Theerasuk Kawamatawong

Role of eosinophilic inflammation and atopy in elderly asthmatic patients.

Background Asthma in the elderly is severe and associated with poor treatment outcome. Although atopy has an important role in pathogenesis, its role in the elderly is unclear, partly due to immune senescence. Objective We aimed to examine the associations of Th2-mediated inflammation with asthma severity in the elderly. Methods Consecutive asthmatics older than 60 years without severe exacerbation within 8 weeks were enrolled. Atopic status was determined by positive serum specific IgE or skin prick test to common aeroallergens. Serum total IgE was measured simultaneously to exhaled fractional concentration of nitric oxide (FeNO). Asthma control level was assessed by using Thai Asthma Control Test (ACT) score. Results Total of 44 elderly asthmatic patients were enrolled. The mean age was 68.9 years and mean age of asthma diagnosis was 46.6 years. Seventy-seven percent of patients were female. Atopic status was found in 45.5% of patients. Uncontrolled asthma classified as ACT score < 20 was noted in 25% of elderly asthma, but its association with either high serum total IgE (≥120 IU/mL), high FeNO (≥50 ppb) or atopic status was not detected. Conclusion One-fourth of elderly asthmatics were clinically uncontrolled, while atopy was confirmed in 45.5%. Neither high total IgE, high FeNO nor atopic status was associated with uncontrolled asthma in the elderly. Other factors might play role in asthma severity in the elderly, and has to be further investigated.

Peak inspiratory flow rate measurement by using In-Check DIAL for the different inhaler devices in elderly with obstructive airway diseases

Background Inhaler device technique is a common cause of treatment failure in patients with asthma and chronic obstructive pulmonary disease. Dry powder inhaler (DPI) requires optimal peak inspiratory flow rate (PIFR) for drug delivery. Low PIFR generation is common in the elderly. Patient lung function and intrinsic inhaler resistance are factors for determining generated PIFR and drug delivery from DPI. Objectives We aimed to identify the PIFR of the older (aged >60 years) and the younger (aged ≤60 years) patients with obstructive airway diseases for the different inhaler devices (Turbuhaler® and Accuhaler). Patients and methods A cross-sectional study was conducted from January to December 2014. Patients with obstructive airway diseases were recruited. Spirometry was performed. PIFR was measured by using an In-Check DIAL device. Individual PIFR values for each inhaler device were obtained for three consecutive measurements and then averaged. Results A total of 139 patients diagnosed with obstructive lung diseases (asthma, n = 109; chronic obstructive pulmonary disease, n = 30) were recruited. Of these, 71 patients (51%) were >60 years. The PIFR generated by the patients who were ≤60 years for nonresistance mode was not different from that generated by those aged >60 years (115.0 ± 15.2 L/min vs 115.4 ± 13.3 L/min, p = 0.86). Regarding the DPI, PIFR generated from the older group was significantly lower than that generated from the younger group for Turbuhaler (72.5 ± 18.8 L/min vs 82.4 ± 21.1 L/min, p = 0.01), but the PIFR generated was not significantly different between the older and the younger groups for the Accuhaler (93.8 ± 22.9 L/min vs 99.4 ± 24.2 L/min, p = 0.86). The low peak expiratory flow rate and PIFR from spirometry were associated with the suboptimal PIFR measured by using In-Check DIAL. Discussion Optimal PIFR is critical for DPI use in the elderly; appropriate DPI selection is essential for management. In-Check DIAL may be useful for detecting inhaler device problem among the elderly. Conclusion Lower PIFR generated from Turbuhaler was noted in patients with airway diseases who were older than 60 years, when compared to the younger patients.

