A cross-sectional study to evaluate factors responsible for uncontrolled asthma

Manoj Meena; Govind Singh Rajawat; Piyush Arora; Suresh Koolwal; Hemant Kumar Sakkarwal; Aashish Kumar Singh

doi:10.4103/ijaai.ijaai_25_22

ORIGINAL ARTICLE

Year : 2022 | Volume : 36 | Issue : 1 | Page : 34-39

A cross-sectional study to evaluate factors responsible for uncontrolled asthma

Manoj Meena¹, Govind Singh Rajawat¹, Piyush Arora², Suresh Koolwal¹, Hemant Kumar Sakkarwal¹, Aashish Kumar Singh¹
¹ Department of Respiratory Medicine, Institute of Respiratory Diseases, Sawai Man Singh Medical College, Jaipur, Rajasthan, India
² Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan, India

Date of Submission	01-Aug-2022
Date of Acceptance	13-Oct-2022
Date of Web Publication	16-Feb-2023

Correspondence Address:
Dr. Manoj Meena
1/H/383, Sector One, Indira Gandhi Nagar, Jagatpura, Jaipur, Rajasthan
India

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/ijaai.ijaai_25_22

Abstract

INTRODUCTION: Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Various triggers, lack of knowledge about the disease, and unawareness about the correct inhalation techniques lead to poor control of the disease. This study aimed to study the factors responsible for uncontrolled asthma using the asthma control test (ACT) and explore other ways to improve asthma control.
MATERIALS AND METHODS: One hundred and eighty diagnosed cases of bronchial asthma according to Global Initiative for Asthma (GINA) guidelines, >18 years were enrolled for the study in an outpatient setting. The level of asthma control was assessed using the self-administered ACT. Factors responsible for uncontrolled asthma were evaluated using a questionnaire based on GINA guidelines.
RESULTS: Our study noted that in the majority (66.11%) of patients, asthma was poorly controlled followed by well-controlled (24.44%). Asthma was perfectly controlled in only 9.44% of patients. The mean value of the ACT score of study subjects was 17.5 ± 4.16 with a median (25^th–75^th percentile) of 17 (15–20) within the range of 7–25. Smoking (P < 0.0001), poor education about asthma (P < 0.0001), social stigma regarding inhaler use (P < 0.0001), wrong inhalation techniques (P < 0.0001), environmental triggers (P < 0.0001), associated comorbidities (P = 0.005), poor adherence to treatment (P < 0.0001), inappropriate therapy (P < 0.0001), and frequent hospitalizations (P = 0.006) were the factors responsible for uncontrolled asthma.
CONCLUSION: The present study identified various factors responsible for the high prevalence of asthma in an outpatient clinical setting. Common risk factors that contribute to poor asthma control were assessed in a comprehensive manner.

Keywords: Asthma, factors responsible for poor asthma control, outpatient setting, uncontrolled asthma

How to cite this article:
Meena M, Rajawat GS, Arora P, Koolwal S, Sakkarwal HK, Singh AK. A cross-sectional study to evaluate factors responsible for uncontrolled asthma. Indian J Allergy Asthma Immunol 2022;36:34-9

How to cite this URL:
Meena M, Rajawat GS, Arora P, Koolwal S, Sakkarwal HK, Singh AK. A cross-sectional study to evaluate factors responsible for uncontrolled asthma. Indian J Allergy Asthma Immunol [serial online] 2022 [cited 2023 Mar 29];36:34-9. Available from: https://www.ijaai.in/text.asp?2022/36/1/34/369805

Introduction

Asthma is a heterogeneous disease, usually characterized by chronic airway inflammation. Asthma is a common chronic respiratory disease affecting 1%–18% of the population in different countries. It is defined by the history of respiratory symptoms such as wheeze, shortness of breath, chest tightness, and cough that vary over time and in intensity, together with variable expiratory airflow limitation. Variation in asthma symptoms is triggered by factors such as exercise, allergen, irritant exposure, change in weather, and viral respiratory infection.^[1] Common predictors of uncontrolled asthma are active and passive smoking, unsealed mattress, workplace triggers, pollution, household pets, improper inhalational technique, social stigma, etc.^[1]

Persistent airway inflammation is associated with airway remodeling and structural changes of the bronchus, resulting in irreversible lung diseases and an accelerating decline in lung function. As a result of these inflammatory changes, patient experience wheeze, cough, reversible airflow obstruction, and airway hyperresponsiveness to a variety of stimuli.^[2],[3],[4] Asthma is generally believed to result from gene–environment interactions. There are several well-known environmental risk factors that have been identified to increase the risk of developing asthma such as exposure to air pollution and tobacco smoke, occupation, atopy, stress, and obesity.^[5]

Optimum asthma control can be achieved by avoiding triggers, judicious selection of quick reliever and controller medication, and appropriate patient education.^[6]

