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• Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Hilary Pinnock & Elisabeth Ehrlich

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Discipline of General Practice, University of Sydney, Sydney, NSW, Australia

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Bronchial carcinoid in a 39-year-old man treated for bronchial asthma: a case report

• Justyna Emeryk 1 ,
• Elżbieta Czekajska-Chehab 2 ,
• Elżbieta Korobowicz 1 ,
• Marta Korbel 3 ,
• Irena Węgrzyn-Szkutnik 1 &
• Janusz Milanowski 1  

Cases Journal volume  2 , Article number:  7414 ( 2008 ) Cite this article

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A case study of 39-year old man with persistent wheezing, episodes of haemoptysis and dry cough unsuccessfully treated with inhaled beta2-agonists and steroids for about 10 months. Chest radiograph revealed a disproportion in dimensions between both lungs, with the left one being smaller than the right one. Spirometry demonstrated a restrictive pattern. During bronchoscopy, a polypoid endobronchial tumor, localized in the left main bronchus, completely occluding its lumen, was found. The tumor was diagnosed as carcinoid. In this case, due to the lack of characteristic symptoms, diagnosis of carcinoid was delayed. Patients unsuccessfully treated for bronchial asthma or chronic obstructive pulmonary disease should undergo bronchoscopic examination.

Case presentation

A 39-year-old white man, working as a house builder, was admitted to our pulmonary ward in August 2007 with an eleven-month history of persistent wheezing, heard not only during auscultation but also by patient himself. This wheezing had no correlation with physical exertion. He also reported a few episodes of haemoptysis within last 7 months and dry cough for about a month. Patient's weight was 81.5 kg, his height was 180 cm. Except from nodular goitre (in euthyreosis), the patient reported no other complaints or diseases in his medical history. His family history was not clinically significant. He had a 10 pack-years smoking history, until the age of 31 when he stopped smoking. He drank alcohol occasionally. His symptoms were unsuccessfully treated with inhaled β 2 -agonists and steroids for about 10 months. Apart from these medications, he took no other drugs. On auscultation, there were wheezes in upper fields of both lungs. The chest radiograph (figure 1 ) showed a disproportion in dimensions and vascular markings between both lungs- the left one was significantly smaller and had decreased vascular markings in comparison to the right one- these findings might be the expression of left lung hypoplasia. The heart silhouette was discretely displaced to the left side.

Chest radiograph performed at admission to the hospital .

Spirometry performed during hospitalization in our clinic showed a restrictive pattern (figure 2 ) with forced expiratory volume in one second (FEV 1 ) of 59% predicted and forced vital capacity (FVC) of 66% predicted. The FEV 1 /FVC ratio was 70% predicted.

Flow-volume curve showing a restrictive pattern performed at admission to the hospital .

Bronchoscopy was performed, revealing a polypoid endobronchial tumor, localized in the left main bronchus (2 cm from tracheal bifurcation), completely occluding its lumen. The tumor was biopsied and the specimen was sent to histological examination which gave the diagnosis of bronchial carcinoid.

Thoracic computed tomography showed a polypoid mass in the left main bronchus with a diameter of about 20 mm. The tumor showed very high enhancement after contrast medium administration: from 9 HU (Hounsfield units) (figure 3a ) to 119 HU in arterial phase (figure 3b ) and 47 HU in parenchymal phase (figure 3c ), which is characteristic for carcinoid.

High enhancement of the tumor (arrow) after contrast medium administration: on the left- before administration of contrast medium, in the middle-after administration; arterial phase, on the right-parenchymal phase .

Hilar and mediastinal nodes were not enlarged. In virtual bronchoscopy, as well as in transparent reconstruction of the airways, a total occlusion of the left main bronchus by the tumor could be observed (Figure 4 and 5 ).

Total occlusion of the left main bronchus by the tumor (arrow) .

Amputation of the left main bronchus by the tumor (arrow) .

The patient was transferred to thoracic surgery ward for surgical treatment. He underwent left pulmonectomy and histopathological analysis of post-operative material confirmed the diagnosis of bronchial carcinoid. There were no complications during post-operative period and the patient was discharged from hospital 10 days after the operation. Then, the patient went abroad and was lost for follow-up until May 2008. On control visit in May, he was in very good condition, presenting no signs of pulmonary disease. On physical examination, except from diminished breath sounds and dullness to percussion over left lung (due to pulmonectomy and consequent pleural fluid accumulation) no abnormalities were found. In control computed tomography there were no signs of recurrence of the disease.

