Authors
Ajoy Samuel Mammena, Madhu Ka, M Raveendran Nairb, P Ravindrana
aPulmonary, Critical Care and Sleep Medicine Department, Cosmopolitan Hospital, Trivandrum;
bPulmonary Medicine Department, Rayo Mayo Clinic, Attingal, Trivandrum*
Abstract
exacerbations or attacks) may occur, even in people taking asthma treatment. When asthma is uncontrolled, these episodes are more frequent and more severe, and may be rarely fatal.
OBJECTIVES
Primary Objective: To assess risk factors for poor asthma control and breakthrough attacks.
Secondary Objectives:
1. To identify patients at risk of breakthrough attacks
2. To counsel the patient on self management program so that he/she himself will be able to predict an impending episode.
Study Design: Prospective Observational Analytical study.
Study Setting: Pulmonary, Critical care & Sleep Medicine, Cosmopolitan Hospital, Trivandrum, a tertiary care centre.
Time Frame of the Study: Time taken for the study was 1 year (October 2014 –October 2015)
Sample Size: A total of 200 patients were selected for the study.
Sampling Strategy: All cases of asthmatic exacerbations of whichever grade were included in the study.
Inclusion Criteria: All consenting patients attending the OPD of the department and the emergency department with acute asthma will be recruited
Exclusion Criteria: Non consenting patients, Children below 14 years of age, Adults above 40 years of age and smokers.
Method of Study: Before recruiting patients, all consenting patients were examined; PEFR estimated and administered the routine treatment to reverse the asthma attack. Informed consent was then obtained and the questionnaire (A locally adapted modified version of the questionnaire used in BRFSS/asthma survey adult questionnaire – 2006) was administered .In the questionnaire the consenting participants are made to answer ‘yes’ or ‘no’ to questions addressed in the questionnaire. The questions consist of the drugs used in asthma, the compliance, the triggering factors, socioeconomic factors and the economic burden of the treatment etc. Patients included in the study were those attending the OPD of the department and the emergency department with acute asthma. Non consenting patients, children below 14 years of age, adults above 40 years of age and smokers were excluded from the study. This study was conducted in accordance with the permission of institutional review board and ethical committee review board who accepted the protocol for the study. Data was entered in Microsoft Excel transported to statistical software (SPSS version 16 for Windows) and analyzed. This study will help to understand the risk factors for the poor asthma control and breakthrough attacks existing in the community so that it can be addressed
RESULTS AND STATISTICS
Major risk factors statistically significant among patients (n=200) were age (OR 17.3 CI: 7.3 – 40.8 ), BMI (OR 8.4 CI: 3.4 – 20.8), those with sneezing or itchy eyes (OR 2.4, CI: 1.9 – 2.9), passive smoking (smokers excluded from recruiting, OR 5.3, CI: 1.1 – 26.6), self confidence of not having a severe asthma attack (OR 15.6, CI: 7.3 – 33.1),difficult to control asthma(taking 3 or more drugs for asthma control(OR 20.6 ,CI: 9.7 – 43.5), going to bed in full stomach (OR 3.4, CI: 1.4 – 8.1). Less important risk factors were sex, taking less than 3 drugs, people taking drugs for allergic rhinitis and asthma, living near roadside, quarrel with family members, awareness regarding the use of medications.
