Experts say diagnosing asthma, COPD early is crucial.
Researchers report that as many as 70% of people with chronic obstructive pulmonary disease (COPD) or asthma could be undiagnosed.
They say that receiving a diagnosis and treatment can dramatically improve health and quality of life for a person with one of those conditions.
They add the people should take respiratory symptoms seriously and consult a physician and request a spirometry test if they’re concerned.
Next time you go to the doctor, maybe ask them to check your breathing — especially if you’ve been experiencing even minor trouble.
Nearly seven out of 10 people with asthma or chronic obstructive pulmonary disease (COPD) are undiagnosed, a situation that can lead to worse long-term health outcomes and lower quality of life than if a person had received diagnosis and treatment earlier, a new study published in the New England Journal of Medicine reports.
This research is the first of its kind to look at not only rates of diagnosis for asthma and COPD but also to detail the effects of early treatment and diagnosis on quality of life and health system burden.
“I’m a practicing pulmonologist and I see a lot of people who come to my office who’ve experienced symptoms of asthma or COPD for months to years, and the diagnosis hasn’t been made,” Dr. Shawn Aaron, a lead study author as well as a respirologist and senior scientist at the Ottawa Hospital Research Institute and a professor at the University of Ottawa in Canada, told Medical News Today.
“So we did this study where we looked at people who were who we diagnosed with no previous history of asthma or COPD and we diagnosed them,” he explained. “We found that compared to people their age, those who are undiagnosed with COPD or asthma have a much worse quality of life. They have impaired work performance and impaired work attendance because they’re taking days off because of their respiratory symptoms. These are people that are suffering sort of silently because they’re not they’re either not seeing their doctors or their doctors are not doing the proper diagnosis.”
Researchers surveyed more than 26,000 people about shortness of breath and lung function to find a group of 595 asthma and COPD diagnoses, which were confirmed using a gold-standard spirometry test.
Of this group, 508 agreed to participate in a clinical study where half received typical clinical care for these conditions and the other half had regular visits with a lung specialist.
Both groups received help with 92% of those seeing lung specialists receiving new medications to treat the conditions as well as 60% of those who received usual care.
Those who saw lung specialists took fewer trips to the doctor in the following year (0.53 compared to 1.12 per participant) and had larger improvements on the St. George’s Respiratory Questionnaire (10 point increase compared to less than 7) when compared to their counterparts receiving usual care.
Researchers reported that both groups also improved far more than if they had remained undiagnosed. They said a four-point improvement on the respiratory questionnaire represents a significant increase in health and quality of life, which each study group experienced.
“Overall, these results are inspiring,” said Dr. Robert Jasmer, a pulmonologist at Pulmonary Associates of Burlingame in California who was not involved in the research.
“Given the specialized training and experience that we as pulmonologists have with patients who have asthma and COPD, it was nice to see the benefits of diagnosis and early treatment confirmed in a community-based study published in a prestigious medical journal,” Jasmer told Medical News Today.
On some level, the findings of this study are common sense. Of course, people with an undiagnosed medical condition do better after receiving a diagnosis.
However, beneath that is the more probing question of just why so many people go undiagnosed with serious respiratory illnesses.
The answer is multi-faceted, but one reason, especially where COPD is concerned, is that it tends to hit people later in life, which can make the symptoms easier to ignore until they progress to a state that’s undeniable, according to Aaron.
“You don’t usually start developing COPD until you’re in your sixties,” he said. “Many people who start developing COPD become more and more short of breath, and the shortness of breath is progressive, and they decline with more shortness of breath every month or two or three. Maybe they’re in denial or just figure that they’re getting older.”
Physicians can also perpetuate this dynamic.
“Sometimes the doctor will wave away the symptoms and the complaints and say, ‘Oh, yeah, well, you’re 65 now, we expect you to be a little short of breath,’” Aaron said. “Sometimes the doctor has good intentions but doesn’t make the diagnosis.”
“If you’re experiencing prolonged cough, it doesn’t go away after eight weeks, or you’re experiencing wheezing or chest tightness — this is not normal. And you shouldn’t assume that everything is fine,” Aaron said. “You should go to your physician and you should insist on the physician ordering a spirometry test for you. What I would tell the public because we now know that if we find this and we treat it, you will get better.”
Jasmer echoed that sentiment.
“This study is important because there has been a lot of negativity for most of my education and career around COPD, especially as being an end-stage and hopeless disease for which treatment is not helpful-that is not correct, so COPD particularly suffers from a major PR problem,” he said. “Public perceptions about COPD being untreatable are not true and asthma is almost entirely treatable and usually completely reversible. While patients with COPD can help their symptoms with lifestyle changes such as quitting smoking and exercising, there are still many other effective medical treatments available that they can discuss with their doctor to further improve their symptoms, which will also improve their quality of life.”