Pulmonary carcinoids comprise 1-2% of all lung tumors. They may develop in many locations in the body but most often, they are found in small intestine (26%), respiratory system (25%) and appendix (19%) [ 1 ].

Carcinoid tumors are classified as typical or atypical according to histopathological criteria. This division has a strict extrapolation to survival rates: in case of typical pulmonary carcinoids 5-year survival rate is over 90%, in atypical ones- it is within the range of 40-60% [ 2 ].

The following symptoms are observed most often in patients with carcinoid localized in respiratory system: haemoptysis, cough, recurrent pulmonary infections, fever, chest discomfort, unilateral wheezing and shortness of breath [ 3 ].

Due to the lack of characteristic symptoms, diagnosis of pulmonary carcinoid is delayed and patients are often misdiagnosed with asthma or chronic obstructive pulmonary disease. According to three studies, there is an average delay of, respectively, 19, 13 and 10 months from the first symptoms to the final diagnosis of carcinoid [ 4 – 6 ]. Although general prognosis for patients with this neoplasm is quite favorable, it is obvious that the earlier diagnosis is made, the chances for radical treatment increase.

As the majority of pulmonary carcinoids (70%) are located in the main or lobar bronchi [ 7 ], they are within the reach of a bronchoscope. According to British Thoracic Society, flexible bronchoscopy is a safe procedure and there are no controlled studies concerning the factors disqualifying a patient from it [ 8 ]. Bronchoscopy cannot replace computed tomography, these both procedures are complementary, but to be able to orientate the treatment and prognosis, we have to know the histopathological diagnosis and the specimens for examination can be easily and safely provided by bronchoscopy.

This case is a good example of misdiagnosis of the disease. Extended clinical diagnosis, including computed tomography and bronchoscopy, should be considered in all cases of bronchial asthma or chronic obstructive pulmonary disease which do not respond to standard treatment.

"Written informed consent was obtained from the patient for publication of this case report and accompanying images. A copy of the written consent is available for review by the Editor-in-Chief of this journal."

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British Thoracic Society guidelines on diagnostic flexible bronchoscopy. Thorax. 2001, 56 (suppl 1): 1-21.

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Justyna Emeryk, Elżbieta Korobowicz, Irena Węgrzyn-Szkutnik & Janusz Milanowski

First Department of Radiology, Medical University of Lublin, Jaczewski Street 8, 20-950, Lublin, Poland

Elżbieta Czekajska-Chehab

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Authors' contributions

JE performed acquisition of data, review of literature and wrote the paper. ECC performed computed tomography imagings and prepared virtual bronchoscopy reconstructions. EK performed histopathological examination of the tumour. MK was responsible for patient care, follow-up and data collection. IWS was responsible for patient care and drafting of paper. JM performed acquisition of data, revised the manuscript and provided general support as the head of department. All authors read and approved the final manuscript.

Microscopic imaging of bronchial carcinoid (hematoxylin and eosin staining) .

Immunohistochemical staining positive for chromogranine A .

Immunohistochemical staining positive for synaptophysin .

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Emeryk, J., Czekajska-Chehab, E., Korobowicz, E. et al. Bronchial carcinoid in a 39-year-old man treated for bronchial asthma: a case report. Cases Journal 2 , 7414 (2008). https://doi.org/10.1186/1757-1626-2-7414

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Published : 16 December 2008

DOI : https://doi.org/10.1186/1757-1626-2-7414

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Treatment of severe asthma: case report of fast action of mepolizumab in a patient with recent sars-cov-2 infection.

