Category: Asthma

Many diseases of the human body are the result of mutations in certain key genes that are responsible for the proper development, anatomy, and function of human homeostasis. Thus, unless a medication or treatment option can be found that specifically targets the consequences of a mutation – for example, a diet that avoids phenylalanine to counteract effects from phenylketonuria (PKU) – curing or even mitigating the disorder is often not easily possible, and patients have to live with their illness, often for an entire lifetime (Blau, 2016). The problem is that while mutations are easily introduced into the human genome and consequently get inherited over several generations, there is no way to repair the mutations and restore the genes to their original, ‘healthy’ status.

Recent studies, however, have seen the development of several techniques that allow the exchange of bases in the DNA with pinpoint precision. One example that has seen the most promise and is slowly moving into clinical trials is the so-called clustered Regularly Interspaced Short Palindromic Repeats and CRISPR-associated protein 9, or in short, CRISPR/Cas9 (Tian et al., 2019). Using this technology, DNA sequences can be specifically targeted and ‘repaired’, thus potentially curing genetic conditions. Importantly, not all genetic conditions can be easily healed even with the technology to repair specific mutations, as not all parts of the body are easily accessible, and some mutations cause problems during development that cannot be easily reversed later on. However, genetic conditions that involve the immune system are likely more easily accessible for genetic therapies, and therefore, CRISPR/Cas9 has been discussed in the treatment of allergies and immunological conditions. Importantly, recent research has identified several mutations that underly airway inflammation and asthma, suggesting ways to treat these conditions using CRISPR/Cas9 (Goodman et al., 2017).

The goals of this paper are to (1.) provide an overview of the CRISPR/Cas9 system, including the latest developments and practical considerations; (2.) take a look at the current research and clinical treatments pertaining to asthma and similar immunological conditions; and (3.) point out ways in which CRISPR/Cas9 can help cure patients afflicted with asthma, or at least mitigate their symptoms.

The CRISPR/Cas9 methodology – from bench to bedside

The CRISPR/Cas9 system has its origins in prokaryotes and likely functions as a primitive immune system. Incoming alien DNA is recognized by the bacterium, attacked, and cut. Prokaryotes usually have a large and diverse repertoire of defense mechanisms, which include restriction endonucleases that have been long used in basic research for their exquisite specificity in cutting DNA sequences. The special feature of the CRISPR/Cas9 system, however, is its ‘programmability’, as it consists of two main components: the Cas9 endonuclease and a ‘guiding’ single-strand RNA fragment, which binds to the complementary DNA strand and thus demarcates the sequence at which Cas9 can cut that strand. Thus, in the lab, the CRISPR/Cas9 system can be specifically targeted to cut in the vicinity of any DNA sequence, as long as there is a guidance RNA (gRNA) molecule present that is complementary to that sequence (Knott & Doudna, 2018). Importantly, the Cas9 endonuclease will only cut a strand open at a specific stretch of sequence; if at the same time DNA nucleotides are present, the cell-internal DNA repair machinery will insert those bases, and it will do so while making mistakes, allowing for the introduction of mutations – or their repair, when the DNA sequence is restored to the wildtype allele.

It is important to note that the CRISPR/Cas9 system is not without flaws. For example, it can induce off-target effects (OTEs), that is, attack sequences that are not in the desired sequence or gene to be mutated. In basic research studies in the lab, OTEs can be controlled through an appropriate experimental design. However, for clinical applications, OTEs need to be eliminated as much as possible. First, the gRNA target sequence needs to be specific enough. If the base pair needs to be changed adjacent to a repetitive sequence, the chances are increased that the system will target other regions within the genome. In addition, local single nucleotide polymorphisms (SNPs) can reduce the affinity of the gRNA fragment to the target DNA, which also increases the likelihood of OTEs (Kimberland et al., 2018).

There are several ways to introduce the CRISPR/Cas9 system into the human body for clinical trials and therapies. First, the system can be delivered via an adenoviral vector; DNA for Cas9 and the guidance RNA are inserted into the adenoviral DNA sequence. The virus is then injected close to the target tissue, upon which it enters the target cells and allows for the CRISPR/Cas9 system to become active. The system can also be attached to artificial vectors, such as synthetic liposomes, injected and subsequently delivered into the target tissue. Third, cells – for example, hematopoietic stem cells (HPSCs) – can be taken from the patient, modified using the CRISPR/Cas9 system ex vivo in the lab, and then reinserted into the patient. The ‘repaired’ stem cells can then proliferate, giving rise to ‘healthy progenitors’. Importantly, the mutation is not eliminated across every tissue in the whole body; however, as many genes are only required in specific tissues, it is enough to abolish the mutation in stem cells that belong to the respective tissue (Gulei & Berindan-Neagoe, 2017).

Asthma and the immune system

Asthma is a chronic lung disease that leaves the airways inflamed. As a consequence, the muscles lining the airways tighten, and the epithelial cells secret a mucus-like substance that narrows the passage of air. The result is troubled breathing, which can become life-threatening in severe cases. In most cases, there is no clear underlying reason for the airway inflammations, which periodically flare up; as a consequence, asthma treatment regimens have emphasized symptom management and mitigation instead of focusing on an actual cure.

As one of the central factors that underly the development of asthma is the inflammation of airway cells, a large body of research has focused on the role of the immune system in asthma. The connection of asthma with allergies is another reason that the immune system may play a decisive role in this condition. Studies have revealed several immunological biomarkers that are associated with an increased risk for asthma and airway inflammation, such as T-cell phenotypes and associated cytokines, endotypes based on eosinophils and neutrophils, and molecules that are derived from lung epithelium, such as osteopontin and CCL-26 (Zissler et al., 2016). Thus, there is a large repertoire of abnormally regulated immune cells that may underly any form of asthma in individual patients. If those patients can be screened for the presence of particular SNPs that are associated with an increased risk for asthma, technologies such as CRISPR/Cas9 can be used to eliminate those SNPs and restore the immune system to its ‘normal’ function.

Importantly, as it is difficult to find one clear reason for the development of asthma, simply changing one or two SNPs may not be enough to control the disease. However, by targeting hematopoietic stem cells (HPSCs), several downstream populations of immune cells can be simultaneously targeted. For example, CRISPR could be used to block certain transcription factors that promote the development of T-helper cell 2 (Th2) phenotypes, which play an important role in promoting inflammation within lung tissue. At the same time, the expression of certain transcription factors that induce T-helper cell 1 (Th1) and regulatory T-cells (Treg) phenotypes could be promoted, resulting in an overall suppression of the Th2 pro-inflammatory pathways and induction of the Th1 and Treg response, which limit inflammation. Thus, CRISPR could be used to regulate certain subsets of the immune system, in addition to repairing the defects in several genes. As many conditions are of polygenic origin, treating asthma and allergies with CRISPR/Cas9 technology could be a useful framework for the mitigation or even cure of a host of other diseases.

CRISPR/Cas9 has been used for the treatment of aggressive lung cancer in a single patient in China (Cyranoski, 2016); several clinical trials have been proposed that use CRISPR to modify cells within the immune system and other organ systems within the body. In the Chinese study, CRISPR/Cas9 was used in an ex vivo approach. If it turns out that such approaches can be used for CRISPR-based therapies, treatments for more diseases could be developed.

Conclusion

CRISPR/Cas9 is a novel, powerful technology that has enormous potential in the cure of several genetic diseases based on its ability for pinpoint editing of specific DNA sequences. Cas9 is an endonuclease that cuts DNA sequences that bind to a small fragment of guidance RNA (gRNA). As the gRNA sequence can be freely chosen, the system can be programmed to work with almost any sequence. Therefore, it promises to provide treatment and even cure for a whole host of different conditions, from neuronal problems to cancer and diseases of the immune system, such as HIV. Asthma is a chronic inflammation of the lungs and the airways; accumulation of the resulting mucus can make it harder for patients to breathe. Asthma is the result of a misregulation of several different pathways, most of which are within the immune system. Current efforts investigate ways in which hematopoietic stem cells (HPSCs) can be taken from the patient, treated with the CRISPR/Cas9 system in the lab, and reintroduced into the patient. One way in which such modified HPSCs can function is through the downregulation of pro-inflammatory pathways and the upregulation of anti-inflammatory responses.

References

1. Blau, N. (2016). Genetics of phenylketonuria: then and now. Human Mutation, 37(6), 508-515.
2. Cyranoski, D. (2016). CRISPR gene-editing tested in a person for the first time. Nature News, 539(7630), 479.
3. Goodman, M. A., Moradi Manesh, D., Malik, P., & Rothenberg, M. E. (2017). CRISPR/Cas9 in allergic and immunologic diseases. Expert Review of Clinical Immunology, 13, 1, 5 – 9.
4. Gulei, D., & Berindan-Neagoe, I. (2017). CRISPR/Cas9: a potential life-saving tool. What’s next? Molecular Therapy – Nucleic Acids, 9, 333-336.
5. Kimberland, M. L., Hou, W., Alfonso-Pecchio, A., Wilson, S., Rao, Y., Zhang, S., & Lu, Q. (2018). 6501. Strategies for controlling CRISPR/Cas9 off-target effects and biological variations in mammalian genome editing experiments. Journal of Biotechnology, 284, 91-101.
6. Knott, G. J., & Doudna, J. A. (2018). CRISPR-Cas guides the future of genetic engineering. Science, 361(6405), 866-869.
7. Tian, X., Gu, T., Patel, S., Bode, A. M., Lee, M. H., & Dong, Z. (2019). CRISPR/Cas9 – an evolving biological tool kit for cancer biology and oncology. npj Precision Oncology, 3(1), 8.
8. Zissler, U. M., Esser‐von Bieren, J., Jakwerth, C. A., Chaker, A. M., & Schmidt‐Weber, C. B. (2016). Current and future biomarkers in allergic asthma. Allergy, 71(4), 475-494.

