Asthma is a disease characterized by attacks of dyspnea resulting from contraction of the bronchial muscles and chronic inflammation, causing spasmodic obstruction of the small bronchi.

Introduction

Asthma is a common respiratory condition characterized by a prolongation of exhalation, with more pronounced interference than during inspiration, due to the relative weakening of the latter. This condition, which manifests itself as difficulty breathing, can affect individuals of all ages, although most develop it in childhood. Asthma attacks vary in severity from person to person and even from episode to episode, but fortunately, fewer than 1 in 20 asthmatics require specialized care. The number of Quebecers suffering from asthma is approximately 900,000 people, including 300,000 children (Quebec Lung Association).

In the field of osteopathy, a complementary therapeutic approach, researchers and practitioners have explored the links between osteopathy and asthma. In 1912, Louisa Burns, DO, shared her experiences on the diagnosis and treatment of asthma at the Pacific College of Osteopathy. She had examined 21 cases of asthma, highlighting the importance of avoiding irritating gases and dust, and demonstrating the effectiveness of osteopathic manipulation in alleviating chronic symptoms.

Burns helped lay the foundation for osteopathic research in the area of ​​lung disease. In a study conducted by Wilson in 1925, although poorly controlled, results showed temporary relief in 15 patients and a 50% reduction in asthma attacks in 10 patients over an extended period, making this study one the first to explore the relationship between osteopathy and asthma.

The following years saw an evolution in osteopathic approaches to the treatment of asthma. In 1959, Kline provided a concise description of osteopathy in the treatment of this disease. He identified somatic dysfunctions in the dorsal vertebrae and ribs, focusing on improving cervical and thoracic mobility, as well as use of the chest pump.

Despite the high prevalence of asthma, non-drug approaches often lack clear consensus. However, holistic therapies, such as osteopathy, are gaining recognition due to evidence showing the benefits of osteopathic manipulation in the treatment of asthma. Osteopathic practitioners often focus on assessing musculoskeletal dysfunction, particularly in the spine and ribs, to improve thoracic mobility and promote optimal respiratory function.

In conclusion, asthma, a common respiratory condition, can benefit from a holistic approach such as osteopathy. Pioneers such as Louisa Burns led the way in understanding the effectiveness of osteopathic manipulation in relieving asthma symptoms. Although more research is needed to solidify this evidence, osteopathy offers an interesting prospect as a complementary approach in the management of asthma.

Causes of Bronchial Asthma

Let’s look at the causes of bronchial asthma, a complex respiratory disease, the etiology of which can be influenced by various factors. Asthma is generally considered a multifactorial disease, involving both genetic predispositions and environmental triggers.

Genetic factors play a significant role in asthma susceptibility. If a family history of asthma, allergies or other respiratory illnesses is present, this may increase the risk of developing this condition. Genetic variations can affect the immune response and airway responsiveness, contributing to the genetic predisposition to asthma.

Allergies are also a major factor in triggering asthma. People sensitive to allergens such as pollen, dust mites, mold, pet hair and insects may develop airway inflammation in response to these substances. This allergic reaction can lead to constriction of the bronchi, causing asthmatic symptoms.

Viral and respiratory infections, especially in children, can be major triggers for the development of asthma. Respiratory tract infections can damage lung tissue and trigger a persistent inflammatory response, contributing to the development of asthma in some individuals.

Exposure to environmental irritants is another risk factor. Tobacco smoke, air pollution, industrial fumes and chemicals can worsen asthma symptoms and contribute to its onset. Avoiding these irritants as much as possible can play a crucial role in preventing asthma.

Finally, factors such as active or passive smoking during pregnancy can increase the risk of developing asthma in children. Additionally, adverse environmental conditions during early childhood, such as early exposure to allergens or poor air quality, may influence the development of this respiratory disease.

