinase (TK) domain of epidermal growth factor receptor (EGFR) gene in patients with advanced non‐small cell lung cancer (NSCLC) correlates with a good response to TK inhibitors. The objective of this review was to assess the usefulness of real‐time endobronchial ultrasound‐guided transbronchial needle aspiration (EBUS‐TBNA) in detecting EGFR mutations in cells recovered from malignant mediastinal nodes from patients with lung adenocarcinoma. A systematic review was carried out in September 2009, and we found that two studies had investigated the usefulness of EBUS‐TBNA for obtaining tissue samples from mediastinal and hilar nodes to analyze EGFR gene mutations. Most patients had advanced‐stage disease. The feasibility of performing an EGFR gene analysis of the EBUS‐TBNA sample ranged from 72.2% to 93.5% in patients with lymph node metastases. Prevalence of EGFR mutations ranged from 9.8% to 25.6%. In conclusion, samples obtained by EBUS‐TBNA in patients with lung adenocarcinoma are suitable for the detection of EGFR gene mutations.

Keywords: real‐time endobronchial ultrasonography needle aspiration (EBUS), epidermal growth factor receptor (EGFR), adenocarcinoma, lung cancer
Correspondence: Ignasi Garcia‐Olivé, Respiratory Service, Hospital Germans Trias i Pujol, Carretera de Canyet s/n, 08916 Badalona, Catalunya, Spain. Tel: (34)‐934‐978920; Fax: (34)‐934‐978722; e‐mail: ignasi.g.olive@gmail.com

“Mild” Chronic Obstructive Pulmonary Disease—Is there a Case for Earlier Treatment?

O’Donnell D, Raghavan N, Ora J, Webb K. “Mild” COPD – Is there a case for earlier treatment? Annals of Respiratory Medicine, February 2010; 1(1):23-30

Review Article

Natya Raghavan ^{1 2}, Josuel Ora ¹, A Katherine Webb ¹ and E Denis O’Donnell ¹
Affiliations: 1Respiratory Investigation Unit, Department of Medicine, Queen’s University and Kingston General Hospital, Kingston, Ontario, Canada and 2Division of Respirology, McMaster University, Hamilton, Ontario, Canada


ABSTRACT

The majority of smokers who suffer from chronic obstructive pulmonary disease (COPD) have milder airway obstruction, as measured by standard spirometry. Relatively few studies have been conducted in mild COPD and, beyond the imperative of smoking cessation, no evidence‐based guidelines for management currently exist. More detailed physiological testing of patients with mild COPD can uncover heterogeneous peripheral airway dysfunction, as manifest by increased airway closure, abnormal distribution of ventilation, and disrupted pulmonary gas exchange. These physiological derangements are further amplified during physical exertion, and can give rise to increased respiratory discomfort and earlier exercise cessation. The clinical consequences of respiratory impairment in milder COPD are variable, but population studies have confirmed an association with increased morbidity, healthcare utilization, and even mortality. The presence of respiratory symptoms in patients with mild COPD and, in particular, self‐reported exertional breathlessness appears to portend more negative clinical outcomes. The rationale for targeted screening (by spirometry) of symptomatic smokers to expedite diagnosis is firmly established but, unfortunately, underdiagnosis of this condition remains a pervasive problem worldwide. In this paper, we review what is currently known about the pathophysiology and clinical consequences of mild COPD in order to provide a foundation for the development of an effective management paradigm.

Keywords: chronic obstructive pulmonary disease (COPD), small airway dysfunction, dyspnea, bronchodilators, lung hyperinflation
Correspondence: Denis E O’Donnell, Department of Medicine, Division of Respirology, Queen’s University, 102 Stuart Street, Kingston, Ontario, Canada, K7L 2V6. e‐mail: odonnell@queensu.ca

Short‐Term Adverse Effects of Carbon Monoxide Pollution on the Respiratory System in Adults: a Systematic Review

Canova C, Torresan S, Maestrelli P. Short-term adverse effects of carbon monoxide pollution on respiratory system in adults: a systematic review. Annals of Respiratory Medicine, February 2010; 1(1):89-98

Review Article

Cristina Canova, Stefania Torresan and Piero Maestrelli
Affiliation: Department of Environmental Medicine and Public Health, University of Padova, Padova, Italy

