Bronchial asthma is one of the most frequent chronic diseases of the respiratory tract. In 2000, the Polish survey showed that the incidence of bronchial asthma was 5.4% in adults and 8.6% in children (1). The number of asthmatic patients increased several-fold during the past 25-30 years (2). Therefore, asthma is a serious diagnostic and therapeutic problem. Its treatment is a challenge for health care professionals, especially those of primary care as they are responsible for the quality of care, patients' education, and costs of therapy paid by both the patient and society.

The aim of the present study was to assess the symptoms, changes in spirometric parameters, and the type of therapy used in 3305 patients in whom bronchial asthma was diagnosed by a family physician.


MATERIAL AND METHODS
The study was performed according to the standards set by the Helsinki Declaration of 1975 regarding the Human Research and was accepted by an institutional Ethics Committee. The study involved 3305 patients (55.5% women and 44.5% men; the mean age 48.3 ±15.9 years). Demographic characteristics of the patients are displayed in Table 1. The study was carried out with a questionnaire distributed to both patients and their physicians. All patients were asked about the frequency and severity of asthma symptoms (dyspnea, cough, limitation of everyday activity, awakenings), scored from 0 to 10, allergy in the family (asthma, allergic dermatitis, hypersensitivity to drugs, allergic rhinitis), smoking of cigarettes (active and passive). Physicians give information concerning the diagnosis and classification of asthma as well as its treatment. In all patients, spirometric measurements of FVC and FEV1 were performed and FEV1%VC rate was calculated, according to the ATS/ERS standards (1, 2). Fig. 1 shows the distribution of BMI of the patients participating in the study. It is worthwhile to mention that overweight and obese subjects dominated in the whole patient population studied.

Table 1. Demographic characteristics of patients.

Fig. 1. Distribution of body mass index values in the group of the examined patients.

RESULTS
Table 2 shows the duration of asthma and the division of all patients, depending on their gender. Duration of asthma exceeding 10 years concerns 338 of female (10.2%) and 259 of male (7.8%) patients, i.e., 597 (18.0%) of all surveyed patients. Asthma was newly diagnosed in 399 (12.0%) of all patients, which included 246 female and 153 male patients. The relevant data for 61 (1.9%) patients were missing.

Table 2. Duration of asthma in relation to patients' gender; n, number of patients.

The number and percentage of patients with respect to asthma severity, reported by the attending physician is demonstrated in Table 3. Episodic asthma was diagnosed in 11.7% (385) of all patients; 6.3% (208) of women and 5.36% (177) of men. Chronic severe asthma was diagnosed in 11.5% (379; 212 women and 167 men) and mild and medium asthma in 39.1% and 37.8% of all patients participating in the study, respectively.

Table 3. Diagnosis of asthma, degree of its severity in relation to the patients' gender; n, number of patients.

Answers to the questionnaire supplied information concerning allergic diseases in the patients, in their family members, exposure to environmental pollutants, including active and passive to tobacco smoking, and the severity of symptoms. The patients surveyed could choose more than one answer. These data are summarized in Table 4 and Table 5. Sixteen percent of respondents declared they were free of asthma, whereas about 84% of patients known about their asthma. Nearly 30% of the respondents had allergic rhinitis, about 9% had atopic dermatitis, and less than 6% had allergy to drugs. Asthma in close relatives of the patients examined was reported by nearly 37%, allergic rhinitis - by about 19%, atopic dermatitis - by over 9% and allergy to drugs by over 5% of them.

Table 4. Frequency of allergic diseases as reported by the patients.

Table 5. Frequency of allergic diseases in the families of respondents.

The questionnaire addressed to the patients also contained questions concerning the exposure to environmental pollutants and the contact with the most common inhaled allergens. These results are shown in Table 6. Cigarettes were smoked by nearly 25% (818) patients and there were over 28% (941) passive smokers, i.e., over 50% of the population studied was exposed to tobacco smoke. More than 33% (1100) of the patients had pets, a humid place of living declared 19% (647), proximity to an industrial area - 19% (644), and proximity to meadows and fields - 28% (918) of patients. Other risk factors or allergens in both place of work and outside it declared more than 17% (576) of patients.

Table 6. Exposure to environmental pollutants, cigarette smoke, and most common inhaled allergens.

Symptoms of asthma

The symptoms of asthma that appeared in the month preceding the survey were evaluated. Cough, dyspnea, limitation of everyday activity, awakenings caused by asthma symptoms were evaluated by the patients themselves. Cough was the most troublesome symptom for all surveyed patients, mean value of its severity was 40.1 (score: 0 to 100), followed by dyspnea (34.6), limitation of everyday activity (33.7), and awakenings at night (31.0) (Table 7). The frequency of asthmatic symptoms is given in Table 8. The information obtained from the patients surveyed enabled to estimate that the symptoms of asthma appear every day in more than 10% and 3 to 6 times per week in more than 20% of patients. About 40% of patients have symptoms 1 to 2 times a week, and no symptoms during the last months had about 20% of patients.

Table 7. Severity of the most common ailments associated with asthma in the examined group of patients.

Table 8. Frequency of asthmatic symptoms in the examined group of patients.