Asthma is more common among U.S. individuals who report cannabis use in the most recent 30 days, with the odds of asthma being significantly even greater among individuals who reported cannabis use 20 to 30 days per month, according to a new study by researchers at Columbia University Mailman School of Public Health, City University of New York and Children’s National Hospital at George Washington University.
Until now little was known about the use of cannabis among youth and its relationship with asthma. The findings are published in the journal Preventive Medicine.
The study results show that the more frequent the use, the higher the likelihood of asthma, and there is little change after adjusting for cigarette use.
“With the growing use of cannabis across the U.S., understanding potential links between cannabis use and asthma is increasingly relevant to population health. This relationship is an emerging area and requires thorough collaborative investigation by experts in these fields,” said corresponding author Renee Goodwin, Ph.D., in the Department of Epidemiology at Columbia Mailman School of Public Health and Epidemiology at the City University of New York.
Data were drawn from the 2020 National Survey on Drug Use and Health a representative, annual survey of 32,893 individuals aged 12 and older in the United States. The researchers used regression modeling to examine the relationship between frequency of any cannabis and/or blunt (i.e., cannabis smoked in a hollowed-out cigar) use in the past 30 days among individuals with current asthma, and adjusting further for demographics and current cigarette smoking.
Current asthma was more common among individuals who reported cannabis use in the most recent 30 days, relative to those who did not (10% vs. 7.4%.) The odds of asthma were significantly greater among individuals reporting cannabis use 20-30 days/month and blunt use 6-15 and 20-30 days/month respectively than in individuals without asthma. Overall, the prevalence of asthma was 7.4% in the sample.
“Our findings add a significant layer to the nascent body of research on potential harms associated with cannabis use by being the first to show a link between cannabis use in the community and respiratory health risks; specifically increased asthma prevalence. Examining asthma prevalence in both adolescents and adults helps to inform public health initiatives and policies geared towards mitigating its risks, and underscores the importance of understanding the interplay between cannabis use and respiratory health.”
Drugs already used by millions to lower cholesterol might someday have a new role: Relieving asthma and COPD.
That’s the hope of a new line of research underway at the University of California, Davis.
A study funded by the U.S. National Institutes of Health is seeking to determine whether a “statin inhaler” might reduce the airway inflammation that makes breathing difficult for folks with illnesses like asthma or chronic obstructive pulmonary disease (COPD).
Taking a statin pill has no significant effect on the airways, but “delivering statins directly to the lung via inhalation might achieve better local tissue drug levels, and therefore, better clinical results,” theorized lead investigator Amir Zeki, a professor of internal medicine who specializes in pulmonary, critical care and sleep medicine at UC Davis.
This research is still in its early stages. However, if it pans out it might offer another treatment option to the more than 26.5 million Americans with asthma and the more than 16 million battling COPD.
Zeki’s team is focusing on what’s known as airway smooth muscle (ASM) — tissue which lies within each airway’s wall and helps control airflow.
The inflammation that drives asthma can trigger a tightening of smooth muscle, restricting airways. This “hyperactivity” of smooth muscle also plays a role in COPD, the researchers explained.
Treatments such as asthmabronchodilators already target receptors on specific smooth muscle cells, triggering a healthy relaxation of the muscle. But these meds aren’t always effective.
“Despite their widespread use, current inhaler therapies that treat asthma and COPD remain inadequate in controlling symptoms for many patients, especially those with moderate to severe disease,” Zeki said in a UC Davis news release. “For this reason, we need novel inhaled medications to treat obstructive airway diseases such as asthma via mechanisms of action different from current standard-of-care therapies.”
That’s where the anti-inflammatory properties of statins come in. Studies in the lab have shown that these drugs enhance the cellular function of airways in various ways.
“To our surprise, we have discovered that statins also work as a bronchodilator, in which they directly relax ASM tissue, leading to the opening of airways,” Zeki said.
Statins taken as pills have not shown any benefit against airway disease, however. That’s because the liver breaks down drugs taken as pills, minimizing any benefit that might accrue by the time the drug makes it to an airway.
Using an inhaler to deliver a statin directly to the airway bypasses that issue.
“This allows us to deliver significantly lower doses to the airways with hopefully greater potency,” Zeki said.
Phase 1 and phase 2 clinical trials are planned in which patients with asthma and COPD will try out statin inhalers for safety and effectiveness.
“We have successfully developed a proprietary formulation that is available and ready for first-in-human testing,” Zeki said. “Our aim is to begin with asthma, but we also have plans to investigate COPD as well.”
Intravenous magnesium sulfate rapidly and safely calms severe asthma attacks unresponsive to initial treatments in children, significantly outperforming the risks of aminophylline in a head-to-head trial.