Background

Asthma is a respiratory and genetic condition characterized by the inflammation and narrowing of airways in the lungs. The inflammation forces airways to swell, contributing to difficulties in breathing (Rubner et al., 2017). During asthma attacks, individuals experience periods of intense coughing, shortness of breath, chest tightness, and wheezing. Individuals with asthma may experience mild to severe symptoms, and a varying frequency of attacks. An individual’s physical activity may be related to the timing of asthma symptoms. Some people experience asthma attacks when exercising, a condition called exercise-induced asthma. Cold, smoke, animal dander, and pollen are other triggers for asthma attacks. The Centers for Disease Control and Prevention (CDC) reports show that about 27 million Americans have asthma (Rubner et al., 2017).

A range of factors accounts for the etiology of asthma. Genetics plays a critical part in the development of asthma (Rubner et al., 2017). A family with a history of asthma indicates that there is a genetic predisposition, an increased risk that other family members may develop it as well. Allergies also account for the development of this condition (Rubner et al., 2017). Some individuals are more allergic than others, particularly when their parents have also experienced allergic reactions. Asthma may also develop from respiratory diseases, especially during early childhood (Rubner et al., 2017). Particular respiratory infections, such as pneumonia, can damage lung tissues and cause inflammation during early childhood. Such damage can inflict life-long breathing struggles. The environment also influences the susceptibility of this disease. Exposure to viral infections and contact with irritants or allergens in early childhood enhances the chances of developing asthma. A poorly developed immune system also heightens the chance of acquiring asthma (Rubner et al., 2017).

Asthma affects people of all ages. Currently, one in 13 people has asthma, and it is the leading chronic condition in children (Asthma Facts and Figures, 2020). The onset typically occurs during childhood and is more prevalent in boys than girls. Although asthma is more common in children it can also develop in adulthood, affecting more women than men. Adult asthma is generally related to exposure of harmful inhalants and other allergens. Asthma profoundly impacts racial minorities, such as African Americans. In the US, the disease kills many more African Americans than any other ethnicity or race (Asthma Facts and Figures, 2020).

Pathology and Symptoms

A complex interaction of genetics and environmental factors predisposes individuals to asthma influencing the onset and severity of the disease (Dharmage et al., 2019). Environmental factors can trigger the development and increase the severity of asthma attacks (Dharmage et al., 2019). These factors include environmental chemicals, air pollutants, and allergens. Tobacco smoking during pregnancy and after birth increases the risk of asthma in children (Quirt et al., 2018). Reduced air quality due to air pollutants also contributes to the development of asthma and the severity of the condition (Dharmage et al., 2019). For instance, most of the asthma cases in the US are reported in areas with low air quality, especially in low-income households. Organic compounds, such as formaldehyde, also show a positive correlation to the development of this condition. Furthermore, a close connection exists between exposure to indoor allergens and the development of asthma. Such allergens include mold, animal dander, and dust mites (Dharmage et al., 2019).

Research implicates many genes in the development of asthma and a person’s predisposition to it. Currently, some of the genes associated with this condition include ADAM33, IL4R, SPINK5, CTLA-4, AND IL10 (Xu, 2014). Notably, environmental factors like allergens can increase the genetic predisposition to asthma (Quirt et al., 2018).

Certain medical conditions also predispose individuals to asthma. Atopic conditions increase the chance of developing asthma (Quirt et al., 2018). Atopic diseases are those conditions that trigger an exaggerated immune response to harmless environmental compounds (Dharmage et al., 2019). Asthma is also prevalent in individuals experiencing hay fever or eczema. Recent studies also link obesity to the development of asthma. The reason is that obesity reduces respiratory functions because of fat buildup (Dharmage et al., 2019). An increase in the adipose tissue also increases the chances of inflammatory states.

People with asthma exhibit symptoms of wheezing, coughing, and shortness of breath with chest pain or tightness and also possibly trouble sleeping (Quirt et al., 2018). A wheezing or whistling sound during exhalation also indicates the presence of this condition in children (Quirt et al., 2018). Respiratory viruses like flu or cold worsen the wheezing and coughing attacks. Factors that indicate exacerbated asthma include frequent symptoms, which disrupt daily activities (Dharmage et al., 2019). Increased breathing difficulties also show a worsening condition.

Research Study

Hypothesis

Challenges related to self-care behaviors among school-going children with asthma emerge as the problem in this research. The research question from the study objectives, states, “what is the effectiveness of Staying Healthy-Asthma Responsible and Prepared (SHARP) on fostering the use of effective asthma self-care behaviors?” (Kintner et al., 2015). SHARP is a program designed to counsel and educate students in this study. A hypothesis developed by the researchers reveals that SHARP is effective in promoting effective self-care behaviors among students with asthma.

Method

The authors utilize a cluster-randomized research design. The research design employs two groups, the SHARP and the control intervention, to determine any improvement in self-care tendencies among students. Participants in the controlled group receive standard care to enhance a comparison with those in the SHARP intervention (Kintner et al., 2015). Notably, this research design facilitates data collection using self-report measures among the participants. The study design is useful in making a comparative analysis of the two interventions. Through this design, the researchers can make direct comparisons of the SHARP intervention to the control intervention to establish superiority. Significantly, the study design minimizes selection and allocation bias in the research. Significantly, the design is also statistically reliable.

The sample in this study comprised 4th and 5th-grade children whose ages ranged between 9 and 12 years. This population had to be diagnosed with asthma and had caregivers to take care of them. Kintner et al. (2015) adopted convenience sampling for the study. Using this technique, the researchers recruited students from different elementary schools from low socio-economic, medically marginalized, moderately sized, minority, and inner-city communities. Initially, the researchers screened 2770 students and caregivers for eligibility. After the screening, Kintner et al. (2015) remained with 216 students and caregivers while excluding the rest due to no asthma diagnosis. Following the preprogram assessment, the researchers remained with a sample of 205 students and caregivers. Kintner et al. (2015) allocated this sample to each of the two groups. The researchers allocated 117 dyads to the SHARP intervention. The remaining 88 dyads were assigned to the control program. The sample was appropriate for the study since the researchers recruited the relevant population for the study. The sampling method was also time and cost-saving for the researchers.

Outcomes

The outcome of the study supports the theory that SHARP can foster the psychological acceptance of asthma among students. The research builds upon previous problems related to difficulty in accepting asthma when transitioning from elementary to junior or middle school. In comparison to the participants in the control group, the SHARP intervention elevates risk prevention and episode management among students with asthma. The SHARP program outlined in this study can be immediately introduced in schools and communities through health education. Apart from asthma, this intervention is also relevant to the management of conditions like diabetes and epilepsy. As evident in this study, a SHARP intervention is critical to advancing nursing practice and fostering pediatric health. Based on the perceived benefits of this intervention, it helps enhance life quality and promotes health among school-aged children. Although asthma is non-communicable, it affects millions of children and teenagers around the world. Asthma impacts academic performance and social skills, which adversely impacts health. Since the researchers provide evidence to prove the efficacy of SHARP, schools and communities need to work with specialist nurses in implementing this intervention.

Further Studies

Future research should be carried out on this subject. Scholars should use this research to carry out cost-effectiveness studies on SHARP for implementation in schools and communities. A hypothesis for this study will indicate that the implementation of the SHARP program will require financial resources, parental support, and community engagement to benefit students with asthma. The outcome of this study will outline that financial costs and resources are necessary to incorporate the intervention in a school setting. Through cost analysis, schools can devise strategies to finance the intervention and improve the wellbeing of asthma students. The research can also explore the viability of implementing community programs for classmates of asthma students to promote acceptance. The program can promote an understanding of asthma and its related effects on individuals. Such knowledge can increase the acceptance of students with asthma among their peers. Therefore, this is essential to improving health among those with asthma.

References:

1. Asthma Facts and Figures |AAFA. (2018, February). Retrieved from https://www.aafa.org/asthma-facts/
2. Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of Asthma in Children and Adults. Frontiers in Pediatrics, 7. doi: 10.3389/fped.2019.00246
3. Kintner, E. K., Cook, G., Marti, C. N., Allen, A., Stoddard, D., Harmon, P., … Egeren, L. A. V. (2014). Effectiveness of a school- and community-based academic asthma health education program on the use of effective asthma self-care behaviors in older school-age students. Journal for Specialists in Pediatric Nursing, 20(1), 62–75. doi: 10.1111/jspn.12099
4. Quirt, J. J., Hildebrand, K. J., Mazza, J. J., Noya, F. J., & Kim, H. J. (2018). Asthma. Allergy, Asthma & Clinical Immunology, 14(S2). DOI: 10.1186/s13223-018-0279-0
5. Rubner, F. J., Jackson, D. J., Evans, M. D., Gangnon, R. E., Tisler, C. J., Pappas, T. E., … Lemanske, R. F. (2017). Early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence. Journal of Allergy and Clinical Immunology, 139(2), 501–507. doi: 10.1016/j.jaci.2016.03.049
6. Xu, W. (2014, March 27). Expression Data Analysis to Identify Biomarkers Associated with Asthma in Children. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985200/

Many diseases of the human body are the result of mutations in certain key genes that are responsible for the proper development, anatomy, and function of human homeostasis. Thus, unless a medication or treatment option can be found that specifically targets the consequences of a mutation – for example, a diet that avoids phenylalanine to counteract effects from phenylketonuria (PKU) – curing or even mitigating the disorder is often not easily possible, and patients have to live with their illness, often for an entire lifetime (Blau, 2016). The problem is that while mutations are easily introduced into the human genome and consequently get inherited over several generations, there is no way to repair the mutations and restore the genes to their original, ‘healthy’ status.

Recent studies, however, have seen the development of several techniques that allow the exchange of bases in the DNA with pinpoint precision. One example that has seen the most promise and is slowly moving into clinical trials is the so-called clustered Regularly Interspaced Short Palindromic Repeats and CRISPR-associated protein 9, or in short, CRISPR/Cas9 (Tian et al., 2019). Using this technology, DNA sequences can be specifically targeted and ‘repaired’, thus potentially curing genetic conditions. Importantly, not all genetic conditions can be easily healed even with the technology to repair specific mutations, as not all parts of the body are easily accessible, and some mutations cause problems during development that cannot be easily reversed later on. However, genetic conditions that involve the immune system are likely more easily accessible for genetic therapies, and therefore, CRISPR/Cas9 has been discussed in the treatment of allergies and immunological conditions. Importantly, recent research has identified several mutations that underly airway inflammation and asthma, suggesting ways to treat these conditions using CRISPR/Cas9 (Goodman et al., 2017).

