Allergol Immunopat hol (Madr).

2009;37(3):122-8

Allergologia et
immunopathologia
INTERNATIONAL JOURNAL OF ASTHMA, ALLERGY AND CLINICAL IMMUNOLOGY
OFFICIAL JOURNAL OF THE SPANISH SOCIETY OF PEDIATRIC ALLERGY AND CLINICAL IMMUNOLOGY

Allergologia et January-February 2009. Vol. 37 - N.º 1

EDITORIAL
The monitoring of bronchial inflammation by bioimpedance

ORIGINAL ARTICLES

immunopathologia
Bioimpedance monitoring of airway inflammation in
asthmatic allergic children
Differential Th1/Th2 balance in peripheral blood
lymphocytes from patients suffering from flea bite-induced
papular urticaria
Prevalence of asthma and other allergic diseases in children
born after in vitro fertilisation
Immunophenotypic profile of T cells in common variable
immunodeficiency: is there an association with different
clinical findings?
Potential association between allergic diseases and
pertussis infection in schoolchildren: Results of two
cross-sectional studies seven years apart

POINT OF VIEW

www.elsevier.es/ ai
Montelukast versus inhaled corticosteroids as monotherapy
for prevention of asthma: which one is best?

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1

ORIGINAL ARTICLE

Triggers in adult asthma: are patients aware of triggers

and doing right?

Özlem Göksela, *, Gülfem E. Çelika, Ferda Öner Erkekola,

Emine Güllüb, Dilșad Mungana and Zeynep Mısırlıgila

a
Depart ment of Chest Diseases, Division of Allergy, Ankara Universit y School of Medicine, Ankara, Turkey
b
Depart ment of Chest Diseases, Ankara Universit y School of Medicine, Ankara, Turkey

KEYWORDS Abstract
Adult pat ient s; Background: As t riggers have a pot ent ial t o induce ast hma exacerbat ions, awareness of t he
Ast hma; pat ient s t o individual t riggers as well as prot ect ive measures might be helpful t o prevent ast hma
Ast hma t riggers; at t acks. Though allergens and allergen avoidance have been st udied ext ensively, t here are only
Aspirin; few st udies on non-allergic t riggers and t heir avoidance for adult pat ient s wit h ast hma. In t his
Behavior; st udy, we want ed t o invest igat e ast hma t riggers and compliance t o t he prevent ive measures in
Cigaret t e smoking; an adult populat ion.
Infl uenza; Met hods: One hundred and t hirt y one adult ast hma pat ient s were enrolled int o t he st udy. A face
NSAIDs; t o f ace int erview was done by using a quest ionnaire including individual ast hma t riggers,
Pollut ion; prevent ion measures against maj or modifi able t riggers and knowledge sources of t he cases.
Tert iary prevent ion Result s: Regardless of ast hma severit y, 59.5 %of t he subj ect s report ed t o be t riggered by more
t han 10 fact ors. The most common t riggers were air pollut ant s (89.3 %) and weat her changes
(81.7 %). Severe group was more frequent ly affect ed by medicat ions, emot ional st ress, weat her
changes and indoor pollut ant s t han ot her severit y groups (p = 0.017, 0.014, 0.049 and 0.018,
respect ively) whereas st ress was report ed more frequent ly by females t han males. Prevent ion
measures were insuffi cient regarding some maj or t riggers.
Conclusion: Adult pat ient s are vulnerable t o several t riggers regardless from underlying severit y
of t he illness. Insuf fi cient compliance t o t he maj or prevent ive measures indicat es t hat new
st rat egies are needed t o prevent ast hma at t acks caused by modifi able t riggers.

© 2008 SEICAP. Published by Elsevier España, S.L. All right s reserved.

*Corresponding aut hor:

E-mail: goksel.ozlem@gmail.com (Ö. Göksel).