DISCUSSION
All 200 recruited patients take medicines for their asthma control. Out of them, 31 (15.5%) take oral medicines alone, 100 (50.0%) take inhalers alone and 69 (34.5%) take both. 76(38%) had > 2 breakthrough attacks and 124(62%) had <2 breakthrough attacks in a year. Reasons for breakthrough attacks Age and breakthrough attacks: 68(63.6%) of people above 30 years of age had >2 breakthrough attacks in a year when compared to 8(8.6%) of those below 30 years of age. (OR, C.I = 17.3(7.3-40.8)) Body Mass Index (BMI) against breakthrough attacks: It is seen that the higher the BMI, the more chance of having an asthma breakthrough attack. (OR, C.I= 8.41(3.4-20.8)) Drug taking habits and breakthrough attacks One drug and breakthrough attacks – 21(16%) had >2 breakthrough attacks and 110(84%) had<2 breakthrough attacks in a year. More than one drug and breakthrough attacks – 55(79.7%) had >2 breakthrough attacks and 14(20.3%) had <2 breakthrough attacks in a year. Taking more than 3 drugs and breakthrough attacks – 55(79.7%) had >2 breakthrough attacks in a year while 14(20.3%) had <2 breakthrough attacks in a year. (OR, C.I = 20.5(9.7-43.5)) Increase in dose of medications used and breakthrough attacks – 67(35.5%) needed increase in dose of drugs for asthma control. (OR, C.I = 16.5(2.0 – 133.2)) Habits and breakthrough attacks Alcohol intake – 9(90%) of those who take alcohol had >2 breakthrough attacks in a year when compared to those who don’t take alcohol, who have 67(35.3%) risk. Going to bed after eating full stomach and breakthrough attacks – 16(64%) of those who go to bed after full stomach had >2 breakthrough attacks in a year when compared to 60(34.3%) of those who do not go to bed with full stomach. (OR, C.I = 3.4(1.4 – 8.2)) Exposures and breakthrough attacks Passive smoking – 6(75%) patients who have exposure to passive smoking had >2 breakthrough attacks in a year compared to 70(36.5%) of those who are not exposed to passive smoking. (OR, C.I = 5.3(1.1 – 26.6)) Exposure to biomass – Those who were exposed to biomass 19(51.4%) had >2 breakthrough attacks a year when compared to 57(37%) of those who were not exposed. Exposure to dust – 13 (48.1%) who were exposed to dust had > 2 breakthrough attacks in a year when compared to 63(36.4%) of those who were not exposed. Environmental pollution – 41(41.4%) of those living near road side had >2 breakthrough attacks and 35(34.7%) of those living near factory had >2 breakthrough attacks. Miscellaneous factors and breakthrough attacks Antihypertensive- 24(88.9%) of those who take anti hypertensives had >2 breakthrough attacks while 52(30.1%) of those not taking any anti hypertensives had >2 breakthrough attacks. Confident of not having severe asthma attack – Out of 100 persons who were confident that they will not have severe asthma, 65(65.7%) had >2 breakthrough attacks in a year while 34(34.3%) had <2 breakthrough attack in a year. (OR, C.I = 15.6(7.3 – 33.1)) Weight gain – Those who have gained weight 11(100%) had >2 breakthrough attacks in a year. (OR, C.I = 0.3(0.3-0.4)). Quarrel with spouse or family members – Out of 6 persons having quarrel with spouse or family members 3(50%) had >2 breakthrough attacks in a year. Financial problem – Out of 110 people having financial problem, 50(45.5%) had >2 breakthrough attacks in a year while 60(54.5%) had <2 breakthrough attacks in a year. (OR, C.I = 2.1(1.1 – 3.7). Awareness regarding use of devices – Out of 55 patients who had awareness about the use of devices 16(29.1%) had >2 breakthrough attacks in a year while 39(70.9%) had <2 breakthrough attacks in year. Out of 145 patients who did not have awareness about the use of devices, 60(41.4%) had >2 breakthrough attacks while 124 (62%) had <2 breakthrough attacks in a year. Dust allergy and breakthrough attacks -124(62%) patients had positive dust allergy history while 76(38%) did not have a history of dust allergy. It is seen that the relationship between those with history of dust allergy and breakthrough attacks is not statistically significant. (OR, CI = 114.7(15.4 – 852.9)). Sedatives – 9(90%) of those taking sedatives had >2 breakthrough attacks. 67(35.3%) of those not taking any sedatives had >2 breakthrough attacks (OR, C.I = 16.5(2.1 – 133.2)) Clinically and statistically significant study variables are presented in two tables (Table 1 & 2).
CONCLUSION
The major risk factors which were statistically and clinically significant for breakthrough attacks of asthma were age, BMI, taking 3 or more drugs for asthma control, those with history of sneezing or itchy eyes, going to bed in full stomach, passive smoking and confident of not having a severe asthma attack. These were highly significant for a breakthrough attack and can be classified as primary risk factors. There are some statistically significant parameters which were not clinically significant. They are history of food allergy, weight gain, financial problem, history of dust allergy. These were not clinically significant as some of them were part and parcel of asthma syndrome. Hence they can be classified as secondary risk factors. Certain parameters taken for the study were not found to be statistically significant. They are awareness regarding use of devices, quarrel with spouse or family members, exposure of biomass fuels, exposure of dust, environmental pollution.