The goals of this paper are to (1.) provide an overview of the CRISPR/Cas9 system, including the latest developments and practical considerations; (2.) take a look at the current research and clinical treatments pertaining to asthma and similar immunological conditions; and (3.) point out ways in which CRISPR/Cas9 can help cure patients afflicted with asthma, or at least mitigate their symptoms.

The CRISPR/Cas9 methodology – from bench to bedside

The CRISPR/Cas9 system has its origins in prokaryotes and likely functions as a primitive immune system. Incoming alien DNA is recognized by the bacterium, attacked, and cut. Prokaryotes usually have a large and diverse repertoire of defense mechanisms, which include restriction endonucleases that have been long used in basic research for their exquisite specificity in cutting DNA sequences. The special feature of the CRISPR/Cas9 system, however, is its ‘programmability’, as it consists of two main components: the Cas9 endonuclease and a ‘guiding’ single-strand RNA fragment, which binds to the complementary DNA strand and thus demarcates the sequence at which Cas9 can cut that strand. Thus, in the lab, the CRISPR/Cas9 system can be specifically targeted to cut in the vicinity of any DNA sequence, as long as there is a guidance RNA (gRNA) molecule present that is complementary to that sequence (Knott & Doudna, 2018). Importantly, the Cas9 endonuclease will only cut a strand open at a specific stretch of sequence; if at the same time DNA nucleotides are present, the cell-internal DNA repair machinery will insert those bases, and it will do so while making mistakes, allowing for the introduction of mutations – or their repair, when the DNA sequence is restored to the wildtype allele.

It is important to note that the CRISPR/Cas9 system is not without flaws. For example, it can induce off-target effects (OTEs), that is, attack sequences that are not in the desired sequence or gene to be mutated. In basic research studies in the lab, OTEs can be controlled through an appropriate experimental design. However, for clinical applications, OTEs need to be eliminated as much as possible. First, the gRNA target sequence needs to be specific enough. If the base pair needs to be changed adjacent to a repetitive sequence, the chances are increased that the system will target other regions within the genome. In addition, local single nucleotide polymorphisms (SNPs) can reduce the affinity of the gRNA fragment to the target DNA, which also increases the likelihood of OTEs (Kimberland et al., 2018).

There are several ways to introduce the CRISPR/Cas9 system into the human body for clinical trials and therapies. First, the system can be delivered via an adenoviral vector; DNA for Cas9 and the guidance RNA are inserted into the adenoviral DNA sequence. The virus is then injected close to the target tissue, upon which it enters the target cells and allows for the CRISPR/Cas9 system to become active. The system can also be attached to artificial vectors, such as synthetic liposomes, injected and subsequently delivered into the target tissue. Third, cells – for example, hematopoietic stem cells (HPSCs) – can be taken from the patient, modified using the CRISPR/Cas9 system ex vivo in the lab, and then reinserted into the patient. The ‘repaired’ stem cells can then proliferate, giving rise to ‘healthy progenitors’. Importantly, the mutation is not eliminated across every tissue in the whole body; however, as many genes are only required in specific tissues, it is enough to abolish the mutation in stem cells that belong to the respective tissue (Gulei & Berindan-Neagoe, 2017).

Asthma and the immune system

Asthma is a chronic lung disease that leaves the airways inflamed. As a consequence, the muscles lining the airways tighten, and the epithelial cells secret a mucus-like substance that narrows the passage of air. The result is troubled breathing, which can become life-threatening in severe cases. In most cases, there is no clear underlying reason for the airway inflammations, which periodically flare up; as a consequence, asthma treatment regimens have emphasized symptom management and mitigation instead of focusing on an actual cure.

As one of the central factors that underly the development of asthma is the inflammation of airway cells, a large body of research has focused on the role of the immune system in asthma. The connection of asthma with allergies is another reason that the immune system may play a decisive role in this condition. Studies have revealed several immunological biomarkers that are associated with an increased risk for asthma and airway inflammation, such as T-cell phenotypes and associated cytokines, endotypes based on eosinophils and neutrophils, and molecules that are derived from lung epithelium, such as osteopontin and CCL-26 (Zissler et al., 2016). Thus, there is a large repertoire of abnormally regulated immune cells that may underly any form of asthma in individual patients. If those patients can be screened for the presence of particular SNPs that are associated with an increased risk for asthma, technologies such as CRISPR/Cas9 can be used to eliminate those SNPs and restore the immune system to its ‘normal’ function.

Importantly, as it is difficult to find one clear reason for the development of asthma, simply changing one or two SNPs may not be enough to control the disease. However, by targeting hematopoietic stem cells (HPSCs), several downstream populations of immune cells can be simultaneously targeted. For example, CRISPR could be used to block certain transcription factors that promote the development of T-helper cell 2 (Th2) phenotypes, which play an important role in promoting inflammation within lung tissue. At the same time, the expression of certain transcription factors that induce T-helper cell 1 (Th1) and regulatory T-cells (Treg) phenotypes could be promoted, resulting in an overall suppression of the Th2 pro-inflammatory pathways and induction of the Th1 and Treg response, which limit inflammation. Thus, CRISPR could be used to regulate certain subsets of the immune system, in addition to repairing the defects in several genes. As many conditions are of polygenic origin, treating asthma and allergies with CRISPR/Cas9 technology could be a useful framework for the mitigation or even cure of a host of other diseases.

CRISPR/Cas9 has been used for the treatment of aggressive lung cancer in a single patient in China (Cyranoski, 2016); several clinical trials have been proposed that use CRISPR to modify cells within the immune system and other organ systems within the body. In the Chinese study, CRISPR/Cas9 was used in an ex vivo approach. If it turns out that such approaches can be used for CRISPR-based therapies, treatments for more diseases could be developed.

Conclusion

CRISPR/Cas9 is a novel, powerful technology that has enormous potential in the cure of several genetic diseases based on its ability for pinpoint editing of specific DNA sequences. Cas9 is an endonuclease that cuts DNA sequences that bind to a small fragment of guidance RNA (gRNA). As the gRNA sequence can be freely chosen, the system can be programmed to work with almost any sequence. Therefore, it promises to provide treatment and even cure for a whole host of different conditions, from neuronal problems to cancer and diseases of the immune system, such as HIV. Asthma is a chronic inflammation of the lungs and the airways; accumulation of the resulting mucus can make it harder for patients to breathe. Asthma is the result of a misregulation of several different pathways, most of which are within the immune system. Current efforts investigate ways in which hematopoietic stem cells (HPSCs) can be taken from the patient, treated with the CRISPR/Cas9 system in the lab, and reintroduced into the patient. One way in which such modified HPSCs can function is through the downregulation of pro-inflammatory pathways and the upregulation of anti-inflammatory responses.

References

1. Blau, N. (2016). Genetics of phenylketonuria: then and now. Human Mutation, 37(6), 508-515.
2. Cyranoski, D. (2016). CRISPR gene-editing tested in a person for the first time. Nature News, 539(7630), 479.
3. Goodman, M. A., Moradi Manesh, D., Malik, P., & Rothenberg, M. E. (2017). CRISPR/Cas9 in allergic and immunologic diseases. Expert Review of Clinical Immunology, 13, 1, 5 – 9.
4. Gulei, D., & Berindan-Neagoe, I. (2017). CRISPR/Cas9: a potential life-saving tool. What’s next? Molecular Therapy – Nucleic Acids, 9, 333-336.
5. Kimberland, M. L., Hou, W., Alfonso-Pecchio, A., Wilson, S., Rao, Y., Zhang, S., & Lu, Q. (2018). 6501. Strategies for controlling CRISPR/Cas9 off-target effects and biological variations in mammalian genome editing experiments. Journal of Biotechnology, 284, 91-101.
6. Knott, G. J., & Doudna, J. A. (2018). CRISPR-Cas guides the future of genetic engineering. Science, 361(6405), 866-869.
7. Tian, X., Gu, T., Patel, S., Bode, A. M., Lee, M. H., & Dong, Z. (2019). CRISPR/Cas9 – an evolving biological tool kit for cancer biology and oncology. npj Precision Oncology, 3(1), 8.
8. Zissler, U. M., Esser‐von Bieren, J., Jakwerth, C. A., Chaker, A. M., & Schmidt‐Weber, C. B. (2016). Current and future biomarkers in allergic asthma. Allergy, 71(4), 475-494.

Background

Asthma is a respiratory and genetic condition characterized by the inflammation and narrowing of airways in the lungs. The inflammation forces airways to swell, contributing to difficulties in breathing (Rubner et al., 2017). During asthma attacks, individuals experience periods of intense coughing, shortness of breath, chest tightness, and wheezing. Individuals with asthma may experience mild to severe symptoms, and a varying frequency of attacks. An individual’s physical activity may be related to the timing of asthma symptoms. Some people experience asthma attacks when exercising, a condition called exercise-induced asthma. Cold, smoke, animal dander, and pollen are other triggers for asthma attacks. The Centers for Disease Control and Prevention (CDC) reports show that about 27 million Americans have asthma (Rubner et al., 2017).

A range of factors accounts for the etiology of asthma. Genetics plays a critical part in the development of asthma (Rubner et al., 2017). A family with a history of asthma indicates that there is a genetic predisposition, an increased risk that other family members may develop it as well. Allergies also account for the development of this condition (Rubner et al., 2017). Some individuals are more allergic than others, particularly when their parents have also experienced allergic reactions. Asthma may also develop from respiratory diseases, especially during early childhood (Rubner et al., 2017). Particular respiratory infections, such as pneumonia, can damage lung tissues and cause inflammation during early childhood. Such damage can inflict life-long breathing struggles. The environment also influences the susceptibility of this disease. Exposure to viral infections and contact with irritants or allergens in early childhood enhances the chances of developing asthma. A poorly developed immune system also heightens the chance of acquiring asthma (Rubner et al., 2017).