There are specific questionnaires such as the asthma control test (ACT); which addresses factors such as demographic data, duration of illness, medications used for asthma therapy, frequency of follow-ups, number of emergency hospitalizations, and patient's knowledge about trigger factors and treatment of asthma. Patients with uncontrolled and controlled asthma were considered ACT scores ≤19 and ≥20, respectively.^[7] A study confirms that 1 out of every 10 asthma patients in the world is from India; also its prevalence in children is far more disappointing.^[8] According to a global asthma report in India around 1.31 billion people, about 6% of children and 2% of adults have asthma.^[8]

The health infrastructure and education levels vary for each country. In a country like India, a lack of awareness about asthma at the primary level contributes to the increase in the prevalence of the disease with time. Till now, very few studies have been done in India to evaluate the factors associated with poor asthma control. To decrease the morbidity from the disease, developing a local approach to control the triggering factors is very much essential in our country. This study was undertaken to look thoroughly at all the factors that contribute to poor asthma control and develop an approach that would help to decrease the burden of the disease in future.

Materials and Methods

A hospital-based descriptive cross-sectional study was done between May 2020 and July 2021 at a tertiary care center for respiratory diseases in Rajasthan and 180 diagnosed cases of bronchial asthma as per Global Initiative for Asthma (GINA) 2021 guidelines, and aged 18 years or more were enrolled for the study.

Patients with mimics of bronchial asthma (congestive heart failure, Chronic obstructive pulmonary disease, and bronchiectasis), acute severe asthma, and diagnosis of asthma <4 weeks were excluded from the study. Asthma is said to be perfectly controlled when the daytime symptoms are less than twice per week, there are no nocturnal symptoms, there is no limitation of activity, the use of reliever medication is less than twice per week, and spirometry is normal.

The sample size is calculated at a 95% confidence level and alpha error of 0.05 assuming the prevalence of uncontrolled asthma being 40% as per the seed article (Ann Thorac Med 2015 April–June: 100–104, factors associated with poor asthma control in the outpatient setting). At the absolute allowable error of 8%, the required sample size for this study would be 144 which can further be increased and rounded off to 180 to allow 20% net attrition.

This study was approved by the ethical committee of the institute. After giving a full explanation regarding the study, written consent was obtained from all enrolled patients. The consent form included details of the study plan. After applying inclusion and exclusion criteria, the study population was selected. Then following evaluation was performed:

Detailed history and physical examination, routine blood investigations, electrocardiography, spirometry, chest X-ray, and two-dimensional echocardiogram were done
Asthma control is assessed by ACT
Various factors associated with asthma were evaluated on basis of a questionnaire according to GINA guidelines.

The presentation of the categorical variables was done in the form of numbers and percentages (%). On the other hand, the quantitative data were presented as the means ± standard deviation (SD) and as median with 25^th and 75^th percentiles (interquartile range). The following statistical tests were applied for the results:

The association of the variables which were quantitative in nature was analyzed using the analysis of variance
The association of the variables which were qualitative in nature was analyzed using the Chi-square test. If any cell had an expected value of <5, then Fisher's exact test was used
Multivariate nominal regression was used to find out significant risk factors of poorly controlled asthma.

The data entry was done in the Microsoft Excel spreadsheet and the final analysis was done with the use of Statistical Package for Social Sciences (SPSS) software, IBM manufacturer, Chicago, IL, USA, version 21.0.

For statistical significance, P < 0.05 was considered statistically significant.

Results

A total of 180 patients were enrolled in this study. Among these, 104 (57.78%) were males and 76 (42.22%) were females. The patient's demographic characteristics, education, and knowledge about asthma and the disease therapy are summarized in [Table 1]. Out of 76 female patients enrolled in the study more than 50% were housewives. Around 66.11% (n = 119) uncontrolled asthma cases were undergraduates as compared to 33.89% (n = 61) who were graduates. Smoking was seen in 60% (n = 108) uncontrolled asthma cases as compared to 40% (n = 72) who were nonsmokers. Most of the uncontrolled asthma patients in our study had a normal body mass index (86.67%, n = 156). Uncontrolled asthma using the ACT score was documented in 66.11% of cases. Around 54.44% of cases (n = 98) had no education about asthma as compared to 45.56% (n = 82) who were aware about the symptoms and triggers of the disease. The majority of the patients (56.11%, n = 111) had a history of pet contact.

