عوامل روانی و خودمدیریتی در آسم کشنده

Several studies that have analyzed differences in psychological and self-management variables between patients with a near-fatal asthma (NFA) attack and asthmatics without a NFA attack (non-NFA) have shown conflicting results, probably due to the heterogeneity of the events studied and the selection of comparison groups. Objective To determine whether NFA patients, in stable situation, have greater psychological morbidity and worse self-management behavior than non-NFA patients with similar sociodemographic and clinical characteristics. Methods A sample of 44 NFA patients (mean=5.65 years after the NFA episode) and 44 non-NFA patients matched for age, sex, and asthma severity was assessed. All patients were in clinical stable situation. Information about sociodemographic, clinical, functional, and morbidity variables was collected for each patient, and the Cognitive Depression Inventory, the Trait-Anxiety Scale, the Toronto Alexithymia Scale, the Practical Knowledge of Self-management questionnaire, and the Medication Adherence scale were administered. Results In comparison with non-NFA patients, NFA patients showed higher levels of trait-anxiety (23.84 vs. 16.86; P=.001) and more difficulties describing and communicating feelings (11.36 vs. 8.90; P=.002). NFA and non-NFA patients did not differ in self-management variables. After adjustment in multivariate logistic regression analysis for age, sex, and asthma severity, significant differences were observed between NFA and control group patients in marital status [odds ratio (OR)=0.26; P=.017; 95% confidence interval (CI)=0.09–0.78], prescribed dose of inhaled corticoids (OR=4.48; P=.006;95% CI=1.53–13.09), and trait-anxiety (OR=1.071;P=.025;95%CI=1.01–1.14). Conclusions NFA patients show higher psychological morbidity than non-NFA, even years after the NFA episode. Abbreviations CDI, Cognitive Depression Index; CG, control group; NFA, near-fatal asthma; STAI-T, Trait-Anxiety Scale; TAS-20, Toronto Alexithymia Scale of 20 items

Near-fatal asthma (NFA) is a clinical condition that has aroused a great interest in recent research because NFA greatly outnumbers asthma deaths [1] and constitutes a disproportionate source of subsequent asthma morbidity and health care costs [2], even though it is numerically rather small. The first studies that have analyzed factors implied in asthma deaths and reports of case series with NFA patients have emphasized the role of several psychological variables on the bad prognosis of bronchial asthma [3], [4], [5], [6] and [7]. However, it must be considered that information was collected retrospectively and data about psychological characteristics of the patients were obtained from hospital records, physicians' notes and reports from relatives, and what significantly compromises their reliability and validity. Moreover, the lack of an adequate control group means that it is not possible to determine whether the reported prevalence of psychological factors is specifically associated with NFA or merely due to severe asthma [8]. Studies that have tried to solve these methodological limitations, using a control group and standardized instruments to assess psychological characteristics, are scarce and their results do not always support an association between psychological factors and NFA [9]. Some studies did not find differences between NFA patients and non-NFA patients in depression or anxiety [10], [11] and [12], knowledge about illness management [13] and [14], or adherence to pharmacological treatment [13] and [15], whereas other investigations showed a higher prevalence of anxiety [8] and alexithymia [16] and [17], and lower levels of medication adherence [18] in NFA patients. Different factors could be involved in these discrepant results. On the one hand, the small sample size in some studies [10], [11] and [12] could have prevented the presence of statistically significant differences. On the other hand, in studies in which significant differences between NFA and non-NFA were obtained [8] and [17], patients were assessed shortly after the acute NFA attack, so the experience of a recent attack could have been an important mediator of psychological status [19], and differences might be temporary. Furthermore, and maybe more important, in the major part of these studies, no matching criteria of age, sex, and illness severity were established in order to select the control group [8], [10], [11] and [12]. The objective of the present study was to determine if, in stable situation, NFA patients differ in psychological variables (depression, anxiety, and alexithymia) and illness management variables (practical knowledge of self-management and report of medication adherence) from asthmatic patients of similar sociodemographic and asthma severity characteristics but without experience of previous near-fatal crises.