Asthma affects people of all ages. Currently, one in 13 people has asthma, and it is the leading chronic condition in children (Asthma Facts and Figures, 2020). The onset typically occurs during childhood and is more prevalent in boys than girls. Although asthma is more common in children it can also develop in adulthood, affecting more women than men. Adult asthma is generally related to exposure of harmful inhalants and other allergens. Asthma profoundly impacts racial minorities, such as African Americans. In the US, the disease kills many more African Americans than any other ethnicity or race (Asthma Facts and Figures, 2020).

Pathology and Symptoms

A complex interaction of genetics and environmental factors predisposes individuals to asthma influencing the onset and severity of the disease (Dharmage et al., 2019). Environmental factors can trigger the development and increase the severity of asthma attacks (Dharmage et al., 2019). These factors include environmental chemicals, air pollutants, and allergens. Tobacco smoking during pregnancy and after birth increases the risk of asthma in children (Quirt et al., 2018). Reduced air quality due to air pollutants also contributes to the development of asthma and the severity of the condition (Dharmage et al., 2019). For instance, most of the asthma cases in the US are reported in areas with low air quality, especially in low-income households. Organic compounds, such as formaldehyde, also show a positive correlation to the development of this condition. Furthermore, a close connection exists between exposure to indoor allergens and the development of asthma. Such allergens include mold, animal dander, and dust mites (Dharmage et al., 2019).

Research implicates many genes in the development of asthma and a person’s predisposition to it. Currently, some of the genes associated with this condition include ADAM33, IL4R, SPINK5, CTLA-4, AND IL10 (Xu, 2014). Notably, environmental factors like allergens can increase the genetic predisposition to asthma (Quirt et al., 2018).

Certain medical conditions also predispose individuals to asthma. Atopic conditions increase the chance of developing asthma (Quirt et al., 2018). Atopic diseases are those conditions that trigger an exaggerated immune response to harmless environmental compounds (Dharmage et al., 2019). Asthma is also prevalent in individuals experiencing hay fever or eczema. Recent studies also link obesity to the development of asthma. The reason is that obesity reduces respiratory functions because of fat buildup (Dharmage et al., 2019). An increase in the adipose tissue also increases the chances of inflammatory states.

People with asthma exhibit symptoms of wheezing, coughing, and shortness of breath with chest pain or tightness and also possibly trouble sleeping (Quirt et al., 2018). A wheezing or whistling sound during exhalation also indicates the presence of this condition in children (Quirt et al., 2018). Respiratory viruses like flu or cold worsen the wheezing and coughing attacks. Factors that indicate exacerbated asthma include frequent symptoms, which disrupt daily activities (Dharmage et al., 2019). Increased breathing difficulties also show a worsening condition.

Research Study

Hypothesis

Challenges related to self-care behaviors among school-going children with asthma emerge as the problem in this research. The research question from the study objectives, states, “what is the effectiveness of Staying Healthy-Asthma Responsible and Prepared (SHARP) on fostering the use of effective asthma self-care behaviors?” (Kintner et al., 2015). SHARP is a program designed to counsel and educate students in this study. A hypothesis developed by the researchers reveals that SHARP is effective in promoting effective self-care behaviors among students with asthma.

Method

The authors utilize a cluster-randomized research design. The research design employs two groups, the SHARP and the control intervention, to determine any improvement in self-care tendencies among students. Participants in the controlled group receive standard care to enhance a comparison with those in the SHARP intervention (Kintner et al., 2015). Notably, this research design facilitates data collection using self-report measures among the participants. The study design is useful in making a comparative analysis of the two interventions. Through this design, the researchers can make direct comparisons of the SHARP intervention to the control intervention to establish superiority. Significantly, the study design minimizes selection and allocation bias in the research. Significantly, the design is also statistically reliable.

The sample in this study comprised 4th and 5th-grade children whose ages ranged between 9 and 12 years. This population had to be diagnosed with asthma and had caregivers to take care of them. Kintner et al. (2015) adopted convenience sampling for the study. Using this technique, the researchers recruited students from different elementary schools from low socio-economic, medically marginalized, moderately sized, minority, and inner-city communities. Initially, the researchers screened 2770 students and caregivers for eligibility. After the screening, Kintner et al. (2015) remained with 216 students and caregivers while excluding the rest due to no asthma diagnosis. Following the preprogram assessment, the researchers remained with a sample of 205 students and caregivers. Kintner et al. (2015) allocated this sample to each of the two groups. The researchers allocated 117 dyads to the SHARP intervention. The remaining 88 dyads were assigned to the control program. The sample was appropriate for the study since the researchers recruited the relevant population for the study. The sampling method was also time and cost-saving for the researchers.

Outcomes

The outcome of the study supports the theory that SHARP can foster the psychological acceptance of asthma among students. The research builds upon previous problems related to difficulty in accepting asthma when transitioning from elementary to junior or middle school. In comparison to the participants in the control group, the SHARP intervention elevates risk prevention and episode management among students with asthma. The SHARP program outlined in this study can be immediately introduced in schools and communities through health education. Apart from asthma, this intervention is also relevant to the management of conditions like diabetes and epilepsy. As evident in this study, a SHARP intervention is critical to advancing nursing practice and fostering pediatric health. Based on the perceived benefits of this intervention, it helps enhance life quality and promotes health among school-aged children. Although asthma is non-communicable, it affects millions of children and teenagers around the world. Asthma impacts academic performance and social skills, which adversely impacts health. Since the researchers provide evidence to prove the efficacy of SHARP, schools and communities need to work with specialist nurses in implementing this intervention.

Further Studies

Future research should be carried out on this subject. Scholars should use this research to carry out cost-effectiveness studies on SHARP for implementation in schools and communities. A hypothesis for this study will indicate that the implementation of the SHARP program will require financial resources, parental support, and community engagement to benefit students with asthma. The outcome of this study will outline that financial costs and resources are necessary to incorporate the intervention in a school setting. Through cost analysis, schools can devise strategies to finance the intervention and improve the wellbeing of asthma students. The research can also explore the viability of implementing community programs for classmates of asthma students to promote acceptance. The program can promote an understanding of asthma and its related effects on individuals. Such knowledge can increase the acceptance of students with asthma among their peers. Therefore, this is essential to improving health among those with asthma.

References:

1. Asthma Facts and Figures |AAFA. (2018, February). Retrieved from https://www.aafa.org/asthma-facts/
2. Dharmage, S. C., Perret, J. L., & Custovic, A. (2019). Epidemiology of Asthma in Children and Adults. Frontiers in Pediatrics, 7. doi: 10.3389/fped.2019.00246
3. Kintner, E. K., Cook, G., Marti, C. N., Allen, A., Stoddard, D., Harmon, P., … Egeren, L. A. V. (2014). Effectiveness of a school- and community-based academic asthma health education program on the use of effective asthma self-care behaviors in older school-age students. Journal for Specialists in Pediatric Nursing, 20(1), 62–75. doi: 10.1111/jspn.12099
4. Quirt, J. J., Hildebrand, K. J., Mazza, J. J., Noya, F. J., & Kim, H. J. (2018). Asthma. Allergy, Asthma & Clinical Immunology, 14(S2). DOI: 10.1186/s13223-018-0279-0
5. Rubner, F. J., Jackson, D. J., Evans, M. D., Gangnon, R. E., Tisler, C. J., Pappas, T. E., … Lemanske, R. F. (2017). Early life rhinovirus wheezing, allergic sensitization, and asthma risk at adolescence. Journal of Allergy and Clinical Immunology, 139(2), 501–507. doi: 10.1016/j.jaci.2016.03.049
6. Xu, W. (2014, March 27). Expression Data Analysis to Identify Biomarkers Associated with Asthma in Children. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3985200/

According to Platts-Mills, asthma is a chronic inflammatory condition of the bronchus/airways and lungs that causes spasm and periodical dilation of the bronchus thereby narrowing it. The enlargement of the dense oesinophilic line near the bronchus/airways causes the individual to wheeze and gasp for air. The barrier to air flow may be resolved spontaneously but in extreme cases the response may only be achieved after using a wide range of medication. Continued swelling results in extreme sensitivity of the airways to different stimuli such as cold, grime, pollen, stress, nervousness, exercise and pollutants (163).

Busse and Holgate observe that asthma is mainly caused by inhalation of allergen that exacerbates a chain of biochemical and tissue reactions resulting in bronchial enlargement, bronchoconstriction and gasping/wheezing. The symptoms are further aggravated by rhinitis and sinusitis, gastric acid reflux, viral infection of the respiratory system or cold and the use of drugs such as aspirin and beta-blocker drugs. The known causative agents of asthma include animal fur, mites, fungi, cockroach allergens, chemicals, fumes, air pollutants and smoke. Other causative agents include exercises, inhaling cold air and stress. The environment plays a major role in the development and triggering or exacerbation of asthma attacks. Other causative agents include genetics ( immunity and respiratory aspects), social aspects such as poverty and poor nutrition and the interactions amongst these aspects (153).

Asthma is typified by swelling of the airways with increased secretion of mucus in the tubes. The symptoms experienced by asthmatics are as a result of bronchial muscle tightening, inflammation and mucus secretion. The widely recognized symptoms of the condition include night cough, short breath, chest pains and wheezing. The above symptoms do not apply to all patients as one may undergo various symptoms at separate times and can also be slight during one attack and worse in another. While some asthmatics have been noted to stay for longer durations minus experiencing the symptoms other asthmatics experience the symptoms on a daily basis. While others have been noted to experience severe attacks during exercises, others experience the attacks as a consequence of viral infections such as colds.

Minor asthma episodes have been documented as the most common of the two types and are known to relieve within short durations while acute attacks are rare and may be prolonged thus require immediate emergency medical attention. This makes it significant to diagnose and treat the symptoms of asthma.