Validity and reliability of the Thai version of the leicester cough questionnaire in chronic cough

BACKGROUND Chronic cough is a common problem potentially disturbing the quality of life (QoL) of coughers. The Leicester Cough Questionnaire (LCQ), previously developed in England, is a validated, self-completed QoL instrument for assessment of chronic cough. This study aimed to develop a Thai version of the LCQ (LCQ-T) and assess its validity and reliability among adult Thai patients with subacute to chronic cough. METHODS A total of 146 patients with a cough lasting for more than 3 weeks consented to participate in this study and self-administered the LCQ-T, together with the following 3 instruments: Borg Cough Scale (BCS), Short Form-36 (SF-36), and Hospital Anxiety Depression Scale (Thai-HADS). The LCQ-T was developed by applying a forward-backward translation approach. The LCQ-T comprises 19 items divided into 3 domains: physical (8 items), psychological (7 items), and social (4 items). To validate the LCQ-T, concurrent validity, internal consistency reliability, and test-retest reliability were assessed. RESULTS Participants included 96 women and 50 men with a mean (SD) age of 59.6 (14.4) years. The concurrent validity comparing LCQ-T to BCS yielded statistically significant Pearson correlation coefficients (r= -0.74, P<0.05). The correlation coefficients for SF-36 and Thai-HADS were also significant. The LCQ-T demonstrated very good internal consistency in all domains and the overall scale, with the Cronbachs alpha coefficients ranging from 0.89 to 0.94. The 3-day repeatability of the LCQ-T in 25 clinically stable patients was high with the intra-class correlation coefficients ranging between 0.81 and 0.90. CONCLUSION LCQ-T is a valid and reliable cough-specific instrument for assessing symptoms and QoL of adult Thai patients with subacute to chronic cough.

The asthma and chronic obstructive pulmonary disease overlap syndrome in tertiary care setting Thailand

Background Asthma and chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) is an increasingly recognized clinical entity. ACOS significantly impacts on patient outcome compared to isolated asthma or COPD. However, ACOS definition and diagnosis criteria have not been well standardized. ACOS prevalence and clinical features in Thailand has never been studied. Objective: To investigate the prevalence and clinical features of ACOS compared to isolated asthma or COPD among patients with clinician-diagnosis of obstructive airway diseases. Objective To investigate the prevalence and clinical features of ACOS compared to isolated asthma or COPD among patients with clinician-diagnosis of obstructive airway diseases. Methods Spirometry, skin prick test (SPT) and allergens specific IgE (sIgE) were done. Serum total IgE, exhaled nitric oxide (FeNO) and blood eosinophils were measured. High resolution computed tomography (HRCT) was performed. Smoking history, pollution, biomass exposure and symptoms (Asthma Control Test [ACT], COPD assessment test [CAT], Modified Medical Research Council Dyspnea Scale [MMCR]) were assessed. Patients were classified to isolated asthma, COPD or ACOS according to predefined definitions for this study. Results A total 92 patients were enrolled: 58 patients with clinician-diagnosed of late onset asthma and 34 with clinician-diagnosed COPD. The mean age was 67.4 years. Thirty-four asthma patients (58.6%) were considered to have ACOS with postbronchodilator forced expiratory volume in 1 second (FEV1)/forced vital capacity ratio <0.7 and/or presence of emphysema on HRCT. In addition, 10 COPD patients (28.6%) were classified as ACOS if they had bronchodilator reversibility (FEV1 ≥ 12% and ≥ 200 mL) and positive SPT or sIgE. Hence, total of 44 from 92 patients (47.8%) with obstructive airway diseases were found to have ACOS, while isolated asthma and COPD were found in 24 patients equally. No difference in symptoms assessed by CAT, ACT, or MMRC was found between 3 groups of patients. Neither serum total IgE nor blood eosinophils counts distinguished ACOS from asthma and COPD (p = 0.83 and p = 0.40). FeNO was higher in pure COPD than ACOS and asthma (p = 0.03). Conclusion ACOS is prevalent in late-onset asthma or clinician-diagnosed COPD who were treated in tertiary care clinic. However, we found no difference in symptoms, blood eosinophils or serum total IgE between groups.