List of causes
  1. Genetic Factors: A family history of asthma increases the risk of developing the disease. Certain genes are associated with a predisposition to asthma, although genetics is only part of the picture.
  2. Environmental factors :
    • Exposure to Allergens: Allergens such as dust mites, mold, pet hair, pollen, and mold can trigger allergic reactions in people with asthma.
    • Exposure to Tobacco Smoke: Active or passive smoking is a major risk factor. Tobacco smoke irritates the airways and worsens inflammation.
    • Exposure to Air Pollutants: High levels of air pollution, particularly fine particles, can worsen asthma symptoms.
  3. Respiratory Infections: Viral infections, particularly in young children, can trigger episodes of asthma and contribute to the development of the disease.
  4. Occupational Factors: Certain work environments expose individuals to irritant or allergenic substances, which can increase the risk of occupational asthma.
  5. Maternal Smoking and In Utero Exposure: Smoking during pregnancy and fetal exposure to tobacco smoke increase the risk of asthma in children.
  6. Psychological Factors: Emotional stress and strong emotions can trigger asthma episodes in some people.
  7. Obesity: Obesity is associated with an increased risk of asthma, although the exact mechanisms of this association are not completely understood.
  8. History of Severe Respiratory Infections in Childhood: Children who have had severe respiratory infections, such as bronchiolitis, may have an increased risk of developing asthma.
  9. Mold: Mold spores in the air, especially in humid or poorly ventilated environments, can trigger asthma symptoms in some susceptible people.
  10. Industrial Emissions: Exposure to industrial emissions, such as factory exhaust, can worsen asthma symptoms, especially in people living near industrial areas.
  11. Climate Change: Climate change can influence air quality and increase the frequency of extreme weather events, which can impact respiratory health.
  12. Indoor Pollution: Indoor pollutants such as household chemicals, air fresheners, mold and dust mites can worsen asthma symptoms, especially in poorly ventilated spaces.
  13. Occupational Exposure: Some workers may be exposed to irritants or allergens in the workplace, which may contribute to the development or worsening of occupational asthma.
  14. Exposure to Pesticides: Pesticide residues present in food, drinking water or the environment can be asthma triggers in some people.
  15. Change of Environment: A move to a new environment, particularly if there is increased exposure to allergens or pollutants, can influence asthma symptoms.
  16. Exposure to Chemicals: Certain chemicals in the air, such as those emitted by fresh paint, solvents or cleaning products, can trigger reactions in people with asthma.
  17. Altitude: Changes in altitude can influence atmospheric pressure and oxygen concentration, which can affect breathing, especially in people predisposed to asthma.
  18. Exposure to Fine Particles: Fine particles in the air, often emitted by the burning of fossil fuels, can penetrate deep into the airways and worsen asthma symptoms.

It is important to note that these risk factors can interact in complex ways, and more than one of them may be present in a given person. Diagnosis and management of asthma requires an individualized approach based on each patient’s specific symptoms and triggers.

Symptoms of bronchial asthma

Symptoms vary from person to person, but common manifestations include dry coughing attacks, difficulty breathing, chest tightness, and sometimes wheezing.

One of the most common signs of bronchial asthma is coughing, especially at night or early in the morning. This cough can be dry and persistent, sometimes triggered by allergens such as dust, pet hair or air pollutants. Asthma patients may also feel a feeling of chest tightness, as if someone is squeezing their chest, which can contribute to anxiety related to difficulty breathing.

Dyspnea, or difficulty breathing, is another characteristic symptom of bronchial asthma. Sufferers may experience difficulty breathing during physical activities or even at rest. This may be related to constriction of the bronchi, restricting airflow and causing a feeling of shortness of breath. Wheezing, also called stridor, occurs when air passes through narrowed airways, creating a high-pitched sound. These wheezing sounds may be heard during inhalation and exhalation, and their intensity may vary depending on the degree of constriction of the airways.

Bronchial asthma triggers are diverse, ranging from common allergens such as pollen and dust mites to environmental irritants like tobacco smoke and air pollution. Some asthma patients may also be sensitive to physical exercise or emotional stress, which can trigger acute episodes of symptoms.

It is essential to note that management of bronchial asthma often involves the use of bronchodilator and anti-inflammatory medications to relieve symptoms and prevent attacks. However, comprehensive management also includes identifying and avoiding potential triggers, as well as adopting a healthy lifestyle.

