BACKGROUND: Although some factors associated with asthma symptom deterioration and risk of exacerbation have been identified, these are not yet fully characterised. We conducted a clinical modelling and simulation study to understand baseline factors affecting symptom control, reliever use and exacerbation risk in patients with moderate-severe asthma during follow-up on regularly dosed inhaled corticosteroid (ICS) monotherapy, or ICS/long-acting beta2-agonist (LABA) combination therapy.
METHODS: Individual patient data from randomised clinical trials (undertaken between 2001 and 2019) were used to model the time course of symptoms (n = 7593), patterns of reliever medication use (n = 3768) and time-to-first exacerbation (n = 6763), considering patient-specific and extrinsic factors, including treatment. Model validation used standard graphical and statistical criteria. Change in symptom control scores (Asthma Control Questionnaire 5 [ACQ-5]), reduction in reliever use and annualised exacerbation rate were then simulated in patient cohorts with different baseline characteristics and treatment settings.
RESULTS: Being a smoker, having higher baseline ACQ-5 and body mass index affected symptom control scores, reliever use and exacerbation risk (p < 0.01). In addition, low forced expiratory volume in 1 s percent predicted, female sex, season and previous exacerbations were found to contribute to a further increase in exacerbation risk (p < 0.01), whereas long asthma history was associated with more frequent reliever use (p < 0.01). These effects were independent from the underlying maintenance therapy. In different scenarios, fluticasone furoate (FF)/vilanterol was associated with greater reductions in reliever use and exacerbation rates compared with FF or fluticasone propionate (FP) alone or budesonide/formoterol, independently from other factors (p < 0.01).
CONCLUSIONS: This study provided further insight into the effects of individual baseline characteristics on treatment response and highlighted significant differences in the performance of ICS/LABA combination therapy on symptom control, reliever use and exacerbation risk. These factors should be incorporated into clinical practice as the basis for tailored management of patients with moderate-severe asthma.
In this study we quantified how individual baseline patient characteristics at the start of treatment influence the response to regular maintenance medication. Specifically, using computer modelling and simulations based on data from individual patients enrolled into clinical trials in moderate–severe asthma, we predicted how much reliever inhaler they need, how well they rate their asthma control, and how likely an asthma attack (exacerbation) is to occur within the next 12 months. Simulation scenarios were then implemented to evaluate opportunities to improve and personalise real-life management of patients in clinical practice. Considering symptom control level, reliever use and other patient-specific factors at the start of treatment, we assessed how well maintenance therapy with inhaled corticosteroids/bronchodilators contributes to symptom improvement and/or reduction in the risk of asthma attacks. These scenarios show that current smokers, people with higher asthma symptom scores, who are obese, and have a longer history of asthma tend to use their reliever inhalers more often. Moreover, this was linked to a higher risk of having an asthma attack and worse symptom control. This pattern appears to compensate in most cases for the effect of the same baseline factors on symptom control. Switching patients who are not responding well to initial treatment with the inhaled corticosteroid, fluticasone propionate, to fluticasone furoate/vilanterol resulted in a significantly greater reduction in reliever inhaler use and risk of asthma attack, compared with those switched to budesonide/formoterol. These findings highlight the importance of tailored choices for optimal management of patients with moderate–severe asthma.

BACKGROUND: Cigar use among adults in the United States has remained relatively stable in the past decade and occupies a growing part of the tobacco marketplace as cigarette use has declined. While studies have established the detrimental respiratory health effects of cigarette use, the effects of cigar use need further characterization. In this study, we evaluate the prospective association between cigar use, with or without cigarettes, and asthma exacerbation.
METHODS: We used data from Waves 1-5 (2013-2019) of the Population Assessment of Tobacco and Health Study to run generalized estimating equation models examining the association between time-varying, one-wave-lagged cigarette and cigar use and self-reported asthma exacerbation among US adults (18+). We defined our exposure as non-established (reference), former, exclusive cigarette, exclusive cigar, and dual use. We defined an asthma exacerbation event as a reported asthma attack in the past 12 months necessitating oral or injected steroid medication or asthma symptoms disrupting sleep at least once a week in the past 30 days. We adjusted for age, sex, race and ethnicity, household income, health insurance, established electronic nicotine delivery systems use, cigarette pack-years, secondhand smoke exposure, obesity, and baseline asthma exacerbation.
RESULTS: Exclusive cigarette use (incidence rate ratio (IRR): 1.26, 95% confidence interval (CI): 1.03-1.54) and dual use (IRR: 1.41, 95% CI: 1.08-1.85) were associated with a higher rate of asthma exacerbation compared to non-established use, while former use (IRR: 1.01, 95% CI: 0.80-1.28) and exclusive cigar use (IRR: 0.70, 95% CI: 0.42-1.17) were not.
CONCLUSIONS: We found no association between exclusive cigar use and self-reported asthma exacerbation. However, exclusive cigarette use and dual cigarette and cigar use were associated with higher incidence rates of self-reported asthma exacerbation compared to non-established use. Studies should evaluate strategies to improve cigarette and cigar smoking cessation among adults with asthma who continue to smoke.

