October 2007

CFC Free and clear

Forthcoming conferences with NAC participation

Using inhalers correctly

Statins - good for the heart and now for the lungs

Pneumococcal vaccine - the value

Hospitalisations for food-related anaphylaxis rising in Australia

Research Funding Opportunities 

Conference Diary 

CFC Free and clear

From the beginning of 2008 all asthma and COPD inhalers in Australia will be either dry powder or will use HFA propellant.

The National Asthma Council Australia has welcomed the news that Australia’s last CFC asthma inhaler, Serevent Metered Dose Inhaler, will be discontinued from December 31, 2007.

According to the Council, which led the charge for the discontinuation of CFC containing inhalers, the phasing out of CFCs in asthma inhalers has been handled carefully and gradually to ensure that patients have ongoing access to their medications.

In the case of Serevent MDI, the green-coloured inhaler which is used to deliver symptom controller (or Long-Acting Beta-Agonist) medication, patients will still be able to use the same medication delivered via the green-coloured Accuhaler, which is CFC-free.

“While CFC use in asthma inhalers was only a very small part of the overall environmental problem, and CFC use in asthma inhalers did not constitute a health risk, every effort to stop further damage to the world's ozone layer and to promote its recovery is critical,” explained Kristine Whorlow, National Asthma Council CEO and an Australian Government nominee on the UNEP Medical Technical Options Committee, which is guiding the world phase-out of CFCs for medical purposes.

 “Australia, as a signatory to the Montreal Protocol, an international agreement to phase out ozone-depleting substances, eliminated most CFC use a few years ago and I am extremely pleased that when it comes to asthma, Australia will be CFC-free in 2008.”

Dry powder or HFA propellant asthma inhalers provide the same health benefits as their CFC-containing predecessors without damaging the ozone layer.

Of course, a number of dry inhalers were available before the CFC phase-out began.

People with asthma who want more information about the phase-out of this last CFC containing inhaler and the need to change to another inhaler should seek information from their doctor.

Forthcoming conferences with NAC participation

GPCE Melbourne 2007

The NAC will host a seminar at GP Conference and Exhibition (GPCE) Melbourne on 18 November 2007, with support from GlaxoSmithKline Australia.

Dr Gary Kilov, GP, and Dr Christopher Worsnop, respiratory physician, will present the 1-hour seminar, “Asthma and COPD: an update on diagnosis and treatment.”

The seminar will focus on five key issues in asthma and COPD:

• Clinching the diagnosis
   

• Asthma control vs severity
   

• Asthma management strategies
   

• COPD screening
   

• COPD management strategies

APSR Gold Coast 2007

The NAC will host a session at the Asian-Pacific Society of Respirology (APSR) Congress at the Gold Coast on 4 December 2007.

Ms Kristine Whorlow will chair the two hour National Asthma Council session, “Asia-Pacific Models of Advocacy and Implementation.”

The speakers represent a number of Asia-Pacific asthma organisations with whom the NAC has been working:

• Spectrum of respiratory disease in Bangladesh: current trends and practices
   - Prof. Md. Rashidul Hassan (Bangladesh Lung Foundation)
   

• The total easy asthma management (TEAM) pilot study
   - Datin Dr Aziah Ahmad Mahayidin (Asthma Council Malaysia)
   

• Asthma management in Sri Lanka: the challenges and practicalities
   - Dr Kirthi Gunasekera (National Asthma Council Sri Lanka)
   

• The strategy for improving asthma management in Taiwan
   - Prof. Sow-Hsong Kuo (Taiwan Asthma Council)
   

• Development of early asthma management in Korea
   - Prof. Sang-Heon Cho (Korea Asthma and Allergy Foundation)
   

•  A simple tool to achieve asthma control
   - Dr Adisorn Wongsa (Thailand Asthma Council)
   

• Guidelines implementation
   - Prof. John Wilson (National Asthma Council Australia)

Using inhalers correctly

Recent research highlights the need for solid patient education with regard to the correct use of asthma inhalers. A German study presented at CHEST 2007 (the 73rd annual international scientific assembly of the American College of Chest Physicians, held October 20-25 in Chicago, USA) found that one out of three patients with asthma or chronic obstructive pulmonary disease (COPD) used their inhalers incorrectly with seniors having the most problems.