List of symptoms
List of symptoms
  1. Difficulty breathing : Shortness of breath is one of the most common symptoms of asthma. A narrowing of the airways causes this event and is caused by tension in the muscles around the airways, causing bronchospasm and inflammation of the airways. The body creates mucus to process this reaction and the lungs become less efficient at transferring oxygen to the small blood vessels on the surface of the lungs.
  2. Cough : Cough caused by asthma is often more common at night and usually manifests as a dry cough that does not expel mucus. This symptom can disrupt sleep, leaving those affected feeling tired the next day. Experts have not yet reached a consensus on what causes coughs to worsen at night. Some think it could be due to increased exposure to allergens, the position one sleeps in, or hormones secreted at night.
  3. Wheezing : Wheezing frequently develops along with shortness of breath, coughing, and chest tightness. People with asthma may develop an audible wheezing sound when they breathe in and out. This symptom is not exclusive to asthma, however, many respiratory conditions can cause wheezing.
  4. Intolerance to cigarette smoke : People with asthma can be seriously affected by second-hand smoke. The chemicals in cigarette smoke irritate the lungs and cause airway constriction. There is also medical evidence that these chemicals can cause more lasting damage. Car exhaust and pollutants in the air can cause similar irritation.
  5. Feeling the changing seasons : Some people develop pollen-induced asthma during seasonal changes when hay fever is common. The trigger, in this case, plant pollen, can be difficult to avoid, making these attacks more frequent and harder to prevent. When hay fever has already irritated the lungs, this makes the symptoms even worse.
  6. Tightness in the chest : A feeling of tightness in the chest, that feeling of someone tightening a belt around the ribs or sitting on their chest, is a common symptom of asthma. The pressure may be continuous or come and go and can be quite severe. This symptom can also affect the neck.
  7. Lips or fingers turn blue : The color of the lips and fingers changes when the body is deprived of oxygen. This symptom is easiest to identify in people with fair skin. Although asthma may explain this sign, many other conditions can also cause bluish lips and fingers, including high altitudes, chronic lung disease, blood clot, blocked arteries, and heart disease. Even if asthma is the cause, the symptom suggests a serious attack and immediate medical attention is essential.
  8. Fainting : A severe asthma attack can lead to loss of consciousness when the flow of oxygen to the brain is interrupted. Excessive coughing can also place the nervous system under sudden strain, leading to a rapid drop in blood pressure. People who feel unwell for any reason should sit or lie down immediately to avoid injury if they become unconscious. Asthma symptoms associated with fainting, near fainting, and dizziness require immediate medical evaluation. A severe asthma attack accompanied by these symptoms can potentially lead to brain damage or even death.
  9. Disorientation : Because asthma reduces the oxygen supply in the blood, it can leave people confused and dizzy. Like many asthma symptoms, however, many factors can cause this symptom, including diabetes and prescription medications. Anyone experiencing prolonged dizziness requires immediate medical attention.
  10. Inability to work hard : The most common complications in asthma patients occur at the start of their work and require a constant supply of oxygen. In case of asthma, the patient cannot breathe much. During exercise, the body demands more oxygen and breathing. The lungs do not perform this function and significantly reduce oxygen supply. A patient may enter a block without being able to respond to an external stimulus. When exercising, the body needs more oxygen. The body is not able to obtain oxygen quickly, because at a time when the concentration of CO2 in the lungs increased, the risk of complications increased with the CO2 saturation of the body.
  11. Hypoxia (less oxygen in the body) : The person’s ability to absorb oxygen is reduced. Hypoxia is a serious problem, where lack of oxygen to the body’s organs leads to organ dysfunction. Hypoxia – It is the condition of the body, in which the oxygen level is lower than normal. Hypoxia can cause a serious asthma attack.
  12. Fatigue : The body produces less energy due to insufficient oxygen. In asthma, our body doesn’t do this; receive sufficient oxygen. Now, lack of energy causes fatigue and can therefore make everyday life more difficult.
  13. Pulmonary dysfunction : Pulmonary dysfunction can complicate lung collapse, lung infection. Pulmonary dysfunction is one of the main complications of asthma. Insufficient oxygen supply and increased CO2 volume in the lungs can disrupt lung function.
  14. Pneumonia : Pneumonia is rarely found in asthma. It can be serious in chronic asthmatic patients. Pneumonia causes pus to form in the lungs. In case of small breathing, less oxygen fuels the cells and even death. It more than increases the chances of pus formation in the lung area. This can cause a lot of complications, such as lung failure.

Prevent asthma

Asthma prevention is of paramount importance to improve the quality of life of individuals and reduce the impact of this chronic respiratory disease. Adopting preventive measures can help minimize the occurrence of attacks and alleviate the severity of symptoms associated with bronchial asthma.

The crucial first step in prevention is to identify and avoid specific asthma triggers. These triggers vary from person to person and can include allergens such as pollen, dust mites, pet hair, as well as environmental irritants like tobacco smoke and air pollutants. Increased awareness of these factors may enable individuals to take proactive steps to reduce their exposure, thereby contributing to the prevention of asthma attacks.

Adopting a healthy lifestyle also plays a key role in preventing asthma. Maintaining a balanced diet, rich in fruits and vegetables, and encouraging regular physical activity help strengthen the immune system and promote respiratory health. Maintaining a healthy body weight may also reduce the risk of developing asthma symptoms, as obesity is often associated with increased airway inflammation.