BACKGROUND: Asthma exacerbation (AE) is a significant clinical problem during pregnancy. This study aimed to identify maternal and perinatal outcomes associated with AE during pregnancy.
METHODS: We conducted a retrospective cohort study using the Peking University Third Hospital database from January 1, 2013 to December 31, 2020. We compared the clinical characteristics and maternal, perinatal and offspring outcomes of asthma with and without exacerbations among women who delivered during this period. The primary outcome was hypertensive disorders of pregnancy (HDP). Univariable and multivariable logistic regression analyses were used to analyze the clinical characteristics of AE during pregnancy and the association between AE and adverse maternal and perinatal outcomes.
RESULTS: The prevalence of asthma during pregnancy increased from 0.52% in 2013 to 0.98% in 2020. Of the 220 patients with asthma during pregnancy included in the study, 105 experienced AE during pregnancy: 62.9% (n = 66) had mild-to-moderate AE and 37.1% (n = 39) had severe AE. Pregnant women with allergic rhinitis have a higher risk of AE during pregnancy. Women who experienced AE were more at risk for hypertensive disorders of pregnancy than women who did not experience any exacerbation (12.4%vs3.5%, p < 0.05).
CONCLUSIONS: The prevalence of asthma among pregnant women in China is on the rise. There is a notable correlation between pregnant women who suffer from allergic rhinitis and an elevated risk of AE during pregnancy. Studies have shown that AE during pregnancy are associated with an increased risk of hypertensive disorders of pregnancy.

Proton-pump inhibitors (PPI) are empirically used to treat asthma symptoms such as cough; however, the effectiveness of PPI on asthma exacerbation has not been well studied. We aimed to evaluate the relationship between PPI use and asthma exacerbation using a large administrative claims database in Japan. We conducted a self-controlled case series using the JMDC Claims Database (JMDC, Inc., Tokyo, Japan). The cases included adult patients with asthma who were prescribed PPI and experienced at least one outcome event between January 2015 and December 2019. The primary outcome was the composite outcome of hospital admissions and unscheduled outpatient clinic visits due to asthma exacerbation. We also conducted stratified analyses based on PPI generation, the presence of gastroesophageal reflux disease (GERD), asthma severity, and the number of allergic comorbidities. A total of 7379 eligible patients were included in the study. PPI prescription was associated with a decrease in the composite outcomes (incidence rate ratio, 0.90; 95% confidence interval, 0.87-0.93). However, PPI prescriptions did not affect the outcomes of hospital admissions (incidence rate ratio, 1.34; 95% confidence interval, 0.86-2.10). Stratified analyses based on PPI generation, the presence of GERD, asthma severity (except for severe asthma), and the number of allergic comorbidities yielded consistent results. PPI use was associated with a moderate decrease in asthma exacerbation, regardless of the patient profile. However, this effect was not as strong as the prevention of hospital admissions, and outcome events were not prevented in patients with severe asthma.