Table 1: Demographic's and education about bronchial asthma and asthma therapy (n=180)

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[Table 2] depicts patient knowledge of asthma triggers and self-management of asthma symptoms. Around 52.78% (n = 95) patients had knowledge about asthma triggers. Around 58.89% (n = 106) knew how to prevent asthma symptoms but 72.22% (n = 130) were not aware about self-treatment of moderate-to-severe asthma symptoms. Approximately 72.78% of the patients (n = 131) had written treatment plan for asthma exacerbation whereas27.22% (n = 49) did not had any written plan. There were 109 patients out of 180 (60.56%) who had a misconception that steroids are unsafe for longer use, whereas 103 patients (57.22%) had a misconception that inhaled steroids are addictive on longer use. Around 55.56% of patients (n = 100) had a misconception that the disease will worsen with regular use of inhalers and 110 patients (61.11%) used the reliever medication on a need basis, whereas 112 patients (62.22%) discontinued the medication of their own after primary symptomatic relief. Oral steroids were used by 113 (62.78%) and 97 (53.89%) patients who used add-on bronchodilator therapy of their own, respectively. The treatment regimen was formoterol + budesonide in most of the cases (n = 55), followed by salbutamol metered-dose inhaler (MDI) monotherapy (n = 36). Regular follow-up and good compliance to inhalation therapy were seen in only 41.11% (n = 74) cases. Associated social stigma to inhaler use was one of the main reasons for therapy discontinuation and was evident in 58.89% (n = 106) cases [Table 3]. Incorrect technique for MDI/dry-powder inhaler (DPI) inhalation was seen in 104 (57.78%) cases. The main reason for the discontinuation of inhalation devices in asthma patients was associated social stigma associated with inhaler use (58.89% of cases) and incorrect technique of inhalation (57.78%) resulting in subtherapeutic response and subsequently therapy discontinuation [Figure 1].

Figure 1: Factors responsible for discontinuation of asthma medication device in study subjects

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Table 2: Patient's knowledge about trigger for asthma and management of asthma

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Table 3: Factors responsible for discontinuation of asthma medication device in study subjects

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On performing multivariate regression [Table 4], lack of knowledge about the prevention of symptoms and self-discontinuation with relief were independent factors affecting poorly controlled asthma. Patients with knowledge of the prevention of symptoms had significantly lower chances of poorly controlled asthma with an adjusted odds ratio of 0.025 (0.001–0.566) and patients who did a self-discontinuation of inhalers with relief had significantly higher chances of poorly controlled asthma with adjusted odds ratio of 64.489 (2.994–1389.043).

Table 4: Multivariate nominal regression to find out significant risk factors of poorly controlled asthma

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Discussion

To the best of our knowledge, there are only very few studies conducted in India with a respectable sample size which have evaluated factors responsible for uncontrolled asthma in a comprehensive manner. Knowing the triggers factors and filling the lacunae in patient education about the disease can certainly add in achieving good control of asthma and can reduce the morbidity caused by the disease.

Poorly controlled asthma has a negative impact on health-related quality of life.^[9] Moreover, poorly controlled severe asthma can raise an individual's risk of exacerbations, hospitalization, and death.^[10] This may include restrictions on physical activity, sleep disorder, time off from school or work, poor life satisfaction, and emotional and psychological stress. More than half of all asthma patients experience uncontrolled asthma despite the introduction of global and national disease management guidelines.^{[11],[12],[13]}

Asthma was classified as "controlled," "partly controlled," and "uncontrolled." Asthma is said to be controlled when the daytime symptoms are less than twice per week, there are no nocturnal symptoms, there is no limitation of activity, the use of reliever medication is less than twice per week, and spirometry is normal. Partly controlled asthma is when there is one or two of the features with daytime symptoms more than twice per week, reliever medications more than twice per week, any night symptoms, any limitation of activity, and spirometry peak expiratory flow or forced expiratory volume 1 s is < 80%. Uncontrolled asthma is when there are three or more features of partly controlled asthma in any week.^[14]

Numerous standardized clinical tools and questionnaires are available to assess asthma control. Asthma Control Scoring System,^[15] Asthma Control Questionnaire,^[16] ACT,^[17] and Asthma Therapy Assessment Questionnaire^[18] are among a few of them.

The present cross-sectional study was conducted to evaluate asthma control at a tertiary care center on an outpatient basis. Rao^[19] conducted a similar cross-sectional study of patients with poorly controlled asthma at a referral center and concluded that poorly controlled asthma cases require a detailed evaluation of comorbid conditions and allergen sensitization profiles.

Al-Zahrani et al.^[20] has made a cross-sectional descriptive study of the factors associated with poor asthma control and identified a high prevalence of uncontrolled asthma in the primary outpatient clinical setting and common risk factors that contribute to poor asthma control. The above study also opted a similar methodology in their study.