A recent randomized trial published in Andes Pediatrica found that intravenous magnesium sulfate (MgSO4) at a dose of 50mg/kg led to greater improvement in symptoms compared to intravenous aminophylline for children with acute severe asthma failing initial emergency room treatment.1
The study divided 131 children into two groups – one receiving a single 50mg/kg dose of MgSO4 and one receiving a 5mg/kg loading dose of aminophylline followed by a 1mg/kg/hour infusion for 3 hours. The MgSO4 group showed significantly greater improvement in clinical asthma severity scores and oxygen saturation levels. They also had a 68% lower relative risk of hospital admission and 84% lower risk of needing additional rescue medications compared to the aminophylline group.2
MgSO4, the form of magnesium found in Epsom salt known as magnesium sulfate, was well tolerated with only one transient side effect reported, compared to more concerning risks with aminophylline including cardiac arrhythmias and seizures.3,4 The authors concluded MgSO4 is a safer and more effective add-on treatment for severe pediatric asthma attacks not responding to initial inhaled bronchodilators and corticosteroids.
The mineral magnesium is essential for over 300 bodily processes and naturally assists proper lung function. Intravenous MgSO4 is inexpensive, readily available in most hospitals, and simple to administer. This study provides evidence it could replace riskier drugs like aminophylline for severe asthma flare-ups in children.
More research is still needed to confirm optimal MgSO4 dosing protocols. But these findings suggest readily supplementing magnesium levels during acute asthma crises may significantly benefit outcomes for the most severely afflicted young patients.
Chronic obstructive pulmonary disease (COPD) is a term for a group of chronic lung conditions including chronic bronchitis, refractory asthma, and emphysema. Several supplements and remedies may help ease COPD symptoms.
People with COPD find it increasingly difficult to breathe. Among other symptoms, they may experience coughing, wheezing, and a feeling of tightness in the chest.
According to the COPD Foundation, people with COPD may need 430–720 more calories per day than other people due to the effort they need to exert breathing.
In fact, 25–40%Trusted Source of people with COPD are also dealing with malnutrition, which interferes with their long-term outlook.
At present, there is no cure for COPD. However, the American Lung Association suggests that eating a high fat, low carbohydrate diet can be helpful for people with breathing problems.
There are also several supplements and remedies people with COPD can try to support their medical treatment and help them manage their condition. Keep reading to learn more.
Researchers have identified the following minerals for COPD treatment and support:
5. Magnesium
Magnesium supports lung function, but some COPD medications may interfere with the body’s ability to absorb it.
People should also exercise caution when taking magnesium supplements for COPD. It can interfere with some drugs and cause side effects.
6. Calcium
Calcium can help the lungs function, but some COPD medications may cause the body to lose calcium. This makes it even more important for people with COPD to consider increasing calcium-rich foods in their diet.
If a person cannot reach their calcium needs through diet, it may be necessary to take a calcium supplement.
Researchers have identified the following additional supplements for COPD treatment and support:
7. Omega-3 fatty acids
Increasing the intake of omega-3 fatty acids may reduce inflammation in people with COPD. Although omega-3s are present in fish, seeds, and nuts, some people take fish oil supplements to make sure they get enough of this nutrient.
COPD is chronic and progressive, which means it does not go away and tends to get worse with time. People with COPD need to meet with their doctor regularly to monitor and manage their condition.
Even though prescription drugs cannot reverse the gradual decline in breathing capacity, they can help people with COPD manage their symptoms.
Also, getting regular flu shots can help people with COPD prevent illnesses that could cause serious complications. For these reasons, people with COPD need regular medical care.
Although taking supplements for COPD can be helpful, people with this condition need to speak with a doctor or other qualified healthcare professional about all the supplements they are taking or planning to take.
Vitamins, minerals, herbs, and other products may interact and interfere with COPD medications. They can also cause side effects.
Although there is currently no cure for this condition, medical treatment can help people manage their symptoms. Using herbal and nutritional supplements for COPD may also help with symptom management.
Children with high levels of total cholesterol may be at risk for asthma later in life, according to an abstract presented at the American Academy of Allergy, Asthma & Immunology Annual Meeting.
In a systematic literature review, HeysungBaek, MD, PhD, of Hallym University Kangdong, and colleagues analyzed 11 studies published between January 2000 and March 2022 to determine the relationship between dyslipidemia and asthma in children.
Children with high levels of total cholesterol may be at risk for asthma later in life.
Researchers observed inconsistent results across the selected studies, which they noted were mainly cross-sectional.
Next, researchers performed a retrospective multicenter cohort study of children aged younger than 15 years with either high total cholesterol (> 170 mg/dL; n = 29,038) or normal total cholesterol (170 mg/dL; n = 88,823) using electronic health records from five hospitals. Researchers propensity score matched the children and evaluated the risk for asthma using a Cox proportional hazard model and pooled meta-analysis.
