Graham Douglas

British guideline on the management of asthma: A national clinical guideline

These guidelines have been replaced by British Guideline on the Management of Asthma. A national clinical guideline. Superseded By 2012 Revision Of 2008 Guideline: British Guideline on the Management of Asthma. Thorax 2008 May; 63(Suppl 4): 1–121.

Outcomes of Childhood Asthma and Wheezy Bronchitis. A 50-Year Cohort Study

RATIONALE Cohort studies suggest that airflow obstruction is established early in life, manifests as childhood asthma and wheezy bronchitis, and continues into early adulthood. Although an association between childhood asthma and chronic obstructive pulmonary disease (COPD) in later life has been demonstrated, it is unclear if childhood wheezy bronchitis is associated with COPD. OBJECTIVES To investigate whether childhood wheezy bronchitis increases the risk of COPD in the seventh decade. METHODS A cohort of children recruited in 1964 at age 10 to 15 years, which was followed up in 1989, 1995, and 2001, was followed up again in 2014 when at age 60 to 65 years. Discrete time-to-event and linear mixed effects models were used. MEASUREMENTS AND MAIN RESULTS FEV1 and FVC were measured. COPD was defined as post-bronchodilator FEV1/FVC <0.7. Childhood wheezing phenotype was related to 1989, 1995, 2001, and 2014 spirometry data. Three hundred thirty subjects, mean age 61 years, were followed up: 38 with childhood asthma; 53 with childhood wheezy bronchitis; and 239 control subjects (of whom 57 developed adulthood-onset wheeze between ages 16 and 46 yr). In adjusted multivariate analyses, childhood asthma was associated with an increased risk of COPD (odds ratio, 6.37; 95% confidence interval, 3.73-10.94), as was childhood wheezy bronchitis (odd ratio 1.81; 95% confidence interval, 1.12-2.91). The COPD risk increased with childhood asthma, and wheezy bronchitis was associated with reduced FEV1 that was evident by the fifth decade and not an accelerated rate of FEV1 decline. In contrast, adulthood-onset wheeze was associated with accelerated FEV1 decline. CONCLUSIONS Childhood wheezy bronchitis and asthma are associated with an increased risk of COPD and reduced ventilatory function.

The prevalence of adult onset wheeze: longitudinal study

In contrast to wheeze in childhood, less is known about the prevalence of and factors associated with wheeze in adulthood. We studied the onset of wheezing in adults who had had no respiratory symptoms as children. A 1964 random community survey in Aberdeen of 2511 children aged 10-14 years identified 121 children with asthma and 167 with wheeze with infection. The outcome at age 34-40 years of these children with wheeze, together with that of 167 children selected from those who were asymptomatic, has been described.1 In 1995 we tried to contact the 2056 individuals (now aged 39-45 years) who had had no childhood wheezing; 1799 subjects were traced. We posted questionnaires about symptoms, smoking, and employment to 1758 surviving subjects, of whom 1542 (87.7%) responded (75.0% of 2056). Attacks of wheezing ever …

British guidelines on the management of asthma: what's new for 2011?

Since 1999 the British Guidelines on the Management of Asthma have been produced jointly by the British Thoracic Society (BTS) and Scottish Intercollegiate Guideline Network (SIGN) using a rigorous evidence-based methodology. Sections within the guideline have been revised regularly, with the Pharmacological Management section being updated nearly every year. We believe this has resulted in a ‘living guideline’ that is responsive to new research and is current for clinicians. For 2011, two new sections have been added on Monitoring and Control and Asthma in Adolescents. There is increasing awareness that current control is a good predictor of future exacerbations.1 There is also some evidence that biomarkers might be useful in predicting future asthma control.2 Perhaps not unexpectedly, this new section is able to identify more areas where evidence is lacking than where evidence can be found to support practice. In adults and children there is very little evidence that addition of biomarkers to validated symptom scores improves asthma control; indeed, most of the evidence points towards biomarkers not assisting in the management of asthma. Such biomarkers include peak expiratory flow, spirometry, bronchial hyper-responsiveness and exhaled nitric oxide (Feno). Although not …

Corynebacterium afermentans subsp. lipophilum : Multiple abscess formation in brain and liver

Corynebacterium afermentans, a species recently identified, has previously been isolated from human blood cultures. We report the case of a previously healthy 39-year-old man who developed a brain abscess and a liver abscess due to Corynebacterium afermentans subsp. lipophilum. The liver abscess penetrated through the diaphragm to cause pleural effusion and periostitis of the ribs. We believe this is the first reported case of disseminated infection with abscess formation due to this organism.

Long acting β2 agonists in adult asthma

A 30 year old man with asthma, previously well controlled with inhaled beclometasone 100 μg (two puffs twice daily) and salbutamol (as required), presented to his general practitioner with a three month history of increasing breathlessness and wheeze, primarily overnight and in the mornings. He was a non-smoker with no obvious trigger factors. He reported using his inhaler as prescribed, and his technique was satisfactory. He had no other medical history and no symptoms of allergic rhinitis. His general practitioner suggested a further inhaler containing a long acting β2 agonist (LABA), but the patient expressed concerns as he had read that these inhalers were linked to an increased risk of fatal asthma. LABAs have become an increasingly popular treatment over the past two decades as a supplement to inhaled corticosteroids in the management of persistent asthma.1 They have a bronchodilator effect when bronchomotor tone (the state of airway smooth muscle contraction or relaxation regulating airway calibre) is low, and a protective (or “airway stabilising”) effect with increased bronchomotor tone.2 Salmeterol and formoterol (the two LABAs in widespread clinical use) are lipophilic, bind to airway smooth muscle β2 adrenoceptors and exert effects for approximately 12 hours. Salmeterol has a slower onset of action (10-30 minutes) than formoterol (1-3 minutes). Both drugs can be prescribed in single inhaler devices, but they are commonly given with different inhaled corticosteroids with varying doses in combination inhaler devices (table 1⇓, fig 1⇓). Fig 1  Examples of different types of inhaler device used to deliver long acting β2 agonists (LABAs) to the airways: (a) Symbicort Turbohaler, (b) Seretide Accuhaler, (c) Seretide metered dose inhaler, (d) Fostair metered dose inhaler, (e) Flutiform metered dose inhaler View this table: Table 1  Combination inhaled corticosteroid and long acting β2 agonist (LABA) preparations licensed for …

