Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205

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Egyptian Journal of Chest Diseases and Tuberculosis

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Assessment of bronchial asthma management among adult patients

in Chest Department of Zagazig University Hospitals in the
period (2011–2012)
Ramadan Nafie a, Mohamed Awad Mohamed a, Abeer Elhawary a,⇑, Hesham El-Shelkamy b
a
Chest Department Faculty of Medicine Zagazig University, Egypt
b
Zagazig Chest Hospital, Egypt

a r t i c l e i n f o a b s t r a c t

Article history: In some countries like Egypt and especially in Sharkia Governorate, many diseases. may be managed by
Received 8 February 2017 any general practitioner or other specialty other than the presumed one without following international
Accepted 7 March 2017 guidelines and this may lead to over or under diagnosis and consequently over or under treatment and
Available online 17 March 2017
even occurrence of complications.
Objectives: The objective of this study is to assess patients who have been labelled as bronchial asthma
Keywords: regarding: a- how they were diagnosed, b- what treatment have been prescribed to them by their chest
Bronchial asthma
physicians and to assess if they follow GINA guidelines or not.
GINA guidelines
Sharkia Governorate
Aim of the work: Improve health status of patients and reduce complications from bronchial asthma.
Patients and methods: This study was carried out at Chest Department (outpatient sections), Zagazig
University Hospital from September 2011 to September 2012 on 220 adult patients labelled and managed
as bronchial asthma, 57 males and 163 females with an age range from 18 years old to 50 years old. Their
diagnosis was reviewed if it is matched with GINA guidelines or not. Criteria of asthma diagnosis were
reviewed through GINA guidelines (2008) [1].
Results: Only a low percentage (12.2%) of asthmatic patients was advised to do PEFR and spirometry.
Corticosteroids and b2 agonist were prescribed to all bronchial asthma patients by their chest physicians.
As regards antibiotics, they were prescribed to (88.1%), while mucolytics and expectorates were pre-
scribed to (61.8%), and LTRA was described to (33.2%) of bronchial asthma patients. A high percentage
(92.3%) of bronchial asthma patients were treated according to GINA guidelines.
Conclusion: There is a satisfactory implementation of local and international asthma management
guidelines.
Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-
nd/4.0/).

Introduction overlap with other diseases, e.g. chronic obstructive pulmonary

Asthma is a chronic inflammatory disorder of the airways
where many cells and cellular elements play a role. The chronic
inflammation is associated with airway hyper-responsiveness that
causes recurrent episodes of breathlessness, wheezing, coughing,
and chest tightness particularly at night or in the early morning.
These episodes are usually associated with widespread airflow
obstruction within the lung that is often reversible either sponta-
neously or with treatment. Furthermore, many of the symptoms
Peer review under responsibility of The Egyptian Society of Chest Diseases and
Tuberculosis.
⇑ Corresponding author.
E-mail address: dr_abeer72@yahoo.com (A. Elhawary).
disease (COPD). Consequently, asthma largely remains a clinical
diagnosis supported by diagnostic testing [1].
The management of bronchial asthma is largely based on phar-
macotherapy which relies more on the inhaled route, both to
diminish the dose of applied drug and hence the risk of systemic
side effects decreases, and to localise therapy to the target organ
[2].
It was found that the majority of patients used drug regimens
were not in compliance with the consensus guidelines. It is likely
that many subjects are, in fact, undertreated. This is consistent
with the findings of many studies and is supported by finding that
many patients required their short-acting bronchodilator daily
[3,4].

http://dx.doi.org/10.1016/j.ejcdt.2017.03.003
0422-7638/Ó 2017 The Egyptian Society of Chest Diseases and Tuberculosis. Production and hosting by Elsevier B.V.
This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).
198 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205

In general asthma undertreatment is more likely to put patients Methods

at risk rather than over treatment particularly if treatment is given
as far as possible by the inhaled route which minimizes adverse All selected patients were subjected to the following:
reactions [5]. Their diagnosis was reviewed if it is matched with GINA guide-
Many deaths and much unnecessary morbidity have been asso- lines or not by a constructed questionnaire quoted from Attia
ciated with overreliance on bronchodilator with underuse of (1997) [16] including asking them about:
inhaled and oral corticosteroid treatment and failure to make
objective measurements of severity and with inadequate supervi- 1. Personal history.
sion. These recommendations promote greater use of inhaled 2. Chest complaint.
anti-inflammatory drugs, even in patients with apparently mild 3. Past history.
asthma. Objective monitoring of progress based on the patient’s 4. Family history of bronchial asthma or atopic disease.
own measurements of Peak expiratory flow rate where possible; 5. Associated medical problems.
and greater participation of the patient or parents in the manage- 6. Examination done to them by their chest physicians.
ment of the condition [6]. 7. Chest X-ray.
Clinical guidelines are designed to help practitioners and 8. Pulmonary functions (spirometry and/or peak expiratory
patients make decisions regarding the appropriate health care for flow) done to them by their chest physicians.
specific circumstances [7]. Guidelines have existed for decades 9. Drugs (including bronchodilators and anti-inflammatory
and hundreds have been published for many diseases [8] including drugs for asthma) that were prescribed and their side effects.
asthma [9] and allergic rhinitis [10,11]. 10. Frequency of their asthma related hospital admissions dur-
The goal of guidelines is their wide spread within the medical ing the past 12 months.
community to all health care professionals and patients in order 11. Patient education.
to improve patients care [12]. 12. Assessment of patient’s compliance with asthma medication
The role of asthma guidelines is important but, the recent was done by The Asthma Control Questionnaire (ACQ): a
updates focus more on control than on severity due to a new validated six-item questionnaire to assess asthma control
understanding of the disease, [13–15]. over the past week. Items address:
In some countries like Egypt and specially in Sharkia Gover- a) How frequently were the patients woken by their asthma.
norate, many diseases e.g. bronchial asthma, diabetes mellitus, b) How bad were their symptoms when they woke up.
hypertension, etc. may be managed by any general practitioner c) How limited were they in their activities.
or other specialty other than the presumed one without following d) How much shortness of breath they had.
international guidelines and this may lead to over or under diagno- e) How much of the time they wheezed.
sis and consequently over or under treatment and even occurrence f) The average number of puffs of short-acting bronchodilator
of complications. Also it is observed that some chest physicians they used each day. Patients respond to each item on a 7
don’t follow international guidelines in managing bronchial point scale (0–6) and a mean score is calculated. Patients
asthma patients. with a mean score of >1.5 were considered to have poorly
controlled asthma [17].
Research question
Criteria of asthma diagnosis were reviewed through GINA
guidelines (2008) [1]
Are patients of bronchial asthma had been managed by their
chest physicians with Global Initiative for Asthma (GINA)
Medical history
guidelines?