Results showed a link between high levels of total cholesterol and future asthma development in the children (pooled HR = 1.3; 95% CI, 1.12-1.52).
“Elevated total cholesterol levels in children had a potential association with asthma development,” Baek and colleagues wrote.
This ancient remedy for respiratory ailments may be worth a try
A woman relaxes inside a salt cave made out of Himalayan salt blocks.
Asthma affects over 25 million people in the U.S., and the numbers are rising every year. Although there is no known cure for asthma, and the condition is normally managed long-term with prescription medications, there are some simple diet and lifestyle steps, like identifying possible“trigger allergens” and getting adequate omega-3 fatty acids, that may help reduce the frequency and severity of asthma attacks.
One lesser-known tool in the armory of potential asthma aid is a simple salt inhaler (or “salt pipe”)—a small and inexpensive device through which you breathe air that is infused with microscopic salt particles. Salt therapy—also known as halotherapy—has been shown in several studies to improve lung function in those suffering from mild to moderate asthma, as well as other respiratory conditions.
Inhaling salty air to improve respiratory health is not a new idea. Physicians from past ages prescribed trips to the seaside to relieve a host of ailments. Scientific interest in the health benefits of salty air was sparked more methodically in the mid-1800s when Feliks Boczkowski, a Polish doctor observed that men working in salt mines had fewer respiratory problems than those working in other types of mines. About a century later, during World War II, Karl Hermann Spannagel, a German doctor, similarly observed that patients who hid in salt caves to avoid bombing experienced improved respiratory health. Therapeutic salt rooms quickly followed in several European countries and have since made their way to the U.S., gaining in popularity. They are believed to help relieve respiratory problems and common skin conditions like eczema, as well as strengthen the immune system.
Researchers acknowledge that salt has antibacterial and anti-inflammatory effects, but are not sure about just how this affects asthma patients. The American Lung Association suggests that salt may thin mucus in the airways of asthma patients, making it easier to expectorate.
Research on the effects of salt on alleviating symptoms of asthma is limited and hard data is sparse, but anecdotal evidence is growing. For those suffering from the life-impacting effects of chronic asthma, using a salt inhaler as a complement to their standard asthma management plan may be beneficial—improving respiratory function and quality of life, and in some cases allowing for reduced dependence on asthma medications.
Halotherapy is increasingly being recognized as a viable option that can complement standard treatment. Kurt Stradtman, FDN-P, AADP, a functional diagnostic nutrition practitioner, told The Epoch Times that “Salt inhalers are very beneficial at improving respiratory health. When tiny salt particles are inhaled in a controlled environment like with a salt inhaler, these salt particles draw in moisture, in this case, mucus from the lining of the lungs. This can effectively help alleviate respiratory symptoms naturally. Salt therapy can be beneficial for both acute and chronic respiratory conditions.”
Since Dr. Oz first touted the respiratory health benefits of salt inhalers on his TV show, multiple studies on salt therapy have produced some encouraging results. A review of 13 studies related to halotherapy published in the March 2022 edition of Alternative Therapies in Health and Medicine concluded that halotherapy “has been found to have a positive effect on patients suffering from chronic respiratory diseases, improving mucociliary elimination and lung function.”
Another, comprehensive review of 18 studies examining the effect of halotherapy on adult and child asthma patients, was published in the Nov. 22, 2021 edition of the journal Healthcare. It consistently found halotherapy to have positive therapeutic effects, which included improved mucociliary clearance (the ability to clear mucus from the respiratory airways), and reduced occurrence of nighttime asthma attacks.
The study authors concluded that “All studies seem to sustain the overall positive effects of halotherapy as adjuvant therapy on asthma patients with no reported adverse events. Halotherapy is a crucial natural ally in asthma, but further evidence-based studies on larger populations are needed.”
Proponents of halotherapy report that it is a very safe natural treatment, with no significant side effects other than possibly a sore throat that could result from prolonged exposure. Still, available studies related to halotherapy are limited in number and duration, with no available data on potential long-term effects.
It is important to note that a salt inhaler is not a replacement for asthma medications, which have well-documented effectiveness and are essential to asthma management for millions of people. Rather, it’s possible that halotherapy could help to prevent or alleviate chronic asthma symptoms, leading to reduced dependence on medications—and that would be a win for both patient and doctor. Always consult with your doctor or healthcare professional before trying a new therapy or making medication changes.
Stradtman adds, “I feel like it’s a safe option for most anyone, but it’s always important to check with your healthcare provider before starting just to be sure.”
Mepolizumab use was associated with fewer exacerbations, reduced oral corticosteroid use and lower costs among patients with asthma on Medicaid, according to a study published in The Journal of Allergy and Clinical Immunology: In Practice.