1. Introduction

1.1. covid-19 and pediatric asthma, 1.2. management and treatment of severe asthma, 2. materials and methods, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Indolfi, C.; Dinardo, G.; Klain, A.; Decimo, F.; Miraglia del Giudice, M. Treatment of Severe Asthma: Case Report of Fast Action of Mepolizumab in a Patient with Recent SARS-CoV-2 Infection. Life 2024 , 14 , 1063. https://doi.org/10.3390/life14091063

Indolfi C, Dinardo G, Klain A, Decimo F, Miraglia del Giudice M. Treatment of Severe Asthma: Case Report of Fast Action of Mepolizumab in a Patient with Recent SARS-CoV-2 Infection. Life . 2024; 14(9):1063. https://doi.org/10.3390/life14091063

Indolfi, Cristiana, Giulio Dinardo, Angela Klain, Fabio Decimo, and Michele Miraglia del Giudice. 2024. "Treatment of Severe Asthma: Case Report of Fast Action of Mepolizumab in a Patient with Recent SARS-CoV-2 Infection" Life 14, no. 9: 1063. https://doi.org/10.3390/life14091063

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A Case Report of Central Bronchiectasis in a Poorly Controlled Asthmatic Adolescent With Allergic Bronchopulmonary Aspergillosis and Secondary Spontaneous Pneumothorax

Kasireddy sravanthi.

1 Pediatrics, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND

Devika Jadhav

Sampada tambolkar, shailesh b meshram.

2 Respiratory Medicine, Dr. D. Y. Patil Medical College, Hospital & Research Centre, Dr. D.Y. Patil Vidyapeeth, Pune, IND

Manojkumar G Patil

Shailaja mane.

Allergic bronchopulmonary aspergillosis (ABPA) is a multifaceted immune hypersensitivity reaction occurring in the lungs and bronchi, triggered by exposure and colonization of Aspergillus species, commonly Aspergillus fumigatus (A. fumigatus) . It typically affects individuals who are immunocompetent but predisposed, such as those with bronchial asthma and cystic fibrosis. Diagnosis involves various methods including chest radiography, computed tomography, identification of eosinophilia, elevated serum IgE (immunoglobulin E) levels, and immunological tests for Aspergillus antigen. Left undiagnosed and untreated, ABPA can advance to bronchiectasis and/or pulmonary fibrosis, leading to significant morbidity and mortality.

Introduction

Aspergilli , a widespread type of fungi, consist of approximately 185 species, with A. fumigatus, Aspergillus niger , and Aspergillus flavus being the most prevalent ones known to cause diseases in humans. Among these, A. fumigatus predominantly contributes to cases of ABPA, a condition characterized by an inflammatory reaction to Aspergillus present in the mucus of individuals with underlying lung conditions such as persistent asthma and cystic fibrosis (CF). Various immune factors, such as atopy and specific immunogenic human leukocyte antigen (HLA) types in asthma patients, as well as genetic factors like mutations in the CF transmembrane conductance regulator (CFTR) gene in CF patients, elevate the susceptibility to ABPA in these populations [ 1 ].

ABPA manifests in around 1-2% of children with asthma and 2-15% of individuals with CF [ 2 ]. Establishing the prevalence of ABPA in asthmatics has proven problematic due to the absence of standardized diagnostic criteria. Consider ABPA in patients with chronic breathing difficulties (airway limitation) and a pre-existing lung condition like asthma or CF. A positive skin test result for Aspergillus , increased serum IgE (>417 IU/L), fungal-specific IgE and IgG antibodies, and imaging modalities are all part of the diagnostic workup for ABPA [ 1 ].

Case presentation

A 13-year-old male child presented to the outpatient department with complaints of fever, cough, and worsening asthma symptoms such as dyspnea and episodic wheezing for three years. His cough was productive, yellowish, and non-blood-stained. He was admitted with similar complaints in the past four times and was treated for pneumonia. His symptoms were relieved with treatment but didn’t improve completely. He was diagnosed with asthma at the age of eight years and progressed gradually over the past three years. He was managed with inhaled corticosteroids and short-acting beta-agonists. Spirometry showed significant bronchodilator reversibility of +23.23% and 240 ml.

On admission, the child was afebrile with a pulse of 102 beats per minute, respiration rate of 38 per minute, peripheral pulses well felt, oxygen saturation of 84% on room air and blood pressure of 100/72 mm Hg. Saturation improved to 91% on oxygen by mask. On general examination, mild cyanosis and clubbing were present. Auscultation of the chest revealed bilaterally equal air entry and bilateral crepitations with expiratory wheeze. The child was conscious and alert. Further physical examination demonstrated no other pathological findings. Family history was not significant. Routine laboratory investigations and chest X-rays were done as shown in Table ​ Table1 1 and Figure ​ Figure1 1 .

