Clinical Characteristics of Bronchial Asthma Amongst a Sample of Patients in South West Nigeria Jumbo J 1,Ikuabe PO 1, Dinyain VE 2 1 Department of Internal Medicine, 2 Department of Oral and Maxillofacial Surgery, Niger Delta University, Wilberforce Island, Bayelsa State, Nigeria Corresponding Author: Dr Johnbull Jumbo E-mail: johnbulljumbo@gmail.com Niger Delta Medical Journal, February 2015; 1 (1): 46-51 ABSTRACT Background Asthma is a major cause of morbidity and mortality in both developing and the developed world. Common symptoms of asthma include wheezing, chest tightness, dyspnoea and cough. The characteristics of these symptoms which are variable, often paroxysmal and provoked by allergic or non-allergic stimuli are useful in diagnosis. Objectives The present study seeks to determine some of the factors which might be of importance in the precipitation of asthmatic attacks as well as symptoms profile among a sample of patients in South West Nigeria. Methods It was a cross sectional analytical study in which patients with spirometric evidence of bronchial asthma were recruited consecutively from the outpatient clinics of Obafemi Awolowo University Teaching Hospital Complex (OAUTHC), Ile-Ife between October, 2009-January, 2011. A modified form of the Medical Research Council (MRC) Chronic Respiratory Questionnaire was used to record information on socio- demographic data, clinical history and examination findings of each patient. Results A total of sixty five patients who fulfilled the inclusion criteria were recruited into the study. Thirty eight (58.5%) were females and 27(41.5%) were males. Twenty seven (41.5%) subjects had no family history, while 16 (24.6%) and 12 (18.5%) had maternal and paternal family history respectively. Cough was the most common symptom presenting in 54, (83%) of the patients followed by breathlessness presenting in 52, (80%) of the respondents. Exposure to dust was the commonest trigger factor, among the respondents occurring in 61 (94%). This was closely followed by fumes and smoke exposure occurring in 55 (85%) of the respondents. Conclusion This study revealed that cough, breathlessness, wheeze and chest tightness, and positive family history of asthma and atopy were common but in varying degrees among the study subjects. Also in this study, dust and fumes were found to be the commonest trigger factors of asthma among the patients. Key words: Clinical Characteristics, Bronchial Asthma, South West, Nigeria. Nig Del Med J 2015;1(1): 46-51 page 46
INTRODUCTON Bronchial asthma is a chronic inflammatory condition that affects about 300 million people world-wide.. 1 It is a major cause of morbidity and mortality in both developing and the developed world. There is a rising incidence in developing countries, probably due to higher level of atopic sensitization due to rapid urbanization of the rural areas and exposure to air pollution. Urbanization rate is projected to grow from 42% to 59% by 2025, with a concomitant rise in the number of asthmatics to 100 million over the same period.1. Asthma accounts for one in every 250 deaths worldwide and 1% of all disability adjusted life years 2. Common symptoms of asthma include wheezing, chest tightness, dyspnoea and cough. The characteristics of these symptoms which are variable, often paroxysmal and provoked by allergic or non-allergic stimuli are useful in diagnosis. The complete causes of asthma are unknown. Hereditary plays a role as well as allergens and environmental factors. Atopy, the genetic predisposition for the development of an 1gE mediated response to common aeroallergens is the strongest identifiable factor for developing asthma 3. While medications play an essential role in the management of asthma, appropriate management of asthma involves much more: identifying and avoiding allergens and other asthma triggers; symptoms profile and frequency of attacks. The present study seeks to determine some of the factors which might be of importance in the etiology and precipitation of asthmatic attacks as well as symptoms profile among a sample of patients in South West Nigeria. It is hoped that knowledge of these factors will contribute towards better understanding of asthma and its rational management. METHODOLOGY This study was carried out in the Medical clinics/wards of Obafemi Awolowo University Teaching Hospitals Complex (OAUTHC) located in Ile-lfe, a suburban town in South Western Nigeria. This hospital combines primary, secondary and tertiary health care delivery services. It was a cross sectional study in which consecutive asthmatics were recruited. Patients with bronchial asthma were recruited consecutively from the outpatient clinics of OAUTHC, Ile-Ife and Wesley Guild Hospital, llesa. A