Introduction Viruses are the most common triggering factors for asthma exacerbation during the autumn and winter seasons. Viruses, such as influenza A and rhinovirus, play a major role in the occurrence of severe exacerbation of asthma. This association between viral infection and asthma exacerbation in children is a result of the antiviral response of the immune system and various anti-inflammatory phenomena. In this work, we aimed to identify the virological profile of asthma exacerbation in children and analyze the correlation between viral infection type and the severity of exacerbation. Materials and methods This retrospective study was conducted from January 2016 to January 2024. The study included children hospitalized for asthma exacerbation associated with signs of viral-like respiratory infection with positive virological testing by multiplex real-time polymerase chain reaction or rapid test in the case of influenza A or respiratory syncytial virus (RSV). Data analysis was performed with Microsoft Excel and SPSS software using a previously established data collection sheet Results Thirty cases were collected for the study period. The mean age of the patients was 4 years and 8 months, with a male-to-female ratio of 3.3. Eighteen patients were known to have asthma, of which nine had uncontrolled asthma, and exacerbation was inaugural in 12 patients. Viral shedding was found in 14 patients. A viral agent was found in all patients, with coinfection of two or more viruses in three patients. The viruses found were influenza A (18 cases), coupled rhinovirus/enterovirus (eight cases), RSV (eight cases), human metapneumovirus (three patients), and parainfluenza type IV in only one inaugural patient. Asthma exacerbation was severe in 20 patients, moderate in eight patients, and two patients had severe acute asthma requiring intensive care management. We noted a higher frequency of severe exacerbation among those with an influenza A viral infection. All patients with RSV infection exhibited moderate exacerbation. No other significant correlation between asthma severity and other types of viruses was found. Conclusions Our results demonstrate the major role played by viruses in triggering asthma exacerbation, primarily influenza virus, followed by enterovirus, rhinovirus, RSV, and metapneumovirus. Larger-scale studies should be carried out to establish a more complete virological profile and further investigate the viral factor in the management of asthma in children.

BACKGROUND: Asthma is the most prevalent chronic respiratory condition in children. An asthma exacerbation (AE) is a frequent reason for emergency department (ED) visits. An important step in the management of a moderate to severe AE is the administration of systemic corticosteroids (SCS) within 1 h after ED presentation. This study aimed to determine the timing of SCS administration and correlate this with the length of stay and oxygen therapy duration and to explore factors predicting timely administration.
METHODS: This study used a retrospective multicenter observational design based on electronic medical records review. Children aged < 18 years, presenting to the ED with a moderate to severe AE were included.
RESULTS: 205 patients were included. Only 28 patients received SCS within 60 min after ED arrival. The median time to SCS administration was 169 min (Q1 92-Q3 380). A correlation was found between timing and oxygen treatment duration (r = 0.363, p < 0.001) and length of stay (r = 0.368, p < 0.001). No patient characteristics predicted timely SCS administration.
CONCLUSIONS: Three in four children who presented with a moderate to severe AE at the ED did not receive SCS within the first hour. A prolonged timing of SCS administration correlated with a prolonged length of stay and extended need for oxygen support.

BACKGROUND: Asthma is one of the most common chronic respiratory diseases with inflammatory involvement and has a high burden worldwide. This study aimed to determine the effect of Thymus vulgaris (TV) on cough in children between 5 and 12 years old with mild to moderate asthma exacerbation.
METHODS: In this randomized, triple-blind clinical trial, 60 children between the ages of 5 and 12 with asthma exacerbations were randomly divided into two groups. The intervention group (n = 30) was given TV powder at a dose of 20 mg/kg every 8 hours, prepared as syrup, along with routine medical treatment for a week, and the control group (n = 30) received only routine medical treatment with placebo syrup. At the end of the week, clinical and laboratory symptoms, and spirometry data were re-recorded for both groups. Finally, the recorded factors were compared and statistically analyzed.
RESULTS: The results showed that after the intervention, activity-induced cough reduced, and difference was statistically significant between the two groups (p = 0.042), but the reduction in wheezing and breathlessness had no statistically significant difference. Spirometry data showed a significant difference in forced expiratory volume in 1 second (FEV1) between the two groups after intervention (p = 0.048), but this difference was not significant in FEV1/FVC (forced vital capacity), peak expiratory flow (PEF), and forced expiratory flow at 25-75% of the vital capacity (FEF25-75%).
CONCLUSIONS: The results show that TV syrup may be useful as an adjuvant treatment in children with asthma exacerbations.

To examine the numbers and characteristics of children affected by asthma exacerbation in Chengdu, China, before and after the COVID-19 pandemic to inform efforts to manage childhood asthma in the post epidemic era.
Data were retrospectively collected from children admitted for asthma exacerbation to Chengdu Women and Children\'s Central Hospital between January 2017 and December 2022. Rates of hospitalization, ages of the affected children, comorbidities and infections, and relationships between hospitalization and seasonal or environmental factors were examined before and after the epidemic.
Fewer children were hospitalized for asthma exacerbation, yet more hospitalized children had severe exacerbation after the epidemic than before. Rates of hospitalization varied considerably with time of year, and the timing of peak hospitalizations differed before and after the epidemic. Only before the epidemic, rates of hospitalization for asthma exacerbation were positively correlated with humidity. Infants made up a smaller proportion of hospitalized children after the epidemic than before, with preschool children accounting for most hospitalizations after the epidemic. The proportion of children hospitalized for asthma exacerbation who also had pneumonia was significantly smaller after the epidemic than before. Conversely, the proportion of children hospitalized for asthma exacerbation who also had allergic diseases was significantly greater after the epidemic than before.
The epidemiology of asthma exacerbation in children changed after the epidemic. Future efforts to manage the condition in the paediatric population should focus on severe asthma exacerbation, prevention and management of allergic diseases, and the influence of meteorological and environmental factors.