 A clinical diagnosis of asthma is often prompted by episodic

Aim of the work attacks of breathlessness, chest tightness, wheezing, and cough.
 Episodic symptoms with the following are also helpful diagnos-
Improve health status of patients and reduce complications tic guides:
from bronchial asthma. 1. Positive family history of asthma.
2. Atopic diseases.
Objectives 3. Allergen exposure.
4. Seasonal variability of symptoms.
The objective of this study is to assess patients who have been 5. Worsening at night.
labelled as bronchial asthma regarding: a- how they were diag- 6. Responding to appropriate asthma therapy.
nosed, b- what treatment have been prescribed to them by their
chest physicians and to assess if they follow GINA guidelines or Physical examination
not.
The most usual abnormal physical finding is wheezing on aus-
cultation, a finding that confirms the presence of airflow limitation.
Patients and methods However, in some people with asthma, wheezing may be absent or
detected only when the person exhales forcibly, even in the pres-
This study was carried out at Chest Department (outpatient sec- ence of significant airflow limitation.
tions), Zagazig University Hospital from September 2011 to
September 2012 on 220 adult patients labelled and managed as Diagnostic tools
bronchial asthma, 57 males and 163 females with an age range
from 18 years old to 50 years old.  Measurements of lung function.
Those patients were selected from the attendants at the outpa-  Measurements of lung function provides:
tient chest clinic and Ministerial decisions clinic for treating 1. Reversibility.
patients, Chest Department, Zagazig University Hospital. 2. Variability.
 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205
3. Assessment of the severity of airflow limitation.
4. Complementary information about asthma control.
Spirometry
 The degree of reversibility in FEV1 which indicates a diagnosis
of asthma is generally accepted as 12% and 200 ml from
the pre- bronchodilator value.
 Increase in FEV1 of 12% and 200 ml after inhaled short acting
b2 agonist (e.g. salbutamol 400 mcg by MDI + spacer or 2.5 mg
by nebulizer).
Or increase in FEV1 of 12% and 200 ml after trial of steroid
tablets (prednisolone 30 mg /day for 14 days), [18].
 FEV1 / FVC ratio <0.80 suggest airflow limitation.
Peak expiratory flow
Measurements by peak flow meter can be important aid in both
diagnosis and monitoring of asthma.
GINA guidelines for treatment (GINA, 2008) [1]:
Then after the diagnosis has been reviewed, prescriptions to the
selected patients by their chest physicians were reviewed if they
were matched with GINA guidelines or not.
Statistical analysis
Data were processed by SPSS software package version 10.
Qualitative data were presented as number and percentage. Quan-
titative data like age were summarized by mean and standard
deviation.
One sample Chi–Square Test (goodness of fit) compares the
observed and expected frequencies in each category to test either
that all categories contain the same proportion of the value.
Chi–Square test used to estimate the association between qual-
itative variables like association between compliance to treatment
and hospital admission, Fisher’s Exact test is recommended when
expected cell is less than 5. Probability less than 0.05 is considered
significant.
Results
See Tables 1–17.
Discussion
Asthma is one of the most common chronic pathological condi-
tions throughout the world and has been the focus of clinical and
public health interventions during recent years [19]. It is estimated
that 300 million people worldwide were affected by asthma lead-
ing to approximately 250,000 deaths per year [20]. Clinical guide-
lines are designed to help practitioners and patients make
Table 2
Smoking habits among studied asthmatic patients with special reference to sex.
Sex Smoking habits
Total number of patients Smoker
No.
Male 57 12
Female 163 1 0.6%
Total 220 13
199
decisions regarding the appropriate health care for specific circum-
stances [7]. Guidelines have existed for decades and hundreds have
been published for many diseases [8] including asthma [9] and
allergic rhinitis [10,11].
The goal of guidelines is their wide dissemination within the
medical community to all health care professionals and patients
in order to improve patient’s care [12]. The objective of this study
was to assess patients who have been labelled as bronchial asthma
regarding: a- how they were diagnosed, b- what treatment have
been prescribed to them by their chest physicians and to assess
if they follow GINA guidelines or not.
The results of this study were compared with that of Attia
(1997) [16] who was assessing the management of bronchial
asthma in Sharkia Governorate among specialists and non-
specialists.
This study was planned in a trial to assess whether there is
improvement in the management of bronchial asthma by chest
physicians as regarding applying GINA guidelines or not a long
the last decade.
In this study the frequency of age of bronchial asthma patients
with a mean age of 37.05 ± 9 is in agreement with Laforest et al.
(2006) [21] where mean age in their study was 34.7 ± 10.0 Table 1.
As regard smoking habits, the majority of patients were non
smokers (99.4% females, 78.9% males) Table 2 and this finding is
in agreement with Attia (1997) [16] who found that the majority
of patients in his study were non smokers (96.8% females, 65.7%
males). Also this finding is in agreement with Laforest et al.
(2006) [21] who found that the majority of bronchial asthma
patients were non smokers (85.1%) in their study.
These findings confirm the awareness of bronchial asthma
patients of the harmful effects of smoking on their health.
In this study it was found that plain X-ray chest was widely rec-
ommended by chest physicians as 81.3% of bronchial asthma
patients were advised to do plain X-ray chest Table 3 and this is
in agreement with Angus et al. (1994) [22] who found that plain
X-ray chest was recommended to 86% of their bronchial asthma
patients by chest physicians also in agreement with Attia (1997)
[16] who found that plain X-ray chest was recommended to
81.5% of his bronchial asthma patients by chest physicians in Shar-
kia Governorate. This may be explained by the fact that inspite of
not needing plain x- ray chest to diagnose bronchial asthma it
was recommended by the majority of chest physicians in order
to exclude other abnormalities or complications, and actually plain
x- ray is an extension of clinical examination.
Table 1
Age distribution among studied asthmatic patients.
Age (years) Age (years) %
X- SD 37.05 ± 9.3
Range 18–50
<30 years 50 22.7
30 85 38.6
40 + 85 38.6
X = mean; SD = Standard deviation.
p
Non smoker
% No. %
21% 45 78.9% Fisher’s Exact 0.000
162 99.4%
5.9% 207 94.1%
200 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205