0301-0546/ $ - see front mat t er © 2008 SEICAP. Published by Elsevier España, S.L. All right s reserved.
Ast hma t riggers
Introduction
Ast hma is a chronic inf lammat ory disease of t he airways
whi ch af f ect s mi l l i ons of peopl e t hroughout t he word.
Ast hma exacerbat ions may be caused by a variet y of fact ors
def ined as “ t riggers” which incl ude bot h al l ergens, and
non-al l ergic f act ors such as viral inf ect ions, pol l ut ant s,
drugs and ot hers. 1-5 Theref ore, awareness of t he pat ient s
about individual t riggers as well as measures against t hese
t riggers might be helpful t o prevent some ast hma at t acks.
However, creat ing a low-allergen environment in pat ient s’
homes and reduced exposure t o indoor allergens has been
shown t o be inef f ect ive at reducing ast hma sympt oms. 1, 2, 6
Theref ore, ot her non-allergic t riggers and act ions t aken
against t hese fact ors, as well as assessing t he out comes in
ast hma cont rol could be of int erest .
The main non-allergic ast hma t riggers are indoor air pol-
lut ant s, including passive and act ive smoking, harmful fumes
and gases f rom heat ing devices, out door air pollut ant s in-
cluding exhaust gases, cert ain weat her and at mospheric
condit ions, infl uenza infect ions, psychological fact ors, phys-
ical act ivit ies and cert ain medicat ions such as aspirin and
ot her non-st eroidal ant i-infl ammat ory drugs (NSAIDs), and
bet a blockers. 1,2 Act ually, all of t hese f act ors are a part of
rout ine daily lif e of pat ient s wit h ast hma, and t heref ore
have pot ent ial t o induce ast hma episodes in vulnerable cas-
es. Alt hough t he st udies which invest igat e t he effect of t er-
t iary prevent ion act ions t aken against indoor allergens on
ast hma out comes are from some t ime ago, t here is evidence
t hat prevent ive measures f or non-allergic ast hma t riggers
might provide a benefi cial out come on ast hma sympt oms
and, t herefore, on ast hma cont rol. However, t he number of
st udies on ast hma t riggers and prevent ive measures is lim-
it ed and most ly analysed children based on t he report s of
parent s or caregivers. 7-10 There are only a few st udies which
invest igat e ast hma t riggers in adult ast hma. 3,11,12 These st ud-
ies indicat ed t hat non-allergic t riggering f act ors were im-
port ant predict ors of pat ient s’ general well-being; ast hma
cont rol; and management of ast hma, compared t o allergic
t riggers.
In t his st udy, our principal obj ect ive was t o document t he
prof ile of ast hma t riggers of our adult pat ient group and
t heir abilit y t o cope wit h t hese t riggers in t heir daily life. In
det ail, our aims were: 1) t o quant it y ast hma t riggers; 2) t o
det ermine what behaviours t hese adult s have used t o re-
duce t heir exposure t o maj or t riggers; and which fact ors af-
fect t hese behaviours; and 3) t o assess ast hma informat ion
sources in an adult clinical populat ion in Turkey.
Material and methods
Patient selection and the study design
The st udy was conduct ed in t he out pat ient allergy clinic of
our t ert iary universit y hospit al. A t ot al of 131 adult pat ient s
wit h ast hma were consecut ively enrolled int o t his cross-sec-
t ional st udy. Ast hma diagnosis was based on a hist ory of re-
current sympt oms of wheezing, short ness of breat h, cough
and demonst rat ion of obj ect ive signs of reversible airway
obst ruct ion by means of at least > 12 %increase in FEV1 aft er
15 minut es wit h an inhalat ion of 200 mg salbut amol. 1,2
123
Demographics (age, gender, education, occupation, smoking
st at us) and disease charact erist ics (durat ion and severit y of
ast hma, presence of at opy, family hist ory of allergy) were re-
corded. Ast hma severit y was det ermined by t he frequency of
ast hma sympt oms, pulmonary funct ion t est s, and medicat ion
requirement s according t o int ernat ional ast hma guidelines.
Disease was classifi ed as mild int ermit t ent , mild persist ent ,
moderat e persist ent and severe persist ent ast hma. 1
At opy was defi ned by posit ive skin prick t est s (SPT), which
were perf ormed using a st andardised panel including Der-
mat ophagoides pt eronyssinus, Dermat ophagoides f arinae,
grass, t ree, weed pollens; cat , dog, cockroach, Al t ernaria
and Cl adospor i um ant igens (Al l ergo Pharma/ Germany).
A wheal diamet er of 3 mm great er t han negat ive cont rol was
considered posit ive.
Ast hma t riggers, act ions t aken against t hese t riggers, and
informat ion sources of t he pat ient s were assessed by a ques-
t ionnaire which was developed by t he aut hors t o serve t he
requirement s of t he t opic of “ prevent ion of ast hma sympt oms
and exacerbat ion” in t he int ernat ional ast hma guidelines. 1
A face-t o-face int erview bet ween pat ient s and a chest physi-
cian/ allergy specialist was conduct ed t o fi ll out t he quest ion-
naire. Aft er a pilot t rial in a small group of pat ient s, t he st udy,
has t hen been set for t he t arget st udy group.
The quest ionnaire consist ed of t hree main t opics wit h ei-
t her yes/ no or mul t i pl e choi ce quest i ons. In part one,
non-allergic t riggering fact ors report ed as t he most common
t riggers in t he ast hma t ext books and t he int ernat ional guide-
l ines were l ist ed in random order (see Appendix 1). The
st udy subj ect s were asked t o highlight t he name(s) of t he
t riggers which worsen t heir ast hma sympt oms. In part t wo;
t ert iary prevent ion measures relat ed t o prevent ing some
maj or ast hma t riggers and t he at t it ude changes t hat had
been made by pat ient s in t heir rout ine life following ast hma
diagnosis were invest igat ed. Finally in t he last part of t he
quest ionnaire, t he informat ion sources of t he pat ient s were
evaluat ed. All pat ient s gave verbal informed consent t o be
included in t he st udy.
Statistics
The st at ist ical analyses were performed by comput er soft -
ware (SPSS version 11.0, Chicago, Illinois). Descript ive st a-
t ist ics were expressed as mean ± SEM and n (%). Cat egorical
dat a were t est ed by Chi-square t est . One way ANOVA was
used for t he comparison of cont inuous variables in different
ast hma severit ies. As t here were only a few number of sub-
j ect s wit h mild int ermit t ent ast hma, dat a on t hese subj ect s
were combined wit h t hose wit h mild persist ent ast hma in
st at ist ical analysis. A p value less t han 0.05 was considered
as st at ist ically signifi cant .
Results
Demographics and disease characteristics
A t ot al of 131 adul t pat ient s wit h ast hma [ F/ M: 106/ 25
(80.9/ 19.1 %) and mean age 45.4 ± 0.9] were included in t he
st udy. The mean durat ion of ast hma was 11. 7 ± 0. 9 years.
Sixt y fi ve pat ient s (49.6 %) had posit ive SPT. Most of t he pa-
t ient s had mild persist ent ast hma (n = 57; 43.5 %) (Table I).
 124 Göksel Ö et al