A total sample of 44 NFA patients (63.6% female; mean age=53.80±20.44, range 18–83) and 44 CG patients (63.6% female; mean age=54.25±17.48 years, range 21–86) took part in the study. In NFA patients, time elapsed since the last near-fatal crisis ranged from 1 month to 11 years (mean±S.D.=5.65±2.85 years). Following Global Initiative for Asthma criteria [21], in each group, nine subjects (20.5%) have moderate persistent asthma and 35 subjects (79.5%) have severe persistent asthma. Table 1 summarizes the demographic, clinical, functional, and morbidity characteristics of the NFA group and the CG. No significant differences were found between groups except for prescribed dose of inhaled corticoids [χ2(1, N=88) with Yates' correction=12.787; P<.001]. Table 1. Sociodemographic, clinical, functional, and morbidity characteristics of NFA and CG Variable GC (n=44) NFA (n=44) Test statistic P n % n % Age 18–35 years 12 27.3 8 18.2 χ2=4.586 .101 36–65 years 15 34.1 25 56.8 >65 years 17 38.6 11 25.0 Educational level Primary school 27 61.4 30 68.2 χ2=1.124 .570 Secondary school 11 25.0 7 15.9 University 6 13.6 7 15.9 Marital status Single/separated/divorced/widowed 22 50.0 9 20.5 χ2=7.171a .007 Married/unmarried partner 22 50.0 35 79.5 Employment Status Paying job 11 25.0 14 31.8 χ2=0.223a .636 Unemployed 33 75.0 30 62.8 Location of residence Rural 14 31.8 17 38.6 χ2=0.199a .655 Urban 30 68.2 27 61.4 Socioeconomic status (family income) ≤€1500/month 35 79.5 40 90.9 Fisher's Exact test .229 >€1500/month 9 20.5 4 9.1 Pulmonary function Mild (≥80%) 16 36.4 18 40.9 χ2=0.192 .908 Moderate (60–80%) 15 34.1 14 31.8 Severe (≤60%) 13 29.5 12 27.3 Frequency and severity of symptoms Mild 13 29.5 15 34.1 χ2=0.440 .803 Moderate persistent 19 43.2 16 36.4 Severe persistent 12 27.3 13 29.5 Inhaled corticoids Low-medium doses 8 18.2 26 59.1 χ2=12.787a .0003⁎ High doses 34 77.3 18 40.9 No answer 2 – Oral corticoids (in the last 12 months) Yes 12 27.3 5 11.4 Fisher's Exact test .103 No 32 72.7 39 88.6 Frequency of emergency room visits (in the last 12 months) None 24 54.5 36 81.8 χ2=1.218a .270 ≥1 11 25.0 8 18.2 No answer 9 20.5 – – Frequency of hospitalizations (in the last 12 months) None 32 72.7 32 72.7 χ2=0.015a .904 ≥1 10 22.7 12 27.3 No answer 2 4.6 – – ⁎ Bonferroni adjustments require a P to be <.004 in order to be considered significant. a Calculated with Yates' correction. Table options Taking into account criteria to quantify severity of depressive symptoms established by Beck et al. [31], 11 patients of the NFA group and 6 CG patients obtained a score higher than nine (cutoff point established to determine the presence of depressive symptoms). In the NFA group, four patients showed mild symptoms, whereas seven showed moderate symptoms. In the CG, five patients showed mild symptoms, and only one patient showed severe symptoms. When we compared patients' scores in trait-anxiety with normative data for Spanish population [32], in the NFA group, 16 patients (36.4%) scored above the 75th percentile, indicating high levels of clinical anxiety, whereas only two patients of the CG (4.5%) showed these high levels (Fisher's Exact test P=.0004). As regards alexithymia, only four patients of the NFA group (9%) scored 61 or more, considered as a cutoff point to classify subjects as alexithymics. No alexithymic patients were found in the CG. Comparisons between NFA and CG in psychological variables showed significantly higher trait-anxiety (t=3.51; P=.001) and more difficulties describing feelings in NFA patients (t=3.16; P=.002) (see Table 2). Table 2. Scores on depressive symptoms, trait-anxiety, and alexithymia of NFA and CG NFA GC t P-values n Mean±S.D. (range) n Mean±S.D. (range) CDI 44 7.13±7.03 (0–22) 44 3.88±5.86 (0–29) 2.35 .021 STAI-T 44 23.84±10.77 (6–59) 44 16.86±7.64 (3–41) 3.51 .001⁎ TAS-20 44 43.91±9.27 (22–70) 40 40.70±7.05 (29–59) 1.77 .080 Factor 1: difficulty to identify feelings 44 10.25±4.87 (7–28) 40 9.07±3.06 (7–21) 1.34 .185 Factor 2: difficulty to describe feelings 44 11.36±4.34 (5–23) 40 8.90±2.68 (5–16) 3.16 .002⁎ Factor 3: externally oriented thinking 44 22.30±4.93 (9–31) 40 22.73±4.79 (9–31) −0.40 .687 ⁎ Bonferroni adjustments require a P to be <.008 in order to be considered significant. Table options Scores obtained for the assessed self-management variables (practical knowledge and adherence) can be found in Table 3. As regards practical knowledge of self-management, data from one NFA patient and four CG patients were considered invalid, so results correspond to a sample of 43 NFA and 40 non-NFA patients. Scores on the scale of adherence to inhaled medication were obtained only from 36 NFA and 28 CG patients because the remaining subjects reported that they did not remember with sufficient accuracy their level of medication adherence in the last 3 months. In the scale of adherence to oral medication, due to the small number of patients whom this type of pharmacological treatment had been prescribed to, response rate was even lower, and data were only obtained from 23 NFA patients and nine non-NFA patients. Table 3. Scores on practical knowledge of self-management of acute asthma and medication adherence NFA GC Statistic test P a Hypothetical scenarios of practical knowledge of self-management Slow onset attack [mean±S.D. (range)] 7.86±4.07 (0–17) 8.45±3.59 (1–14) t=−0.698 .487 Initial nonuse of peak flowmeter [n (%)] 43 (100) 40 (100) – – Delay in seeking of medical help [n (%)] 18 (41.9) 9 (22.5) χ2=2.712b .100 Delayed or nonuse of oral corticoidsc [n (%)] 11 (91.7) 5 (100) Fisher's Exact test 1.00 Delayed or nonuse of emergency ambulance services [n (%)] 21 (48.8) 24 (60.0) χ2=0.639b .424 Rapid onset attack [mean±S.D. (range)] 8.51±4.31 (0–17) 10.98±4.98 (0–20) t=−2.413 .018 Initial nonuse of peak flowmeter [n (%)] 43 (100) 40 (100) – – Delay in seeking of medical help [n (%)] 20 (46.5) 10 (25.0) χ2=3.275b .070 Delayed or nonuse of oral corticoidsc [n (%)] 11 (91.7) 5 (100) Fisher's Exact test 1.00 Delayed or nonuse of emergency ambulance services [n (%)] 21 (48.8) 22 (55.0) χ2=0.117b .733 Medication adherence Adherence to inhaled medication [mean±S.D. (range)] 2.97±1.05 (0–4) 2.86±1.43 (0–4) t=0.370 .713 Adherence to oral medication [mean±S.D. (range)] 3.22±0.90 (1–4) 3.11±1.27 (0–4) t=0.267 .791 a Bonferroni adjustments require a P to be <.004 in order to be considered significant. b Calculated with Yates' correction. c Only in patients whom this medication had been prescribed to (NFA: n=12; non NFA: n=5). Table options Scores on practical knowledge and adherence were low and not significantly different between both groups of patients after Bonferroni adjustment (see Table 3). In logistic regression analysis, variables included in the maximum model as independent variables were age; sex; asthma severity; and those sociodemographic, clinical, or psychological variables that emerged as statistically significant in the univariate analysis (marital status, prescribed dose of inhaled corticoids, depressive symptoms, trait-anxiety, and Factor 2 of alexihtymia). After adjustment for age, sex, and asthma severity, significant differences were observed between NFA and CG patients in marital status [odds ratio (OR) 0.26; P=.017; 95% confidence interval (CI)=0.09–0.78], prescribed dose of inhaled corticoids (OR=4.48; P=.006; 95% CI=1.53–13.09), and trait-anxiety (OR=1.071; P=.025; 95% CI=1.01–1.14). NFA patients showed significantly higher levels of trait-anxiety than non-NFA patients, independently of marital status and prescribed dose of inhaled corticoids.