Bryan affirmed that there is neither cure nor treatment for asthma and that the asthma medications are administered to manage, stop, and prevent the symptoms. An individual may have to use more than one drug to control asthma due to changes in body response to the drugs. The medications are in various forms and may include inhalers, injections and pills and are meant to reduce severity of attacks and to improve the airflow. Asthma drugs are in two key classes, namely; bronchodilators and anti-inflammatory agents. Anti-inflammatory drugs lessen inflammation and mucus secretion in the bronchus. As a consequence, the airway tends to be insensitive and have reduced chances of probable reaction to the causative agents. The drugs are taken on a daily basis and leads to lesser symptoms, improved airflow, insensitive bronchus, reduced bronchus damage and fewer attacks. Bronchodilators on the other hand are medicines that are used to relax the bronchial muscle bands that constricts around the bronchus during an attack. The drugs are mainly used in the rapid opening of the bronchus to enable airflow into and out of the lungs and also to clear and reduce mucus secretions. Bronchodilators are used in relieving asthma symptoms in the short term and are used to control and prevent asthma attacks in the long run. To manage asthma in children, relieving medicines should be administered to children with mild attacks while those with severe and frequent attacks should undergo preventive therapy while on relieving drugs (26).

Busse and Holgate noted that the following findings in an investigation meant to find the relationship between microscopic and macroscopic findings of gastroesophagael reflux. Gastroesophagael reflux symptoms existed in 65 percent of all asthmatics. This was relative to Simpson’s finding that put the percentage at 66. Gastroesophagael reflux was associated with the existence of microscopic oesophagitis with not consistent histopathologic microscopic changes.The most common symptom of gastroesophagael reflux was abdominal pain which was later confirmed in Turkey where 67 percent of the patients had gastroesophagael reflux symptoms. The findings noted that endoscopy showed increased gastroesophagael reflux disease lesions with increased asthma severity. Another study carried out to find the correlation between breast feeding and asthma revealed that exclusive breastfeeding of infants for the initial four months after birth reduced chances of developing asthma before six years.

The study found that the use of other milk types apart from breast milk before the end of the first four months was a key risk factor for asthma in infants. The study which was carried out in western Australia discovered that in comparison to infants who have undergone exclusive breastfeeding during the initial four months after birth, children who were not exclusively breastfed had 27 percent chances of developing asthma before their sixth birthday, 44 percent chances of wheezing more than three times by age of one year; 44 percent chances off having gasped for air in the previous twelve months; and 74 percent chances of having had sleep disorders in the previous 12 months period. Breast milk was noted to transmit immunity from the mother to the infant and improved forbearance to infection, hence raising the chances of survival (965).

Platts-Mills states that there exists a direct correlation between dental hygiene and asthma, in that asthmatics have a high rate of cavities, bad breath and gum disease due to prolonged use of inhalers. Dental materials such as toothpaste and dentifrices and fissure sealants were possible asthma trigger factors.Dental treatment reduced the lung capacity of asthmatics by 15 percent. A study carried out in Mexico with 1160 participants (children) noted that the occurrence of tooth decay stood at 17.9 percent of the total participants. 19.5 percent of the participants were asthmatic and 73.5 percent of them had asthma symptoms during the day while 60 percent experienced the symptoms both at night and day. The occurrence of dental decay stood at 19.9 percent and was increased in children who exhibited symptoms at night than those who experienced the symptoms during the day. The logistic regression model exhibited that there was no direct correlation between asthma and tooth decay while a vital correlation was noted to exist between asthma symptoms that were experienced at night and dental decay (98).

Works Cited

Busse, William W. and Stephen T Holgate. Asthma and Rhinitis, Volume 2. Hoboken. New Jersey: John Wiley & Sons, 2008.

Bryan, Jenny. Asthma. London (UK): Heinemann Library, 2005.

Platts-Mills, Thomas. Asthma:Causes and Mechanisms of an Epidemic Inflammatory Disease. London: Lewis Publishers, 1999.

The Case

A 22-year-old pregnant woman with a diagnosis of asthma is experiencing a change in the severity of asthma symptoms. She uses both an albuterol MDI and fluticasone MDI with increased regularity. Shortness of breath is present, and she was hospitalized twice last year for poorly controlled asthma. She also went to the emergency department three times during the last month. The situation is affecting her sleep and physical activity.

Increased coughing is the clearest sign of her asthma not being in control. Shortness of breath during exercise suggests the presence of exercise-induced bronchospasm that can accompany uncontrolled cases of asthma (National Heart, Lung, and Blood Institute, 2017). The case mentions the decreased effectiveness of the fluticasone MDI that she uses which can also be a clue to her condition (Zanforlin, Corsico, DI Marco, Patella, & Scichilone, 2016).

Her pregnancy might be the leading factor for her condition. Commonly, pregnancy leads to the presence of a positive human chorionic gonadotropin, as well as hormonal imbalance. These factors are likely affecting the effectiveness of her fluticasone MDI, which makes her lose control of the condition (Baldacara & Silva, 2017).

NIS guidelines suggest that her condition falls under “moderate severity asthma.” The frequency of her SABA use is increased, asthma is limiting her activity and night awakenings have increased pointing to this classification. Her patterns of MDI use in the last two months and the bronchospasm suggest that her asthma is poorly controlled (National Heart, Lung, and Blood Institute, 2017).

The NIS guidelines recommend monthly visits to the physician to monitor and assist in treatment. The use of albuterol is appropriate for pregnant women and should continue. However, fluticasone MDIs have shown to be ineffective and should not be utilized (National Heart, Lung, and Blood Institute, 2017). For long-term care, budesonide can be used, as it has no evident negative effect on pregnant women their children (Goldie & Brightling, 2013).

References

Baldacara, R., & Silva, I. (2017). Association between asthma and female sex hormones. Sao Paulo Medical Journal, 135(7), 46-59. Web.

Goldie, M., & Brightling, C. (2013). Asthma in pregnancy. The Obstetrician & Gynaecologist, 15(4), 241-245. Web.

National Heart, Lung, and Blood Institute. (2017). Guidelines for the Diagnosis and Management of Asthma (EPR-3) – NHLBI, NIH. Web.

Zanforlin, A., Corsico, A. G., DI Marco, F., Patella, V., & Scichilone, N. (2016). Asthma in pregnancy: one more piece of the puzzle. Minerva Medica, 107(1), 1-4. Web.

Asthma is recognised as one of the major non-communicable chronic respiratory diseases worldwide. The most recent approximate number of people suffering from asthma globally is about 235 million (WHO, 2013). The prevalence rate of this disease is increasing annually (Global Asthma Network, 2014).

This air passage condition remains underdiagnosed, underreported, and undertreated; moreover, the exact causes of asthma are still unknown, but some of the primary contributing factors are chemical pollutants present in the air, as well as indoor and outdoor allergens (WHO, 2013). The cases of asthma caused by occupational factors compose the primary focus of this paper. Critical analysis of several research studies exploring this topic will be carried out to deepen the understanding of mechanisms of research on occupational asthma and its determinants.

When it comes to occupational asthma risks, there exist JEMs or job exposure matrices designed for epidemiological studies and serve as a tool to assess the exposure to various workplace risk factors. Lillienberg, Dahlman-Höglund, Schiöler, Torén, and Andersson (2014) researched older and newer JEMs to find the differences in exposure assignment in them. The authors collected data from a large random sample and processed the data with the help of Cox regression models and Cohen’s kappa. The findings revealed a high degree of agreement between the established and the modified JEMs in the category of “any exposure”, but detected differences in regard to some particular types of exposure.

The primary objective of this study matched the selected sampling technique and sample size; the authors used a large sample (over 13 200 subjects) because the assessment of the large-scale tool such as JEM was required. Since a substantial body of data had to be processed – the authors drew to statistical tools helping find agreement in the two matrices and distinguish the results in men from those in women. One of the major limitations of this study could be the preferred method of data collection – two questionnaires filled in by the subjects.

When dealing with numerical and precise data, such a method can be a weakness due to the difficulty to test whether or not the answers provided by the participants were honest and fair. In order to determine the actual exposure statistics, the findings of this study would have to be compared to those of an expert assessment. Overall, the results of this study supported the initial argument of the authors in regard to the need for frequent updates and modifications of JEMs in order for them to reflect the most relevant and valid results.

Another study focusing on the use of JEMs was that by Kim et al. (2016) there, the authors attempted to identify correlations between the patterns of asthma exacerbation and occupational exposures. Approaching this study critically, it is possible to notice that the size of the researched sample was rather large (over 1300 respondents), which increased the reliability, validity, and generalisability of the findings. Another strong point of this study design is its mechanism of comparison the reported asthma exacerbation rates to workplace exposure according to JEM – a scientifically confirmed set of assigned exposures. This approach made the entire design easy to repeat in a different area and with a different sample. Also, it helped name specific triggers of occupational asthma exacerbation, addressing which could help minimise the problem.

Due to job specificity and specialisation, in many workplaces, occupational asthma is one of the major organisational problems. In contrast with the previous two sources, the study by Jonaid et al. (2015) is focused on the exploration of asthma triggers in a specific industry instead of covering the contributors generally. In particular, the authors investigated the contributors of allergic reaction in the workers of the bakery industry exposed to high molecular weight substances such as different types of flour and enzymes. The authors collected the data from 436 participants (a purposeful sample of bakery workers) and used medical surveillance evaluation in combination with self-administered questionnaires.

The results of the questionnaires were compared to the participants’ medical history. Further, with the help of multivariable logistic regression, the authors could identify the correlations between the occupational contributors to sensitisation and asthma symptoms reflected in medical histories. The authors found that based on the current health status of the workers and their levels of exposure to occupational asthma, they could predict the onset or exacerbation of the condition in the future. In addition, some other studies of with similar objectives used this type of design combining a questionnaire with the research of harmful exposures (Lofstedt, Hagstrom, Bryngelssona, Holmstrom, &Rask-Andersen, 2017; Larcombe, Kicic, & Mullins, 2017).

The authors paid special attention to the achievement of a high level of validity of the results by means of testing and checking their findings. Moreover, the questionnaire responses that were provided by the participants were correlated with the documented medical records of their health status – in this manner, the authors made sure that the answers received from the questionnaire reflected the reality. In that way, it is possible to notice that bias was avoided in a variety of different ways, and this aspect adds to the overall reliability of the results. In addition, even though this study focused on the exploration of asthma triggers in a particular industry, the authors chose an approach that did not depend on the specificity of the workplace. As a result, despite its narrow focus, this study can be repeated in another industry and in a different workplace.