ABSTRACT

Carbon monoxide (CO) is a gas emitted as a byproduct of incomplete combustion and represents one of the most common and widely distributed air pollutants. Chronic exposure of adults to CO has been associated with neurological injuries and cardiovascular disorders induced by tissue hypoxia. It remains to be established whether environmental CO exposure is associated with short‐term adverse effects on the respiratory system. This paper aims to review the investigations that considered the effects of outdoor CO on lung function and hospital or emergency admissions for respiratory causes in adults. The studies were identified by searching electronic databases from 1990 to September 2009. The first search identified 82 papers that considered the effect of outdoor pollution on lung function in adults. From these, just six panel studies measured CO among the air pollutants. We identified three studies that reported a significant association between lung function and airborne CO in adult asthmatics and one in chronic obstructive pulmonary disease (COPD) patients. Overall, there is moderate evidence that CO affects lung function in asthmatics, whereas inconsistent results are available in COPD patients. The search on CO effects on respiratory exacerbation identified 23 time series papers, which considered the association between daily outdoor CO measures and hospital admissions or emergency visits for respiratory diseases. A significant association between CO pollution and respiratory diseases was detected by the majority of these studies, in particularly considering COPD. A direct association between CO and exacerbation of respiratory diseases lacks biologic plausibility. CO could be a marker of other combustion products, measured or not measured in ambient air, such as ultrafine particles. If CO is a marker of other harmful substances, possibly the limits based on its biological properties are not adequate to protect human subjects from adverse reactions.

Keywords: air pollution, spirometry, respiratory diseases, lung function, hospitalization, carbon monoxide, exacerbation
Correspondence: Cristina Canova, Department of Environmental Medicine and Public Health, University of Padova, Via Loredan 18, 35151 Padova, Italy. Tel: (39)‐0498275752; Fax: (39)‐0498275392; e‐mail: cristina.canova@unipd.it

Influenza Vaccination and COPD: Recommendations and Realities

Vozoris N. Influenza Vaccination and COPD: Recommendations and Realities.  Annals of Respiratory Medicine, February 2010; 1(1):19-22

Review Article


T Nicholas Vozoris
Affiliation: Division of Respirology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada


ABSTRACT

Respiratory exacerbations are characteristic of chronic obstructive pulmonary disease (COPD) and are associated with poorer health outcomes. The seasonal influenza virus is a common viral pathogen in COPD exacerbations. Prevention of influenza‐related exacerbations is therefore important. The objectives of this review article are to summarize current international guidelines regarding seasonal influenza vaccination in COPD, and then to discuss two important issues relating to influenza vaccination in COPD: the low uptake of influenza vaccination and the conflicting nature of the evidence regarding its effectiveness. Despite strong universal recommendation for a broad influenza vaccination strategy in COPD, influenza vaccine uptake in COPD is low internationally, and studies examining vaccine effectiveness in COPD show mixed results. Demonstrating and disseminating evidence of the potential merits of influenza vaccination in COPD is necessary before we can confidently and successfully pursue policies of mass vaccination.

Keywords: seasonal influenza virus, influenza vaccination, chronic obstructive pulmonary disease
Correspondence: Nicholas Vozoris, Division of Respirology, Department of Medicine, University of Toronto, Medical Sciences Building, Room 6263, 1 King’s College Circle, Toronto, Ontario, Canada, M5S 1A8. Tel: (1)‐416‐978‐1562; Fax: (1)‐416‐971‐2112; e‐mail: nick.vozoris@utoronto.ca

A Look to the Future: Potential Therapeutic Options for Pulmonary Arterial Hypertension

O’Callaghan D, Jais X, Montani D, Sitbon O, Simonneau G, Humbert M. A look to the future: potential therapeutic options for pulmonary arterial hypertension. Annals of Respiratory Medicine, February 2010; 1(1):105-112


Review Article

Dermot S O'Callaghan ^{1 2 3}, Xavier Jaïs ^{1 2 3}, David Montani ^{1 2 3}, Olivier Sitbon ^{1 2 3}, Gérald Simonneau ^{1 2 3} and Marc Humbert ^{1 2 3}
Affiliations: ¹ Université Paris‐Sud and ² Centre National de Référence de l’Hypertension Pulmonaire Sévère, Service de Pneumologie et Réanimation Respiratoire, Hôpital Antoine Béclère and ³ INSERM U999, Hypertension Artérielle Pulmonaire


ABSTRACT

Pulmonary arterial hypertension (PAH) is a disease characterized by dysregulated vascular proliferation and remodeling of small pulmonary arteries, which leads to progressively increased pulmonary vascular resistance and right ventricular failure. Despite the remarkable therapeutic advances that have been made over the past two decades, disease progression is inevitable in the majority of patients, underscoring the need for novel approaches. An increased understanding of the complex pathobiology of PAH has facilitated the identification of a number of possible novel pharmacologic targets. This in turn has led directly to the development and prospective evaluation in randomized studies of therapeutic approaches that act on relevant aberrant pathways not addressed by currently available treatments. This review provides an overview of emerging approaches that may become part of the future therapeutic armamentarium for this deadly disease.