Our study noted that in the majority (66.11%) of patients asthma was poorly controlled, followed by well-controlled (24.44%). Asthma was perfectly controlled in only 9.44% of patients. The mean value of the ACT score of study subjects was 17.5 ± 4.16 with a median (25^th–75^th percentile) of 17 (15–20) within a range of 7–25. In a similar study, Rao reported that most cases of perfectly controlled asthma had adhered to the treatment and were on appropriate guideline-based therapy (76%). The rate of adherence varies across studies and most studies show less than 50% adherence to treatment in cases of poorly controlled asthma.^[20] However, a study was done in Brazil by Souza-Machado et al.^[21] which included 160 severe asthmatics and found that 70.9% of patients had adhered to treatment. A study from India done by Sagadevan et al.^[22] revealed that obesity, smoking, GERD, and increasing age were the factors associated with poor asthma control, however, we did not find a significant association of age and obesity with poor asthma control in our study.

This study was conducted at a tertiary care center which is also a referral center for difficult-to-treat asthma cases which might be one of the reasons for a higher proportion of uncontrolled asthma in our study. The percentage of uncontrolled asthma cases in our study was around 66%. Most cases are presented to us after being treated by primary general physicians who are very less aware about GINA guidelines. Lack of awareness about the disease symptomatology and improperly framed treatment regimen at the primary level was one of the reasons for higher numbers of uncontrolled asthma reaching at our center.

Our study also noted that in the majority (74.44%) of patients, an environmental factor trigger (exposure to pollutants, allergens, and drugs) was present, 43.89% of patients had a history of pet contact, and 64.44% of patients associated comorbidities were present. In around 48.28% of patients, atopic rhinitis was present as the main comorbidity, followed by GERD (37.93%) and atopic dermatitis (10.34%), and GERD + atopic rhinitis + atopic dermatitis was seen in (2.59%). GERD + atopic rhinitis was present in only 1 out of 116 patients (0.86%). This inference was similar to other studies done to evaluate asthma control.

Our study noted the mean ± SD of age in poorly controlled asthma was 41.72 ± 9.05 years which was significantly higher as compared to perfect controlled asthma (33.24 ± 9.65) and well-controlled asthma (31.75 ± 7.5) (P < 0.0001). The proportion of patients with poorly controlled asthma was significantly higher in males (75.96%) as compared to females (52.63%). The proportion of patients with poorly controlled asthma was significantly higher in factory workers, farmers, grain handlers, laborers, pharmaceutical company workers, and shopkeepers as compared to autorickshaw drivers, government job personnel, housewives, students, and teachers. The prevalence of poorly controlled asthma was significantly higher in undergraduates (85.71%) and less in graduates (27.87%). Active smokers had poorly controlled asthma (92.41%) as compared to nonsmokers (48.61%) and passive smokers (37.93%). There was no association between obesity and uncontrolled asthma in our study.

Lack of awareness about asthma and its triggers was seen in patients of poorly controlled asthma cases. These subsets of patients had poor follow-up as well and poor compliance to inhaled medications. In the majority of patients, social stigma regarding the use of asthma inhaler devices and inadequate inhalation technique was present and this association was seen more in poorly controlled, followed by well-controlled and perfectly controlled asthma.

Patients who had knowledge of triggering factors, prevention of symptoms, and treatment of moderate-to-severe symptoms are more associated with well-controlled and perfectly controlled and less with poorly controlled asthma. Patients who were adherent to a written asthma treatment plan had perfectly controlled asthma, followed by well-controlled and patients with poorly controlled asthma had no written asthma treatment plan.

Misconceptions in patients about asthma medication safety, the addictive potential on longer use, worsening with regular use, use of reliever medication on a need basis, self-discontinuation with relief, add-on steroid monotherapy, and add-on bronchodilator monotherapy were more associated with poorly controlled asthma, followed by well-controlled and perfectly controlled asthma. The majority of patients with no treatment regimen had poorly controlled asthma. The majority of patients using DPI formoterol + budesonide had well-controlled asthma. MDI salbutamol monotherapy and on-need treatment were associated with poorly controlled asthma.

Knowing the factors that interfere in achieving good asthma control is necessary to reduce the burden of the disease. The ACT is certainly a validated tool which can very well assess the level of asthma control and can help the treating physician in planning the step-up and step-down therapy to achieve good control of symptoms.

Similar to a few other studies,^[23] this study also reveals that many patients have misconceptions about asthma treatment, safety, and the addictive potential of inhaler use. These misconceptions can be overcome by educating the patients about the disease and making the patients aware about the triggers and do's and do not's of the disease.

Conclusion

Identifying the trigger and assessing the level of asthma control with the help of ACT can help in achieving good asthma control. Improving communication with the patients and educating them about the disease will definitely help in nullifying the social stigma associated with inhaler use in this disease.

Strength and limitations of the study

All the patients were directly interviewed with the help of a prestructured questionnaire which resulted in comprehensive information about the factors responsible for uncontrolled asthma. A review of all the medical records available also helped in figuring out the treatment irregularities and improperly framed regimens at the primary level. This was a single-center study for a limited duration of time and the population screened at a single tertiary care center was not representative of the entire state or country.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

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