Occupational exposure to asthmagens and adult onset wheeze and lung function in people who did not have childhood wheeze: A 50-year cohort study

BACKGROUND There are few prospective studies that relate the development of adult respiratory disease with exposure to occupational asthmagens. OBJECTIVE To evaluate the risk of adult onset wheeze (AOW) and obstructive lung function associated with occupational exposures over 50years. METHODS A population-based randomly selected cohort of children who had not had asthma or wheezing illness, recruited in 1964 at age 10-15years, was followed-up in 1989, 1995, 2001 and 2014 by spirometry and respiratory questionnaire. Occupational histories were obtained in 2014 and occupational exposures determined with an asthma-specific job exposure matrix. The risk of AOW and lung function impairment was analysed in subjects without childhood wheeze using logistic regression and linear mixed effects models. RESULTS All 237 subjects (mean age: 61years, 47% male, 52% ever smoked) who took part in the 2014 follow-up had completed spirometry. Among those who did not have childhood wheeze, spirometry was measured in 93 subjects in 1989, in 312 in 1995 and in 270 subjects in 2001 follow-up. For longitudinal analysis of changes in FEV1 between 1989 and 2014 spirometry records were available on 191 subjects at three time points and on 45 subjects at two time points, with a total number of 663 records. AOW and FEV1<LLN were associated with occupational exposure to food-related asthmagens (adjusted odds ratios (adjORs) 95% CI: 2.7 [1.4, 5.1] and 2.9 [1.1, 7.7]) and biocides/fungicides (adjOR 95% CI: 1.8 [1.1, 3.1] and 3.4 [1.1, 10.8]), with evident dose-response effect (p-trends<0.05). Exposure to food-related asthmagens was also associated with reduced FEV1, FVC and FEF25-75% (adjusted regression coefficients 95% CI: -7.2 [-12.0, -2.4], -6.2 [-10.9, -1.4], and -13.3[-23.4, -3.3]). Exposure to wood dust was independently associated with AOW, obstructive lung function and reduced FEF25-75%. Excess FEV1 decline of 6-8ml/year was observed with occupational exposure to any asthmagen, biocides/fungicides and food-related asthmagens (p<0.05). CONCLUSIONS This longitudinal study confirmed previous findings of increased risks of adult onset wheezing illness with occupational exposure to specific asthmagens. A novel finding was the identification of food-related asthmagens and biocides/fungicides as potential new occupational risk factors for lung function impairment in adults without childhood wheeze.

“Systematic review” of asthma education studies

We were disappointed that Sudre et al 1 felt there was insufficient documentation and excessive variability in studies of education programmes for adults with asthma published between 1979 and 1998. We feel that their conclusion is largely because they did not perform a rigorous systematic review of papers in this area. Systematic reviews of research evidence are undoubtedly invaluable scientific activities. They establish whether scientific findings are consistent and can be generalised across populations, settings, and other variations. Systematic reviews should be based on the “gold standard” of published randomised clinical trials. However, in the 77 trials reported Sudre et al included 35 studies which were not randomised controlled trials. They also give no information about which interventions were found to have statistically significant effects. They include a study which simply asked patients whether they preferred audiovisual information or written information and did not have any intervention,2 a study which has not been published,3 …

Asthma trends Causes of wheeze and asthma may differ

EDITOR, - Two papers report the outcome of childhood asthma in Tasmania1 and Melbourne2 in subjects now in their 30s. We reported a 25 year follow up of schoolchildren in Aberdeen3,4 and think that our findings influence the interpretation of these Australian papers. In the 1964 random community survey that provided the baseline for our study, subjects were classified as having asthma, “wheeze in the presence of respiratory infection” (wheezy bronchitis), or no respiratory symptoms (comparison subjects).5 Review after 25 years of subjects from each group showed that 61% of those who had had asthma in childhood continued to wheeze in adult life, compared with 30% of those who had had wheezy bronchitis; 11% of the comparison subjects had developed wheeze since the original study. Of the subjects who had not had symptoms in childhood who were reviewed by Mark A Jenkins and colleagues, 10.6% had developed symptoms by the age of 29-32,1 a similar percentage to that in our study. Of those who had had symptoms in childhood, 25.6% continued to experience symptoms as adults, a much smaller percentage than we had found. The reason for the difference from our results may lie in the ages at the time of the original studies: the Tasmanian children were identified at age 7, while ours were selected at 10 to 15, when a number of wheezy children would have already grown out of their symptoms. Another explanation may lie in the definition of symptoms in adults: Jenkins and colleagues defined them as the “occurrence of an asthma attack within the previous 12 months,” which is a more stringent definition than that used in our study (wheeze in the past 12 months) or the study by Helmut Oswald and colleagues (wheeze in the past three …

Authors' reply to Hasford.

We thank Hasford for his comments on our article,1 2 particularly those relating to the Salmeterol Multicenter Asthma Research Trial (SMART).3 However, the trial found that the occurrence of the primary outcome (respiratory related deaths or life threatening …