Table 3
Frequency of investigations (chest X-ray, PEFR, spirometry) advised by chest physicians to bronchial asthma patients.

Investigation Medical advise

Advised Not advised Total X2 P
No. % No. % No. %
Chest X-ray (CXR) 179 81.3 41 18.7 220 100 86.5 0.000
PEFR 27 12.2 193 87.8 220 100 125.2 0.000
Spirometry 27 12.2 193 87.8 220 100 125.2 0.000

X2 = Chi square; P = Probability of difference.

PEFR = Peak Expiratory Flow Rate.

Also it was found that spirometric pulmonary function and peak
expiratory flow rate (PEFR) were requested to only 12.2% of bron-
chial asthma patients by chest physicians and this finding is in dis-
agreement with Attia (1997) [16] who found that spirometric
pulmonary function was recommended to only 1% of bronchial
asthma patients by chest physicians while PEFR was recommended
to 10% of bronchial asthma patients by chest physicians in Sharkia
Governorate.
These findings show that there is slightly increase of the aware-
ness of chest physicians of the importance of applying guidelines in
their diagnosis of bronchial asthma also the availability of these
medical tools help chest physicians to think about using these con-
firmatory diagnostic means.
Also, some patients of bronchial asthma came to the physicians
in between the attacks so spirometry and PEFR will not be the best
method of choice to diagnose them.
There is also a need to improve physician compliance with
objective measurements (Putnam et al., 2001) [23]. A survey of
asthma management related to using spirometry demonstrated
that 25% of primary care providers did not obtain any objective
measures of pulmonary function tests in new asthma patients. This
contrasted with a rate of 3% among asthma specialists. However,
only 31% of specialists and 14% of primary care physicians stated
that they performed pulmonary function tests (PFTs) [24,25].
In the current study it was found that corticosteroids and b2
agonist were prescribed to all bronchial asthma patients by their
chest physicians Table 4 and this finding is in disagreement with
Attia (1997) [16] who found that corticosteroids were prescribed
to 64.6% of bronchial asthma patients by their chest physicians
and b2 agonist were prescribed to 63.3% of bronchial asthma
patients by their chest physicians in Sharkia Governorate. These
findings confirm again the awareness of chest physicians of the
importance of using anti-inflammatory agents and b2 agonist in
controlling and relieving of bronchial asthma.
Also it was found that theophylline was prescribed to 53.1% of
bronchial asthma patients by their chest physicians Table 4 and
this finding is in agreement with Attia (1997) [16] who found that
theophylline was prescribed to 51.7% of bronchial asthma patients
by their chest physicians in Sharkia Governorate.
Antibiotics were prescribed to 88.1% of bronchial asthma
patients while mucolytics and expectorants were prescribed to
61.8% of bronchial asthma patients by their chest physicians
Table 4 and these findings are in contradiction with Attia (1997)
[16] where antibiotics were prescribed to 54.1% of bronchial
asthma patients while mucolytics and expectorants were pre-
scribed to 56.1% of bronchial asthma patients by their chest physi-
cians in Sharkia Governorate.
Laforest et al. (2006) [21] suggest that the use of antibiotics in
asthma remains common in primary care despite the appearance
of new efficient controller therapies; they found that antibiotics
were prescribed to 43.8% of bronchial asthma patients by their
chest physicians and this finding is lower than that observed in this
study. The antibiotics abuse by chest physicians may be due to that
if patients expect antibiotics, then doctors may find it is easier to
write a prescription than to explain to the patient why it is not nec-
essary [26]. Also it may be explained partially by the fact that the
infection may be the exacerbating factor in the majority of bron-
chial asthma patients. Moreover, if doctors believe that patients
want antibiotics, then they may prescribe them in order to satisfy
their patients [27].
Finally, some physicians may overprescribe antibiotics because
they lack professional knowledge about proper antibiotic usage
[28–30].
Leukotriene Receptor Antagonist (LTRA) were prescribed to
33.2% of bronchial asthma patients by their chest physicians and
this finding is in agreement with Laforest et al. (2006) [21] who
found in their study that LTRA were prescribed to 33.6% of bron-
chial asthma patients by their chest physicians. LTRA used as
add-on therapy may reduce the dose of inhaled corticosteroids
required by patients with moderate to severe asthma [31], and
may improve asthma control in patients whose asthma is not con-
trolled with low or high doses of corticosteroids.
Regarding the combination of inhaled Long acting b2 agonist
and inhaled corticosteroids (COMBO) they were prescribed to
90% of bronchial asthma patients by their chest physicians while
inhaled corticosteroids (ICS) solely were prescribed to 5% of bron-
chial asthma patients, oral corticosteroids to 2.7%, injectable form
of corticosteroids to 2.3% Table 5 and these findings were in contra-

Table 4
Percentage distribution of studied asthmatic patients according to prescribed medications by chest physicians.