Keywords: pulmonary arterial hypertension, nitric oxide, prostacyclin, vasoactive intestinal peptide, tyrosine kinase inhibitor, serotonin, cell‐based therapy
Correspondence: Dermot S O’Callaghan, Centre National de Référence de l’Hypertension Pulmonaire Sévère, Service de Pneumologie, Hôpital Antoine Béclère, Assistance Publique—Hôpitaux de Paris, Université Paris‐Sud, 157 rue de la Porte de Trivaux, 92140 Clamart, France. Tel: (33)‐1‐45‐37‐47‐72; Fax: (33)‐1‐46‐30‐38‐24; e‐mail: dsocallaghan@yahoo.com

Role of Regulatory T‐cells in Chronic Obstructive Pulmonary Disease

Plumb J, Smyth L, Singh D. Role of regulatory T-cells in COPD.  Annals of Respiratory Medicine, February 2010; 1(1):45-52

Review Article


Jonathan Plumb, Lucy JC Smyth and Dave Singh
Affiliations: University of Manchester, NIHR Translational Research Facility, University Hospital of South Manchester Foundation Trust


ABSTRACT

Chronic Obstructive Pulmonary Disease (COPD) is characterized by progressive and irreversible airflow limitation, caused in most cases by cigarette smoking. Increased CD8 cell numbers are associated with disease progression, and the presence of tertiary immune cell follicles in the lungs of COPD patients indicates a possible disease autoimmune component. T regulatory cells (Tregs) play an essential role in the control of adaptive immunity. This article reviews the current understanding of number and location of Tregs in lung compartments (airway lumen, parenchyma and follicles) in COPD patients. Treg lineages are detailed and their potential roles in COPD are considered. We discuss Treg function in COPD patients with a view to explaining the ongoing pulmonary inflammation despite Treg presence.

Keywords: chronic obstructive pulmonary disease, lymphocytes, follicles, autoimmunity, T regulatory cells
Correspondence: Dr. Jonathan Plumb, University of Manchester, NIHR Translational Research Facility, Airway Pharmacology Group, 2nd Floor ERC, University Hospital Of South Manchester Foundation Trust, Southmoor Road, Manchester, UK M23 9LT. Tel: 0161‐2915920; e‐mail: jonathan.plumb@manchester.ac.uk

Asthma in Adults: Is the Prevalence Increasing?

James A, Hunter M, Musk AW. Asthma in Adults: Is the Prevalence Increasing?  Annals of Respiratory Medicine, February 2010; 1(1):69-74

Review Article


L Michael Hunter ^{1 2}, AW (Bill) Musk ^{1 2 4 5} and L Alan James ^{2 3 5}
Affiliations: ¹Department of Respiratory Medicine, ²Busselton Population Medical Research Foundation and ³Department of Pulmonary Physiology/West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Nedlands, Western Australia; ⁴School of Population Health and ⁵School of Medicine and Pharmacology, University of Western Australia, Crawley, Australia


ABSTRACT

Repeated cross‐sectional studies in adults indicate that there has been a marked increase in doctor‐diagnosed asthma over the last few decades. Some studies suggest that this increase has resulted from increased reporting of respiratory symptoms commonly associated with asthma such as wheeze or cough and phlegm. A rise in the prevalence of risk factors commonly associated with asthma such as atopy, rhinitis, and obesity has been suggested to contribute to this increase. Lack of change in airway hyperresponsiveness in the adult populations where this has been studied suggests that other causes such as changes in diagnostic trends, increased asthma awareness and better availability and efficacy of medications are likely to have contributed to the increased reporting of diagnosed asthma. This article provides an overview of the changing prevalence of doctor‐diagnosed asthma in adults and discusses the factors that may have contributed to the increase.