TLC: total leucocyte count; RBC: red blood cell; CRP: C-reactive protein

Red arrow: gloved finger appearence

The child having experienced multiple episodes of pneumonia following asthma treatment combined with the clinical picture, tuberculosis infection was suspected. Given India's status as a developing nation with tuberculosis prevalence, a thorough tuberculosis workup was conducted, but laboratory and radiological findings ruled out the infection. A sweat chloride test was done to rule out CF which returned to be negative. Despite this, clinical and laboratory assessments pointed towards uncontrolled asthma as the likely diagnosis.

A high-resolution computed tomography was done, which revealed extensive areas of cystic, tubular and varicoid bronchiectasis with bronchial wall thickening of the subsegmental and segmental bronchi giving the finger-in-glove appearance in all the lobes of bilateral lungs with central distribution suggestive of ABPA, as shown in Figure ​ Figure2 2 .

Red arrow: tubular bronchiectasis; yellow arrow: cystic bronchiectasis

Additionally, blood tests indicated peripheral eosinophilia with an absolute eosinophil count of 1053/ µL and significantly elevated serum total IgE 2428 IU/ml, positive blood test for Aspergillus specific IgE 49.6kUA/L and Aspergillus specific IgG 142 mgA/L, as listed in Table ​ Table2. 2 . His blood culture was negative, but sputum culture tested positive for Pseudomonas aeruginosa.  

IgE: Immunoglobulin E; IgG: immunoglobulin G

Despite proper management, the child did not improve. On day-3 of admission, repeat chest radiography and computed tomography (CT) were done in view of no clinical improvement, which showed left-sided moderate pneumothorax as shown in Figure ​ Figure3, 3 , and a characteristic signet ring sign was seen as shown in Figure ​ Figure4. 4 . Pneumothorax was managed by inserting an intercostal tube as shown in Figure ​ Figure5. The 5 . The child's condition improved significantly, and after confirming lung re-expansion on chest X-ray, the chest tube was safely removed after seven days. After stabilizing the patient, a bronchoscopy procedure was performed revealing mucus plugs in the airways, which were cleared and sent for investigation. Bronchoalveolar lavage (BAL) for malignant cytology and CBNAAT (Cartridge-Based Nucleic Acid Amplification Test) tested negative. KOH mount of BAL showed branched septate hyphae and spores. This finding further supported the diagnosis of ABPA.

Red arrow: pneumothorax

Red arrow: signet ring sign

Red arrow: intercostal tube

The child was given Prednisolone at 0.5mg/kg/day for two weeks followed by 0.5mg/kg on alternate days for the next four weeks, slowly tapered and stopped over four months. Itraconazole 200mg/day was given for 16 weeks. After regular evaluations (every month), the exacerbations became less frequent, and the need for follow-up was reduced. He showed significant improvement in his health and consistently managed his daily routine after six months.

ABPA is characterized by a complex interplay of immune responses to A. fumigatus. Although the precise pathophysiology is yet unknown, a number of immunological responses are seen, such as abnormal T-lymphocyte responses and A. fumigatus-specific IgE-mediated type-1 and type-3 hypersensitivity. Upon inhalation, A. fumigatus spores germinate into hyphae within the bronchi, releasing diverse proteins and toxins that trigger inflammatory responses. Individuals with asthma and CF who develop ABPA often exhibit genetic susceptibility factors. For instance, the absence of HLA-DQ2 and the presence of HLA-DR2 and/or HLA-DR5 increase the risk of ABPA upon exposure to Aspergillus . Conversely, the presence of HLA-DQ2 is believed to confer a protective effect against ABPA [ 3 , 4 ].

The diagnosis of ABPA is a challenging task because of the overlap in both clinical and radiographic symptoms. A mix of clinical examination, laboratory studies, and radiographic results is used to make the diagnosis, as shown in Tables ​ Tables3, 3 , ​ ,4 4 .