The research showed that 32.1% of patients made at least one essential error while using a dry powder inhaler (DPI) and that the error rate increased with age and severity of airway obstruction.

DPIs rely on the force of patients’ inhalation to activate, deliver, and manage the flow of medication to the lungs, compared with pressurized metered-dose inhalers (MDIs), that use propellents to deliver a measured dose of medication to the patient.

Dr Wieshammer and colleagues from the University of Heidelberg in Germany observed 224 patients with asthma or COPD using one of four common DPIs - Aerolizer, Diskus, HandiHaler, and Turbuhaler. Patients were asked about the instruction they received on using their inhaler and to demonstrate their inhalation technique. The overall error rate (the percent of patients making at least one error) was 32%. Regarding inhaler-specific error rates, Aerolizer has the lowest error rate at 9.1%, followed by Discus at 26.7%, Turbuhaler at 34%, and HandiHaler at 53.1%. Previous instruction by medical personnel on how to use the inhaler had a major impact on the error rate. In patients who had not received instruction, the error rate was 52.6%, whereas only 23.1% of the trained patients made essential errors.

Error rate also increased with age and severity of lung obstruction. Patients under age 60 had a 20.0% error rate, while those 60-years and over had an error rate of 41.6%. Patients with normal lung function had an error rate of 25.0%, while patients with severe obstruction had an error rate of 63.6%.

Researchers speculate that decreased cognitive and psychomotor skills, as well as a COPD-specific cognitive impairment, may make it difficult for older patients to properly use DPIs. Although the study authors do not advise against the use of DPIs in older patients, they recommend checking older patients’ inhalational technique at every health-care encounter in order to ensure the efficacy of treatment. Because DPIs rely on the force of a person's inhalation to propel medication into the lungs, DPIs are not recommended for children under age 5, people with severe asthma or those suffering a severe attack.

NAC recommendations on delivery devices and matching them to the person with asthma's needs are shown below.  

Reference

Asthma Management Handbook 2006 - Delivery devices

Statins: good for the heart and now for the lungs

Statins are known to be good for lowering cholesterol and maybe even fighting dementia, and now they have another reported benefit: they appear to slow decline in lung function in the elderly - even in those who smoke. According to researchers in Boston, USA it may be statins’ anti-inflammatory and antioxidant properties that help achieve this effect.

The investigators found that subjects taking statins experienced a markedly slower annual decline in lung function. In FEV₁, statin users lost 10.9 ml on average, whereas nonusers lost an average of 23.9 ml each year - more than twice that of the statin group. Similarly, statin users lost an average of 14 ml a year in FVC, whereas nonusers lost an average of 36.2 ml.

To determine whether smoking status modified that effect, the researchers also divided their subjects into four smoking groups: never-smokers, long-ago quitters, recent quitters and current smokers. Within each smoking group, those not taking statins were estimated to experience faster declines in FEV₁ and FVC than those taking statins, with the size of the effect varying a bit with smoking status.

To investigate whether statins had an effect of loss of lung function, the researchers used data from the ongoing and longitudinal Veterans Administration Normative Aging Study, which began in 1963. They analysed 803 subjects who had had their lung function measured at least twice between January 1995 and June 2005. Both forced expiratory volume in one second (FEV1) and forced vital capacity (FVC) were measured. The study subjects also completed questionnaires on pulmonary disorders, smoking and medication usage.

The investigators found that subjects taking statins experienced a markedly slower annual decline in lung function. In FEV1, statin users lost 10.9 ml on average, whereas nonusers lost an average of 23.9 ml each year - more than twice that of the statin group. Similarly, statin users lost an average of 14 ml a year in FVC, whereas nonusers lost an average of 36.2 ml.

Although further research work is required before any definitive conclusions can be drawn, these finding do support the hypothesis that statins reduce the annual loss of lung function that occurs with age.