Keywords: Asthma, epidemiology, prevalence, atopy, allergy, respiratory disease
Correspondence: A/ProfessorAlan James, Department of Pulmonary Physiology/West Australian Sleep Disorders Research Institute, Level 5, G Block, Sir Charles Gairdner Hospital, Hospital Avenue, Nedlands, WA 6009, Australia. Tel: (61)8‐9346‐2888; Fax: (61)8‐9346‐2034; e‐mail: Alan.James.SCGH@health.wa.gov.au

Surgical Treatment of Diffuse Malignant Pleural Mesothelioma: a Review

Hillerdal G. Surgical Treatment Of Diffuse Malignant Pleural Mesothelioma: A Review.  Annals of Respiratory Medicine, February 2010; 1(1):79-84

Review Article

Gunnar Hillerdal
Affiliations: Department of Lung Diseases, Karolinska University Hospital

ABSTRACT

For more than 30 years, extrapleural pneumonectomy (EPP) has been practiced in suitable patients with diffuse malignant pleural mesothelioma. There has been a general feeling among many surgeons that this prolongs life. However, despite nearly 2000 published patients treated with EPP, no randomized study has ever been performed. This is most unfortunate with a potentially life‐threatening, invalidating, and very costly therapy in today’s era of evidence medicine. In published materials on PPE, the mean overall survival varies between 9 and 23 months; for almost as many in whom pleurectomy only was performed, it is 9–26 months. Patients subjected to EPP are very heavily selected, and this might explain the better outcome when compared with non‐surgical groups of patients. In fact, a recently published study showed an overall survival with chemotherapy only of 22 months in a subgroup filling the criteria usually used for EPP. Thus, it is high time to perform a randomized study to prove the efficiency of EPP.

Keywords: pleural mesothelioma, surgery, survival, review, randomized study
Correspondence: Gunnar Hillerdal, Department of Lung Diseases, Karolinska University Hospital, SE 171 76 Stockholm, Sweden. Tel: (+46)‐8‐3177000; Fax: (+46)‐8‐337998; e‐mail: gunnar.hillerdal@karolinska.se

Management of Asthmatic Adolescents

Elers J, Backer V. Management of Asthmatic Adolescents.  Annals of Respiratory Medicine, February 2010; 1(1):61-68

Review Article

Jimmi Elers and Vibeke Backer
Affiliations: Respiratory and Allergy Research Unit, Bispebjerg Hospital

ABSTRACT

This review explores issues in the diagnosis and management of asthmatic adolescents. Asthma is the most common chronic disease in childhood/adolescence. Uncontrolled asthma impairs quality of life, reduces attendance in school, sport, and physical activities, and results in enormous economic health costs. Many asthmatic adolescents accept considerable asthma symptoms as being part of their disease, and are not aware of the degree of control that is possible. Low adherence to prescribed controller medications is a common problem because of concern about side‐effects. Smoking status must be considered in asthmatic adolescents. Proper inhalation technique must be viewed. Physician‐related factors include lack of knowledge of the etiology of asthma, insufficient communication, and underestimate of the prevalence of asthma, and/or overestimate of asthma control, resulting in inadequate prescription of controller medication. In order to improve asthma management, useful international guidelines have been developed. National Heart, Lung, and Blood Institute (NHLBI), British Thoracic Society (BTS), and Global Initiative for Asthma (GINA) guidelines, updated in 2008, provide physicians with a useful tool to manage asthma in adolescents in order to gain asthma control over time. Correct diagnosis, identifying comorbidities in asthmatic adolescents, and regular assessment of asthma control are essential to good management. Patients, parents, and physician must know what well‐controlled asthma looks like. Asthma management includes several therapy modalities: asthma education, environmental control, and pharmacotherapy. Implementation of the international guidelines by physicians treating adolescents with asthma is fundamental to reduce the incidence of uncontrolled asthma. The purpose of the current review is to assist physicians in improving asthma control among their adolescent patients.

Keywords: Asthma, adolescents, management, treatment, control, monitoring
Correspondence: Jimmi Elers, Respiratory and Allergy Research Unit, Bispebjerg Hospital, Bispebjerg bakke 23, DK‐2400 København NV, Denmark. Tel: (45)‐35313569; Fax: (45)‐35312179; e‐mail: jele0004@bbh.regionh.dk

Aspects of Spirometry and Inhaler Therapy in Frail Elderly Patients: Barriers and Alternatives

Allen S. Aspects of spirometry and inhaler therapy in frail elderly patients: barriers and alternatives.  Annals of Respiratory Medicine, February 2010; 1(1):53-59

Review Article

C Stephen Allen
Affiliations: The Royal Bournemouth Hospital and Centre of Postgraduate Medical Research and Education, Bournemouth University