Table I. Demographics and clinical feat ures of t he st udy subj ect s (n = 131)

Variables Mild int ermit t ent Mild persist ent Moderat e persist ent Severe persist ent F/ x2* P

n (%) 7 (5) 57 (44) 50 (38) 17 (13)

Sex (F) n(%) 6 (86) 46 (81) 42 (84) 12 (71) 1.4 0.475
Age (years, mean ± SEM) 40.8 ± 1.3 42.8 ± 1.3 48 ± 1.5 48.2 ± 3.1 4.4 0.014
Educat ional level n(%)
Primary school 1 (14) 29 (51) 27 (54) 7 (41)
High school 2 (29) 18 (32) 12 (24) 5 (29)
Universit y degree 4 (57) 10 (17) 11 (22) 5 (29) 10.2 0.248
Occupat ion n(%)
Housewife 2 (29) 27 (47) 23 (46) 6 (35)
Working at any 4 (57) 18 (32) 17 (34) 6 (35)
professional j ob
Ret ired 1 (14) 12 (21) 10 (20) 5 (29) 7.9 0.438
Cigaret t e smoking n(%)
Never smoked 7 (100) 48 (84) 30 (60) 10 (59)
Ex-smoker — 6 (10) 11 (22) 6 (35)
Current smoker — 3 (5) 9 (18) 1 (6) 14.1 0.007
Amount of cigaret t es — 12.8 ± 4.7 11.7 ± 2.1 13.7 ± 6.6 0.07 0.931
(pack-years, mean ± SEM)
Family hist ory of at opy n (%) 3 (43) 24 (42) 23 (46) 5 (29) 2.9 0.233
At opy rat e n (%) (posit ive 2 (29) 35 (61) 20 (40) 8 (47) 6.4 0.169
skin prick t est ing)
Durat ion of ast hma 13.5 ± 3.7 9.1 ± 1.8 11.9 ± 1.5 19.5 ± 2.8 6.4 0.002
(years, mean ± SEM)
*Denot es value “ F” for cont inuous variables, “ x2” for nominal variables.