* Inner 2/3rd of chest CT field; AF:  Aspergillus fumigatus ; ABPA: allergic bronchopulmonary aspergillosis; IgE: immunoglobulin E; IgG: immunoglobulin G

AF: Aspergillus fumigatus , Total IgE (Immunoglobulin E): 1 kU/L=2.4 ng/mL, 1 kU/L=1 IU/ml, *Transient (nodules, consolidation, tram‑track sign, fleeting opacities, finger in glove/toothpaste opacities) or fixed (ring shadows, bronchiectasis, or fibrosis); ABPA: allergic bronchopulmonary aspergillosis, CF: cystic fibrosis, CT: computerized tomography

ABPA should be considered in asthmatic patients exhibiting certain indicators. These include new or recent infiltrates on lung imaging, suggestive of pneumonia or tuberculosis, alongside clinical and laboratory evidence of asthma that remains uncontrolled despite appropriate treatment. Additionally, ABPA may be suspected in cases of unresolved pneumonia and bronchiectasis, regardless of asthma history. The potential differentials for ABPA encompass uncontrolled asthma, tuberculosis, pneumonia, foreign body inhalation, immotile cilia syndrome, pulmonary infiltrates with eosinophilia, cystic fibrosis without ABPA, and sarcoidosis [ 3 ].

Managing ABPA requires a dual strategy that involves both controlling the immune response to alleviate symptoms and prevent immune-related complications and reducing the organism's burden to minimize the host's exposure to the triggering stimulus [ 9 ]. The 2016 guidelines by the Infectious Diseases Society of America recommend oral corticosteroids to reduce inflammation in ABPA, with inhaled corticosteroids for asthma control in affected individuals [ 10 ]. For symptomatic patients, those with CF and low FEV1, or those with ABPA complicated by mucoid impaction, bronchiectasis, or chronic pulmonary aspergillosis, itraconazole is the first-line antifungal treatment [ 9 ].

The primary treatment approach for ABPA typically involves systemic glucocorticoids, supplemented by antifungal medications and anti-IgE therapy such as omalizumab. During exacerbations in stages 1 and 3, glucocorticoids are administered at a dose of 0.5-1mg/kg for 14 days, followed by a tapering regimen over three to six months, or longer if necessary, with alternate-day usage. Stage 2, characterized by remission, and stage 5, where fibrosis has developed, generally do not necessitate glucocorticoid therapy. Stage 4 signifies a scenario where attempts to taper glucocorticoids have failed, prompting the need for continued long-term therapy [ 11 ].

During exacerbations of ABPA, antifungal therapy using a 16-week course of itraconazole has shown efficacy in improving treatment response. This allows for a reduction in glucocorticoid dosage by 50%, along with a decrease in total serum IgE levels by 25% or more. In children, the recommended dose is 5 mg/kg/day administered in a single dose. If the calculated dose exceeds 200mg, it should be divided equally and given twice daily. However, caution is necessary, as a typical dosage regimen of 7mg/kg/day in children may lead to hepatotoxicity, necessitating close monitoring of liver function [ 11 ].

Antifungal therapy helps decrease the fungal burden, antigenic stimulus, and inflammatory response, thereby reducing the need for systemic corticosteroids [ 12 ]. Azole antifungals, like itraconazole, are usually administered at 200 mg twice daily for 16 weeks [ 13 ]. The combination of itraconazole and prednisolone has been shown to significantly lower the one-year exacerbation rate compared to the use of either drug alone [ 12 ].

Conclusions

While ABPA in bronchial asthma is relatively uncommon, it should be considered in the list of potential causes of uncontrolled or difficult-to-treat asthma. Early identification before irreversible lung damage occurs is crucial for a favorable prognosis, emphasizing the importance of prompt treatment. Monitoring radiological findings and IgE levels is essential as clinical features alone may not reliably indicate ABPA progression or remission. Therefore, a comprehensive approach that includes vigilant observation of both imaging and immunological markers is necessary for effective management of ABPA in asthma patients.

Disclosures

Human subjects: Consent was obtained or waived by all participants in this study.

Conflicts of interest: In compliance with the ICMJE uniform disclosure form, all authors declare the following:

Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.

Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.

Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work.

