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Air pollution is a well known public health problem that involves both long-term and acute effects. An outcome associated with traffic-related air pollution is respiratory illness. Many studies have described the relationship between asthmatic symptoms and traffic-related air pollution; however, few have investigated the potential of air pollution to cause asthma itself, especially among adults. The overall aim of this thesis was to study the relationship between vehicle exhaust levels at home and the prevalence of self-reported annoyance and asthmatic symptoms, and the incidence of asthma and rhinitis. These relationships were evaluated using different indicators of exposure with a high spatial resolution. Three different data sets were used for the four papers included in this thesis. The first paper (paper I) is based on a questionnaire that was sent to a random selection of the adult population within three Swedish cities (Gothenburg, Uppsala, and Umeå) as part of the Swedish Environmental Protection Agency’s health-related environmental monitoring. The aim was to study the degree of self-reported annoyance and the prevalence of asthmatic symptoms in relation to the levels of vehicle exhaust outside the home. The level of exposure was described using modeled levels of nitrogen dioxide (NO2) as the exposure indicator. The second paper (paper II) is based on new asthma cases identified within the Obstructive Lung disease In Northern Sweden (OLIN) study, each with a matched referent. The aim of this study was to analyze if new cases of asthma had higher levels of vehicle exhaust outside the home compared to the population controls. Exposure was assessed using both measured levels of NO2 outside each home, and by summarizing the amount of traffic within a 200 metre buffer surrounding each participant’s home. Papers III and IV were based on the Respiratory Health in Northern Europe (RHINE) Cohort, a prospective cohort of adults included in 1990 and followed up with in 1999. The proportion of new cases of asthma (papers III and IV) and rhinitis (paper IV) were identified based on the answers from the initial and follow-up questionnaires. In paper III, exposure was assessed by using meteorological dispersion models to calculate the levels of NO2 outside each home as an indicator of the levels of vehicle exhaust. As an alternative indicator, the distance from each participant’s home to the nearest major road was calculated using geographical information system (GIS) tools. The exposure assessment in paper IV was also based on meteorological dispersion models, but expressed the levels of vehicle exhaust as particle mass concentration. The results show that the levels of vehicle exhaust outside the home are significantly correlated with the degree of self-reported annoyance and the prevalence of asthmatic symptoms, and also with the risk of developing asthma, but not rhinitis, among adults. The odds ratio (OR) for high annoyance to vehicle exhaust and reporting asthmatic symptoms was 1.14 (95% Confidence Interval, CI 1.11-1.18) and 1.04 (95% CI 1.01-1.07) per 1 µg/m3 increase in the NO2 level outside the home, respectively. Paper II showed there was a non-significant tendency for increased risk of developing asthma among those living with high levels of vehicle exhaust outside their home. This finding was then supported by papers III and IV, showing a significant relationship between the onset of asthma and the mean (winter) levels of NO2 outside the home (OR=1.46, 95% CI 1.07-1.99 per 10 µg/m3) and the levels of vehicle exhaust particles outside the home. In paper III, living close to a major road was significantly related to the risk of developing asthma. No significant results were shown between vehicle exhaust and rhinitis. In conclusion, vehicle exhaust outside the home is associated with the prevalence of annoyance and asthmatic symptoms, and with the risk of developing asthma, but not rhinitis, among adults.