70 report ed more t han 10 f act ors as t riggering t heir ast hma,

59 whereas 30. 5 % (n = 40) and 9. 9 % (n = 13) of t he subj ect s
60
report ed t o be t riggered by 6-10 t riggers and 2-5 t riggers,
50 respect ively (Fig. 1). All pat ient s report ed at least t wo t rig-
%of pat ient s

gers and each of t he t riggers in t he list was report ed by at

40
least one pat ient .
30
30
Triggers
20 Exposure t o any pollut ant s such as cigaret t e smoking, out -
11 door and indoor pollut ion were t he most common t riggering
10
f act ors (n = 117; 89. 3 %); f ol l owed by exposure t o dust
0 (n = 99; 75.5 %); st rong odours (n = 95; 72.5); emot ional dis-
> 10 6-9 2,5 t ress (n = 94; 71. 7 %) and upper airway inf ect ions (n = 91;
Figure 1. Quant ifi cat ion of environment al t riggers. 69.4 %) (Table II).

Fact ors af f ect ing t he t riggers

Regarding t he severit y of ast hma; t here were no differences
bet ween gender, educat ion level, occupat ion, family hist ory
of allergy and individual at opy rat e. The pat ient s wit h mod-
erat e t o severe ast hma were older and smoked more t han
mild ast hma pat ient s (p < 0.05). Severe ast hma pat ient s had
longer ast hma durat ions.
Part I: Quantification and classification of triggers
Number of t riggering f act ors
The mean number of t riggering f act ors in t he st udy group
was 11.8 ± 0.4. The maj orit y of t he subj ect s (n = 78; 59.5 %)
Regarding t he mean number of t riggers; t here was no differ-
ence among groups wit h various severit y degrees, age, gen-
der and individual at opy.
The pat i ent s wi t h severe persi st ent ast hma report ed
weat her changes, medicat ions, emot ional fact ors and indoor
pollut ant s as t riggers more t han mild and moderat e severit y
groups did (p = 0.049, 0.017, 0.014, and 0.018, respect ive-
ly). Female subj ect s and t he subj ect s wit h higher educat ion
r epor t ed emot i onal st r ess as t r i gger s mor e f r equent l y
(p = 0.025 and 0.016, respect ively). There was no relat ion-
ship bet ween t he t ype of t riggers and individual at opy, age
or ast hma durat ion.
Ast hma t riggers 125

Table II. Type of t riggering fact ors according t o severit y of ast hma. Values are expressed as n(%)

Variables Whole Mild Mild Moderat e Severe F/ x2* P

Group Int ermit t ent Persist ent Persist ent Persist ent
n = 131 n=7 n = 57 n = 50 n = 17

Exposure t o any pollut ant

Passive smoking 92 (70.2) 5 (71.4) 40 (70.2) 33 (66) 14 (82.4) 1.2 0.546
Out door air pollut ion 105 (80.1) 5 (71.4) 45 (78.9) 40 (80) 15 (88.2) 1.9 0.369
Indoor air pollut ion 60 (45.8) 0 (0) 23 (40.4) 25 (50) 12 (70.6) 8.0 0.018
Weat her changes 107 (81.7) 5 (71.4) 45 (78.9) 42 (84) 15 (88.2) 6.0 0.049
St rong scent s 95 (72.5) 5 (71.4) 41 (71.9) 35 (70) 14 (82.4) 0.9 0.636
Emot ional fact ors 94 (71.7) 6 (85.7) 35 (61.4) 38 (76) 15 (88.2) 8.4 0.014
Upper airway infect ion 91 (69.5) 4 (57.1) 39 (68.4) 34 (68) 14 (82.4) 2.0 0.36
Exercise 72 (55) 4 (57.1) 30 (52.6) 25 (50) 13 (76.5) 4.9 0.08
Medicat ions 27 (20.6) 1 (14.3) 7 (12.3) 12 (24) 7 (41.2) 8.1 0.017
*Denot es value “ F” for cont inuous variables, “ x2” for nominal variables.