The diagnosis of asthma in patients with subdivisions regarding the severity (severe, moderate, mild, and episodic) and duration of disease are shown in Fig. 2. Half of the patients, diagnosed with chronic severe asthma (188 patients, i.e., 6% of all examined asthmatics), suffered from the disease over 10 years, whereas only 10 patients in this group had asthma since 1 year. In 259 patients (8% of the whole examined cohort), duration of chronic moderate asthma was over 10 years, and in the largest group - 2 to 5 years (362 patients, i.e., 11%). A similar situation was in the subgroup of patients with chronic mild asthma: in the largest subgroup the duration of asthma was 2 to 5 years (354 patients). In 19 patients of the subgroup with sporadic asthma, the duration of disease was over 10 years, in 25 patients - 5 to 10 years, in 53 patients - 2 to 5 years, in 62 patients - 1 to 2 years, and in 85 patients up to 1 year.

Fig. 2. Graphic representation of the severity and duration of asthma.

Fig. 3 shows the number of groups of drugs used in combination to treat asthma patients in relation to the severity of disease. A small subgroup of patients with severe asthma did not take any drugs, while some patients with sporadic asthma take 2, 3, or even 4 combinations of drug groups. The groups of drugs are detailed in Table 9. The majority of the patients used long-acting beta2-mimetics (67%) and inhaled glucocorticosteroids (GSC) (83%) on a regular basis. The dominant pattern of inhaling short-acting beta2-mimetics in case of emergency was more frequently than once per week (Table 10). Of the one hundred twenty four patients using emergency short-acting beta2-mimetics, 124 did not take any other drugs, 49 patients took additionally long-acting beta2-mimetics, but no drugs from other groups, and 295 patients used inhaled GCS, but no other drugs (except in emergency).

Fig. 3. The number of administered groups of drugs and in relation to asthma severity.

Table 9. Groups of drugs used by asthmatic patients regularly or in case of emergency.

Table 10. Frequency of use of short-acting beta-mimetics in emergency.

Out of the patients surveyed, who did not take emergency short-acting beta2-mimetics, there was a subgroup regularly using long-acting beta2-mimetics, but not using inhaled GCS (25 patients) or any other drugs. A few patients regularly used long-acting beta2-mimetics and only methylxanthines, or antileukotriens. Long-acting beta2-mimetics and inhaled GCS, on a regular basis, were used by 194 patients, and only inhaled GCS - by 108 patients.

Fig. 4. The percentile rank of patients whose FEV1 was below or above the lower limit of the norm (LLN), according to the severity of asthma.

Fig. 5. FEV1 values and stages of asthma severity.

Fig. 6. FVC values and stages of asthma severity.

Spirometric examination

Spirometric measurements were carried out in all examined patients; the main results are shown in Table 11. Fig. 7 shows the percentage of patients whose FEV1 was below or over above the lower limit of the norm, ranked according to the severity of asthma. In Table 12 the subdivision of asthma, according to the severity of symptoms, FEV1%FVC values, percent of patients of various asthma severity, and percentiles are given. The majority of the patients were between the 5th and 95th percentile, according to expectations. Below the 5th percentile there was 906 (27.4%) of the patients, including 224 (6.8%) who were diagnosed with severe asthma, 400 (12.1%) with moderate asthma, 208 (6.3%) with mild asthma, and 74 (2.2%) with sporadic asthma.

Table 11. Pulmonary function.

Fig. 7. FEV1%FVC values and stages of asthma severity.

Table 12. Distribution of the examined patients depending on the FEV1%FVC values and percentiles and on asthma severity.

Figs. 5, 6, and 7 show FEV1, FVC, and FEV1%FVC values, respectively, and the distribution of the examined patients in relation to the severity of asthma.


DISCUSSION

The principles of successful asthma control and management include, according to the GINA experts, the following:
• minimalization of symptoms, ideally the absence of symptoms;
• use of short-acting bronchodilators rarely or never;
• no need for unplanned or emergency visits to doctor's office due to exacerbations;
• occupational, social, everyday, and physical unlimited activities, adequately to the age;
• normal values of PEF or spirometric parameters.

The aim of asthma management is a selection of medicines which would allow reaching the above-mentioned goals. The assessment of the percentage of asthma patients meeting these criteria has not been feasible until recent global studies on asthma control and severity (3, 4). The aim of the Asthma Insights and Reality in Europe (AIRE) study (3), carried out in the years 1998-2000, was to get insight into the opinions the asthmatic patients express concerning their health, drugs used, and expectations. The obtained data were compared with the actual guidelines for asthma management. It has been found that neither the goals of asthma management nor the principles of pharmacotherapy are realized.

Comparing the AIRE study with the results of the present study, one may come to a conclusion that asthmatic patients are still not treated according to the guidelines, but the situation seems slightly better than that at the time of the AIRE study. It should be realized that a large portion of the presently examined patients met the criteria of asthma control, given by GINA (5). However, part of the examined cohort, particularly with sever asthma, had limited physical activity and had to use short-acting bronchodilators more often than 2-3 times a week. Smoking and passive exposure to tobacco smoke of over 50% of the examined patients is of great concern. Apparently, patient education in this area is insufficient (6). However, the majority of asthmatic patients (over 80%) are properly treated, i.e., with inhaled GCS.

We conclude that in the Polish population of asthmatics the management of symptoms, albeit improved, still falls short of the internationally set goals. The symptoms of asthma are seen relatively often; about 20% of patients complain of everyday ailments. However, 30% of patients do not report any symptoms. Inhaled glucocorticosteroids are regularly used by 83% of patients,

Acknowledgements: Supported by Astra-Zeneca Poland

Conflicts of interest: The authors had no conflicts of interest to declare in relation to this article other than what is stated in the Acknowledgements section (above).


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