This research project aims to provide insights into the psychobiology of personality of individuals living with chronic asthma to inform treatment planning. Personal experience in observing emotional and social difficulties in an asthmatic child over years and an article on the effects of asthma medication on the cognitive and psychosocial functioning of asthmatic learners raised awareness of the problem. Medical illnesses, acute and chronic, are often accompanied by a number of disease-related stressors or events that produce stress. Stress-induced changes in the nerve and immune system affect cognitive and emotional functioning that adversely affect personality development and significantly decrease the individual’s quality of life, particularly if sustained over a long period of time. This project followed a quantitative mode of enquiry, and personality profiles were compiled at hand of the 16-PF Questionnaire. The research sample consisted of 11 Afrikaans speaking, 18-year-old asthmatic individuals from the same school. Significantly meaningful characteristics associated with chronic asthma were identified, i.e., a highly tense temperament, accompanied by low resilience, subjective anxiety, low self-worth, as well as surgency or uninhibited behaviour, tempered by moderate spontaneity and warmness. It is envisioned that these insights might significantly inform planning of treatment regimes and lifestyle modification programmes. Stress relief might improve neuroendocrine and immune functioning, delay disease progression, and reduce morbidity and mortality. The focus is thus on a general stress-coping model in order to improve quality of life. / Dissertation (MEd (Educational Psychology))--University of Pretoria, 2007. / Educational Psychology / unrestricted

O propósito deste estudo é apresentar um plano de assistência médica à criança asmática da cidade de são Paulo, Brasil, o maior centro industrial da América do Sul. São apresentadas características clínicas e epidemiológicas dessa importante síndrome, que atualmente é considerada um dos principais problemas de Saúde Pública na infância. O projeto visa a assistência médica para uma estimativa de 300.000 crianças com asma em um sistema de Saúde Pública regionalizado, integrado e hierarquizado, usando recursos locais disponíveis de modo coordenado e eficiente. / The purpose of this study is to present a plan for medical assistence to asthmatic children living in São Paulo City, Brazil, the biggest industrial center of South America. Clinical and epidemiological characteristics are presented of this important syndrome which currently is considered one of the leading local public health problems in infancy. The plan covers the medical assistance to an estimated 300.000 children with asthma by a regionalized, integrated and hierarchic Public Health System, using available local resources in an efficient, coordinated way.

O propósito deste estudo é apresentar um plano de assistência médica à criança asmática da cidade de são Paulo, Brasil, o maior centro industrial da América do Sul. São apresentadas características clínicas e epidemiológicas dessa importante síndrome, que atualmente é considerada um dos principais problemas de Saúde Pública na infância. O projeto visa a assistência médica para uma estimativa de 300.000 crianças com asma em um sistema de Saúde Pública regionalizado, integrado e hierarquizado, usando recursos locais disponíveis de modo coordenado e eficiente. / The purpose of this study is to present a plan for medical assistence to asthmatic children living in São Paulo City, Brazil, the biggest industrial center of South America. Clinical and epidemiological characteristics are presented of this important syndrome which currently is considered one of the leading local public health problems in infancy. The plan covers the medical assistance to an estimated 300.000 children with asthma by a regionalized, integrated and hierarchic Public Health System, using available local resources in an efficient, coordinated way.

Many respiratory patients misuse their inhaler. Although training improves their inhaler technique, patients do forget the correct inhaler use with time. In the current work, three clinical studies investigated novel tools designed with feedback mechanisms to ensure patients use the correct inhalation method when using their inhaler. Research Ethics Committee approval was obtained and all the participants signed an informed consent form. In the first study, the recruited asthmatic children (n=17) and adults (n=39) had their metered dose inhaler (MDI) technique assessed. Those who attained the recommended inhalation flow rate (IFR) of < 90 l/min through their MDI formed the control group. Whilst those who had a poor MDI technique with an IFR ≥ 90 l/min were randomized into either the verbal counselling (VC) group; or the 2ToneTrainer (2TT) group that, in addition to the verbal training, received the 2ToneTrainer MDI technique training device equipped with an audible feedback mechanism of correct inhalation flow. All the participants were assessed on two occasions (6 weeks apart) for their inhalation flow rate, asthma control and quality of life. The study showed that the 2ToneTrainer tool was as efficient as verbal training in improving and maintaining the asthmatic patients' MDI technique, particularly using the recommended slow inhalation flow through the MDI. Although statistically insignificant, potential improvement in quality of life was demonstrated. The 2ToneTrainer tool has the advantage of being available to the patients all the time to use when they are in doubt of their MDI technique. In the second research study, the inhalation profiles of asthmatic children (n=58) and adults (n=63), and of COPD patients (n=63) were obtained when they inhaled through the novel Spiromax dry powder inhaler (DPI) which was connected to an electronic pressure change recorder. From these inspiratory profiles; the peak inhalation flow, inhalation volume and inhalation acceleration rate were determined. The variability (23%-58%) found in these inhalation profile parameters among various patient groups would be expected in all DPIs. The effect of the inhalation acceleration rates and volumes on dose emission characteristics from DPIs should be investigated. Attention, though, should be paid to the patients' realistic inhalation profile parameters, rather than the recommended Pharmacopoeial optimal inhalation standard condition, when evaluating the in-vitro performance of DPIs. Finally, in preschool asthmatic children, the routine use of the current AeroChamber Plus spacer (n=9) was compared with that of a novel version; the AeroChamber Plus with Flow-Vu spacer (n=10) over a 12-week period. The Flow-Vu spacer has a visual feedback indicator confirming inhalation and tight mask-face seal. The study showed that the new AeroChamber Plus with Flow-Vu spacer provided the same asthma control as the AeroChamber Plus in preschool children and maintained the same asthma-related quality of life of their parents. However, the parents preferred the new Flow-Vu spacer because its visual feedback indicator of inhalation reassured them that their asthmatic children did take their inhaled medication sufficiently.