Part II: Behaviours and attitude changes COX-2 inhibit ors

7%
by patients following asthma diagnosis Paracet amol No change
28 % 65 %
Cigaret t e smoking habit s
When t he general smoking habit s were asked, of all t he re-
spondent s 72. 5 % (n = 95) decl ared t hat t hey had never
smoked. The rest of t he pat ient s (n = 23, 17.6 %) had quit t ed
smoking, whereas 9. 9 % (n = 13) st ill cont inued smoking.
When asked specifi cally “ Did you quit cigaret t e smoking be-
cause of your ast hma diagnosis?” among 24 cases who were
smokers at t he t ime of ast hma diagnosis, 45.8 %(n = 11) re-
port ed quit t ing cigaret t e smoking because of ast hma diag-
nosis.

Infl uenza vaccinat ion and st rat egies f or prevent ion
f rom infl uenza
When asked “ What kind of behaviour changes have you done
against fl u infect ions aft er your ast hma diagnosis?” 31 %of
t he pat ient s (n = 46) report ed beign vaccinat ed regularly
against infl uenza. Regarding t he general recommended pro-
cedures for prevent ion of infl uenza (i.e.: vaccinat ion; wear-
ing mask; keeping away from infect ed people); 45 %(n = 59)
and 41.9 %(n = 55) of t he subj ect s had performed one or t wo
of t hese act ions, respect ively, whereas only seven subj ect s
(5.3 %) had performed all t hree.
Analgesic use
When pat ient s were asked “ Did you do any changes about
your analgesic pref erence af t er your ast hma diagnosis?”
85 pat ient s (64.9 %) report ed not t o have any analgesic pref-
erence, whereas t he remaining 46 cases (35 %) rest rict ed
t heir analgesic pref erence t o cert ain analgesics (Fig. 2).
Among t hose, 37 pat ient s (80 %) report ed t hat t hey preferred
paracet amol following ast hma diagnosis, while 9 (20 %) used
COX-2 inhibit ors. Among 37 pat ient s who pref er paracet a-
mol, 27 pat ient s (73 %) had analgesic int olerance (AI); t he
remaining 10 pat ient s (27 %) had no hist ory of aspirin and/ or
NSAID relat ed adverse ef f ect . Eight of nine pat ient s who
used COX-2 inhibit ors (meloxicam/ nimesulide) had AI and
used t hese drugs as t heir doct ors advised aft er negat ive oral
provocat ion t est s wit h t hese drugs.
Figure 2. Analgesic preference of t he pat ient s aft er ast hma
diagnosis.
Fact ors ef f ect ing behaviour and at t it ude changes
Regarding t he f act ors af f ect ing t he compliance of t he pa-
t ient s t o t he prevent ion measures; only higher educat ion
level was found t o be relat ed wit h bet t er compliance wit h
vaccinat ing against infl uenza (p = 0.017). Age, ast hma dura-
t ion and severit y, higher educat ion or having inf ormat ion
about ast hma were not relat ed wit h compliance t o ot her
prevent ion measures.
Part III
Inf ormat ion sources about ast hma
When asked, “ Where did you obt ain specifi c knowledge and
avoidance measures about ast hma including ast hma t rig-
gers?” (Doct ors, nurses, special books or brochures f or pa-
t i ent s wi t h ast hma, ast hma educat i on semi nar s web,
writ t en and visual media), t he maj orit y report ed t o be in-
formed about ast hma primarily by t heir physicians (n = 119;
90.8 %) (Fig. 3). Only four pat ient s declared t hat t hey were
not informed by any educat ional it ems relat ed t o t heir ast h-
ma. Thirt y-seven subj ect s (28.2 %) had part icipat ed in ast h-
ma educat ion seminars in our depart ment at least once.
126 Göksel Ö et al

100 t han previously report ed. 3 This discrepancy could part ly be

explained by female predominance of our st udy populat ion.
90
In our st udy, f emale subj ect s were inf luenced more f re-
80 quent ly by emot ional st ress t han males. Ot her t han emo-
t ional f act ors, exposure t o indoor pollut ant s and weat her
70 changes were also ot her signifi cant t riggers in our cases. We
60
may assume t hat as severe cases spend t oo much t ime in-
doors t hey are exposed more frequent ly t o indoor pollut ant s
%cases

