The Diagnosis of Potentially Fatal Asthma in Hospitalized Adults: Patient Characteristics and Increased Severity of Asthma

doi:10.1378/chest.102.2.515

Chest

Volume 102, Issue 2, August 1992, Pages 515-518

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We evaluated various patient characteristics in patients hospitalized for asthma during 1987 to 1990. Potentially fatal asthma was identified in 26 of 87 adult patients (29.9 percent) hospitalized. Patients with PFA had increased frequency of prednisone use prior to hospitalization (p<0.001), shorter duration of symptoms before hospitalization (p<0.001), longer hospitalization (p<0.001), were more likely to have had three or more prior hospitalizations (p<0.001), and had reduced presenting peak expiratory flow rates (p<0.05). Major psychiatric diagnoses and noncompliance were significantly related to PFA cases. The diagnosis of PFA identifies a higher risk patient with asthma. The data suggest that at the time of hospitalization the PFA patient has had a shorter recognized prodrome of increased respiratory symptoms, reduced peak expiratory flow rates and greater likelihood of major psychiatric disease or noncompliance. Effective ambulatory control of PFA and non-PFA is advisable with earlier use and higher dosages of oral corticosteroids.

Section snippets

Patient Identification

A computer-generated list of patients ages 45 years and less who were discharged with the diagnosis of asthma from an adult tertiary care hospital (Northwestern Memorial Hospital, Chicago, Ill) was obtained. The inclusive dates were October, November and December for the years 1987, 1988, 1989 and 1990 because of the increased number of respiratory infections and asthma exacerbations during those months in the Chicagoland region.³⁷ Patients included needed to have the principal diagnosis of

RESULTS

There were 87 cases suitable for evaluation consisting of 61 non-PFA and 26 PFA cases. No asthma fatalities occurred during the study period. The number of criteria for the diagnosis of PFA in 26 cases is presented in Table 1. A comparison of PFA and non-PFA cases is listed in Table 2. Most patients were receiving 12-h theophylline preparations and inhaled β-adrenergic agonists. In the 26 PFA patients, 22 (84.6 percent) were using theophylline and 20 (76.9 percent), β-adrenergic agonists prior

DISCUSSION

The morbidity and mortality from asthma have been increasing over the last decade.7, 8, 9, 10 Also of interest is the observation that the asthma mortality rate is disproportionately higher in specific urban areas.⁸ The reasons for this are not clear and are most likely multifactorial.⁸ In 1988, four diagnostic criteria were proposed identifying patients with PFA.²² Based on observations from subsequent clinical experience, these high-risk patients required intensive anti-asthma therapy that