Medications Medical advise X2 P

Prescribed Not prescribed Total
No. % No. % No. %
Corticosteroids (All forms) 220 100 0 0 220 100 Can’t computed –
b2 agonist (All forms) 220 100 0 0 220 100 Can’t computed –
Theophylline (All forms) 117 53.1 103 46.9 220 100 0.89 0.345
Antibiotics 194 88.1 26 12.9 220 100 128.2 0.000
Mucolytics and expectorants 136 61.8 84 38.2 220 100 12.3 0.000
LTRA 73 33.2 147 66.8 20 100 24.9 0.000

LTRA = Leukotriene Receptor Antagonist.

 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205 201

Table 5
Percentage distribution of studied asthmatic patients according to the form of corticosteroids prescribed by chest physicians.

Corticosteroids Medical advise

Prescribed Not prescribed Total
No. % No. % No. %
COMBO 198 90 22 10 220 100
ICS solely 11 5 209 95 220 100
Oral 6 2.7 214 97.3 220 100
Injection 5 2.3 215 97.7 220 100

X2 = 495.9; P = 0.000.
COMBO = Inhaled long acting b2 agonist + Inhaled corticosteroids.
ICS = Inhaled corticosteroids.

diction with Attia (1997) [16] who found that COMBO were pre-
scribed to 75% of bronchial asthma patients by their chest physi-
cians, ICS solely were prescribed to 92.1%, oral corticosteroids
were prescribed to 50%, injectable form of corticosteroids to
45.7%. This COMBO therapy confirm the awareness of chest physi-
cians about the problem which may result from solely use of long
acting b2 agonist (LABA) (which was declared by FDA and Health
Canada) that the regular use of rapid-acting b2 agonist in both
short and long acting forms may lead to relative refractoriness to
b2 agonist [32]. Also there is a possible increased risk of asthma-
related death associated with the use of salmetrol in a small group
of individuals [33]. So FDA and Health Canada stated that LABA are
not a substitute for inhaled or oral glucocorticosteroids, and should
only be used in combination with an appropriate dose of inhaled
glucocorticosteroids [34].
Most of bronchial asthma patients coming to chest physicians
for consultation are those of moderate or severe persistent asthma
not those of intermittent or mild persistent asthma and according
to our egyptian guidelines and GINA guidelines the preferred man-
agement is to add LABA to inhaled steroids than doubling the dose
of inhaled steroids. Also these findings are in disagreement with
Laforest et al. (2006) [21] who found that COMBO were prescribed
to 70.8% of bronchial asthma patients by their chest physicians, ICS
solely were prescribed to 43.1%, oral corticosteroids were pre-
scribed to 38% of bronchial asthma patients by their chest physi-
cians. However these findings are in agreement with Geijer et al.
(2004) [35] and GINA (2007) [36] who found that combination
therapy with an inhaled corticosteroid and a long-acting b2-
agonist is now a recommended treatment option in patients not
controlled with a low dose of inhaled corticosteroids.
These findings confirm again the awareness of chest physicians
of the importance of using inhaled anti-inflammatory agents com-
bined with inhaled bronchodilator in controlling bronchial asthma
and limiting the usage of oral and injectable form of corticosteroids
to avoid their side effects. This awareness is concluded from mul-
tiple national and international conferences and implementation of
national guidelines which does not differ much from GINA
guidelines.
These findings confirm that chest physicians follow GINA guide-
lines in treatment of bronchial asthma patients.
The management of bronchial asthma is largely based on phar-
macotherapy which relies more on the inhaled route, both to
diminish the dose of applied drug and hence the risk of systemic
side effects decreases, and to localize therapy to the target organ
[2]. Salmeterol/Fluticasone propionate combination was signifi-
cantly more effective than fluticasone propionate alone [37].
Increase availability of COMBO drugs in Ministerial decisions
clinic for treating patients in Zagazig University Hospital share in
the increase of COMBO drugs prescriptions to bronchial asthma
patients, for example the amount of COMBO drugs in the form of
Salmeterol/Fluticasone propionate combination received at Minis-
terial decisions clinic for treating patients in Zagazig University
Hospital was 1250 COMBO drugs and the amount prescribed was
1217 in the period from 1st of January 2012 to 23 of August
2012. Another example the amount of COMBO drugs in the form
of Formetrol/Budesonide combination received at Ministerial deci-
sions clinic for treating patients in Zagazig University Hospital was
400 COMBO drugs and the amount prescribed was 386 in the same
period.
COMBO was prescribed to 90% of bronchial asthma patients by
their chest physicians while inhaled b2 agonist solely was pre-
scribed to 6.4%, oral b2 agonist to 3.6% Table 6 and these findings
are in agreement with Barnes et al. (1993) and Bone (1996)
[38,39] who stated that oral b2 agonist should occupy a marginal
role in asthma management while these findings are in disagree-
ment with Attia (1997) [16] who found that COMBO was pre-
scribed to 75% of bronchial asthma patients by their chest
physicians, inhaled b2 agonist solely was prescribed to 87.5%, oral
b2 agonist to 45.9%. Also these findings are in disagreement with
Laforest et al. (2006) [21] who found that COMBO was prescribed
to 70.8% of bronchial asthma patients by their chest physicians,
inhaled b2 agonist solely was prescribed to 29.9% of bronchial
asthma patients by their chest physicians.
However, physicians’ statements in the study by Chapman et al.
(2008) [40] demonstrate that when the patient’s asthma was
uncontrolled they were more likely to intervene, particularly by

Table 6
Percentage distribution of studied asthmatic patients according to the form of b2 agonist prescribed by chest physicians.