50 and are more vulnerable t o at mospheric changes. Recogni-

t ion and management of t hese t riggering fact ors among pa-
40 t ient s wit h ast hma can be expect ed t o improve sympt oms
30 and qualit y of life. 15,16
In general, fewer t riggers were report ed in pat ient s who
20 were male, married, wit h cohabit ant s, and having a higher
educat ion. Moreover, higher severit y of ast hma was found t o
10 be associat ed wit h higher scores on a number of Ast hma
0 Trigger Invent ory subscales. 12 On t he cont rary, in our st udy,
we did not observe any difference in varying severit y degree
Do

Bo

Br

Se

In

Nu

M
ed
te
oc

of ast hma in gender and educat ional level wit h regard t o t he

ok
ct

rs
rn

i
in

es
hu
or

a
s

ar

et
s

number of t riggers. This observat ion could be a predict or of

r es

Figure 3. Information sources about triggers of the study group.
Discussion
Alt hough t he import ance of t he environment al t riggers on
ast hma management has been well described, t his issue for
adult pat ient s wit h ast hma seems t o be neglect ed. Empha-
sizing t his dat a, t his st udy showed t hat our group of female
predominant ast hma pat ient s are faced wit h several t rigger-
ing fact ors regardless of t he underlying severit y of t he dis-
ease. More import ant ly, prevent ive measures against some
modifi able t riggers were insuffi cient .
In t his st udy, t he degree of ast hma severit y of t he indi-
viduals seemed t o af f ect t riggering f act or pat t ern. In t his
sense, pat ient s wit h severe ast hma report ed t o be affect ed
more f requent ly by medicat ions such as aspirin and ot her
NSAIDs, emot ional st imulat ions and weat her changes t han
t he ot her severit y degrees. Aspirin and ot her NSAIDs hyper-
sensit ivit y have been report ed t o be more f requent in se-
vere persist ent ast hma pat ient s t han in mild t o moderat e
ast hma. 13,14 Our result s also confi rmed t his dat a. Emot ional
st imulat ion was report ed by more t han 80 % of t he severe
ast hma pat ient s as ast hma t rigger in our st udy. Rit z et al.
report ed t hat emot ional t riggering fact ors were signifi cant ly
associat ed wit h severit y of ast hma. 11 In t heir st udy, Rit z et
al. used short f orm 36 healt h survey quest ionnaire (SF 36)
and showed t hat only psychological fact ors explained unique
variance in t he SF-36 physical and ment al composit e scores,
and higher t rigger scores were associat ed wit h lower healt h
st at us. They al so demonst rat ed t hat pat ient s wit h more
f requent experience of psychological ast hma t riggers re-
present ed great er airway const rict ion t o emot ional f il m
present at ions in t he laborat ory condit ions. 11 In accordance
wit h t his fi nding, in our st udy group, presence of emot ional
f act ors was signifi cant ly higher in severe ast hma pat ient s
having more limit ed airway funct ions. However, we did not
analyse t he effect of t hese t riggers on daily life of t he pa-
t ient s.
On t he ot her hand, emot ional fact ors have signifi cant im-
port ance not only in severe cases but also in pat ient s wit h
mild t o moderat e ast hma, being over 60 %, which is higher
comparable pot ent ial f or t he development of ast hma epi-
sodes in all ast hma pat ient s wit h varying severit y. Toget her
wit h t he previous fi ndings which showed t hat t he severit y of
ast hma exacerbat ions was not rel at ed t o t he underl ying
severit y of chronic disease, 17 our fi ndings part icularly em-
phasize t he vulnerable part of all ast hma severit ies t o envi-
ronment al t riggers. However, our dat a does not provide
inf ormat ion about t he ef f ect of t hese t riggers on ast hma
out comes.
In t his st udy, t he secondary aim was t o evaluat e t he pre-
vent ive measures against maj or t riggers subj ect t o be modi-
fi ed by t he pat ient s. As previously st at ed, t ert iary allergen
avoidance was not evaluat ed as it is beyond t he scope of
t his st udy. First ly, regarding cigaret t e smoking habit s, t he
maj orit y of our cases never smoked. However, among t he
cases who were smoking at t he t ime of ast hma diagnosis,