modified form of the Medical Research Council (MRC) Chronic Respiratory Questionnaire was used to record information on socio- demographic data, clinical history, examination findings and lung function parameters of each patient. Patients with spirometric evidence of asthma 4, without acute exacerbations of asthma in the prior 4 weeks, and aged 16-55 years were included. All asthmatics who have co-morbid conditions like hypertensive heart failure and COPD, patients with uncertain diagnosis of asthma and patients with acute severe asthma were excluded. A modified form of the Medical Research Council (MRC) Chronic Respiratory Questionnaire and a pro-forma was used to record information on socio- demographic data, clinical history and examination findings of each patient. Data obtained were analyzed with a statistical computer software, Statistical Package for Social Sciences (SPSS) version 15.0, the socio demographic data of the patients collected using Medical Research Council (MRC) questionnaires were summarized. Categorical variables were expressed as percentages. Ethical clearance was sought and obtained from the Ethical Clearance Committee of the OAUTHC and informed consent was obtained from all the subjects included in the study. Nig Del Med J 2015;1(1): 46-51 page 47
RESULTS A total of sixty five patients who fulfilled the inclusion criteria were recruited into the study. Socio demographic characteristics of the patients who participated in the study are shown below in Table 1. Twenty five (38.5%) of the subjects were between 21-30 years age group. Females constituted 38 (58.5%) of the study subjects while 27 (41.5%) were males. TABLE 1: SOCIODEMOGRAPHIC HEALTH CHARACTERISTICS OF THE SUBJECTS Variables Age (years) Frequency n=65 <21 8 12.3 21-30 25 38.5 31-40 14 21.5 41-50 12 18.5 51 6 9.2 and above Educational Status Primary 9 13.8 Secondary 16 24.6 Post-secondary 40 61.6 Sex Male 27 41.5 Female 38 58.5 Occupation Civil servant 23 35.4 Traders 6 9.2 Schooling 28 43.1 Artisan 2 3.1 Farming 3 4.6 Unemployed 3 4.6 BMI (Kg/Metre 2 ) <18 19 29.2 18-24.9 26 40.0 25 and above 20 30.8 Percentage(%) Table 2 shows the symptom profile among the respondents. Cough ranked top 54 (83.1%) among the common symptoms these patients frequently had. Breathlessness was present in 52 (80.0%) of them. Forty six (70.8%) developed chest tightness among others. TABLE 2: SYMPTOM PROFILE AMONG THE ASTHMATIC SUBJECTS Symptom Frequency Percentage (%) n = 65 Cough Breathlessness Wheeze Chest tightness Chest pains Others(catarrh, fever etc) 54 52 51 46 27 13 83.1 80.0 78.5 70.8 41.5 20.0 Table 3 shows the presence of family history of asthma and atopy among the subjects. Twenty seven (41.5%) subjects had no family history, while 16 (24.6%) and 12 (18.5%) had maternal and paternal family history respectively. TABLE 3: FAMILY HISTORY OF ASTHMA AND ATOPY Family history of Frequency Percentage (%) atopy and asthma n=65 None Mother Father Siblings Others(mother and siblings, father and siblings 27 16 12 5 5 41.5 24.6 18.5 7.7 7.7 The common triggers factors, among the subjects are shown in table 4. Exposure to dust was the commonest trigger factor, 61 (94%) among the respondents. This was closely followed by fumes and smoke exposure, 55 (85%). Use of NSAIDs as a precipitant was present in 9 (14%) of the subjects. Figure 1 (Pie Chart) showing the average frequency of attacks among the asthmatic subjects. Twenty three subjects (35.4%) had attacks on the average of once a week while 20 (30.8%) had attacks on the average of once a month. Nig Del Med J 2015;1(1): 46-51 page 48
TABLE 4: COMMON TRIGGER FACTORS AMONG THE SUBJECTS Trigger Frequency Percent (%) Dust 61 93.8 Fumes / 55 84.6 smoke Dry weather 34 52.3 Cold weather 50 76.9 Pollen 17 26.2 URTI 30 46.2 NSAID 9 13.8 Perfume 30 46.2 Paint 35 53.8 Emotions 21 32.2 Animal dander 15 23.1 URTI- Upper Respiratory Tract Infection NSAIDs- Non-Steroidal Anti-Inflammatory Drugs 24.6% 9.2% 30.8% 35.4% Once a week Once a month Once a year Once in two years Figure 1: Frequency (%) of asthmatic attacks among the subjects. DISCUSSION In this study bronchial asthma was found to be commoner among the females, 38 (58.5%) of the respondents were found to be females. This was similar to a previous study on bronchial asthma which showed it to be commoner among the females 5.During childhood, asthma was found to be more prevalent in males 6-7. This however reverses in adulthood after initially approaching similar proportion in adolescence. It is thought that hormonal influence which start at menarche accounts for the increase in asthma onset and severity among adult females 8-9. It has been hypothesized that sex hormones appear to modulate airway tone 10 as inflammation is