Revisión sistemática

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Lay-led and peer support interventions for adolescents with asthma

Año 2017
Revista Cochrane Database of Systematic Reviews
Enlaces Pubmed , DOI , PMC

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BACKGROUND:

Adolescents with asthma are at high risk of poor adherence with treatment. This may be compounded by activities that worsen asthma, in particular smoking. Additional support above and beyond routine care has the potential to encourage good self-management. We wanted to find out whether sessions led by their peers or by lay leaders help to reduce these risks and improve asthma outcomes among adolescents.

OBJECTIVES:

To assess the safety and efficacy of lay-led and peer support interventions for adolescents with asthma.

SEARCH METHODS:

We identified trials from the Cochrane Airways Trials Register, which contains reports of randomised trials obtained from multiple electronic and handsearched sources, and we searched trial registries and reference lists of primary studies. We conducted the most recent searches on 25 November 2016.

SELECTION CRITERIA:

Eligible studies randomised adolescents with asthma to an intervention led by lay people or peers or to a control. We included parallel randomised controlled trials with individual or cluster designs. We included studies reported as full text, those published as abstract only and unpublished data.

DATA COLLECTION AND ANALYSIS:

Two review authors screened the searches, extracted numerical data and study characteristics and assessed each included study for risk of bias. Primary outcomes were asthma-related quality of life and exacerbations requiring at least a course of oral steroids. We graded the analyses and presented evidence in a 'Summary of findings' table.We analysed dichotomous data as odds ratios, and continuous data as mean differences (MD) or standardised mean differences, all with a random-effects model. We assessed clinical, methodological and statistical heterogeneity when performing meta-analyses, and we described skewed data narratively.

MAIN RESULTS:

Five studies including a total of 1146 participants met the inclusion criteria for this review. As ever with systematic reviews of complex interventions, studies varied by design (cluster and individually randomised), duration (2.5 to 9 months), setting (school, day camp, primary care) and intervention content. Most risk of bias concerns were related to blinding and incomplete reporting, which limited the meta-analyses that could be performed. Studies generally controlled well for selection and attrition biases.All participants were between 11 and 17 years of age. Asthma diagnosis and severity varied, as did smoking prevalence. Three studies used the Triple A programme; one of these studies tested the addition of a smoke-free pledge; another delivered peer support group sessions and mp3 messaging to encourage adherence; and the third compared a peer-led asthma day camp with an equivalent camp led by healthcare practitioners.We had low confidence in all findings owing to risk of bias, inconsistency and imprecision. Results from an analysis of asthma-related quality of life based on the prespecified random-effects model were imprecise and showed no differences (MD 0.40, 95% confidence interval (CI) -0.02 to 0.81); a sensitivity analysis based on a fixed-effect model and a responder analysis suggested small benefit may be derived for this outcome. Most other results were summarised narratively and did not show an important benefit of the intervention; studies provided no analysable data on asthma exacerbations or unscheduled visits (data were skewed), and one study measuring adherence reported a drop in both groups. Effects on asthma control favoured the intervention but findings were not statistically significant. Results from two studies with high levels of baseline smoking showed some promise for self-efficacy to stop smoking, but overall nicotine dependence and smoking-related knowledge were not significantly better in the intervention group. Investigators did not report adverse events.

AUTHORS' CONCLUSIONS:

Although weak evidence suggests that lay-led and peer support interventions could lead to a small improvement in asthma-related quality of life for adolescents, benefits for asthma control, exacerbations and medication adherence remain unproven. Current evidence is insufficient to reveal whether routine use of lay-led or peer support programmes is beneficial for adolescents receiving asthma care.Ongoing and future research may help to identify target populations for lay-led and peer support interventions, along with attributes that constitute a successful programme.

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British guideline on the management of asthma.

Año 2003
Revista Thorax
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Revisión sistemática

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Key clinical activities for quality asthma care: recommendations of the National Asthma Education and Prevention Program.