only 45 %had quit t ed smoking aft er ast hma had been diag-
nosed. Int erest ingly, half of t he current smokers report ed
envi ronment al t obacco smoke as an ast hma t ri gger f or
t hemselves. Act ually t his dat a emphasize t hat even t hough
t he smoking rat e is below t he developed count ries’ smoking
rat ios, 18 smoking st ill seems t o be an import ant healt h prob-
lem for pat ient s wit h ast hma in our count ry. Physicians who
are dealing wit h ast hma should ask about act ive or passive
smoking as a part of rout ine checklist of nonspecifi c ast hma
t riggers especially, and be support ive t o quit smoking f or
t his part icular group of pat ient s. However, alt hough such in-
t ervent ions should defi nit ely include individual component s,
larger policy-level int ervent ions are oft en necessary as well.
We hope t hat t he new regulat ion in Turkey which bans smok-
ing in all f orms of public places (ef f ect ive af t er May 19,
2008) will be helpful in t his process. 19
The ot her maj or prevent ive measure it em was infl uenza
vaccinat ion. As pat ient s wit h ast hma are part icularly sus-
cept ible t o serious complicat ions from infl uenza, we regu-
larly advise our pat ient s wit h moderat e t o severe ast hma
t o t ake an infl uenza vaccinat ion every year as suggest ed by
int ernat ional guidelines. 1,2,20 But , despit e t he high rat io of
upper ai rway i nf ect i ons, i ncl udi ng common col d, as an
ast hma t ri gger i n accordance wi t h previ ous dat a, 21 we
showed t hat onl y 30 % of t he pat i ent s were vacci nat ed
against infl uenza regularly and only pat ient s wit h higher
Ast hma t riggers
educat ion level t ended t o be vaccinat ed. Fear of allergic
side effect s of vaccinat ion can part ly explain t his low rat e
of vaccinat ion, but economic reasons might also have con-
t ribut ed as reimbursement of t he vaccine was not of f ered
by t he healt h insurance syst em during t he st udy durat ion.
As a good progress in healt h syst em policy, t he Turkish gov-
ernment now provides free infl uenza vaccines t o risk groups
including ast hma, will be an aid t o cont rol ast hma at t acks
caused by infl uenza.
Regarding analgesic preference, t he maj orit y of our cases
(65 %) did not exhibit any analgesic pref erence because of
ast hma and t hey used any analgesics when indicat ed. The
remaining 46 cases (35 %) rest rict ed t heir analgesic prefer-
ence t o cert ain analgesics such as paracet amol (80 %) and
cyclooxygenase (COX)-II (20 %) inhibit ors. Avoidance of t he
use of aspirin and ot her NSAIDs is not recommended in pa-
t ient s wit h ast hma wit hout a hist ory of adverse event s t o
aspirin or ot her NSAIDs. 1,2 However, as an int erest ing piece
of dat a, 27 %of t he pat ient s who used paracet amol had no
hist ory of aspirin and/ or NSAID relat ed adverse effect . This
observat ion shows t hat t here is a t endency by Turkish physi-
cians t o prescribe paracet amol t o some ast hmat ics regard-
l ess of t he hi st or y of anal gesi c i nt ol er ance (AI) i n our
count ry. On t he ot her hand, in general, for cases wit h ast h-
ma and AI, a st ruct urally dif f erent drug f rom t he culprit
agent is recommended t o be prescribed aft er it s t olerabilit y
was assessed wit h a negat ive oral provocat ion t est s. 22,23 Sup-
port ing t his approach, COX-2 inhibit ors were advised in eight
pat ient s who had AI af t er a negat ive oral provocat ion t est
performed in our clinic.
Regarding t he f act ors ef f ect ing behaviour and at t it ude
changes in our part icular group of ast hma pat ient s, impor-
t ant l y, no f act ors incl uding higher educat ional l evel s or
knowledge levels seemed t o cause behavioural change. The
maj orit y of our group had been educat ed about ast hma
eit her by t heir physicians or by ot her sources. However, it is
well document ed t hat knowledge alone does not change be-
haviour. 24 According t o t he t heory proposed by Bandura,
people can learn t hrough observat ion via a live or a sym-
bolic model, and; int rinsic reinforcement such as pride, sat -