Relationship between the presence of bronchiectasis and acute exacerbation in Thai COPD patients

Background The prevalence rate of bronchiectasis in COPD is variable. Coexisting bronchiectasis and COPD may influence COPD severity and exacerbation. Objective We investigated whether bronchiectasis is associated with frequent or severe COPD exacerbation. Lower airway bacterial and mycobacterial infections are a possible mechanism for bronchiectasis. Materials and methods A cross-sectional study was conducted in 2013–2014. COPD exacerbations and hospitalizations were reviewed. Spirometry and CT were performed. COPD symptoms were assessed by using the COPD assessment test (CAT) and modified Medical Research Council (mMRC) dyspnea scale. Sputum inductions were performed and specimens were sent for microbiology. Results We recruited 72 patients. Global Initiative for Chronic Obstructive Lung Disease (GOLD) A, B, C, and D, were noted in 20%, 27.1%, 14.3%, and 38.6% of the patients, respectively. Frequent exacerbations (≥2) and/or ≥1 hospitalization in the previous year were observed in 40.3% of patients. Median mMRC of COPD with frequent and non-frequent exacerbations was 1.0 (range 1–2) and 2.0 (range 1–3), (p=0.002), respectively. Median CAT of COPD with frequent and non-frequent exacerbations was 20.5 (3–37) and 11.0 (2–32), (p=0.004), respectively. CT-detected bronchiectasis was observed in 47.2% of patients. Median mMRC of COPD with and without bronchiectasis was 1.0 (0–4) and 1.0 (0–4) (p=0.22), respectively. Median CAT of COPD with and without bronchiectasis was 16.2 (95% CI: 12.9–19.6) and 13.0 (3–37), (p=0.49), respectively. The lower post-bronchodilator forced expiratory volume in 1 second (FEV1) of COPD with frequent exacerbations than those without was noted (p=0.007). The post-bronchodilator forced expiratory volume at 1 second percent in patients with and without bronchiectasis was not different (p=0.91). After adjusting for gender, severity of airflow obstruction, severity of COPD symptoms, the odds ratio for bronchiectasis with frequent and/or severe exacerbation was 4.99 (95% CI: 1.31–18.94), (p=0.018). Neither bacterial nor mycobacterial airway infection was associated with bronchiectasis or frequent exacerbation. Conclusions Bronchiectasis is common in Thai COPD. It was associated with frequent exacerbation or hospitalization. Mycobacterial tuberculosis in COPD patients with bronchiectasis was uncommon.

Erratum: Correction of Figure 1: The asthma and chronic obstructive pulmonary disease overlap syndrome in tertiary care setting Thailand

[This corrects the article on p. 227 in vol. 7, PMID: 29094021.].

Minimal Clinically Important Differences (MCIDs) of the Thai Version of the Leicester Cough Questionnaire for Subacute and Chronic Cough

OBJECTIVES To investigate the minimal clinically important differences (MCIDs) of the Thai version of the Leicester Cough Questionnaire (LCQ-T) in patients with subacute and chronic cough. METHODS Patients with cough for 3 or more weeks were recruited from outpatient clinics. They self-completed the LCQ-T at an initial evaluation and repeated the LCQ-T with a Global Rating of Change scale at follow-up. For the anchor-based method, the MCID was defined as a change in the LCQ scores that corresponded to the smallest improvement in Global Rating of Change score (+2 to +3). For distribution-based methods, the MCIDs were estimated from the standard error of measurement and a half and one-third of the SD of the LCQ score changes from baseline to follow-up. RESULTS A total of 107 patients were included. The causes of cough were postinfectious cough/bronchitis (35.5%), asthma (20.6%), rhinosinusitis (16.8%), bronchiectasis (17.8%), and chronic obstructive pulmonary disease (9.3%). The anchor-based method yielded MCIDs of 1.1, 0.4, 0.4, and 0.4 for the total, physical, psychological, and social domains, respectively. The distribution-based method using standard error qof measurement yielded MCIDs of 0.8, 0.3, 0.3, and 0.3, whereas those using a half SD yielded MCIDs of 2.0, 0.6, 0.8, and 0.8 and those using one-third SD yielded MCIDs of 1.4, 0.4, 0.5, and 0.5 for the total, physical, psychological, and social domains, respectively. CONCLUSIONS The MCIDs of the LCQ-T for subacute and chronic cough are 1.1, 0.4, 0.4, and 0.4 for the total, physical, psychological, and social domains, respectively. These estimates should be useful in making meaningful interpretations of the changes in quality of life because of cough.