In order to deepen the scientific knowledge of a certain issue, it could be researched on a large scale using cohort studies or systematic reviews; and also, the analysis of a single case could help expand what is known about the problem. The latter approach as employed by Vandenplas et al. (2008) in their study if a single case of a worker whose asthma and rhinoconjunctivitis symptoms were caused by his long-term exposure to herbal (chamomile) dust at a tea packing factory. The individual was tested using deliberate exposure to black and chamomile tea particles. His reactions to the substances were measured in the clinical environment, and the conclusion was made that the aforementioned worker did, in fact, develop his symptoms due to working with chamomile tea for 11 years.

The results of this study are very specific and are limited to the reaction and symptoms of a single subject. The authors mentioned that, to their knowledge, this report of asthma symptoms was the first in the history of medicine that found chamomile to be the trigger. Despite the extremely narrow specification, this study as a significant scientific weight as the pioneer in the sphere of studying and documenting a potentially new set of asthma triggers that have not been identified previously. Of course, more reports linking the symptoms of asthma and other respiratory conditions with tea-packing occupations are needed for a full-scale investigation to begin in this industry.

In contrast with the previous research that focused on the industry that is not known as a typical source of occupational asthma, the research by Baldi et al. (2014) investigated the risk of respiratory conditions in agricultural specialisations – a field with a high rate of occupational asthma prevalence. A wide variety of factors correlated with the presence and absence of allergy were assessed in a purposeful sample of 1246 asthmatic employees. Multivariate analysis of the data collected from the participants’ occupations and medical histories found a series of factors typical to allergic and non-allergic subjects.

Assessing this study, it is necessary to notice the large size of its sample, adding to the generalisability of findings. Also, the authors used an approach that can be repeated in a different area for the purpose of expanding the known body of information. Due to the large amounts of numerical data, the authors chose to use multivariate analysis in order to detect patterns. In order to elaborate on their findings, the authors also included the demographics of their participants so that it was possible to match the findings to the socioeconomic and biological factors and notice potential correlations.

Conclusion

The critical analysis of several scientific studies focusing on the exploration of occupational asthma and its triggers revealed two major approach – the ones focusing on the problem in general, and thus working with large samples for higher representability and generalizability and the ones choosing to investigate the problem of occupational asthma in a narrower setting of a particular industry; the authors of latter kind of articles work with a specific set of triggers and a purposeful sample.

In addition, the approach has a case study design and focuses on an individual scenario. Though rare, this approach is highly valuable for the pioneering studies opening a new field of research and new potential triggers. Moreover, large-scale studies use questionnaires to assess workers exposures to asthma triggers. The use of this data collection method should be combined with a more reliable data mining method since questionnaires alone allow too much potential bias to serve as the sources of quantitative data.

References

Baldi, I., Robert, C., Piantoni, F., Tual, S., Bouvier, G., Lebailly, P., & Raherison, C. (2014). Agricultural exposure and asthma risk in the AGRICAN French cohort. International Journal of Hygiene and Environmental Health, 217(4-5), 435-442. Web.

Global Asthma Network. (2014). The global asthma report 2014. Web.

Jonaid, B., Rooyackers, J., Stigter, E., Portengen, L., Krop, E., & Heederik, D. (2015). Predicting occupational asthma and rhinitis in bakery workers referred for clinical evaluation. Occupational and Environmental Medicine, 0, 1-9. Web.

Kim, J., Henneberger, P., Lohman, S., Olin, A., Dahlman-Höglund, A., Andersson, E., … Holm, M. (2016). Impact of occupational exposures on exacerbation of asthma: a population-based asthma cohort study. BMC Pulmonary Medicine, 16(1). Web.

Larcombe, A., Kicic, A., & Mullins, B. (2017). Comment on “long-term effects of diesel exhaust particles on airway inflammation and remodeling in a mouse model” by Kim et al. Allergy, Asthma & Immunology Research, 9(2), 185. Web.

Lillienberg, L., Dahlman-Hoglund, A., Schioler, L., Toren, K., & Andersson, E. (2014). Exposures and asthma outcomes using two different job exposure matrices in a general population study in Northern Europe. Annals of Occupational Hygiene, 58(4), 469-481. Web.

Lofstedt, H., Hagstrom, K., Bryngelssona, I., Holmstrom, M., & Rask-Andersen, A. (2017). Respiratory symptoms and lung function in relation to wood dust and monoterpene exposure in the wood pellet industry. Upsala Journal of Medical Sciences, 1-8. Web.

Vandenplas, O., Pirson, F., D’Alpaos, V., Vander Borght, T., Thimpont, J., & Pilette, C. (2008). Occupational asthma caused by chamomile. Allergy, 63(8), 1090-1092. Web.

WHO. (2013). Asthma. Web.

Pathophysiology

Asthma is typically defined as a chronic disease that affects the patient’s airways, impeding the process of breathing (National Heart, Lung, and Blood Institute, 2014). The understanding of how asthma is developed and by what factors it is triggered has been altered significantly over the past few years. At present, the pathophysiology of the disease is rather intricate since several conditions have been identified as the leading causes of asthma.

For instance, “Bronchospasms, edema, excessive mucus, and epithelial and muscle damage” (Lynn & Kushto-Reese, 2015, p. 49) are typically viewed as the key contributors to asthma development in patients (Lynn & Kushto-Reese, 2015). Each of the conditions listed above causes the development of bronchoconstriction with bronchospasms, therefore, making airways narrow (Lynn & Kushto-Reese, 2015). As a result, the premises for an asthma attack are created (see Appendix A).

It should be borne in mind, though, that the degree of disease variation in patients hinges on not the symptoms but the age thereof, as a recent study indicates (Kudo, Ishigatsubo, & Aoki, 2013). For instance, in children under 6, the development of the disease is typically preceded by the asthma-like symptoms that manifest themselves roughly at the age of three (Centers for Disease Control and Prevention, 2017).

A deficit in lung function can be observed in the identified group of patients at the age of 11-16. The force expiratory volume, however, remains consistent. The observations mentioned above are strikingly different from the ones carried out in a group of children that developed asthma after the age of three. Particularly, the specified patients did not show the propensity toward the development of lung function deficit (National Heart, Lung, and Blood Institute, 2014).

Genomic Issues

Asthma is currently viewed as a disease induced by both environmental and genetic factors. Therefore, understanding the genomic characterization of the disease is crucial to its management. Genome-wide association studies (GWASs) carried out lately indicate that the PGAP3 gene, or PERLD1, defines the development of asthma in patients (Li et al., 2013).

It should be noted, though, that there are uncertainties in the current research on the subject of genomes and asthma. For instance, a recent analysis of the issue shows that, while PGAP3 has a tangible effect on the development of allergic reactions to specific elements, it is GSDMB that determines the propensity toward the disease development in patients: “STARD3/PGAP3 may act on the allergic component of asthma while the GSDMB/ORMDL3/GSDMA locus may mediate its effect by a shared mechanism acting on most forms of asthma” (Lavoie-Charland, Berube, Boulet, & Bosse, 2016, p. 909). Therefore, there are at least two genomes that possibly cause the development of asthma in patients (Lavoie-Charland et al., 2016).

A whole-blood expression quantitative trait loci (eQTL) used in the research conducted by aaa showed that the functional variants of 17q12-21 are also associated with the development of allergic reactions toward a set of specific irritants (Andiappan et al., 2016). It is remarkable, though, that 17q12-21 affects the development of allergic asthma yet not rhinitis (Andiappan et al., 2016). Particularly, there is a connection between the genes at 17q12-21 and the polymorphism rs8076131 (Andiappan et al., 2016).

It should be borne in mind, though, that rs8076131 is not the only polymorphism that is associated with asthma. The article written by Schedel et al. (2015) shows that rs4065275, as well as the group of polymorphisms within ORMDL3, in general, is linked directly to the TH2 cytokines levels and, therefore, affects the susceptibility to asthma, especially among children (Schedel et al., 2015). However, further studies of the identified connection, as well as how the genomes in question affect the development of the disease, is required.

Literature Review

Seeing that asthma cannot be cured completely, the current approaches to managing it are aimed primarily at reducing the symptoms (e.g., coughing, shortness of breath, etc.) and improving the patients’ quality of life. At present, active engagement of patients and, if needed, their parents or legal guardians in the process of managing the disorder is viewed as a necessity. For the people that are capable of taking care of themselves, the promotion of patient independence is considered a crucial step in addressing the adverse effects of asthma successfully (Jain et al., 2014).

Two primary types of asthma treatment are utilized presently. These are short-term relievers (bronchodilators, particularly, dry powder inhalers and nebulizers (Daley-Yates, Mehta, Chan, Despa, & Louey, 2014)) and long-term disease control medications (Loymans et al., 2014).

Among the former, corticosteroids that are administered orally or intravenously are typically listed. Short-term relievers, which include bronchodilators, are used for three primary goals, i.e., the relaxation of the smooth muscle by stimulating beta-2 receptors, prevention of the cholinergic nerves activation, and cessation of the phosphodiesterase (PDE) enzymes’ functioning so that the further dilation of the bronchial airways could be possible (Normansell & Welsh, 2015). Long-term medication, in turn, also include corticosteroids (e.g., budesonide, beclomethasone, fluticasone, etc.). Apart from corticosteroids, leukotriene modifiers (zileuton, montelukast, etc.) are used to reduce the threat of an asthma attack (Lajqi, Ilazi, Kastrati, & Islami, 2015).

Data Collection

Approach

To gather the essential information about asthma, its development, and treatment, as well as other issues associated with the disease, an overview of the recent studies and the databases that contained the general information about asthma was required. Therefore, a literature review was used as the primary approach to data collection and its further interpretation so that it could be utilized in the study. As a result, a comprehensive review of the available information became possible.

Keywords

Searching for the relevant data required using specific keywords. It should be noted, though, that the information about different aspects of the disease had to be utilized in the research. Therefore, different sets of keywords were used for each of the search processes.