Managing emotional stress is another important aspect of asthma prevention. Stress can act as a potential trigger for asthma attacks, and therefore, stress management techniques such as meditation, deep breathing and yoga can help maintain emotional balance, thereby reducing the risk of triggering symptoms.

  1. Avoiding environmental triggers: Some asthmatics are sensitive to environmental triggers such as tobacco smoke, allergens (dust mites, mold, pet hair), air pollutants, and irritating chemicals. Avoiding or minimizing exposure to these triggers can help prevent asthma.
  2. Maintain a clean and healthy environment: Reducing allergens inside the home, such as regular cleaning, humidity management, and adequate ventilation, can help prevent asthma exacerbations.
  3. Promote a healthy lifestyle: Adopting a healthy lifestyle, including a balanced diet, regular physical activity, and stress management, can strengthen the immune system and help prevent respiratory diseases, including asthma.
  4. Vaccinations: Vaccinations against flu and pneumonia can help prevent respiratory infections that could trigger asthma attacks.

Osteopathic Principles in Asthma Management

Osteopathy emphasizes the body’s ability to self-regulate and self-heal, highlighting the interconnectedness of the body’s systems. In managing asthma, osteopathic physicians (DOs) may apply these principles:

  1. Structural Alignment: Ensuring proper alignment of the spine and thoracic cage can enhance respiratory mechanics and reduce strain on the respiratory muscles.
  2. Respiratory Function: Techniques aimed at improving diaphragmatic movement and rib cage mobility can facilitate better airflow and oxygenation.
  3. Circulation and Lymphatic Drainage: Enhancing blood flow and lymphatic drainage can help reduce inflammation and support the immune response.

Osteopathic Manipulative Treatment (OMT) Techniques

Several OMT techniques may be used to help manage asthma symptoms:

  1. Rib Raising: This technique involves gently lifting and mobilizing the ribs to improve thoracic mobility and facilitate deeper breathing.
  2. Diaphragmatic Release: Techniques aimed at releasing tension in the diaphragm can enhance diaphragmatic excursion and improve respiratory efficiency.
  3. Thoracic Inlet Release: This technique focuses on relieving restrictions in the thoracic inlet to improve lymphatic drainage and reduce congestion.
  4. Soft Tissue Techniques: Gentle stretching and massage of the muscles surrounding the chest and upper back can help alleviate muscle tension and improve respiratory function.

Osteopathic chest pump

The use of the osteopathic chest pump technique in the treatment of asthma has been explored by several researchers over time. This osteopathic approach focuses on improving thoracic mobility with an emphasis on specific manipulations of the rib cage. Research by practitioners has shed light on the potential effectiveness of this technique in managing asthma symptoms.

One of the first references to this technique dates back to 1959, when Kline provided a concise description of osteopathy in the treatment of asthma. In his study, Kline identified somatic dysfunctions in the dorsal vertebrae and ribs. He emphasized the importance of improving cervical and thoracic mobility, while highlighting the use of the thoracic pump as a key component of the osteopathic approach.

(Kline JA. An examination of the osteopathic management of bronchial asthma. Yearbook Acad Appl Osteopathy. 1959:27-13.)

The osteopathic chest pump typically involves specific manipulations to promote movement of the ribs and thoracic spine. The basic idea is to optimize respiratory mechanics by improving the mobility of thoracic structures, which can have a positive impact on lung function.

An older study by Wilson in 1925, although poorly controlled, showed temporary relief in 15 patients and a 50% reduction in asthma attacks in 10 patients over an extended period. This study laid the foundation for osteopathic research in the field of lung disease, exploring the relationship between osteopathic manipulations, including the chest pump technique, and relief of asthmatic symptoms.

(Wilson PT. Experimental work in asthma at the Peter Bent Brigham Hospital. JADA. 1925;25:212-214. Wilson PT. Specific technic for asthma. JADA. 1926;25:47. Wilson PT. The osteopathic treatment of asthma. JADA. 1959;45:491-492.)

More recently, researchers have continued to evaluate the effectiveness of the osteopathic chest pump in the context of asthma. These studies have often sought to measure objective changes in lung function, frequency and severity of asthma attacks after osteopathic manipulation sessions.

Although promising results have been observed in some studies, it is important to note that research in this area is still ongoing. Osteopathic approaches, including the chest pump technique, are often considered complementary therapies and can be integrated alongside conventional medical treatments.