But because this population comprises individuals aged 65 years and older as well as younger individuals with long-term disabilities, these findings may not be generalizable to the full U.S. population, Sanjay Sethi, MD, professor and chief of pulmonary, critical care and sleep medicine at Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, and colleagues wrote.
Data were derived from Sethi S, et al. J Allergy Clin Immunol Pract. 2022;doi:10.1016/j.jaip.2022.10.021.
Sanjay Sethi
“Most trial and real-world data on the impact of the use of drugs such as mepolizumab (Nucala, GSK) in patients with asthma is from young individuals,” Sethi, who is also vice president of health sciences at Jacobs School of Medicine and Biomedical Sciences, told Healio. “Asthma may differ in its manifestations and response to therapies in elderly individuals, which prompted this study.”
The researchers examined data from 1,278 patients (64.3% women; mean age, 67.9 years) with one or more prescription or administration claims for mepolizumab for asthma between Jan. 1 and Dec. 31, 2017, in the CMS fee-for-services Medicare datasets.
The baseline period spanned the 12 months before the index date, and the follow-up period spanned the following 12 months.
Compared with the baseline period, there was a 27% relative reduction in the proportion of patients who experienced an asthma exacerbation during the follow-up period, which met statistical significance (P < .0001), as well as a 36% relative reduction in the mean number of exacerbations leading to hospitalization per patient per year (P = .0164).
The number of patients with an exacerbation who needed hospitalization also fell from 99 (8%) to 60 (5%) from baseline to the follow-up, for a relative reduction of 40% (P = .0014).
The proportion of patients with one claim or more for all non-mepolizumab asthma treatments additionally fell. Comparing the follow-up to the baseline period, significantly fewer patients had one or more claim for:
single-agent inhaled corticosteroids (62% vs. 66%; P = .03);
short-acting beta 2 agonists (76% vs. 85%; P < .0001);
short-acting muscarinic agonists (22% vs. 28%; P = .003);
long-acting muscarinic agonists (33% vs. 41%; P < .0001); and
leukotriene receptor antagonists (64% vs. 71%; P < .001).
The researchers also noted a significant 16% relative reduction in the proportion of patients with any oral corticosteroid (OCS) use from the baseline to the follow-up period (P < .0001) along with a 35% relative reduction in the mean number of OCS claims (P < .001).
Total costs fell from baseline to follow-up by $888 (P = .0002), as did pharmacy costs ($275; P < .0001), outpatient costs ($341; P = .0033) and other costs including skilled nursing facilities, home health agencies and hospice ($51; P = .0011). Inpatient costs fell by $219, but this did not reach statistical significance.
Further, the proportion and mean number of exacerbations and exacerbations leading to hospitalizations significantly fell from baseline to follow-up specifically for the 76% of the population who were aged 65 years or older, the researchers continued.
“The response rate in this elderly population to mepolizumab, measured in terms of reduction in exacerbations, hospitalizations and OCS use, were all of a magnitude larger than we had expected,” Sethi said. “Elderly patients with asthma have more fixed airway disease, comorbid COPD and other chronic conditions that could blunt the response to biologics.”
Based on these real-world findings, the researchers concluded that mepolizumab treatment was likely to result in fewer exacerbations, reductions in use of OCS, and reductions in health care costs related to exacerbations.
“These findings would suggest that in the appropriate patient with severe uncontrolled asthma, biologics such as mepolizumab should be considered irrespective of the patient’s age and comorbidities,” Sethi said.
However, Sethi cautioned that all such database real-world studies demonstrate association, not causation.
“A randomized placebo-controlled trial in an elderly severe uncontrolled asthma population that confirms and extends the findings of this study would be the next logical step,” he said.
Patients with the rs2305480 variant of the GSDMB gene who had a pet dog as a baby did not have an increased risk for persistent wheeze or asthma, according to a study published in TheJournal of Allergy and Clinical Immunology.
This finding occurred despite the fact that the GSDMB missense variant (G allele) of rs2305480, which is located in the 17q12-21 locus, has been associated with asthma and asthma exacerbations. Infants with the variant and pet cats, however, did not experience the same effect, Mauro Tutino, PhD, research associate in the division of infection, immunity and respiratory medicine of the School of Biological Sciences at University of Manchester, and colleagues wrote.
Patients with the rs2305480 variant of the GSDMB gene who had a pet dog as a baby did not have an increased risk for persistent wheeze or asthma.
To evaluate gene-environment interactions between the 17q12-21 locus and pet ownership in infancy, the researchers examined data from the Study Team for Early Life Asthma Research (STELAR) consortium, which comprised five unselected birth cohorts of 15,941 children in the United Kingdom. These participants had never or infrequent wheeze (52.4%), early-onset preschool remitting wheeze (18.6%), early-onset middle-childhood remitting wheeze (9.8%), persistent wheeze (10.4%) and late-onset wheeze (8.8%).