B2 agonist Medical advise

Prescribed Not prescribed Total
No. % No. % No. %
COMBO 198 90 22 10 220 100
Inhaled b2 agonist solely 14 6.4 206 93.6 220 100
Oral 8 3.6 212 96.4 220 100

X2 = 318.45; P = 0.000.
COMBO = Inhaled long acting b2 agonist + Inhaled corticosteroids.
202 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205

Table 7
Percentage distribution of studied asthmatic patients according to theophylline prescribed by chest physicians.

Theophylline Medical advise X2 P

Prescribed Not prescribed Total
No. % No. % No. %
Oral 113 51.3 107 48.7 220 100 0.89 0.34
Injection 4 1.8 216 98.2 220 100 485 0.000

adjusting medication by increasing prescriptions for inhaled corti-
costeroids alone or in combination with long-acting b2agonist
bronchodilators, in keeping with a current popular trend towards
attempts to reduce exacerbations [41].
As regard the oral theophylline, it was prescribed to 51.3% of
bronchial asthma patients by their chest physicians while inject-
able form of theophylline was prescribed to 1.8% Table 7 and these
findings are in disagreement with Attia (1997) [16] who found that
oral theophylline was prescribed to 22.5% of bronchial asthma
patients by their chest physicians while injectable form of theo-
phylline was prescribed to 3.5%. Also Laforest et al. (2006) [21]
found that oral theophylline was prescribed to only 2.2% of bron-
chial asthma patients by their chest physicians.
These findings show that theophylline wasn’t prescribed widely
as chest physicians understand the risk of adverse effects of theo-
phylline and difficulty in monitoring therapy. The higher prescrip-
tion of theophylline in this study may be explained by the fact that
chest physicians may prefer to give their patients the benefit of the
modest anti-inflammatory properties of theophylline when given
in a lower dose beside its bronchodilator effect than never giving
it and this is in accordance with Barens (2003) [42]. Also, available
evidence suggests that sustained-release theophylline (the form
which has been given in this study) has a little effect as a first line
controller [43]. Theophylline may provide benefit as add-on ther-
apy in patients who do not achieve control on inhaled glucocorti-
costeroids alone [44].
In the current study LTRA was prescribed to 33.2% of bronchial
asthma patients by their chest physicians Table 8 and this finding
is in agreement with Laforest et al. (2006) [21] who found that
LTRA was prescribed to 33.6% of bronchial asthma patients by their
chest physicians.
It was found that mucolytics and expectorants were prescribed
to 61.8% of bronchial asthma patients by their chest physicians
Table 9 and this finding is in agreement with Attia (1997) [16]
who found that mucolytics and expectorants were prescribed to
56.1% of bronchial asthma patients by their chest physicians. Also
this finding is in contradiction with Laforest et al. (2006) [21] who
found that mucolytics and expectorants were prescribed to 37.2%
of bronchial asthma patients by their chest physicians.
There was a high percentage (92.3%) of bronchial asthma
patients were treated according to GINA guidelines, while a low
percentage (7.7%) of bronchial asthma patients were not treated
according to GINA guidelines Table 10.
Also there was 88.2% of bronchial asthma patients were compli-
ant with their asthma medications Table 11 and this finding is in
accordance with Taylor et al., (1999) and Walders et al., (2005)
[45,46] who found that in asthma, compliance rates are particu-
larly challenging and ranges from less than 30% to 70–80% in adult
patients on asthma medications.
It was shown that 88.2% of bronchial asthma patients weren’t
admitted at hospital during the past 12 months while 8.2% of them
were admitted at hospital once during the past 12 months due to
asthma exacerbation however 3.6% were admitted more than once
during the past 12 months also due to asthma exacerbation Table 12
and these findings are in agreement with Laforest et al. (2006) [21]
Table 10
Percentage distribution of studied asthmatic patients matching the rules of GINA
guidelines in their treatment.
Bronchial asthma patients Medical advise
Number %
Matching GINA guidelines 203 92.3
Not matching GINA guidelines 17 7.7
Total 220 100
X2 = 157.1; P = 0.000.

Table 8
Percentage distribution of studied asthmatic patients according to LTRA prescribed by
Table 11
chest physicians.
Percentage distribution of studied asthmatic patients according to their compliance
LTRA Medical advise with their asthma medication.

Number % Item Number %

Prescribed 73 33.2 Compliant 194 88.2
Not prescribed 147 66.8 Non- compliant 26 11.8
Total 220 100 Total 220 100

LTRA = Leukotriene Receptor Antagonist. X2 = 128.3; P = 0.000.

Table 9 Table 12
Percentage distribution of studied asthmatic patients according to mucolytics and Percentage distribution of studied asthmatic patients according to hospital admission
expectorants prescribed by chest physicians. during the past 12 months.