Many respiratory patients misuse their inhaler. Although training improves their inhaler technique, patients do forget the correct inhaler use with time. In the current work, three clinical studies investigated novel tools designed with feedback mechanisms to ensure patients use the correct inhalation method when using their inhaler. Research Ethics Committee approval was obtained and all the participants signed an informed consent form. In the first study, the recruited asthmatic children (n=17) and adults (n=39) had their metered dose inhaler (MDI) technique assessed. Those who attained the recommended inhalation flow rate (IFR) of < 90 l/min through their MDI formed the control group. Whilst those who had a poor MDI technique with an IFR ¿ 90 l/min were randomized into either the verbal counselling (VC) group; or the 2ToneTrainer (2TT) group that, in addition to the verbal training, received the 2ToneTrainer MDI technique training device equipped with an audible feedback mechanism of correct inhalation flow. All the participants were assessed on two occasions (6 weeks apart) for their inhalation flow rate, asthma control and quality of life. The study showed that the 2ToneTrainer tool was as efficient as verbal training in improving and maintaining the asthmatic patients¿ MDI technique, particularly using the recommended slow inhalation flow through the MDI. Although statistically insignificant, potential improvement in quality of life was demonstrated. The 2ToneTrainer tool has the advantage of being available to the patients all the time to use when they are in doubt of their MDI technique. In the second research study, the inhalation profiles of asthmatic children (n=58) and adults (n=63), and of COPD patients (n=63) were obtained when they inhaled through the novel Spiromax dry powder inhaler (DPI) which was connected to an electronic pressure change recorder. From these inspiratory profiles; the peak inhalation flow, inhalation volume and inhalation acceleration rate were determined. The variability (23% - 58%) found in these inhalation profile parameters among various patient groups would be expected in all DPIs. The effect of the inhalation acceleration rates and volumes on dose emission characteristics from DPIs should be investigated. Attention, though, should be paid to the patients¿ realistic inhalation profile parameters, rather than the recommended Pharmacopoeial optimal inhalation standard condition, when evaluating the in-vitro performance of DPIs. Finally, in preschool asthmatic children, the routine use of the current AeroChamber Plus spacer (n=9) was compared with that of a novel version; the AeroChamber Plus with Flow-Vu spacer (n=10) over a 12-week period. The Flow-Vu spacer has a visual feedback indicator confirming inhalation and tight mask-face seal. The study showed that the new AeroChamber Plus with Flow-Vu spacer provided the same asthma control as the AeroChamber Plus in preschool children and maintained the same asthma-related quality of life of their parents. However, the parents preferred the new Flow-Vu spacer because its visual feedback indicator of inhalation reassured them that their asthmatic children did take their inhaled medication sufficiently.