enhanced in some women during the menstrual cycle and during pregnancy but relieved in others. The reason for this is yet to be established. This study showed the common triggers of asthma among the subjects. Exposure to dust, fumes and smoke constituted the commonest triggers among the subjects. This finding is similar to previous work done by Erhabor et al 11 who found out that strong smells, fumes and house-dust mite constitute some of the commonest trigger factors for asthma. Perfumes and fragrances constituted a known trigger in 46% of the subjects. In a study done by Millqvist et al 12, exposure to these aromas was found to be associated with chest tightness and wheezing in 20.7% of asthmatic patients, and asthma exacerbations in 26%, 17% and 8% of patients with severe, moderate and mild asthma respectively. In this study, Upper Respiratory Tract Infection (URTI) constituted a known trigger in 46% of the subjects. This figure is however, lower than the one reported by Gbadero et al 13 among paediatric age group which showed that viral infection constituted trigger in 58% of the subjects among urban Nigerian children. This is understandable in view of the fact that URTI is a major trigger factor in paediatric age group 13. A possible explanation of how URTI precipitates an attack of asthma is that the mucosal inflammation associated with URTI results in airway smooth muscle contraction secondary to mediators release from inflammatory cell 14. The reasons for the exaggerated response of asthmatic airways Nig Del Med J 2015;1(1): 46-51 page 49
are not completely understood, but a study has identified a deficient epithelial type I interferon response as an important susceptibility mechanism for viral infection 15. In this study, emotion was found to be a trigger factor for asthma in 32% of the respondents. This is similar to the findings of Mosaku et al 16 in their study of the relationship between asthma and psychological factors in 100 asthmatics using 30-item version general health questionnaire. They found out that 36% of the patients had psychopathology. Psychosocial variable significantly associated with asthma include worrying, crying, fighting, anger, mental tension and menstruation. Hyperventilation provoked by anxiety is common in asthmatics and can lead to a vicious cycle, the hyperventilation causing bronchoconstriction as a result of hypocapnia and airway drying, which is then followed by an increase in anxiety. 17 This study also stated the symptom profile among the subjects. This study showed that the cardinal symptoms of bronchial asthma were cough, breathlessness, wheeze and chest tightness. Breathlessness, chest tightness, and cough have been highlighted as prominent presenting symptoms of asthma in several studies. 18,19 Asthma aggregates within families and is a complex multi-factorial disease with the involvement of environment and genetic components. Parental history of asthma and atopic dermatitis may contribute to severe exacerbation of asthma. This study showed that 43.1% of respondents had a family history of asthma or atopy in either parents, while 15.4% had a positive family history in their siblings or other relations. The positive family history of asthma is in keeping with findings of other studies. 20,21. LIMITATION This study is limited because it is a hospitalbased study so may not be representative of all the asthmatics in the general population. A community-based study would have added value to the findings. CONCLUSIONS This study revealed that clinical characteristic of cough, breathlessness, wheeze and chest tightness, and positive family history of asthma and atopy are common but in varying degrees among the study subjects. Also in this study, dust and fumes were found to be the common trigger factors among the patients. ACKNOLEDGEMENT The authors wish to thank all members of the Respiratory Unit, of the Department of Medicine, OAUTHC, Ile-Ife where this work was carried out for all their efforts, time and assistance. Our special thanks go to Prof GE Erhabor who is the head of the unit. We thank all the subjects that participated in this study for their cooperation. REFERENCES 1. Smith OH, Malore DG, Lawson KA, Okamoto LJ, Battista C, Saunders WB. A national estimate of the economic cost of asthma. Am J. Respir Crit Care Med 1997; 156: 787-793. 2. Masoli M, Fabian D, Holt S, Beasley R. The global burden of asthma: Executive summary of the GINA Dissemination Committee Report. Allergy 2004; 59: 469-78. 3. Ninan TK and Russell G. Respiratory symptoms and atopy in Aberden school children: evidence from two surveys 25 years apart. BMJ 1992; 304:873-5. Nig Del Med J 2015;1(1): 46-51 page 50
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