Table 1. Keywords used in the Search Process.

Databases

In the course of the search, ResearchGate and NCBI were used as the key databases for locating the essential information. The two resources were selected because they provide academic, peer-reviewed, and credible articles. Less trustworthy databases were discarded.

Electronic Clinical Tools

No electronic clinical tools were utilized in the research. Since there was no need for a quantitative study, including the information from HER provided by local healthcare facilities did not seem necessary. Instead, an all-embracive analysis of the articles obtained from scholarly databases was conducted.

Clinical Guideline for Asthma Management

At present, the U.S. standards for asthma management are defined by the guide provided by the NCBI in 2007 (National Heart, Lung, and Blood Institute, 2007). Even though the identified resource is comparatively old, it remains the basis for the diagnosis and management of asthma. The guide provides detailed information about the nature of the problem, its pathophysiology, and the available treatment methods.

The guide places an especially strong emphasis on the importance of patient education as the path to successful management of the disease: “Asthma self-management education should be integrated into all aspects of asthma care, and it requires repetition and reinforcement” (National Heart, Lung, and Blood Institute, 2007, p. 93). The identified guideline should be improved and followed closely nowadays by introducing social media into the process of patient education as the means of keeping the target population updated on the latest information and promoting cooperation between a nurse and the community.

For instance, engaging asthma patients in a dialogue by encouraging them to participate in Facebook discussions of the problem and responding to the information posted by the healthcare services will be a crucial step on the way to improving the management of asthma. Furthermore, a range of myths about asthma will be debunked. As a result, patients will feel empowered for developing independence in identifying asthma-related symptoms and searching for the assistance of healthcare experts (Panzera et al., 2013).

Treatment Approaches

As stressed above, the complete treatment of asthma is impossible at present; instead, its consistent management is used to improve the quality of the patient’s life (Jain et al., 2014). Therefore, an approach to handling the disorder in a long-term perspective needs to be considered. Furthermore, one must keep in mind that there are treatment strategies for three stages of asthma development (i.e., the so-called green, yellow, and red zones) (Yin et al., 2012). For this purpose, the stepwise approach must be used (Inoue et al., 2017). A common treatment framework implies carrying out the following steps:

1. Identifying the severity of the problem (i.e., either a green, yellow, or red zone stage);
2. Providing the patient with a quick-relief medication, if necessary (Albuterol, Levalbuterol, Metaproterenol, or Terbutaline) (U.S. National Library of Medicine, 2017);
3. Expectorating the secretions of the patient so that the further aggravation of the problem could be avoided;
4. Maintaining the airway clean so that the necessary medications could be administered to the patient;
5. Continuing to provide long-term medications such as dry powder inhalers and nebulizers (1-2 puffs a day) if the short-term medication is efficient;
6. Educating the patient about the symptoms, the necessity to avoid the allergens, the need to use the provided medications (1-2 puffs of nebulizers per day), etc. (Inoue et al., 2017).

Alternative treatment approaches may involve the use of fluid therapy (in case of a patient experiences dehydration) and pharmacologic therapy, which allows determining the patient’s response to medications (Bendjelid, Rex, Scheeren, & Critchley, 2015). However, the plan outlined above creates premises for all-embracive management of asthma and, thus, should be viewed as the superior one.

Best Approach: Selection and Rationale

As stressed above, the framework involving the classification of the asthma attack severity and the identification of the patient’s age (i.e., the stepwise approach) allows for the best results. The reason for choosing the specified strategy as the most efficient one is that it helps determine the patients’ needs fast and accurately. As a result, the chances for a patient outcome increase greatly (Inoue et al., 2017).

The use of fluid therapy, while also being quite effective, cannot be seen as an independent strategy for managing asthma since it does not include the comprehensive model that can be used to assist any asthma patient. Instead, it can only be utilized in specific cases of certain asthma severity. Therefore, it cannot be viewed as the ultimate tool for handling asthma cases (Bendjelid et al., 2015).

Consequently, the stepwise approach must be considered the most effective tool. It produces an immediate result and contributes to a massive improvement in the patient’s condition. Furthermore, the identified framework helps monitor asthma in patients of any age, from newborns to adults. The fact that the strategy allows for a minimum of adverse effects should also be considered one of its primary advantages (Inoue et al., 2017). Thus, it should be used as the basis for handling asthma cases.

Follow-up Treatment and Referrals

The further management of the case involves educating the patient about asthma and its management. Particularly, independence must be encouraged. The patient must be able to identify the symptoms that may pose a threat to their well-being and contact the healthcare services. Patient referrals must be considered a necessity in case of an asthma episode exacerbation. Subsequent tests carried out by an immunologist are obligatory for the further analysis of the problem and the identification of the possible treatment options. Furthermore, patient education must follow the treatment process so that further instances of asthma could be addressed efficiently.

References

Andiappan, A. K., Sio, Y. Y., Lee, B., Suri, B. K., Matta, S. A., Lum, J., … Chew, F. T. (2016). Functional variants of 17q12-21 are associated with allergic asthma but not allergic rhinitis. Journal of Allergy and Clinical Immunology, 137(3), 758-766. Web.

Asthma: Practice essentials, background, anatomy. (2017). Web.

Bendjelid, K., Rex, S., Scheeren, T., & Critchley, L. (2015). Year in review in journal of clinical monitoring and computing 2014: Cardiovascular and hemodynamic monitoring. Journal of Clinical Monitoring and Computing, 29(2), 203-207. Web.

Centers for Disease Control and Prevention. (2017). Learn how to control asthma. Web.

Daley-Yates, P. T., Mehta, R., Chan, R. H., Despa, S. X., & Louey, M. D. (2014). Pharmacokinetics and pharmacodynamics of fluticasone propionate and salmeterol delivered as a combination dry powder from a capsule-based inhaler and a multidose inhaler in asthma and COPD patients. Journal of Aerosol Medicine and Pulmonary Drug Delivery, 27(4), 279-289. Web.

Inoue, H., Nagase, T., Morita, S., Yoshida, A., Jinnai, T., & Ichinose, M. (2017). Prevalence and characteristics of asthma–COPD overlap syndrome identified by a stepwise approach. International Journal of Chronic Obstructive Pulmonary Disease, 12(1), 1803-1810. Web.

Jain, V. V., Allison, R., Beck, S. J., Jain, R., Mills, P. K., Mccurley, J. W., … Peterson, M. W. (2014). Impact of an integrated disease management program in reducing exacerbations in patients with severe asthma and COPD. Respiratory Medicine, 108(12), 1794-1800. Web.

Kudo, M., Ishigatsubo, Y., & Aoki, I. (2013). Pathology of asthma. Frontiers in Microbiology, 4(263), 1-16. Web.

Lajqi, N., Ilazi, A., Kastrati, B., & Islami, H. (2015). Comparison of Glucocorticoid (Budesonide) and Antileukotriene (Montelukast) effect in patients with bronchial asthma determined with body plethysmography. Acta Informatica Medica, 23(6), 347-351. Web.

Lavoie-Charland, E., Berube, J. C., Boulet, L. P., & Bosse, Y. (2016). Asthma susceptibility variants are more strongly associated with clinically similar subgroups. Journal of Asthma, 53(9), 907-13. Web.

Li, L., Kabesch, M., Bouzigon, E., Demenais, F., Farrall, M., Moffatt, M. F., … Liang, L. (2013). Using eQTL weights to improve power for genome-wide association studies: A genetic study of childhood asthma. Frontiers in Genetics, 4(103), 1-14. Web.

Loymans, R. J., Gemperli, A., Cohen, J., Rubinstein, S. M., Sterk, P. J., Reddel, H. K., … Riet, G. T. (2014). Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: Network meta-analysis. BMJ, 348(1), 1-16. Web.

Lynn, S. J., & Kushto-Reese, K. (2015). Understanding asthma pathophysiology, diagnosis, and management Learn about new research findings and current treatment strategies for this common disorder. American Nurse Today, 10(7), 49-51.

National Heart, Lung, and Blood Institute. (2007). Guidelines for the diagnosis and management of asthma (EPR-3): Full report. Web.

National Heart, Lung, and Blood Institute. (2014). What is asthma? Web.

Normansell, R., & Welsh, E. (2015). Asthma can take over your life but having the right support makes that easier to deal with. Informing research priorities by exploring the barriers and facilitators to asthma control: A qualitative analysis of survey data. Asthma Research and Practice, 1(1), 11-21. Web.

Panzera, A. D., Schneider, T. K., Martinasek, M. P., Lindenberger, J. H., Couluris, M., Bryant, C. A., & Mcdermott, R. J. (2013). Adolescent asthma self-management: Patient and parent-caregiver perspectives on using social media to improve care. Journal of School Health, 83(12), 921-930. Web.

Schedel, M., M., S., Gaertner, V. D., Toncheva, A. A., Depner, M., Binia, A., … Kabesch, M. (2015). Polymorphisms related to ORMDL3 are associated with asthma susceptibility, alterations in transcriptional regulation of ORMDL3, and changes in TH2 cytokine levels. Journal of Allergy and Clinical Immunology, 136(4), 758-768. Web.

U.S. National Library of Medicine. (2017). Asthma – Quick-relief drugs. Web.

Yin, H. S., Gupta, R. S., Tomopoulos, S., Wolf, M. S., Mendelsohn, A. L., Antler, L., … Dreyer, B. P. (2012). Readability, suitability, and characteristics of asthma action plans: Examination of factors that may impair understanding. Pediatrics, 131(1), 118-128. Web.

Appendix A

Abstract

The title of the article gives a clear idea of the research question to be investigated. It is clearly and meaningfully worded to give readers a clear picture of the study. The first author works in the Emergency Department of Case Western Reserve School of Medicine, Cleveland, Ohio.

The second author works in the Division of Pulmonary and Critical Care. Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois. The last author works in the Department of Emergency Medicine, American University of Beirut, Beirut, Lebanon.

The authors have expertise in emergency cases involving pulmonary and respiratory conditions. The study reviewed randomised controlled trial articles that were obtained via online searches (Brenner, Corbridge & Kazzi, 2009). A total of 5 randomised controlled trials were reviewed on intubation, but no trial was considered on mechanical ventilation.