Author Contributions

Concept and design:   Kasireddy Sravanthi

Acquisition, analysis, or interpretation of data:   Kasireddy Sravanthi, Devika Jadhav, Sampada Tambolkar, Shailesh B. Meshram, Shailaja Mane, Manojkumar G. Patil

Drafting of the manuscript:   Kasireddy Sravanthi

Critical review of the manuscript for important intellectual content:   Kasireddy Sravanthi, Devika Jadhav, Sampada Tambolkar, Shailesh B. Meshram, Shailaja Mane, Manojkumar G. Patil

Supervision:   Devika Jadhav, Sampada Tambolkar, Shailesh B. Meshram, Shailaja Mane, Manojkumar G. Patil

Asthma as a risk factor and allergic rhinitis as a protective factor for COVID-19 severity: a case-control study

• Miscellaneous
• Published: 24 August 2024

Cite this article

• Martha Débora Lira Tenório 1 , 2 ,
• Gabriel Valentim dos Santos Menezes Siqueira 3 ,
• Gustavo Costa Caldas 3 ,
• Roque Pacheco de Almeida 1 , 3 ,
• Amélia Ribeiro de Jesus 1 , 3 &
• Paulo Ricardo Martins-Filho   ORCID: orcid.org/0000-0001-8779-0727 1 , 2 , 4  

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The COVID-19 pandemic has resulted in significant global morbidity and mortality. The disease presents a broad clinical spectrum, significantly influenced by underlying comorbidities. While certain conditions are known to exacerbate COVID-19 outcomes, the role of chronic inflammatory airway diseases such as asthma and rhinitis in influencing disease severity remains controversial. This study investigates the association between asthma and allergic rhinitis and the severity of COVID-19 outcomes in a specific geographical region prior to widespread vaccine deployment.

We conducted a case-control study with unvaccinated adult patients who had laboratory-confirmed COVID-19 by polymerase chain reaction (PCR). Cases were defined as severe or critical COVID-19 patients requiring intensive care unit (ICU) admission, and controls were non-severe patients without signs of viral pneumonia or hypoxia. We utilized the International Study of Asthma and Allergies in Childhood (ISAAC) questionnaire to assess the presence of asthma and allergic rhinitis. The association between these chronic inflammatory airway diseases and the severity of COVID-19 was evaluated using multivariate logistic regression analysis.

A total of 122 patients were analyzed, with 61 in each group. The presence of asthma (9 patients) was associated with an increased likelihood of severe COVID-19 (OR = 13.0; 95% CI 1.27-133.74), while rhinitis (39 patients) was associated with a protective effect against severe outcomes (OR = 0.36; 95% CI 0.13–0.99). No significant association was found between the frequency of asthmatic episodes or the severity of rhinitis and the severity of COVID-19 outcomes.

This study underscores the divergent effects of chronic inflammatory airway diseases on COVID-19 severity, with asthma associated with a higher likelihood of severe outcomes and rhinitis potentially offering protective effects. These findings enhance our understanding of the complex interactions between respiratory allergies and COVID-19, emphasizing the importance of targeted clinical management and public health strategies.

Key message

• Asthma increases the likelihood of severe COVID-19 outcomes.

• Allergic rhinitis may provide protection against severe COVID-19.

• Comorbidities strongly influence COVID-19 severity.

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Acknowledgements

PRMF is a research productivity fellow at the National Council for Scientific and Technological Development (CNPq), Brazil.

This study did not receive financial support.

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Martha Débora Lira Tenório, Roque Pacheco de Almeida, Amélia Ribeiro de Jesus & Paulo Ricardo Martins-Filho

Investigative Pathology Laboratory, Federal University of Sergipe, Aracaju, SE, Brazil

Martha Débora Lira Tenório & Paulo Ricardo Martins-Filho

Department of Medicine, Federal University of Sergipe, Aracaju, SE, Brazil

Gabriel Valentim dos Santos Menezes Siqueira, Gustavo Costa Caldas, Roque Pacheco de Almeida & Amélia Ribeiro de Jesus

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MDLT contributed to the conception, study design, data collection, data analysis, interpretation, writing of the manuscript, and manuscript revisions. GVSMS and GCC contributed to the data collection, interpretation, and manuscript revisions. RPA and ARJ contributed to the conception, study design, interpretation, and manuscript revisions. PRMF contributed to the study design, data collection, data analysis, interpretation, writing of the manuscript, and manuscript revisions. All authors have read and agreed to the published version of the manuscript.

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Lira Tenório, M., dos Santos Menezes Siqueira, G., Costa Caldas, G. et al. Asthma as a risk factor and allergic rhinitis as a protective factor for COVID-19 severity: a case-control study. Eur Arch Otorhinolaryngol (2024). https://doi.org/10.1007/s00405-024-08893-6

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Received : 27 May 2024

Accepted : 03 August 2024

Published : 24 August 2024

DOI : https://doi.org/10.1007/s00405-024-08893-6

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