Año 2003
Revista MMWR. Recommendations and reports : Morbidity and mortality weekly report. Recommendations and reports / Centers for Disease Control
Enlaces Pubmed

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In 1997, the National Asthma Education and Prevention Program (NAEPP), coordinated by the National Heart, Lung, and Blood Institute, published the second Expert Panel Report (EPR-2): Guidelines for the Diagnosis and Management of Asthma (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Expert Panel Report 2: Guidelines for the diagnosis and management of asthma. Bethesda MD.: US Department of Health and Human Services, National Institutes of Health, 1997; publication no. 97-4051. Available at http://www.nhlbi.nih.gov.ezproxy.puc.cl/guidelines/asthma/asthgdln.pdf). Subsequently, the NAEPP Expert Panel identified key questions regarding asthma management that were submitted to an evidence practice center of the Agency for Healthcare Research and Quality to conduct a systematic review of the evidence. The resulting evidence report was used by the Expert Panel to update recommendations for clinical practice on selected topics. These recommendations (EPR-Update 2002) were published in 2002. (National Heart, Lung, and Blood Institute, National Asthma Education and Prevention Program. Guidelines for the diagnosis and management of asthma -- update on selected topics 2002. J Allergy Clin Immunol 2002;110[November 2002, part 2]. Available at http://www.nhlbi.nih.gov.ezproxy.puc.cl/guidelines/asthma/index.htm).

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Revisión sistemática

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Psychopathology in Difficult Asthma, review.

Año 2015
Revista The Journal of asthma : official journal of the Association for the Care of Asthma
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Abstract Objective Within the asthma population, difficult asthma (DA) is a severe condition in which patients present with frequent exacerbations, hospitalizations and emergency room visits. The identification and treatment of psychopathology is included in the management of DA. Psychopathology is supposed to predispose patients to DA or vice versa; psychopathology may develop as a consequence of DA. We reviewed the available literature on empirical findings regarding psychopathology in adult patients with DA. Methods Studies in English language journals using MEDLINE, Cochrane and PsycINFO databases, were retrieved by an electronic search published from 1990 till July 2014. Results Literature on psychopathology in DA is scarce. The search identified 16 articles of which only 6 articles were specifically about psychopathology in adult patients with DA. Almost half of patients with DA had evidence of psychopathology at both syndrome and symptom level. Moreover, psychopathology appeared to be related to frequent exacerbations in patients with DA. Conclusions This literature review suggests a high prevalence of psychopathology of patients with DA, although it remains unclear whether psychopathology occurs more often in DA compared to ´stable asthma´. More research is needed on a possible role of psychopathology on clinical signs and symptoms in DA.

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Estudio primario

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The prevalence of environmental exposure to perceived asthma triggers in children with mild-to-moderate asthma: data from the Childhood Asthma Management Program (CAMP).

Año 2001
Revista The Journal of allergy and clinical immunology
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BACKGROUND:

The Childhood Asthma Management Program, a 5-year randomized clinical trial of treatments for childhood asthma, has enrolled and characterized a cohort of 1041 children with mild-to-moderate asthma.

OBJECTIVE:

We sought to describe self-reported sensitivities and environmental exposures and investigate the relationships between self-report of these exposures as asthma triggers and their prevalence in the home.

METHODS:

Self-reports of sensitivities and home exposures were obtained by interview with the child or parent. Sensitivities were further assessed by using allergy skin testing (prick or puncture) against a core battery of allergens. Home exposures were further assessed by using analysis of a home dust sample.

RESULTS:

Environmental exposures were surprisingly common despite self-reported sensitivities to environmental factors. Of patients reporting that cigarette smoking frequently causes asthma symptoms, 26% reported having at least one parent who smokes cigarettes. Thirty-nine percent of patients reporting that exposure to animals frequently causes asthma symptoms live with a furry pet in their home. We found a smaller proportion of homes with a high level of cat allergen (P <.001) among the children who reported that animals frequently or always trigger asthma symptoms compared with those who reported that animals never or occasionally trigger asthma symptoms, suggesting modification of the home environment. No such results were seen for dog exposure. However, clinical symptoms did not reduce exposure to parental cigarette smoking (P =.15), house dust (P =.31), or damp and musty areas (P =.51).

CONCLUSION:

These data suggest that children with mild-to-moderate asthma are frequently symptomatic and exposed to a wide variety of environmental exposures that are perceived to trigger symptoms by means of self-report. Although environmental modification of asthmatic homes may occur, many children remain exposed to agents that are known to trigger their asthma.

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Meta-analysis: effect of long-acting beta-agonists on severe asthma exacerbations and asthma-related deaths.