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Medication Adherence in Patients With Severe Asthma Prescribed Oral Corticosteroids in the U-BIOPRED Cohort
2021, Chest
Citation Excerpt :
There was poor agreement between the methods for determining medication adherence (κ test, –0.106; 95% CI, –0.266 to 0.054; P = .268). Poor adherence to oral corticosteroids is a major contributory factor to poor symptom control and hospitalizations5,23; poor adherence to ICS has been linked to death from asthma.24 Despite recommendations that medication adherence should be routinely checked in primary care,25 the optimal method to assess adherence is not clear.
Although estimates of suboptimal adherence to oral corticosteroids in asthma range from 30% to 50%, no ideal method for measurement exists; the impact of poor adherence in severe asthma is likely to be particularly high.
What is the prevalence of suboptimal adherence detected by self-reporting and direct measures? Is suboptimal adherence associated with disease activity?
Data were included from individuals with severe asthma taking part in the U-BIOPRED (Unbiased Biomarkers for the Prediction of Respiratory Disease Outcomes) study and prescribed daily oral corticosteroids. Participants completed the Medication Adherence Report Scale, a five-item questionnaire used to grade adherence on a scale from 1 to 5, and provided a urine sample for analysis of prednisolone and metabolites by liquid chromatography-mass spectrometry.
Data from 166 participants were included in this study: mean (SD) age, 54.2 (± 11.9) years; FEV₁, 65.1% (± 20.5%) predicted; female, 58%; 37% completing the Medication Adherence Report Scale reported suboptimal adherence; and 43% with urinary corticosteroid data did not have detectable prednisolone or metabolites in their urine. Good adherence by both methods was detected in 49 of the 142 (35%) of participants in whom both methods were performed; adherence detection did not match between methods in 53%. Self-reported high adherers had better asthma control and quality of life, whereas directly measured high adherers had lower blood eosinophil levels.
Low adherence is a common problem in severe asthma, whether measured directly or self-reported. We report poor agreement between the two methods, suggesting some disassociation between self-assessment of medication adherence and regular oral corticosteroid use, which suggests that each approach may provide complementary information in clinical practice.
Benefits of subspecialty adherence after asthma hospitalization and patient perceived barriers to care
2017, Annals of Allergy, Asthma and Immunology
Citation Excerpt :
Asthma is a chronic potentially life-threatening disease characterized by inflammation of the airways leading to reversible airway obstruction.1–3
Comparative studies have demonstrated that asthma education to pediatric patients decreases average hospital usage and that allergy specialists provide stronger asthma education and more improved outcomes.
To evaluate the real-world benefits of allergy subspecialty involvement outside inpatient consultation and the impediments for patients in establishing allergy subspecialty care.
The study population was composed mostly of minority children 0 to 18 years old seen at a large university-affiliated stand-alone children's hospital who had a hospital discharge diagnosis of asthma from 2009 to 2013. The retrospective portion of the study compared all variables pertaining to asthma, teaching, and discharge reconciliation for the following subgroups: patients recommended to allergy and immunology (AI) follow-up who adhered to the appointment (adherent), patients recommended to AI follow-up who did not adhere (nonadherent), and patients not recommended to AI follow-up (non-referred). In the phone interview portion of the study, the nonadherent patients were contacted to identify barriers to AI follow-up.
Of the referred sample, the adherent group had significantly fewer visits to the pediatric intensive care unit, days in the pediatric intensive care unit, and days in the hospital. Providing more specific hospital discharge instructions increased AI follow-up and hospital teaching given on the baseline admission decreased hospital visits. Phone interviews showed that nonadherent patients most commonly missed follow-up because the parents believed it unnecessary because their child showed acute improvement or from advice from their primary care physician.
These results showed improvement in outcomes for patients who attended AI follow-up and specifically identified key barriers that could be addressed in a standardized form to prevent nonadherence in the future.
Asthma exacerbations: Origin, effect, and prevention
2011, Journal of Allergy and Clinical Immunology
Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children in the Western world. Despite advances in asthma management, acute exacerbations continue to occur and impose considerable morbidity on patients and constitute a major burden on health care resources. Respiratory tract viruses have emerged as the most frequent triggers for exacerbations in both children and adults; however, the mechanisms underlying these remain poorly understood. More recently, it has become increasingly clear that interactions might exist between viruses and other triggers, increasing the likelihood of an exacerbation. In this article we begin with an overview of the health, economic, and social burden that exacerbations of asthma carry with them. This is followed by a review of the pathogenesis of asthma exacerbations, highlighting the various triggers responsible and multiple interactions that exist between them. The final section first addresses what preventative measures are currently available for asthma exacerbations and subsequently examines which of the new treatments in development might lessen the burden of exacerbations in the future.
Psychologic distress and maladaptive coping styles in patients with severe vs moderate asthma
2010, Chest
Though several biologic factors have been suggested to play a role in the development and persistence of severe asthma, those associated with psychologic factors remain poorly understood. This study assessed levels of psychologic distress and a range of disease-relevant emotional and behavioral coping styles in patients with severe vs moderate asthma.
Eighty-four patients (50% women, mean [M] age 46 years) with severe (n = 42) and moderate (n = 42) asthma were recruited. Severe asthma was defined according to American Thoracic Society criteria. Patients underwent demographic and medical history interviews and pulmonary function and allergy testing. Patients also completed questionnaires measuring asthma symptoms and the Millon Behavioral Medicine Diagnostic Inventory, which assesses psychologic distress and emotional/behavioral coping factors that influence disease progression and treatment.
After adjustment for covariates and applying a correction factor that reduced the significant P level to < .01, patients with severe vs moderate asthma reported experiencing more psychologic distress, including worse cognitive dysfunction (F = 6.72, P < .01) and marginally worse anxiety-tension (F = 4.02, P < .05). They also reported worse emotional coping (higher illness apprehension [F = 9.57, P < .01], pain sensitivity [F = 10.65, P < .01], future pessimism [F= 8.53, P < .01], and interventional fragility [F = 7.18, P < .01]), and marginally worse behavioral coping (more functional deficits [F = 5.48, P < .05] and problematic compliance [F = 4.32, P < .05]).
Patients with severe asthma have more psychologic distress and difficulty coping with their disease, both emotionally and behaviorally, relative to patients with moderate asthma. Future treatment studies should focus on helping patients with severe asthma manage distress and cope more effectively with their illness, which may improve outcomes in these high-risk patients.
Psychological and self-management factors in near-fatal asthma
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Citation Excerpt :
Studies that have tried to solve these methodological limitations, using a control group and standardized instruments to assess psychological characteristics, are scarce and their results do not always support an association between psychological factors and NFA [9]. Some studies did not find differences between NFA patients and non-NFA patients in depression or anxiety [10–12], knowledge about illness management [13,14], or adherence to pharmacological treatment [13,15], whereas other investigations showed a higher prevalence of anxiety [8] and alexithymia [16,17], and lower levels of medication adherence [18] in NFA patients. Different factors could be involved in these discrepant results.
Several studies that have analyzed differences in psychological and self-management variables between patients with a near-fatal asthma (NFA) attack and asthmatics without a NFA attack (non-NFA) have shown conflicting results, probably due to the heterogeneity of the events studied and the selection of comparison groups.
To determine whether NFA patients, in stable situation, have greater psychological morbidity and worse self-management behavior than non-NFA patients with similar sociodemographic and clinical characteristics.
A sample of 44 NFA patients (mean=5.65 years after the NFA episode) and 44 non-NFA patients matched for age, sex, and asthma severity was assessed. All patients were in clinical stable situation. Information about sociodemographic, clinical, functional, and morbidity variables was collected for each patient, and the Cognitive Depression Inventory, the Trait-Anxiety Scale, the Toronto Alexithymia Scale, the Practical Knowledge of Self-management questionnaire, and the Medication Adherence scale were administered.
In comparison with non-NFA patients, NFA patients showed higher levels of trait-anxiety (23.84 vs. 16.86; P=.001) and more difficulties describing and communicating feelings (11.36 vs. 8.90; P=.002). NFA and non-NFA patients did not differ in self-management variables. After adjustment in multivariate logistic regression analysis for age, sex, and asthma severity, significant differences were observed between NFA and control group patients in marital status [odds ratio (OR)=0.26; P=.017; 95% confidence interval (CI)=0.09–0.78], prescribed dose of inhaled corticoids (OR=4.48; P=.006;95% CI=1.53–13.09), and trait-anxiety (OR=1.071;P=.025;95%CI=1.01–1.14).
NFA patients show higher psychological morbidity than non-NFA, even years after the NFA episode.
An exploration of factors underlying asthma care and morbidity: A factor analysis of clinical variables
2008, Journal of Allergy and Clinical Immunology
Citation Excerpt :
Socioeconomic factors such as income or poverty status,45 educational level,46 not having a personal physician,38 or insurance status13 have been shown to be associated with asthma morbidity. Behavioral factors associated with increased asthma morbidity include smoking,15 illicit drug use,47 psychiatric factors,9,48 lack of social support,4 crowding,45 or language barriers.49 Compared with socioeconomic or demographic factors, there is more variability in how psychosocial variables are defined and measured.46,50-55
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To use exploratory factor analysis to define underlying factors operative in asthma treatment and morbidity, and characterize their interrelationships and association with 6-month morbidity.
Children (n = 197) presenting to an emergency department for an acute asthma episode were followed for 6 months (follow-up data available for 84%). Baseline data included demographics, asthma history, current and past symptoms, and current treatment and management. Factor analysis was used to summarize the underlying relationships between variables. Correlations between factors and 6-month morbidity were calculated.
Factor analysis revealed that 4 factors provided a parsimonious summary of the variables. The factors were labeled current symptom severity, quality of care indicators, previous severe disease, and sociodemographic factors. Positive correlations were observed between quality of care, current symptom severity, and previous severe disease. The factor describing sociodemographic factors was inversely related to current symptom severity and quality of care. Previous severe disease significantly predicted 6-month morbidity.
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View all citing articles on Scopus