Introduction

The authors of his article did not state any study hypothesis or question. They mentioned the intensity of the problem in their introductory paragraphs. However, they did not address the significance of studying or reviewing the data for intubation and mechanical ventilation of acute asthmatic patients.

The investigators did not give any predictions before doing the reviews. Evidence-based study reviews need to have the significance of the studies, and clear predictions of the outcome. This was a big shortcoming on the part of the authors.

Several studies have been carried out to investigate and report clinical relevant data on intubation and mechanical ventilation of acute asthmatic patients (McFadden Jr, 2003). A study noted that there are about 2 million emergency visits by patients with acute asthma annually.

Other studies have recognised the importance of intubation and mechanical ventilation in patients with acute asthma. Intubation and mechanical ventilation have been shown to reduce mortality cases in patients with acute asthma attacks

Most of the research sources used by the authors were recent (5-10 years). They gave the authors of the past research credit by citing them appropriately. While there is no condemnation of past research findings, this area of research has had controversies. The controversies have led to more studies being done to ascertain the clinical truth (Shapiro, 2001).

Methods

The study review did term searches online. The terms were intubation and mechanical ventilation. The intubation search yielded 41 randomised controlled trials and 6 meta-analyses. Only 5 randomised controlled trials were used for reviews in the study.

The mechanical ventilation search yielded 5 randomised controlled trials and 4 meta-analyses. All the randomised controlled trials and meta-analyses were not considered for review. The authors reviewed literature from the five randomised controlled trials for intubation.

Results

The authors made sense of the research findings by interpreting them appropriately. From the literature review of the 5 randomised controlled trials, the authors chose seven (7) key areas to be addressed. Their choices were based on their clinical experience.

The key areas addressed were: prevention of intubation, criteria for intubation, intubation techniques, appropriate ventilator settings, post intubation management, management of ventilated patient and prevention and treatment of complications.

Discussion

The authors’ discussion encompassed comparison to other research studies on the subject. The authors recognised the effort by other researchers in finding ways to prevent intubation, and finding the criteria for intubation. They also addressed the needs of ventilation in a patient with acute asthma.

The authors discussed the issues on post intubation management, an issue that has been studied by past researches extensively. Their last area to discuss was prevention and treatment of complications arising from mechanical ventilation and intubation.

Research has demonstrated that complications arise in patients who have undergone intubation and mechanical ventilation. Research recommends appropriate procedures for dealing with such complications. Appropriate management of complications helps to save lives of patients (Lougheed, Fisher & O’Donnell, 2006). The authors have failed to mention the limitations and biases, thus they have failed in giving their verdict on the degree of clinical relevance of the studies.

The authors only used 5 randomised controlled trials from intubation searches. They rejected the other trials that were found and all the meta-analyses articles. In addition, the authors did not review randomised controlled trial and meta-analyses articles found on mechanical ventilation.

They did not give the criterion for selecting the articles. The number of articles used for the review was too few to give good conclusion on the subject. In addition, the absence of reviews of articles on mechanical ventilation made the review weak.

Conclusion

The article is quite relevant to respiratory professional care. The article discusses seven key points that are of significance to respiratory professional care. The authors have detailed the processes of intubation and mechanical ventilation in patients with acute asthma.

The authors have also detailed the appropriate actions to be taken when complications arise from intubation and mechanical ventilation procedures. The article gives crucial information relevant to professionals in respiratory care.

References

Brenner, B., Corbridge, T., & Kazzi, A. (2009). Intubation and mechanical ventilation of the asthmatic patient in respiratory failure. Proceedings of the American Thoracic Society, 6(4), 371-379.

Lougheed, M. D., Fisher, T., & O’Donnell, D. E. (2006). Dynamic Hyperinflation During Bronchoconstriction in Asthma Implications for Symptom Perception. Chest Journal, 130(4), 1072-1081.

McFadden Jr, E. R. (2003). Acute severe asthma. American journal of respiratory and critical care medicine, 168(7), 740-759.

Shapiro, J. M. (2001). Intensive care management of status asthmaticus. Chest Journal, 120(5), 1439-1441.

Introduction

Asthma is a chronic inflammatory disease of the airways and a major health risk in childhood not only in Australia, but also in other developed and developing countries across the world (Calogero et al 2009).

Although the risk factors for childhood asthma include smoking during pregnancy, familial record of asthma, young maternal age at pregnancy and low socioeconomic standing (Li et al 2013), available country-specific literature demonstrates that there is a multiplicity of factors responsible for the prevalence of childhood asthma despite hospitalisation rates for asthmatic children going down as demonstrated in Figure 1(Chua et al 2011).

This report discusses three such factors, namely deprived neighbourhoods, latitude and ultraviolet (UVR) exposure, and lack of effective guidelines to diagnose and treat asthma in infants.

Findings

In their study, Li et al (2013) found that cases of childhood asthma have been on the rise in developed countries due to the increasing number of families residing in deprived neighbourhoods.

This study found that the level of neighbourhood deprivation influences the risk of childhood asthma through several general mechanisms, which include “unfavourable health-related behaviours, neighbourhood social disintegration (i.e. criminality, high mobility, or unemployment), low social capital, and neighbourhood stress mediated by factors that can influence immunological and/or hormonal stress reactions” (Li et al 2013, p. 656).

In the Australian context, living in deprived neighbourhoods has been associated with an increase in childhood asthma as such neighbourhoods not only cause air pollution and related effects, but also trigger isolation from health-promoting environments (e.g., safe places to exercise, decent housing, smoking-free areas) and services (Berenznicki et al 2013).

Figure 1 Asthma & Bronchitis Hospitalisation Levels in Selected Asia Pacific Countries (Source: Chua et al 2011)

Hughes et al (2011, p. 328) report that “asthma prevalence has been shown to correlate negatively with latitude (lower prevalence at higher latitude) and positively with ambient UVR.”

Although findings have not been conclusive, there is a likelihood that asthma cases in Australia are on the rise particularly in areas with increasing geographic latitude, which inevitably decreases the amount of vitamin D that people are able to get through exposure to sun (Krstic 2011).

Indeed, according to this author, there is considerable evidence to show that vitamin D deficiency triggered by decreasing sun exposure and increasing geographical latitude in the varied Australian landscape is responsible for the development and exacerbation of asthma.

Lastly, available literature demonstrates that the national Asthma Council of Australia (NAC) guidelines on the diagnosis, treatment and management of asthma in infants are controversial due to the considerable body of opinion reinforcing the fact that “a diagnosis of asthma should not be made in the first year of life as wheezing in infancy is very common” (Calogero et al 2009, p. 143).

Indeed, according to these authors, “very few clinical studies are available to guide treatment of persistent wheezing in infants, and, in the absence of evidence, similar medications are used to treat wheezing in infants as used to treat asthma in older children” (p. 143).

This orientation has presented many challenges to healthcare practitioners particularly in terms of the efficacy of drugs prescribed to infants, hence the need for effective asthma management guidelines for this group of the population (Berenznicki et al 2013).

Conclusion

From the findings presented above, it is evident that childhood asthma remains a considerable burden in Australia due to socioeconomic, geographic, and health-related issues such as deprived neighbourhoods, decreasing sun exposure and increasing latitude, and lack of effective guidelines on the diagnosis, treatment and management of asthma in infants.

These factors need to be addressed to lower the prevalence of asthma in Australian children and ensure that asthma no longer presents a substantial burden to the health care system.

Recommendations

To deal with the factor of deprived neighbourhoods, it is important for the local council and other relevant stakeholders to commit adequate resources to the socioeconomic and physical development of neighbourhoods that are largely perceived as deprived.

Such resources can be used to educate deprived families about favourable health-related behaviours and also to develop structures and amenities that will guard against social disintegration (Li et al 2013).

To decrease the rate of childhood asthma, the local council needs to develop education programs on what families need to do to ensure that they do not expose their young children to vitamin D deficiencies, as this element has been found to influence the development and exacerbation of asthma (Krstic 2011).

Such educational programs need to be incorporated into the mainstream public health campaigns to achieve effectiveness in ensuring that people understand how environmental factors can increase the rate of childhood asthma.

Lastly, concerted efforts need to be made to fill the gaps in childhood asthma management by coming up with a body of evidence that could be used to diagnose, treat, and manage asthma in infants. There is need for the relevant health agencies to not only develop effective asthma guidelines for managing infants, but also to come up with effective drugs that could be used by this group of the population.

List of References

Berenznicki, BJ, Norton, LC, Beggs, SA, Gee, P & Berenznicki, LRE 2013, ‘Review of the management of childhood asthma in Tasmania’, Journal of Paediatrics and Child Health, vol. 49 no. 8, pp. 678-683.

Calogero, C, Kusel, MMH, Van Bever, HPS & Sly, PD 2009, ‘Management of childhood asthma in western Australia’, Journal of Paediatrics and Child Health, vol. 45 no. 3, pp. 139-148.

Chua, KL, Ma, S, Prescott, S, Ho, MHK, Ng, DK & Lee, BW 2011, ‘Trends in childhood asthma hospitalisation in three Asia Pacific countries’, Journal of Paediatrics and Child Health, vol. 47 no 10, pp. 723-727.

Hughes, AM, Lucas, RM, Ponsonby, AL, Chapman, C, Coulthard, A, Dear, K…Williams, D 2011, ‘The role of latitude, ultraviolet radiation exposure and vitamin D in childhood asthma and hay fever: An Australian multicenter study’, Paediatric Allergy and Immunology, vol. 22 no. 3, pp. 327-333.

Krstic, G 2011, ‘Asthma prevalence associated with geographical latitude and regional insolation in the United States of America and Australia’, PLoS ONE, vol. 6 no. 4, pp. 1-9.

Li, X, Sunquist, J, Calling, S, Zoller, B & Sundquist, K 2013, ‘Mothers, places and risk of hospitalisation for childhood asthma: A nationwide study from Sweden’, Clinical & Experimental Allergy, vol. 43 no. 6, pp. 652-658.