Mucolytics & Expectorants Medical advise Bronchial asthma related hospital admission Medical advise
Number % Number %
Prescribed 136 61.8 None 194 88.2
Not prescribed 84 38.2 Once 18 8.2
Total 220 100 More than once 8 3.6
Total 220 100
X2 = 12.3; P = 0.000.
X2 = 24.9; P = 0.000. X2 = 298.5; P = 0.000.
 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205 203

who found that 93% of bronchial asthma patients weren’t admitted
at hospital during the past 12 months while 5.6% of them were
admitted at hospital once during the past 12 months due to asthma
exacerbation however 1.4% were admitted more than once during
the past 12 months also due to asthma exacerbation.
Also, 97.4% of bronchial asthma patients who were compliant
with their asthma medications weren’t admitted at hospital during
the past 12 months while 80.8% of bronchial asthma patients who
weren’t compliant with their asthma medications were admitted
at hospital either once or more during the past 12 months. Table 13
This proves that non-compliance with asthma medications result
in exacerbation that may need hospitalization and even intensive
care unit admission.
This current study showed that the most common side effect of
systemic drugs used in the treatment of bronchial asthma was
weight gain (10.4%) and the least was palpitation (4.5%) however
tremors represents 5.4%, insomnia 7.7% and abdominal discomfort
6.3% Table 14.
Therapy with LABA causes fewer systemic adverse effects-such
as cardiovascular stimulation, skeletal muscle tremors and
hypokalemia-than oral therapy [32]. Theophylline adverse effects
include gastrointestinal symptoms, loose stool, cardiac arrhythmia,
seizures and even death. Nausea and vomiting are the most com-
mon early events [15].
As regard the local side effects of inhaled corticosteroids among
bronchial asthma patients it was found that oropharyngeal

Table 13
Relationship between bronchial asthma related hospital admission during the past 12 months and compliance with asthma medications.

Compliance Admission
No admission One or more admission Total
No. % No. % No. %
Compliant 189 97.4 5 2.6 194 100
Non-compliant 5 19.2 21 80.8 26 100

Fisher’s exact P = 0.000.

Table 14
Frequency of some side effects of asthma medications (systemic drugs).

Side effect Patients X2 p

Complained Not complained Total
No. % No. % No. %
Palpitation 10 4.5 210 95.5 220 100 181 0.000
Tremors 12 5.4 208 94.5 220 100 174.6 0.000
Weight gain 23 10.4 197 89.5 220 100 137.6 0.000
Insomnia 17 7.7 203 92.3 220 100 157.3 0.000
Abdominal discomfort 14 6.3 206 93.6 220 100 167.5 0.000

X2 = 6.76; P = 0.15.

Table 15
Frequency of local side effects of inhaled corticosteroids among bronchial asthma patients.

Side effect Patients X2 p

Complained Not complained Total
No. % No. % No. %
Oropharyngeal candidiasis 17 8.1 192 91.9 209 100 153.8 0.000
Dysphonia 13 6.2 196 93.8 209 100 167.5 0.000
Cough 6 2.8 203 97.2 209 100 196.6 0.000

X2 = 5.89; P = 0.052.

Table 16
Percentage distribution of studied asthmatic patients according to the group of antibiotic prescribed by chest physicians.

Antibiotics Medical advice

Prescribed Not prescribed
No. % No. %
Beta lactam 7 3.6 213 96.8
Aminoglycosides 6 3.1 214 97.3
Tetracyclines 3 1.5 217 98.6
Chloramphenicol 0 0 220 100
Sulfonamides 4 2.1 216 98.2
Macrolides 22 11.3 198 90
Quinolones 142 73.2 78 35.5
Combination 10 5.2 210 95.5