ABSTRACT

As patients age beyond 65 years, the proportion who are unable to perform spirometry or learn to use an inhaler increases. This impedes the accurate assessment of respiratory diseases and reduces the opportunity for reliable self‐administered treatment. The most important barrier to spirometry and inhaler use in old age is cognitive impairment, and studies have shown that patients with a Mini Mental State Examination (MMSE) score of <24/30, and/or Abbreviated Mental Test Score (AMTS) <7/10, and/or inability to copy intersecting pentagons are not likely to perform spirometry reliably or learn to use any inhaler device consistently. Age itself is not the determining factor, and most elderly people with normal cognition can do spirometry and use an inhaler correctly. Patients with mild to moderate cognitive problems are the most vulnerable in this respect as their impairment can be easily missed, in which case alternative arrangements might not be made. The routine use of cognitive screening tests, such as the MMSE, helps to identify such patients. Patients unable to use an inhaler almost always need assisted inhaled therapy with an attendant using a spacer device or nebulizer. For some patients with mild cognitive impairment, partial spirometry, such as forced expiratory volume in 1 s (FEV1) alone or FEV1/FEV3 ratio, can be achieved and can be used cautiously as part of an overall clinical respiratory assessment. Slow (relaxed) vital capacity is not a useful alternative to forced vital capacity (FVC) for elderly patients with cognitive impairment.

Keywords: elderly, spirometry technique, inhaler technique, cognitive function
Correspondence: Stephen C Allen, The Royal Bournemouth Hospital and Centre of Postgraduate Medical Research and Education, Bournemouth University, Bournemouth, Dorset BH7 7DW, UK

A Systematic Review of Serial Peak Expiratory Flow Measurements in the Diagnosis of Occupational Asthma

Moore V, Jaakkola M, Burge PS. A Systematic Review Of Serial Peak Expiratory Flow Measurements In The Diagnosis Of Occupational Asthma.  Annals of Respiratory Medicine, February 2010; 1(1):31-44

Review Article

Vicky C Moore ¹, Maritta S Jaakkola ^{2 3}  and P Sherwood Burge ¹

Affiliations: ¹Occupational Lung Disease Unit, Birmingham Heartlands Hospital, Birmingham, UK; ²Respiratory Medicine Unit, Department of Internal Medicine, Institute of Clinical Medicine, University of Oulu, Oulu, Finland and ³Institute of Occupational and Environmental Medicine, University of Birmingham, Birmingham, UK

ABSTRACT

This paper systematically reviews literature on the application of serial peak expiratory flow (PEF) measurements in the diagnosis of occupational asthma and calculates summary estimates of the sensitivity, specificity, and feasibility of serial PEFs.

Methods
Papers were searched for on the Medline database via the PubMed website (http://www.ncbi.nlm.nih.gov/sites/entrez) and on the Birmingham Chest Clinic departmental website www.occupationalasthma.com from 2004 until April 2009 using the search terms “Peak flow AND occupational asthma” and “Peak flow AND work related asthma”. Abstracts were screened to select those justifying a full paper review. Papers used in the British Occupational Health Research Foundation (BOHRF) guidelines (current until June 2004) were also reviewed. Case studies and narrative reviews were excluded. Type of analysis, quality of paper, sensitivity, and specificity of serial PEFs compared with reference tests and return rates were documented. Results were pooled from all studies to produce overall estimates.

Results
A total of 80 abstracts were reviewed, leading to 23 full papers for further review plus 15 papers from the 2004 BOHRF review. Seven papers were excluded (mostly for duplicate data), leaving 31 papers for inclusion. The pooled sensitivity of serial PEF fulfilling minimum data quantity requirements for a diagnosis of occupational asthma was 82% (95% CI 76–90%), and the pooled specificity was 88% (95% CI 80–95%). Return rates were similar between PEFs requested through workplace studies (85%) and those requested in a clinical setting (78%), with 61% being interpretable for a diagnosis of occupational asthma from either setting.

Conclusion
Based on a systematic literature search, serial PEF measurement is a feasible, sensitive, and specific test for the diagnosis of occupational asthma, when potential sources of error are understood.

Keywords: occupational asthma, peak expiratory flow, sensitivity, specificity, return rate, adequate data quantity
Correspondence: Vicky Moore, Occupational Lung Disease Unit, Department of Respiratory Medicine, Birmingham Heartlands Hospital, Bordesley Green East, Birmingham B9 5SS, UK. Tel: (44)‐121‐424‐2745; Fax: (44)‐121‐772‐4259; e‐mail: vicky.c.moore@heartofengland.nhs.uk