Año 2006
Revista Annals of internal medicine
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BACKGROUND:

Long-acting beta-agonists may increase the risk for fatal and nonfatal asthma exacerbations.

PURPOSE:

To assess the risk for severe, life-threatening, or fatal asthma exacerbations associated with long-acting beta-agonists.

DATA SOURCES:

English- and non-English-language searches of MEDLINE, EMBASE, and Cochrane databases; the U.S. Food and Drug Administration Web site; and references of selected reviews through December 2005.

STUDY SELECTION:

Randomized, placebo-controlled trials that lasted at least 3 months and evaluated long-acting beta-agonist use in patients with asthma. All trials allowed the use of as-needed short-acting beta-agonists.

DATA EXTRACTION:

Outcomes measured were Peto odds ratio (OR) and risk difference of severe exacerbations requiring hospitalization, life-threatening exacerbations requiring intubation and ventilation, and asthma-related deaths. The OR for asthma-related deaths was obtained from the Salmeterol Multi-center Asthma Research Trial (SMART).

DATA SYNTHESIS:

Pooled results from 19 trials with 33 826 participants found that long-acting beta-agonists increased exacerbations requiring hospitalization (OR, 2.6 [95% CI, 1.6 to 4.3]) and life-threatening exacerbations (OR, 1.8 [CI, 1.1 to 2.9]) compared with placebo. Hospitalizations were statistically significantly increased with salmeterol (OR, 1.7 [CI, 1.1 to 2.7]) and formoterol (OR, 3.2 [CI, 1.7 to 6.0]) and in children (OR, 3.9 [CI, 1.7 to 8.8]) and adults (OR, 2.0 [CI, 1.1 to 3.9]). The absolute increase in hospitalization was 0.7% (CI, 0.1% to 1.3%) over 6 months. The risk for asthma-related deaths was increased (OR, 3.5 [CI, 1.3 to 9.3]), with a pooled risk difference of 0.07% (CI, 0.01% to 0.1%).

LIMITATIONS:

The small number of deaths limited the reliability in assessing this risk, and 28 studies did not report information on the outcomes of interest.

CONCLUSIONS:

Long-acting beta-agonists have been shown to increase severe and life-threatening asthma exacerbations, as well as asthma-related deaths.

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Estudio primario

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Asthma in adolescents: a randomized, controlled trial of an asthma program for adolescents and young adults with severe asthma.

Año 2002
Revista Canadian respiratory journal : journal of the Canadian Thoracic Society
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BACKGROUND:

Asthma is common and is often poorly controlled in adolescent subjects.

OBJECTIVE:

To determine the impact of an age-specific asthma program on asthma control, particularly on exacerbations of asthma requiring emergency department treatment, and on the quality of life of adolescents with asthma.

METHODS:

The present randomized, controlled trial included patients who were 15 to 20 years of age and had visited emergency departments for management of their asthma. The interventional group attended an age-specific asthma program that included assessment, education and management by a team of asthma educators, respiratory therapists and respiratory physicians. In the control group, spirometry was performed, and the patients continued to receive usual care from their regular physicians. The outcomes were assessed by a questionnaire six months after entry into the study.

RESULTS:

Ninety-three subjects entered the study and were randomly assigned to the intervention or control group. Of these, only 62 patients were available for review after six months. Subjects in both the control and the intervention groups showed a marked improvement in their level of asthma control, reflected primarily by a 73% reduction in the rate of emergency department attendance for asthma. Other indexes of disease control, including disease-specific quality of life, as assessed by questionnaires, were improved. There was, however, no discernible difference between the subjects in the two groups, with the exception of an improvement in favour of the intervention group in the symptom (actual difference 0.7, P=0.048) and emotional (actual difference 0.8, P=0.028) domains of the asthma quality of life questionnaire. The overall quality of life score favoured the intervention group by a clinically relevant difference of 0.6, but this difference did not reach statistical significance (P=0.06).

CONCLUSIONS:

Although all subjects demonstrated a significant improvement in asthma control and quality of life, the improvement attributable to this intervention was limited to two domains in disease-specific quality of life.

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Estudio primario

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Asthma self-management skills and the use of asthma education during pregnancy.