Overall, 2,587 of the children had data on genotype, with 52% harboring the G allele of rs2305480, and pet ownership during their first year of life (cat owners, n = 438; dog owners, n = 344; both, n = 109). Further, 2,475 participants had latent class analysis (LCA) data, and 2,354 had data on asthma ever at age 16 years (AE16).
The researchers also examined data from the Avon Longitudinal Study of Parents and Children (ALSPAC) cohort separately, which included 6,149 children with both genotype (52% harboring G allele of rs2305480) and pet ownership information, 5,850 of whom had LCA data and 2,991 had data on AE16 phenotype.
In an additive model, researchers confirmed the G allele of rs2305480 was associated with increased risk for persistent wheeze (OR = 1.37; 95% CI, 1.25-1.51).
IBased on a meta-analysis of summary statistics for pet ownership during the first year of life, the researchers determined that there was no association between ownership of cats or dogs with asthma or any wheezing classes.
When stratifying results by pet ownership, results of fixed-effects models showed that infants who did not own a pet and had the G allele of rs2305480 had an increased risk for the AE16 phenotype (OR = 1.24; 95% CI, 1.12-1.38) and the LCA classes for late-onset (OR = 1.25; 95% CI, 1.06-1.48) and persistent (OR = 1.61; 95% CI, 1.4-1.86) wheeze.
Also among those with the G allele of rs2305480, cat owners had an increased risk for the AE16 phenotype (OR = 1.2; 95% CI, 1.02-1.43) and persistent wheeze (OR = 1.28; 95% CI, 1.02-1.6), whereas dog owners showed reduced risk for persistent wheeze (OR = 0.95; 95% CI, I0.73-1.24).
The researchers also found evidence of a significant multiplicative interaction odds ratio (ORint) between dog ownership and the rs2305480 genotype in relation to persistent wheeze, whereby dog ownership significantly attenuated the risk of the rs2305480 asthma-risk allele (random-effect ORint = 0.59; P = 8.3 × 10–4). Cat owners experienced a similar trend that did not reach statistical significance, whereas dual cats and dogs experienced the same attenuation of risk for persistent wheeze as those who owned dogs.
Using data from one of the cohorts to examine biological mechanisms for these findings, researchers also found that dust endotoxin levels were significantly higher in the houses of pet owners, with higher endotoxin levels associated with reduced risk for persistent wheeze (OR = 0.89; P = .04).
“The attenuating effect of dog ownership on persistent wheeze for those with the asthma-risk allele observed in the current study is likely due to an environmental exposure for which dogs are a proxy (ie, microbiota, endotoxin levels),” the researchers wrote, adding that future studies should use precise phenotyping to confirm the generalizability of these results among non-European populations.
This study is significant because there have been controversies about the so-called protective effect against asthma of having a cat or a dog in infancy since 1999. This paper shows that among patients with a particular genetic background, dog exposure seems to be protective.
In my own experience, I have encountered patients who were allergic to cat or dog regardless of whether they were exposed to dogs during infancy.
However, these findings will have no practical effect, because a dog lives for 10 to 20 years, and the child will be exposed to dog allergens during this entire period. This paper only assessed exposure during the first year of life. As soon as the child is sensitized to dog, if he or she is exposed to a dog or cat, there will be an increased risk for asthma.
Next, the researchers should assess the effect of dog exposure from infancy through age 12 years in this subgroup.
Frédéric de Blay, MD
Head of Chest Diseases Department, University Hospital of StrasbourgPresident, French Federation of Allergology
Moderate levels of ozone and fine particulate matter were associated with nonviral asthma attacks among children and adolescents living in low-income urban areas, according to a study published in The Lancet Planetary Health.
Exposure to these pollutants also was associated with molecular changes in patients’ airways during nonviral attacks, indicating potential mechanisms behind the attacks, Matthew C. Altman, MD, MPhil, associate professor in the department of medicine, division of allergy and infectious diseases at University of Washington School of Medicine, and colleagues wrote.
Asthma attacks had a non-viral cause and were associated with locally elevated levels of fine particulate matter and ozone in outdoor air in nearly 30% of urban children and adolescents studied.
“The NIAID Inner City Asthma Consortium has been studying the asthma epidemic in urban children in low-income households for several decades,” Altman told Healio, adding that viral respiratory infections are well known to trigger asthma exacerbations, although other triggers are less understood.
In previous studies, Altman continued, the researchers noted a surprisingly high rate of nonviral asthma exacerbations in urban children, of which they sought to identify the etiology and mechanisms.