In conclusion, the osteopathic chest pump represents a specific approach within osteopathy to treat asthma symptoms. Historical and more recent studies have suggested that this technique may play a role in improving thoracic mobility and potentially managing asthma attacks. However, further research is needed to better understand its effectiveness and determine how it can be optimally integrated into overall asthma management.

Evidence and Research

Research on the efficacy of osteopathic treatment for asthma is ongoing, with some studies indicating potential benefits:

  1. Improvement in Respiratory Function: Some studies have shown that OMT can lead to improvements in pulmonary function tests, such as increased forced vital capacity (FVC) and forced expiratory volume in one second (FEV1).
  2. Reduction in Symptoms: Patients receiving OMT for asthma have reported reductions in symptoms such as wheezing, coughing, and shortness of breath.
  3. Quality of Life: OMT has been associated with improvements in overall quality of life for asthma patients, potentially due to better symptom management and enhanced respiratory function.
  4. Decreased Medication Use: Some studies suggest that OMT may help reduce the need for bronchodilators and corticosteroids in asthma management.

Key Studies

  1. Noll et al. (2008): This study found that OMT combined with conventional asthma treatment improved peak expiratory flow rates and reduced symptoms in pediatric asthma patients.
  2. Licciardone et al. (2010): A randomized controlled trial showed that OMT significantly improved pulmonary function and quality of life in adults with chronic asthma.

Recent studies continue to explore the benefits of osteopathic manipulative treatment (OMT) for asthma management, reinforcing its potential alongside conventional treatments.

  1. An Osteopathic Modular Approach to Asthma: A Narrative Review (2020): This review discusses the application of OMT techniques for asthma management, presenting both historical and contemporary perspectives. The study highlights time-efficient and well-tolerated OMT techniques that can complement current medical treatments, such as biologics and inhaled corticosteroids​ (Journal of Osteopathic Medicine)​.
  2. Effect of Osteopathic Maneuvers in the Treatment of Asthma: Review of Literature (2015): Although slightly older, this review emphasizes the efficacy of osteopathic techniques as supplementary non-medicated treatments for asthma. The findings suggest improvements in quality of life, symptom perception, and reduced medication usage in patients who received OMT​ (MTPRehabJournal)​.

These studies underscore the growing evidence supporting the integration of OMT into asthma treatment plans, reflecting ongoing advancements and interest in holistic and complementary approaches in osteopathic medicine.

4o

Integration with Conventional Treatment

While OMT can be beneficial for asthma patients, it should not replace conventional asthma treatments such as inhaled corticosteroids, bronchodilators, and other prescribed medications. Instead, OMT should be viewed as a complementary therapy that can enhance overall asthma management and patient well-being.

Conclusion

In conclusion, asthma, a common respiratory condition, impacts the lives of many individuals by causing breathing difficulties often starting in childhood. However, holistic approaches such as osteopathy have emerged as promising adjuncts in the management of this disease. The pioneering work of Louisa Burns in the early 20th century laid the foundation for osteopathic research by shedding light on the effectiveness of osteopathic manipulation in alleviating chronic asthma symptoms.

Subsequent studies, such as that of Wilson in 1925 and that of Kline in 1959, explored the relationship between osteopathy and asthma, highlighting specific somatic dysfunctions in the spine and ribs. The introduction of the osteopathic chest pump technique was a significant development, focusing on improving thoracic mobility to positively influence lung function.

Although the high prevalence of asthma persists, non-drug approaches, particularly holistic therapies such as osteopathy, offer encouraging prospects. However, it is essential to emphasize that research in this area is still ongoing, and although promising results have been observed, more in-depth studies are needed to consolidate the evidence and determine the optimal integration of osteopathy into the comprehensive management of asthma.

Prevention remains a crucial aspect of asthma management, emphasizing avoidance of environmental triggers, maintaining a clean and healthy environment, promoting a healthy lifestyle, and vaccinating against respiratory infections. In this context, the osteopathic chest pump is emerging as a specific approach within osteopathy, showing promise in improving thoracic mobility and potentially reducing asthma symptoms.

Ultimately, although osteopathy offers an interesting perspective as a complementary approach in the management of asthma, it must be considered as an integral part of a holistic and personalized approach for each patient. The future of research and medical practice will continue to explore these avenues to improve the quality of life of people with asthma.