Reference

Stacey E. Alexeeff, Augusto A. Litonjua, David Sparrow, Pantel S. Vokonas, and Joel Schwartz Statin Use Reduces Decline in Lung Function: VA Normative Aging Study Am. J. Respir. Crit. Care Med. 2007; 176: 742-747. http://ajrccm.atsjournals.org/content/vol176/issue8/

Pneumococcal vaccine - the value

Among patients hospitalised with community-acquired pneumonia (CAP), those who had previously received the pneumococcal vaccine had a lower risk of death and admission to the intensive care unit than patients who were not vaccinated, according to research undertaken by Dr Jennie Johnstone from the University of Alberta, Edmonton, in Canada.

Although 23-valent polysaccharide pneumococcal vaccine (PPV) does not prevent CAP, it might still improve outcomes in those who develop pneumonia.

From 2000 to 2002, the researchers prospectively collected data on all adults with CAP admitted to six hospitals in Capital Health, the largest integrated health delivery system in Canada. Polysaccharide pneumococcal vaccine status was ascertained by interview, medical record review, and contact with physicians and community health offices. The primary outcome was the composite of in-hospital mortality or intensive care unit (ICU) admission. Multivariable regression was used to determine the independent association between PPV use and outcomes, after adjusting for patient characteristics, pneumonia severity, and propensity scores.

Of the 3415 patients, 22 percent had been vaccinated with PPV, and 624 died or were admitted to the intensive care unit (ICU). Those who had been vaccinated with PPV were less likely to die or be admitted to the ICU than those who had not been vaccinated (10 percent vs. 21 percent). This finding was mostly a result of lower ICU admissions—less than 1 percent of those vaccinated were admitted to the ICU, compared with 13 percent of those who were not vaccinated. Results were similar when the researchers looked only at patients older than 65 or those living in nursing homes—groups for whom universal PPV vaccination is recommended.

Although 2,416 of the patients were eligible for vaccination upon being discharged from the hospital, only 215 (9 percent) received PPV at this time.

Patients with CAP who had prior PPV had about a 40% lower rate of mortality or ICU admission compared with those who were not vaccinated. This provides additional support for recommending PPV to those at risk of pneumonia. Overall, the importance of adopting current adult pneumococcal vaccination guidelines seems clear.

Further Information

VACCINE UPDATE for people with asthma, COPD, heart disease or diabetes - for consumers

Roles of influenza and pneumococcal vaccinations in subgroups with asthma, COPD, diabetes or heart disease - for health professionals

Reference

Jennie Johnstone; Thomas J. Marrie; Dean T. Eurich; Sumit R. Majumdar, Effect of Pneumococcal Vaccination in Hospitalized Adults With Community-Acquired Pneumonia. Arch Intern Med. 2007;167:1938-1943. http://archinte.ama-assn.org/cgi/content/abstract/167/18/1938

Hospitalisations for food-related anaphylaxis rising in Australia

Allergic conditions are on the rise in developed countries and Australian investigations have found that hospitalisations for anaphylaxis (a severe allergic reaction often involving more than one body system), urticaria (hives), and angioedema (allergic swelling of the face, lips and tongue) have been increasing since 1990.

In a study from the Australian Centre for Asthma Monitoring (ACAM), a collaborating unit of the Australian Institute of Health and Welfare (AIHW) published in the Journal of Allergy and Clinical Immunology, the prevalence of these conditions was reviewed by looking at records of hospital admissions and deaths in Australia from 1993-2005.

The researchers sought to characterise the cause and nature of the conditions by examining data on patient age, sex and the presence or absence of a food trigger for the event.

They have found that, as in the UK and US, admissions increased in all three conditions and especially for food-related anaphylaxis in children under 5 years of age.

Co-author Professor Guy Marks explained that  'We examined recent time trends in hospitalisations and deaths attributed to anaphylaxis, angioedema and urticaria in Australia, and found that over a 12-year period to 2004-05 there was a continuous increase in the rate of hospital admissions for each of these conditions, but that the nature and causative factors differed between adults and children.'

Hospitalisations attributed to anaphylaxis more than doubled over the study period with the most substantial increase being for anaphylaxis triggered by food.