UNASSIGNED: The evidence for a causal relationship between high-level ozone (O3) exposure and acute exacerbation of asthma among adults is limited, and the conclusions are less definitive.
UNASSIGNED: Here we collected the daily data on asthma cases, O3 exposure, and meteorological factors from 2010 to 2016 in Shijiazhuang, China. We investigated the risk of asthma exacerbation associated with high-level ozone exposure using a polynomial distributed lag model (PDLM). Using a generalized additive model (GAM), we estimated the interactive effects between O3 and other pollutants as well as meteorological factors on asthma exacerbation.
UNASSIGNED: A total of 7270 patients with asthma were enrolled from 22 governmental hospitals in 13 counties. Each 10 μg/m3 increase in O3 concentration on the exacerbation of asthma was associated with a 1.92% (95% CI = 0.80-3.03%) higher risk of asthma exacerbation on day lag 7. The cumulative risk of O3 on asthma exacerbation increased by 18.9% (95% CI = 12.8-25.4%) on the 14th day. High consecutive levels of O3 increase the risk of asthma exacerbation, and the interactive effect of O3 and sulfur dioxide (SO2) appears before the exacerbation onset.
UNASSIGNED: These findings suggested that O3 should be an important risk factor for asthma exacerbation, and health benefits in reducing asthma exacerbation risk would be gained with continued efforts to improve the air quality in China.

A written action plan (WAP) for managing asthma exacerbations is recommended.
We aimed to compare the effect on unscheduled medical contacts (UMCs) of a digital action plan (DAP) accessed via a smartphone web app combined with a WAP on paper versus that of the same WAP alone.
This randomized, unblinded, multicenter (offline recruitment in private offices and public hospitals), and parallel-group trial included children (aged 6-12 years) or adults (aged 18-60 years) with asthma who had experienced at least 1 severe exacerbation in the previous year. They were randomized to a WAP or DAP+WAP group in a 1:1 ratio. The DAP (fully automated) provided treatment advice according to the severity and previous pharmacotherapy of the exacerbation. The DAP was an algorithm that recorded 3 to 9 clinical descriptors. In the app, the participant first assessed the severity of their current symptoms on a 10-point scale and then entered the symptom descriptors. Before the trial, the wordings and ordering of these descriptors were validated by 50 parents of children with asthma and 50 adults with asthma; the app was not modified during the trial. Participants were interviewed at 3, 6, 9, and 12 months to record exacerbations, UMCs, and WAP and DAP use, including the subjective evaluation (availability and usefulness) of the action plans, by a research nurse.
Overall, 280 participants were randomized, of whom 33 (11.8%) were excluded because of the absence of follow-up data after randomization, leaving 247 (88.2%) participants (children: n=93, 37.7%; adults: n=154, 62.3%). The WAP group had 49.8% (123/247) of participants (children: n=45, 36.6%; mean age 8.3, SD 2.0 years; adults: n=78, 63.4%; mean age 36.3, SD 12.7 years), and the DAP+WAP group had 50.2% (124/247) of participants (children: n=48, 38.7%; mean age 9.0, SD 1.9 years; adults: n=76, 61.3%; mean age 34.5, SD 11.3 years). Overall, the annual severe exacerbation rate was 0.53 and not different between the 2 groups of participants. The mean number of UMCs per year was 0.31 (SD 0.62) in the WAP group and 0.37 (SD 0.82) in the DAP+WAP group (mean difference 0.06, 95% CI -0.12 to 0.24; P=.82). Use per patient with at least 1 moderate or severe exacerbation was higher for the WAP (33/65, 51% vs 15/63, 24% for the DAP; P=.002). Thus, participants were more likely to use the WAP than the DAP despite the nonsignificant difference between the action plans in the subjective evaluation. Median symptom severity of the self-evaluated exacerbation was 4 out of 10 and not significantly different from the symptom severity assessed by the app.
The DAP was used less often than the WAP and did not decrease the number of UMCs compared with the WAP alone.
ClinicalTrials.gov NCT02869958; https://clinicaltrials.gov/ct2/show/NCT02869958.