Supported by USPHS grant AI11403 and the Ernest S. Bazley Grant to Northwestern University and Northwestern Memorial Hospital.

Manuscript received August 19; revision accepted November 27.

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Chest

Clinical InvestigationsThe Diagnosis of Potentially Fatal Asthma in Hospitalized Adults: Patient Characteristics and Increased Severity of Asthma

Section snippets

Patient Identification

RESULTS

DISCUSSION

J Allergy

Chest

J Allergy Clin Immunol

Chest

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Br J Dis Chest

J Allergy Clin Immunol

J Allergy Clin Immunol

The principles and practice of medicine

The pathology of bronchial asthma

Arch Intern Med

Deaths from asthma in England and Wales

Thorax

A clinical and pathological study of fatal cases of status asthmaticus

Thorax

Fatal bronchial asthma: a series of fifteen cases with a review of the literature

Thorax

National survey of prevalence of asthma among children in the United States, 1976 to 1980

Pediatrics

Changing patterns of asthma mortality, identifying target populations at high risk

JAMA

Reflections on the rise in asthma morbidity and mortality

JAMA

Increases in deaths from asthma

Ann Allergy

Changing patterns of asthma hospitalization among children: 1979 to 1987

JAMA

Worldwide differences in asthma prevalence and mortality: why is asthma mortality so low in the USA?

Chest

Clinical Investigations
The Diagnosis of Potentially Fatal Asthma in Hospitalized Adults: Patient Characteristics and Increased Severity of Asthma