While there was an increase in all age groups the largest increase was among young children, particularly boys.

There was also an increase in admissions attributed to angioedema among older people, which may be related to adverse reactions to medications.

Among children, admissions for allergic conditions were more common in boys than girls but among adults the gender difference was reversed.

The study group could draw no direct conclusions about underlying reasons for increased rates of hospital admission for these conditions. The increase may reflect an increase in the incidence of these conditions or an increase in their severity, or a combination of these, over the time reviewed.

Reference

Poulos LM, Waters AM, Correll PK, Loblay RH, Marks GB.Trends in hospitalizations for anaphylaxis, angioedema, and urticaria in Australia, 1993-1994 to 2004-2005. J Allergy Clin Immunol. 2007 Oct;120(4):878-84. http://www.jacionline.org/article/PIIS0091674907014406/abstract

Research Funding Opportunities

The National Asthma Council Australia would be pleased to list funding opportunities that may be available for asthma research. Submit brief details for consideration by email to editor@nationalasthma.com.au.

 

Conference Diary

Submit brief conference/meeting details to the National Asthma Council Australia for possible posting in our Conference Diary by email to editor@nationalasthma.com.au.

	American College of Allergy, Asthma & Immunology 9-14 November 2007 Dallas, United States http://www.acaai.org/
	18th ASCIA Annual Scientific Meeting 14-16 November 2007 Esplanade Hotel, Fremantle, Western Australia ASCIA (http://www.allergy.org.au/) in conjunction with: Perth Immunopathology (PIP) Weekend 17-18 November 2007 31st ASEATTA Annual Scientific Meeting 15-18 November 2007 ASCIA Nurses Day 13 November 2007 ASCIA Primary Care Allergy Update Dinner 13 November 2007
	General Practitioner Conference & Exhibition 16-18 November 2007 Melbourne Exhibition Centre GPCE 2007 (http://www.gpce.com.au/melbourne-2007/)
	Asian Intensive Care: problems and solutions 28-30 November 2007 Hong Kong SAR, China Department of Anaesthesia and Intensive Care, the Chinese University of Hong Kong Contact: Ms. Rebecca Luk, Dept. of Anaesthesia and Intensive Care, Prince of Wales Hospital, Hong Kong Fax: (852) 2637 2422 http://www.aic.cuhk.edu.hk/web8/Conference.htm
	Australian Asthma and Respiratory Educators Association 2007 Conference “Come and breathe new life into your practice” 29-30 November 2007 Legends Hotel Surfers Paradise Australian Asthma and Respiratory Educators Association (http://www.aareducation.org.au)
	12th APSR Congress 30 November - 4 December 2007 Gold Coast Convention & Exhibition Centre Broadbeach, Surfers Paradise, Queensland, Australia APSR 2007 (http://www.apsr2007.org)
	World Allergy Organization 2-6 December 2007 Thailand, Bangkok http://www.worldallergy.org/
	Annual Meeting of Taiwan Society of Pulmonary and Critical Care Medicine 8-9 December 2007 Taipei, Taiwan spccm@mars.seed.net.tw http://www.tspccm.org.tw/
2008
	Pulmocon 2008 Working together to promote lung health 20-22 February 2008 Dhaka, Bangladesh http://www.lungbd.org
	11th Asian Congress of Agricultural Medicine and Rural Health 22-24 February 2008 Aurangabad, Maharashtra, India 11asiancongress@pmtpims.org http://www.pravara.com/
	64th Annual Meeting of American Academy of Allergy, Asthma & Immunology 7-11 March 2008 Philadelphia, United States http://www.aaaai.org/
	16th Annual Meeting of The Asian Society For Cardiovascular Surgery 13-16 March 2008 Singapore http://www.ascvs2008.com/ mice@themeetinglab.com
	2008 Annual Scientific Meeting 30 March - 2 April 2008 Melbourne Convention Centre Melbourne, Victoria 2008 ASM TSANZ (http://www.thoracic.org.au/asm2008.html)
	ATS, Annual meeting of the American Lung Association & American Thoracic Society 16-21 May 2008 Toronto, Canada http://www.thoracic.org/