isfact ion, and a sense of accomplishment are import ant t o
learning and fi nally; learning does not necessarily lead t o a
change in behaviour. 24 In t his st udy, we observed t hat our
pat ient s were highly aware about t heir own t riggers, almost
all of t hem had been inf ormed about ast hma; almost one
t hird of t hem had part icipat ed in ast hma educat ion semi-
nars; however t heir applicat ions relat ing t o some maj or t rig-
gers were insuf fi cient according t o Bandura’s t heory. This
fi nding indicat es t he need f or a dif f erent approach in t he
management of t his issue.
In t his sense, an ideal educat ion syst em has been suggest -
ed t o be st ruct ured, individualized, be support ive f or pa-
t ient ’s self -ef fi cacy (our belief in our abilit y t o succeed in
speci f i c si t uat i ons), and shoul d be repeat ed i n cert ai n
periods. 1, 2, 25-28 Alt hough having knowledge does not always
lead t o a change in behaviour; it should be kept in mind,
knowledge might have an indirect effect on ast hma manage-
ment t hrough pat ient s’ abilit y t o adapt t o t he disease. It has
been shown t hat an appropriat e educat ional programme
leads t o bet t er awareness of ast hma by pat ient s25 and can
reduce t he number of home t riggers f or ast hma even f or
low-income communit ies. 29
127
The current st udy has a number of limit at ions. First ly; re-
garding it s self -report ed nat ure, all defi nit ions of t riggers
were open t o percept ion of t he pat ient s. Secondl y; t he
cross-sect ional design cannot imply causalit y and caused a
skewed populat ion in t erms of gender in t his st udy. Owing t o
t his, we t ried t o make our comment in t he light of our group
charact erist ics. Our previous t rials showed t hat t here was a
female predominance in ast hma cases not only in our clinic
but also in ot her part s of Turkey14,30-32 and t his pat t ern is also
an expect ed fi nding for ot her nat ionalit ies. 33,34 Thirdly; since
t he Ast hma Cont rol Test suggest ed by current guidelines in
t he management of ast hma had not been validat ed in our
count ry when we performed t his st udy, we could not include
such an invest igat ion in our st udy mat erials. Inst ead, we
used t he severit y of chronic ast hma as a predict or of under-
lying degree of t he disease.
In conclusion; in t he present st udy, we showed t hat pre-
dominant ly female adult pat ient s wit h ast hma had several
ast hma t riggers which can cause ast hma episodes and t his
feat ure is independent from underlying severit y of ast hma.
Pat ient s wit h severe ast hma represent ed a special t riggering
pat t ern; f emale cases were more vulnerable t o emot ional
t riggers t han males. Our result s also confi rmed t hat compli-
ance t o t he modifi able maj or prevent ion act ivit ies was sig-
ni f i cant l y i nsuf f i ci ent and needs t o be i mpr oved. New
st rat egies t o improve t he awareness of t he ast hma pat ient s
t o t heir own t riggers and compliance t o prevent ive meas-
ures against modifi able fact ors, which are also support ed by
healt h syst em policies when necessary, are needed. This ap-
proach might prevent ast hma at t acks caused by modifi able
t riggers.
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Appendix 1. Ast hma Triggers Quest ionnaire

Please indicat e t hat ; which one of t hese t riggering fact ors below causes worsening
in your ast hma? You can signal more t han one t riggering fact or.

1. Out door air pollut ion (exhaust fumes, ot her harmful gases in t he at mosphere et c)
2. Indoor air pollut ion (heat ing devices such as: gas-st oves, fi re places,
wood-st oves, et c)
3. Cigaret t e smoke
4. Act ive cigaret t e smoking by yourself
5. Weat her changes (hot air, cold air, severe humidit y in t he air et c)
6. St rong scent s (cooking smells, room sprays, smell of det ergent s, perfumes et c)
7. Emot ional st imulat ion (feeling sadness, st ress/ anxiet y)
8. Upper airway infect ions (having a cold, fl u et c)
9. Exercise (walking, swimming, running, bicycles et c)
10. Medicat ions (aspirin, ot her NSAID, ACE inhibit ors, Bet a blockers et c)