X2 = 484.4; P = 0.000.
204 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205
Table 17
Percentage distribution of studied asthmatic patients according to their asthma perception.
Items
Feels enough informed regarding asthma
Feels enough informed regarding anti asthma treatment
Asthma considered as a major concern or handicap
candidiasis represents 8.1%, dysphonia represents 6.2%, cough
represents 2.8% Table 15 and these findings are in agreement with
Kennedy et al. (2000) [47] where oropharyngeal candidiasis repre-
sents 7% and Roland et al. (2004) [48] where dysphonia represents
5–50% while our findings are in disagreement with Buhl (2006)
[49] regarding cough which represents 34% in his study.The most
common antibiotic group prescribed by chest physicians were qui-
nolones (to 73.2% of bronchial asthma patients), while macrolides
were prescribed to (11.3%) of bronchial asthma patients by their
chest physicians Table 16 and these findings are in agreement with
Attia (1997) [16] who found that the most common antibiotic
groups prescribed by chest physicians were quinolones (100%)
and macrolides (70.8%).
In this work, 85% of bronchial asthma patients feel enough
informed regarding asthma, 77% feel enough informed regarding
anti-asthma treatment and 30% consider bronchial asthma as a
major concern or handicap Table 17 and these finding are in agree-
ment with Laforest et al. (2006) [21] who found that 84.5% of bron-
chial asthma patients feel enough informed regarding asthma,
76.7% feel enough informed regarding anti-asthma treatment and
25.2% consider bronchial asthma as a major concern or handicap.
These findings show the awareness of chest physicians of the
importance of patient education about bronchial asthma and the
good relationship between chest physicians and their patients.
Conclusion
Inspite of the relatively increase in the request of PEFR and
spirometry in the diagnosis of bronchial asthma than before, it is
still beyond than the expected ones. Chest physicians follow GINA
guidelines regarding treatment of bronchial asthma patients with
inhalation therapy (b2 agonist and ICS).
There is still abuse in the prescriptions of antibiotics, mucolytics
and expectorants by Chest physicians. Finally, there is a satisfac-
tory implementation of local and international asthma manage-
ment guidelines.
References
[1] Global Initiative for Asthma (GINA) (2008): Global Strategy for Asthma
Management and Prevention. Updated 2007. Retrieved February 2008.
[2] P.G.J. Burney, J.R. Britton, S. Chinns, Descriptive -epidemiology of bronchial
asthma epidemiology in adult population. Results from a community study,
Thorax 42 (1987) 38.
[3] A. Bauman, C.A. Mitchell, R.L. Henry, et al., Asthma morbidity in Australia: an
epidemiological study, Med. J. 156 (1992) 827–831.
[4] T.V. Hartert, H.H. Windom, R.S. Peebles Jr, et al., Inadequate outpatient medical
therapy for patients with asthma admitted to two urban hospitals, Am. J. Med.
100 (1996) 386–394.
[5] T.J.H. Clark, Asthma, an overview. In respiratory medicine, in: R.A.L. Brewis, G.
J. Gibson, D.N. Geddes (Eds.), Bailliere Tindal, London, Philadelphia, Toronta,
1990, p. 545.
[6] British Thoracic Society, Guidelines on the management of asthma. Thorax: 45
(Supp. 51) (1993).
[7] R. Jackson, G. Feder, Guidelines for clinical guidelines [editorial], BM. J. 317
(427) (1998) 428.
[8] S.H. Woolf, R. Grol, A. Hutchinson, M. Eccles, J. Grimshaw, Clinical guidelines:
potential benefits, limitations, and harms of clinical guidelines, BMJ 318 (1999)
527–530.
[9] Global Initiative for Asthma (GINA), Global Strategy for Asthma Management
and Prevention, 2012.
[10] J. Bousquet, N. Khaltaev, A.A. Cruz, J. Denburg, W.J. Fokkens, A. Togias, T.
Zuberbier, et al., Allergic Rhinitis and its Impact on Asthma (ARIA) 2008 update
Number % X2 p
187 85 107.8 0.000
169 77 63.3 0.000
66 30 32.5 0.000
(in collaboration with the World Health Organization, GA (2) LEN and
AllergGen), Allergy 63 (86 Suppl) (2008) 8–160, Print ISSN 0105–4538,
Electronic ISSN 1398–9995.
[11] J.L. Brozek, J. Bousquet, C.E. Baena-Cagnani, S. Bonini, G.W. Canonica, T.B.
Casale, et al., Global Allergy and Asthma European Network; Grading of
Recommendations Assessment, Development and Evaluation Working Group.
Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines, J. Allergy Clin.
Immunol. 126 (3) (2010) 466–476, Print ISSN 0091–6749, Electronic ISSN
1097–6825.
[12] J. Bousquet, T.J.H. Clark, S. Hurd, N. Khaltaev, C. Lenfant, P.O. Byrne, A. Sheffer,
GINA Guidelines on Asthma and Beyond, Journal Compilation, Blackwell
Munksgaard, 2007.
[13] N. Roche, H. Morel, P. Martel, P. Godard, Clinical practice guidelines: medical
follow-up of patients with asthma–adults and adolescents, Respir. Med. 99
(2005) 793–815.
[14] J. Li, J. Oppehneimer, I. Bernstein, R. Nicklas, Attaining optimal asthma control:
a practice parameter, J. Allergy Clin. Immunol. 116 (2005) S3–S11.
[15] Global Initiative for Asthma (2006): Global Strategy for Asthma Management
and Prevention. Revision. 2006.
[16] A.M. Attia, Bronchial asthma management in Sharkia governorate, M.Sc Thesis,
under supervision of Mobasher, A.A., Hussein, R.M., El-Hayawan, H.M., Chest
Department, Zagazig, 1997.
[17] E.F. Juniper, J. Bousquet, L. Abetz, E.D. Bateman, Identifying ’well-controlled’
and ’not well-controlled’ asthma using the Asthma Control Questionnaire,
Respir. Med. 100 (4) (2006) 616–621.
[18] R. Pellegrino, G. Viegi, V. Brusasco, R.O. Crapo, F. Burgos, R. Casaburi, et al.,
Interpretative strategies for lung function tests, Eur. Respir. J. 26 (5) (2005)
948–968.
[19] M. Masoli, D. Fabian, S. Holt, R. Beasley, The global burden of asthma:
executive summary of the GINA Dissemination Committee Report, Allergy 59
(2004) 469–478.
[20] C.H. Fanta, Asthma, N. Engl. J. Med. 360 (10) (2009) 1002–1014.
[21] L. Laforest, E. Van Ganse, G. Devouassoux, S. Chretin, L. Osman, G. Bauguil, Y.
Pacheco, G. Chamba, Management of asthma in patients supervised by
primary care physicians or by specialists, Eur. Respir. J. 27 (2006) 42–50.
[22] R.M. Angus, S. Murray, J.W. Kay, N.C. Thomson, P.K. Patel, Management of
chronic airflow obstruction. Differences in practice between respiratory and
general physicians, Respir. Med. 88 (1994) 497.
[23] W. Putnam, F. Burge, S. Tatemichi, P. Twohig, Asthma in primary care: making
guidelines work, Can. Respir. J. (Suppl A) (2001) 29A–34A.
[24] L.C. O’Dowd, D. Fife, T. Tenhave, R.A. Panettieri Jr, Attitudes of physicians
toward objective measures of airway function in asthma, Am. J. Med. 114 (5)
(2003) 391–396.
[25] M.W. Peterson, Accessing the tools for improved asthma management, Am. J.
Med. 114 (5) (2003) 415–416.
[26] Bryan. Schwartz, Ralph. Gonzales, John F. Steiner, Merle A. Sande, Why do
physicians prescribe antibiotics for children with upper respiratory tract
infections?, JAMA 279 (1998) 881–882
[27] Bennett Daniel, Che-Lun Huang, Tsai-Ling Lauderdale, Health Care
Competition and Antibiotic Use in Taiwan, Harris School of Policy Studies, 8
(2010).
[28] Kai-hu Yao, Yong-hong Yang, Streptococcus pneumoniae diseases in chinese:
past, present and future, Vaccine 26 (4425) (2008) 4433.
[29] Xiaoyun Sun, Sukhan Jackson, Gordon A. Carmichael, Adrian C. Sleigh,
Prescribing behavior of village doctors under China’s new cooperative
medical scheme, Soc. Sci. Med. 68 (2009) 1775–1779.
[30] Najla Saeed Dar-Odeh, Osama Abdalla Abu-Hammad, Mahmoud Khaled
Al-Omiri, Ameen Sameh Khraisat, Asem Ata Shehabi, Antibiotic 29
prescribing practices by dentists: a review, Ther. Clin. Risk Manage. 6
(2010) 301–306.
[31] C.G. Lofdahl, T.F. Reiss, J.A. Leff, E. Israel, M.J. Noonan, A.F. Finn, et al.,
Randomised, placebo controlled trial of effect of a leukotriene receptor
antagonist, montelukast, on tapering inhaled corticosteroids in asthmatic
patients, BMJ 319 (7202) (1999) 87–90.
[32] D.M. Newnham, D.G. McDevitt, B.J. Lipworth, Bronchodilator subsensitivity
after chronic dosing with eformoterol in patients with asthma, Am. J. Med. 97
(1) (1994) 29–37.
[33] H.S. Nelson, S.T. Weiss, E.R. Bleecker, S.W. Yancey, P.M. Dorinsky, The
Salmeterol Multicenter Asthma Research Trial: a comparison of usual
pharmacotherapy for asthma or usual pharmacotherapy plus salmeterol,
Chest 129 (1) (2006) 15–26.
[34] E. Israel, V.M. Chinchilli, J.G. Ford, H.A. Boushey, R. Cherniack, T.J. Crog, et al.,
Use of regularly scheduled albuterol treatment in asthma: genotype–stratified,
randomized, placebo – controlled cross-over trial, Lancet 364 (9444) (2004)
1505–1512.
 R. Nafie et al. / Egyptian Journal of Chest Diseases and Tuberculosis 66 (2017) 197–205
[35] R.M.M. Geijer, W. Van Hensbergen, B.J.A.M. Bottema, C.P. Van Schayck, A.P.E.
Sachs, I.J.M. Smeele et al., NHG Practice Guideline Adult asthma: treatment.
Available at: http//www.nhg.artsennet.nl/upload/104/guidelines2/E27b.htm,
2004.
[36] Global Initiative for Asthma (GINA), Global strategy for asthma management
and prevention. Available at: http://www. ginasthma. com/Guidelineitem,
2007, (Accessed 26th February 2007)
[37] P.M. O’Byrne, H. Bisgaard, P.P. Godard, M. Pistolesi, M. Palmqvist, Y. Zhu,
et al., Budesonide/formoterol combination therapy as both maintenance and
reliever medication in asthma, Am. J. Respir. Crit. Care Med. 171 (2) (2005)
129–136.
[38] P.J. Barnes, A.H. Brnett, R.A.L. Brewis, P.S. Burgo, D. Clark, R.A. Costain,
Management of chronic asthma in adult. Thorax 48(Supp. 51–524) (1993).
[39] R.C. Bone, Goals of asthma management a step-care approach, Chest 109
(1996) 1056–1065.
[40] K.R. Chapman, L.P. Boulet, R.M. Rea, E. Franssen, Suboptimal asthma control:
prevalence, detection and consequences in general practice, Eur. Respir. J. 31
(2008) 320–325.
[41] P.J. Barnes, Using a combination inhaler (budesonide plus formoterol) as
rescue therapy improves asthma control, BMJ 335 (2008) 513.
[42] P.J. Barnes, Theophylline: new perspectives for an old drug, Am. J. Respir. Crit.
Care Med. 167 (6) (2003) 813–818.
205
[43] R. Dahl, B.B. Larsen, P. Venge, Effect of long-term treatment with inhaled
budesonide or theophylline on lung function, airway reactivity and asthma
symptoms, Respir. Med. 96 (6) (2002) 432–438.
[44] R.N. Rivington, L.P. Boulet, J. Cote, H. Kreisman, D.I. Small, M. Alexander, et al.,
Efficacy of Uniphyl, salbutamol, and their combination in asthmatic patients
on high-dose inhaled steroids, Am. J. Respir. Crit. Care Med. 151 (2 Pt 1) (1995)
325–332.
[45] D.M. Taylor, T.E. Auble, W.J. Calhoun, V.N. Mosesso Jr., Current outpatient
management of asthma shows poor compliance with International Consensus
Guidelines, Chest 116 (1999) 1638–1645.
[46] N. Walders, S.J. Kopel, D. Koinis-Mitchell, E.L. McQuaid, Pattern of quick-relief
and long-term controller medication use pediatric asthma, J. Pediatr. 146
(2005) 177–182.
[47] W.A. Kennedy, C. Laurier, D. Gautrin, H. Ghezzo, M. Pare, J.L. Malo, et al.,
Occurrence and risk factors of oral candidiasis treated with oral antifungals in
seniors using inhaled steroids, J. Clin. Epidemiol. 53 (2000) 696–701.
[48] N.J. Roland, R.K. Bhalla, J. Earis, The local side effects of inhaled corticosteroids
Current understanding and review of the literature, Chest 126 (2004) 213–
219.
[49] R. Buhl, Local oropharyngeal side effects of inhaled corticosteroids in patients
with asthma, Allergy 61 (2006) 518–526, http://dx.doi.org/10.1111/j.1398-
9995.2006.01090.x.