Asthma is a chronic and acute condition that causes inflammation of the airways in response to allergens such as viral infections and pollen. This article reviews the developmental anatomy and physiology of the respiratory tract, and considers asthma diagnosis, treatment and management.

This article is intended for the student or the junior registered nurse, however the experienced mentor may find it useful as a framework to help them support the learning needs of mentees.

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The GINA guidelines have redefined the primary goal of asthma treatment as achieving optimum control.

Objectives: To document the level of asthma control in Switzerland, the correlations between the international guidelines by GINA and the ACT's rating of asthma control, current treatment in adolescent and adult Swiss asthma patients and factors associated with asthma control.

Methods: General practitioners and specialists (pulmonologists, allergologists and paediatricians) were invited to participate in the cross-sectional survey. Asthma control was assessed in 1093 asthma patients using both the ACT and the GINA classification for asthma control.

Results: According to the GINA guidelines controlled asthma was found in 290 (27%) patients, when measured with the ACT 124 (11.5%) patients showed sufficient asthma control. 65% of the test results were in accordance with each other, whereas in 85% of the non-matching results the ACT underestimated control according to GINA classification. An ACT cut-off score of ≤17 best identified uncontrolled asthma according to GINA guidelines. 956 (87.7%) patients received controller medication and 849 (77.9%) patients received reliever medication. The following parameters were consistently identified to be significantly associated with insufficient asthma control in both

GINA and ACT measurements: presence of exacerbation, use of reliever medication, switch of therapy and smoking.

Study limitation: For this study only the ACT version for adults was used.

Conclusion: Asthma control remains insufficient in the majority of patients, despite prescription of regular controller medication. This survey confirms the validated ACT to be useful and important in everyday practice as an objective measure for asthma control according to GINA guidelines in order to monitor control and adjust treatment.

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BACKGROUND: Pulmonary rehabilitation has become a cornerstone in the management of patients with stable Chronic Obstructive Pulmonary Disease (COPD). Systematic reviews have shown large and important clinical effects of pulmonary rehabilitation in these patients. However, in unstable COPD patients who have recently suffered an exacerbation, the effects of pulmonary rehabilitation are less established.

OBJECTIVES: To assess the effects of pulmonary rehabilitation after COPD exacerbations on future hospital admissions (primary outcome) and other patient-important outcomes (mortality, health-related quality of life and exercise capacity).

SEARCH STRATEGY: Trials were identified from searches of CENTRAL, MEDLINE, EMBASE, PEDRO and the Cochrane Airways Group Register of Trials. Searches were current as of March 2010.

SELECTION CRITERIA: Randomized controlled trials comparing pulmonary rehabilitation of any duration after exacerbation of COPD with conventional care. Pulmonary rehabilitation programmes needed to include at least physical exercise. Control groups received conventional community care without rehabilitation.

DATA COLLECTION AND ANALYSIS: We calculated pooled odds ratios and weighted mean differences (MD) using random-effects models. We requested missing data from the authors of the primary studies.

MAIN RESULTS: We identified nine trials involving 432 patients. Pulmonary rehabilitation significantly reduced hospital admissions (pooled odds ratio 0.22 [95% CI 0.08 to 0.58], number needed to treat (NNT) 4 [95% CI 3 to 8], over 25 weeks) and mortality (OR 0.28; 95% CI 0.10 to 0.84), NNT 6 [95% CI 5 to 30] over 107 weeks). Effects of pulmonary rehabilitation on health-related quality of life were well above the minimal important difference when measured by the Chronic Respiratory Questionnaire (MD for dyspnea, fatigue, emotional function and mastery domains between 0.81 (fatigue; 95% CI 0.16 to 1.45) and 0.97 (dyspnea; 95% CI 0.35 to 1.58)) and the St. Georges Respiratory Questionnaire total score (MD -9.88; 95% CI -14.40 to -5.37); impacts domain (MD -13.94; 95% CI -20.37 to -7.51) and for activity limitation domain (MD -9.94; 95% CI -15.98 to -3.89)). The symptoms domain of the St. Georges Respiratory Questionnaire showed no significant improvement. Pulmonary rehabilitation significantly improved exercise capacity and the improvement was above the minimally important difference (six-minute walk test (MD 77.70 meters; 95% CI 12.21 to 143.20) and shuttle walk test (MD 64.35; 95% CI 41.28 to 87.43)). No adverse events were reported in three studies.