Año 2005
Revista The European respiratory journal
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During pregnancy, patients with asthma are at risk of poor outcomes, particularly when asthma is poorly controlled. The aim of this study was to determine the level of asthma self-management skills and knowledge among pregnant subjects and describe the implementation of an asthma education programme delivered in an antenatal clinic setting. Pregnant subjects with asthma were assessed by an asthma educator at 20 (n = 211) and 33 weeks gestation (n = 149). Lung function, symptoms, medication use, adherence, knowledge and inhaler technique were assessed. They were asked whether they had a written asthma action plan, or performed peak flow monitoring. Asthma was classified as mild, moderate or severe. At the first visit with the asthma educator, 40% of females reported nonadherence to inhaled corticosteroids, inhaler technique was assessed as inadequate in 16% and 42% had inadequate medication knowledge. Peak flow monitoring was performed by 3% and 15% had a written action plan. There were significant improvements in all aspects of asthma self-management following education. In females with severe asthma, night symptoms and reliever medication use significantly decreased after education. In conclusion, during pregnancy, patients with asthma have poor asthma knowledge and skills, and may benefit from self-management education as part of their obstetric care.

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Estudio primario

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Impact of an asthma carepath on the management of acute asthma exacerbations.

Año 2001
Revista Annals of the Academy of Medicine, Singapore
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INTRODUCTION:

Clinical pathways are being developed to standardise the management of acute asthma with the aim of improving asthma care. We evaluated the impact of an asthma carepath (CP), developed and instituted at a large community-based teaching hospital.

MATERIALS AND METHODS:

Case records of consecutive asthma cases were reviewed after the implementation of a new asthma CP (November 1999 to March 2000). Data from July to October 1998 were used as historical control data [pre-carepath (pre-CP)]. Data collected included patient demographics, investigations performed, treatment prescribed, use of peak expiratory flow rate (PEFR) monitoring, length of stay (LOS) and asthma relapse rates.

RESULTS:

One hundred and eighteen consecutive cases treated according to CP were compared with 67 pre-CP controls. There was no significant difference between the two groups with regard to LOS, use of PEFR monitoring, use of systemic steroids in hospital or asthma relapse after discharge (P > 0.05). A significant decrease in sputum tests (34.3% pre-CP versus 18.6% CP, P = 0.017) and use of antibiotics (62.7% pre-CP versus 30.4% CP, P < 0.001) was observed for patients on CP. The proportion of patients who had their salbutamol reviewed (49.3% pre-CP versus 73.7% CP, P = 0.001) and oxygen reviewed (25.8% pre-CP versus 73.8% CP, P = 0.004) was also significantly higher for cases on CP.

CONCLUSION:

Although the asthma CP did not significantly reduce LOS or early relapse, it was associated with a significant reduction of the use of sputum tests and antibiotics. Review of salbutamol and oxygen as treatment was also more likely.

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Estudio primario

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Kickin' Asthma: school-based asthma education in an urban community.

Año 2008
Revista The Journal of school health
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BACKGROUND:

In urban communities with high prevalence of childhood asthma, school-based educational programs may be the most appropriate approach to deliver interventions to improve asthma morbidity and asthma-related outcomes. The purpose of this study was to evaluate the implementation of Kickin' Asthma, a school-based asthma curriculum designed by health educators and local students, which teaches asthma physiology and asthma self-management techniques to middle and high school students in Oakland, CA.

METHODS:

Eligible students were identified through an in-class asthma case identification survey. Approximately 10-15 students identified as asthmatic were recruited for each series of the Kickin' Asthma intervention. The curriculum was delivered by an asthma nurse in a series of four 50-minute sessions. Students completed a baseline and a 3-month follow-up survey that compared symptom frequency, health care utilization, activity limitations, and medication use.

RESULTS:

Of the 8488 students surveyed during the first 3 years of the intervention (2003-2006), 15.4% (n = 1309) were identified as asthmatic; approximately 76% of eligible students (n = 990) from 15 middle schools and 3 high schools participated in the program. Comparison of baseline to follow-up data indicated that students experienced significantly fewer days with activity limitations and significantly fewer nights of sleep disturbance after participation in the intervention. For health care utilization, students reported significantly less frequent emergency department visits or hospitalizations between the baseline and follow-up surveys.

CONCLUSIONS:

A school-based asthma curriculum designed specifically for urban students has been shown to reduce symptoms, activity limitations, and health care utilization for intervention participants.

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