References

  1. Lee J, McDonald C. Review: Immunotherapy improves some symptoms and reduces long-term medication use in mild to moderate asthma. Ann Intern Med. 2018 Aug 21;169(4):JC17. [PubMed]2.
  2. Tesfaye ZT, Gebreselase NT, Horsa BA. Appropriateness of chronic asthma management and medication adherence in patients visiting ambulatory clinic of Gondar University Hospital: a cross-sectional study. World Allergy Organ J. 2018;11(1):18. [PMC free article] [PubMed]3.
  3. Salo PM, Cohn RD, Zeldin DC. Bedroom Allergen Exposure Beyond House Dust Mites. Curr Allergy Asthma Rep. 2018 Aug 20;18(10):52. [PMC free article] [PubMed]4.
  4. Scirica CV, Celedón JC. Genetics of asthma: potential implications for reducing asthma disparities. Chest. 2007 Nov;132(5 Suppl):770S-781S. [PubMed]5.
  5. Piloni D, Tirelli C, Domenica RD, Conio V, Grosso A, Ronzoni V, Antonacci F, Totaro P, Corsico AG. Asthma -like symptoms: is it always a pulmonary issue? Multidiscip Respir Med. 2018;13:21. [ PMC free article ] [ PubMed ]6.
  6. Aggarwal B, Mulgirigama A, Berend N. Exercise-induced bronchoconstriction: prevalence, pathophysiology, patient impact, diagnosis and management. NPJ Prim Care Respir Med. 2018 Aug 14;28(1):31. [PMC free article] [PubMed]7.
  7. Yii AC, Soh AZ, Chee CBE, Wang YT, Yuan JM, Koh WP. Asthma, Sinonasal Disease, and the Risk of Active Tuberculosis. J Allergy Clin Immunol Pract. 2019 Feb;7(2):641-648.e1. [PMC free article] [PubMed]8.
  8. D’Amato M, Molino A, Calabrese G, Cecchi L, Annesi-Maesano I, D’Amato G. The impact of cold on the respiratory tract and its consequences to respiratory health. Clin Transl Allergy. 2018;8:20. [PMC free article] [PubMed]9.
  9. Burrows B, Barbee RA, Cline MG, Knudson RJ, Lebowitz MD. Characteristics of asthma among elderly adults in a sample of the general population. Chest. 1991 Oct;100(4):935-42. [PubMed]10.
  10. Martin AJ, Landau LI, Phelan PD. Lung function in young adults who had asthma in childhood. Am Rev Respir Dis. 1980 Oct;122(4):609-16. [PubMed]11.
  11. Southworth T, Kaur M, Hodgson L, Facchinetti F, Villetti G, Civelli M, Singh D. Anti-inflammatory effects of the phosphodiesterase type 4 inhibitor CHF6001 on bronchoalveolar lavage lymphocytes from asthma patients. Cytokine. 2019 Jan;113:68-73. [PubMed]12.
  12. Gosens R, Gross N. The mode of action of anticholinergics in asthma. Eur Respir J. 2018 Oct;52(4) [PMC free article] [PubMed]13.
  13. Almadhoun K, Sharma S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): Apr 28, 2023. Bronchodilators. [PubMed]14.
  14. Jilani TN, Preuss CV, Sharma S. StatPearls [Internet]. StatPearls Publishing; Treasure Island (FL): May 1, 2023. Theophylline. [PubMed]15.
  15. Rajan S, Gogtay NJ, Konwar M, Thatte UM. The global initiative for asthma guidelines (2019): change in the recommendation for the management of mild asthma based on the SYGMA-2 trial – A critical appraisal. Lung India. 2020 Mar-Apr;37(2):169-173. [PMC free article] [PubMed]16.
  16. Sly RM. Changing asthma mortality. Ann Allergy. 1994 Sep;73(3):259-68. [PubMed]17.
  17. Melgarejo González-Conde V, Pérez-Fernández V, Ruiz-Esteban C, Valverde-Molina J. Impact of Self-Efficacy on The Quality of Life of Children With Asthma and Their Caregivers. Arch Bronconeumol (Engl Ed). 2019 Apr;55(4):189-194. [PubMed]18.
  18. Banasiak NC. Implementation of the Asthma Control Test in Primary Care to Improve Patient Outcomes. J Pediatr Health Care. 2018 Nov-Dec;32(6):591-599. [PubMed]19.
  19. Konstantakopoulou O, Kaitelidou D, Economou C, Charalambous G. Barriers in Access to Pharmaceutical Care in Greece: The Case Study of the Out-of-Hospital Management of Patients With Acute Asthma. Front Public Health. 2018;6:199. [PMC free article] [PubMed]

RELATED ARTICLESMORE FROM AUTHOR