AUTHORS' CONCLUSIONS: Evidence from nine small studies of moderate methodological quality, suggests that pulmonary rehabilitation is a highly effective and safe intervention to reduce hospital admissions and mortality and to improve health-related quality of life in COPD patients who have recently suffered an exacerbation of COPD.

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BACKGROUND: Current guidelines recommend that acute exacerbations of chronic obstructive pulmonary disease (COPD) be treated with systemic corticosteroids (SCs) for seven to 14 days. Intermittent SC use is cumulatively associated with adverse effects such as osteoporosis, hyperglycaemia and muscle weakness. Shorter treatment could therefore reduce the risk of adverse effects.

OBJECTIVES: To compare the efficacy of short-duration (seven days or fewer) and longer-duration (more than seven days) SC treatment of acute COPD exacerbations in adults.

SEARCH STRATEGY: We searched the Cochrane Airways Group Register of Trials (to April 2011) Cochrane Central Register of Controlled Trials (to April 2011), MEDLINE (from 1950 to October 2010), EMBASE (from 1980 to October 2010) and the reference lists of articles.

SELECTION CRITERIA: Randomised controlled trials comparing different durations of SC (seven days or fewer or more than seven days). Other interventions, e.g. bronchodilators and antibiotics, were standardised; studies in other lung diseases were excluded, unless data on participants with COPD were available.

DATA COLLECTION AND ANALYSIS: Two review authors independently extracted data that were pooled them using Review Manager 5. We sought missing data from authors of studies published as abstracts only.

MAIN RESULTS: We identified seven studies including 288 participants; two studies were fully published and five were published as abstracts. We obtained data for two studies published as abstracts from authors; these two abstracts and the two full papers contributed to meta-analysis. No study specified COPD diagnostic criteria and only one specified exacerbation criteria. Short course treatment varied between three and seven days and longer duration 10 to 15 days, at equivalent daily doses of corticosteroids; five studies used oral prednisolone (dose 30 mg, four studies, one tapered dose) and two studies used intravenous corticosteroid treatment. Mean ages of participants ranged from 64 to 73 years. We assessed the risk of allocation and blinding bias as low for these studies. Primary outcomes: risk of treatment failure did not differ significantly by treatment duration, but the confidence interval (CI) was too wide to conclude equivalence (odds ratio (OR) 0.94, 95% CI 0.38 to 2.36) (three studies, n = 158). Forced expiratory volume in 1 second (FEV(1)) did not differ significantly when measured up to seven days (mean difference (MD) 0.07 L, 95% CI 0.19 to 0.05) or after seven days (MD 0.02 L, 95% CI 0.10 to 0.06) (four studies, n = 197). The likelihood of an adverse event (four studies, n = 102) did not differ significantly by treatment duration, but again the CI was wide (OR 0.58, 95% CI 0.14 to 2.40).

AUTHORS' CONCLUSIONS: We based assessment of the efficacy of short (seven days or less) compared to longer duration (more than seven days) systemic corticosteroid therapy for acute exacerbations of COPD in this review on four of the seven included studies for which data were available. Two studies were fully published and two were published as conference abstracts but trialists were able to supply data requested for the review.The finding in this review that there is no significant increase in treatment failure with shorter systemic corticosteroid treatment for seven days or less for acute exacerbations of COPD, does not give conclusive evidence to recommend change in clinical practice due to a wide confidence interval around the estimate of effect. The four studies which contributed to the meta-analysis were of relatively low quality and five of the seven studies were not published as full articles.  Thus there are insufficient data to allow firm conclusions concerning the optimal duration of corticosteroid therapy of acute exacerbations of COPD to be drawn.

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