“We found the most relevant factor appeared to be local air pollution exposure, especially to fine particulate matter and ozone, even at relatively moderately elevated levels, and found that they caused exacerbations through unique inflammatory pathways,” Altman said.
Study design, results
Altman and colleagues conducted a secondary analysis of 168 children (98 boys) aged 6 to 17 years with exacerbation-prone asthma from Mechanisms Underlying Asthma Exacerbations Prevented and Persistent with Immune-based Therapy Part 1 (MUPPITS1), a prospective and observational cohort study conducted in low-income urban centers of nine U.S. cities. Researchers followed participants between 2015 and 2017 through two respiratory illnesses or for approximately 6 months, whichever came first.
Those who reported a respiratory illness returned to the clinic twice during the 6-day period after their symptoms had begun for nasal sample collection and pulmonary function testing. The researchers categorized each illness as a viral (V+) or nonviral (V–) event and whether it included (Ex+) or did not include (Ex–) an asthma exacerbation.
Also, the researchers downloaded Air Quality Index (AQI) values and individual data for particulate matter at the 2.5 µm (PM2.5) and 10 µm (PM10) scales, ozone, nitrogen dioxide, sulfur dioxide, carbon monoxide and lead for each city during the study’s timeframe.
There were 336 respiratory events, including 143 Ex+ and 193 Ex– events.
In the 9 days preceding and following the start of respiratory symptoms, AQI values were significantly higher, indicating poorer air quality, for the Ex+ events than they were for the Ex– events (P < .0001).
Overall, 33.8% events with detailed assessments were V–, including 29.8% of Ex+ events.
Patients who were both V– and Ex+ were exposed to increased AQI values during the 9 days before and after their illness compared with V+/Ex+, V+/Ex–, and V–/Ex–patients (P < .0001), with similar AQI values between the three latter subgroups. Researchers noted these exacerbations occurred after several days of mean sustained increase in AQI.
Also, the V–/Ex+ group experienced higher concentrations of ozone (P < .0001), nitrogen dioxide (P < .0001) and PM2.5 (P = .0006) during this timeframe than the other groups, although the V+/Ex+ group had modestly higher ozone concentrations as well (P = .0014).
There was an association between higher AQI and V–/Ex+ events in the spring and summer (P < .0001) and winter and fall (P = .0003) compared with other events, with the most pronounced differences in spring and summer.
AQI and ozone values also had significant inverse associations with percentage of predicted FEV1(FEV1%) and FEV1/forced vital capacity ratio during V–/Ex+ events.
Researchers observed a significant association between cumulative AQI values over 3 days and upper airway gene expression modules associated with incipient asthma exacerbations.
Specifically, PM2.5 concentrations were linked to increased epithelial induction of tissue kallikreins, mucus hypersecretion and barrier functions, and ozone concentrations were associated with increased type-2 inflammation.
Comparisons, next steps
The researchers compared these results against data of 419 inner-city youth aged 6 to 20 years with persistent allergic asthma from the randomized, double-blind, placebo-controlled Inner-City Anti-IgE Therapy for Asthma (ICATA) trial. Of 100 asthma exacerbations in this study, 47 were V–.
Like the MUPPITS1 study, patients experiencing V–/Ex+ events also had been exposed to increased AQI, ozone and PM2.5 values compared with the other subgroups (P < .0001), although the effect of nitrogen dioxide was not significant.
Perhaps the most surprising finding, Altman said, was that these pollutants seemed to be associated with asthma exacerbations at only modestly elevated levels by current EPA guidelines.
“This may indicate that measurements underestimate the exposures these children have in their specific urban environments and/or urban children with asthma are more sensitive to these pollutants than has been previously understood/assumed,” he said.
Also, Altman noted that these exacerbations seemed to proceed through distinct inflammatory pathways from viral exacerbations that may not be fully responsive to some current asthma therapies.
Noting that these findings could inform novel asthma management strategies for children in urban areas, the researchers recommended preventive use of personal air quality monitors and air filers around periods of risk.
“Hopefully, this work can help drive the ongoing recognition of need for mitigating air pollution exposure in these urban and other environments,” Altman said, adding that his team is now investigating methods of asthma prevention and treatment in urban children.
“We will incorporate these results into our ongoing and future studies in particular to better understand why some asthma therapies are effective or ineffective in some children and how this may relate to the type of asthma they have and what their environmental exposures are,” he said.
These findings are significant, as they demonstrate the substantial effects of various aspects or components of pollution on asthma exacerbations. Importantly, they separate viral infections and, therefore, examine the effects of pollution specifically. Additionally, they look at pulmonary readouts, including biomarkers.
The study strongly implicates air pollution as a substantial contributor to respiratory exacerbations in inner-city children. The identification of inflammatory mechanisms (specific changes including barrier changes, eosinophil responses and lung function) with specific components of pollution (eg, PM2.5 vs. ozone) begins to uncover the pathways or steps triggered by the pollution.
Also, these findings are consistent with clinical experience focused on high rates of asthma and readmission rates among inner-city children. They really solidify the basic principle that pollution has health consequences that already are evident in children.
The vulnerability of inner-city children to this problem calls attention to their need for more careful medical attention, particularly focused on controlling exposure to pollution and managing their lung diseases. This study substantiates and buttresses the need to curtail pollution, which will not only improve lives, but also presumably save money.
Next, I would like to see a comparison of inner city vs. non-inner-city findings. In other words, do these processes and events occur in all children, or do they especially manifest in the inner city? Can we relate these findings to the vulnerability of inner-city children to diseases in general, or is this related to their increased exposure to air pollution? I also would like to see a prospective study to further prove causality.
But overall, these are important results, and the authors and NIH are to be congratulated.
Marc E. Rothenberg, MD, PhD
Director of the Division of Allergy and Immunology, Cincinnati Children’s Hospital
Director, Cincinnati Center for Eosinophilic Disorders
Healio Allergy/Asthma Peer Perspective Board Member
Disclosures: Rothenberg reports having consultant roles with Adare/Ellodi Pharmaceuticals, Allakos, AstraZeneca, Celgene, ClostraBio, GSK, Guidepoint, PulmOne, Serpin Pharma and Spoon Guru; holding equity interest in Allakos, ClostraBio, PulmOne, Serpin Pharma and Spoon Guru; receiving royalties from reslizumab (Cinqair, Teva Pharmaceuticals), Pediatric Eosinophilic Esophagitis Symptom Severity Module version 2.0 (Mapi Research Trust) and UpToDate (Wolters Kluwer); and inventing patents owned by Cincinnati Children’s Hospital Medical Center.
There is a wealth of evidence that outdoor air pollution harms children. Indeed, prior studies have documented associations between outdoor air pollution and both increased respiratory infections and asthma exacerbations.
The study by Altman and colleagues contributes further by evaluating the association of the AQI to both viral and nonviral asthma exacerbations among children with persistent asthma receiving asthma controller medications.
Concerningly, the association of the AQI with nonviral-triggered asthma exacerbations occurred in the moderate range (51-100 AQI), for which the EPA advises behavioral changes for persons “unusually sensitive” to air pollution. The moderate range is typically below the National Ambient Air Quality Standard (NAAQS) set by the EPA to provide adequate protection for human health.
It is unknown how many children with asthma are “unusually sensitive” to air pollution, or rather who will experience health harms at pollution levels within moderate AQI ranges. My prior work and results of the current study suggest that many children with asthma are likely to have exacerbations even within the moderate range. Indeed, in the MUPPITS1 cohort, 30% of viral-assessed asthma exacerbation events demonstrated an association in the moderate range, which was validated in a larger cohort of children and young adults with asthma (ICATA, 47%).
An important finding of this study is the association of the AQI and nonviral asthma exacerbations in children with persistent asthma below current NAAQS. Positive associations were found for ozone, PM2.5 and nitrogen dioxide all at levels below current NAAQS (0.07 ppm over 8 hours for ozone, 35 micrograms/m3 over 24 hours for PM2.5, 100 ppb over 1 hour for nitrogen dioxide).
The ozone NAAQS is currently under review by the EPA. Multiple health organizations including the American Thoracic Society support reducing the ozone NAAQS to 0.060 ppm and 24-hour PM2.5 standard to 25 micrograms/m3. Such reductions are supported by the findings of Altman and colleagues.
The association of the AQI with asthma exacerbations supports discussion of the AQI during clinical encounters. Although the AQI was not specifically designed as a tool for persons to learn their own personal susceptibilities to air pollution, the results from Altman and colleagues suggest the AQI might be helpful for children with asthma when used in this way.
Many apps provide an AQI, and the standardized EPA AQI is available hourly on the AirNow.gov website and AirNow smartphone app. For patients using the AQI to learn personal susceptibilities, health care providers should monitor for unintended consequences such as decreased overall physical activity. This may be especially important in regions with a high prevalence of moderate AQI days.
It is important to note that the AQI is an individual behavioral intervention to reduce exposure to air pollution. The best and most equitable way to reduce harm from air pollution is to reduce exposure for everyone. Individual interventions should never be at the expense of sound policy.
The association between the AQI and nonviral asthma exacerbations occurred despite treatment with asthma controller medications. As prior studies have also demonstrated a lack of a protective effective of asthma medications against air pollution exposure, more research is needed to determine optimal asthma management to prevent air pollution harms. Additionally, more research is needed to understand if incorporating the AQI in childhood asthma management improves asthma outcomes.
By Ernie Mundell HealthDay Reporter
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