Studying the status of asthma in students at primary and secondary schools in Thai Nguyen city and the effectiveness of controlling asthma with ICS + LABA

1

BACKGROUND
Bronchial asthma (AB) is a fairly common disease among
respiratory tract diseases in our country as well as many countries
around the world. Bronchial asthma (AB) is caused by many factors
and tend to increase gradually. According to the World Health
Organization 2004 (WHO), the world has more than 300 million
patients of Bronchial asthma. There are 6-8% of adults, over 10% of
children under 15 years old. It is to estimate that this number will
increase to 400 million in 2025.
The Western Pacific and South East Asia regions, the situation of
BA of children within 10 years (1984-1994) had increased
considerably, such as in Japan from 0.7% to 8%, Singapore from 50-
20%, Indonesia 2.3 to 9,8%, the Philippines from 6 to 18.8%. In Viet
Nam, the average rate of BA accounts for 5-6% of BA population, in
which, there are 5% in adults, 10% of children under 15 years old, and
it depends on regional changes and environmental pollution.
Recently, the prevention and treatment of BA complied with
instruction from the GINA (Global Initiative for Asthma) has achieved
good results. However, many research results have showed that the
control and treatment of BA is still to have shortcoming, many patients
diagnosed BA is only treated to stop BA without prophylactic treatment
of BA. Therefore, frequently BA recurrent attacks cause more severe
disease and take more cost for treatment of BA. It increases the rate of
emergency hospital admissions, and effect of BA treatment is not high.
In Thai Nguyen, there is not any research on this issue.
Therefore, we carry out this research with 3 following objectives:
1. To describe the status of pupils of primary schools and

secondary schools with bronchial asthma in Thai Nguyen city.
2. To identify some risk factors of BA for pupils of primary and
secondary schools in Thai Nguyen city.
3. To evaluate BA control effectiveness by ICS + LABA (Seretide)
for pupils of primary and secondary Schools in Thai Nguyen city



2

NOVEL CONTRIBUTIONS OF THE THESIS
Determination BA rate of pupils of primary schools and
secondary schools with bronchial asthma in Thai Nguyen city.
Identification of some risk factors of BA for pupils of primary
and secondary schools in Thai Nguyen city.
Giving evidences of positive effect of asthma control with ICS +
LABA (Seretide) in the community
Use of Peak flow meter to follow up changes of indexes of PEF
morning, PEF evening, variation of PEF morning and PEF evening in
the diagnosis and monitoring of asthma control in community.
Application of ACT scores to assess the results of asthma
control in community.

THE STRUCTURE OF THE THESIS
The main part of the thesis consists 107 pages. It includes the
following sections:
Introduction: 2 pages
Chapter 1 - Overview: 29 pages
Chapter 2 - Subjects and research methods: 22 pages
Chapter 3 - Outcomes of the study: 19 pages

Chapter 4 - Comments: 32 pages
Conclusions and Recommendations: 3 pages
The thesis has 35 tables, 7 charts and 129 literature references, of
which, there are 37 Vietnamese literature references, 92 English
references.


3

Chapter 1
OVERVIEW
1.1 Epidemiology of Bronchial Asthma
1.1.1 The circulation of Bronchial Asthma
Bronchial asthma (AB) is a chronic lung disease and the most
common disease in the world. BA happens in all ages and in all
countries. Within 20 years, the recent incidence is increasing more and
more, especially in children. The percentage of children with symptoms
of BA changes from 0 to 30%. It is depended on the survey in each
region in the world.
According to GINA 2004, the global percentage of BA are as
follows: 12 countries with rate of BA above 12%, 16 countries with
rate of BA from 8-12%, 23 countries with rates of BA between 5-8% ,
33 countries with rate of BA below 5%. High rate of BA focuses on
European countries such as Scotland, Giosey, Guosey, Wales, Isle of
Man, England, Newzeland and Australasia (Australia). Lowe rates of
BA are Russia, China, Anbania, Indonesia, Macao etc…
Asia - Pacific regions, recently, epidemiologists have studied
showed that the rates of BA of pupils at the 6-7 years old in Bangkok
increases from 11.0% in 1995 to 15.0% in 2001 and those in Chiang
Mai increase from 5.5% in 1995 to 7.8% in 2001.

The rates of BA of
pupils at the age of 13 and 14 in Chiang Mai increases from 12.7% in 1995
and 8.7% in 2001 and those in Bangkok increase from 13.5% in 1995 and
13.9% in 2001. Pupils at the 12-15 years old in Taiwan, the rate of BA
diagnosed physicians was 4.5% in 1995 and 6% in 2001 , in Singapore
from 1994 to 2001, the rate of asthma at the age from 12 to 15 increase
from 9.9 % to 11.9%. However, the rates of BA decrease from 16.6 to
10.2% at the age of 6 and 7. In Hong Kong, the group of the 13-14 years
old diagnosed asthma was 11.2% in 1995 and 10.2% in 2002. The rate of
asthma of Japanese children was 7.6%.


4

Vietnam is a country of Southeast Asia Region and has a
accelerated rate of BA in recent years. The rate of BA of children under
15 years old in some residential areas in Hanoi in 1998 was 2.7%.
Recent studies on the rate of BA of pupils at school age, the rate of BA
in Hai Phong in 2002 was 9.3%. BA percentage of pupils at school age
in urban and suburbs of Hanoi in 2005 was 10.42%. Studies of pupils at
some secondary schools in Ha Noi in 2003 and in 2006 were 10.3% and
8.74% consecutively.
1.1.2 The burden of Bronchial Asthma
The burden from BA is for not only patients, but also affects to
economics, well-being of families and the burden of the whole society.
For patients with negative health affects to study, work and work,
affects to quality of life and happiness for themselves and their
families, many cases are death or disability.
Study of AIRIAP in Asia and Pacific region, including Vietnam,

shows that proportion of patients leave school and leave of work in a
year is 30-32% (16-34% in Viet Nam) and the ratio of emergency
hospital admission is 34% (of which, that in Vietnam is 48%); patients
with insomnia in the four weeks was 47% (71% in Vietnam).
1.2 Risk factors of BA
Risk factors affecting bronchial asthma can be divided into two categories:
pathogenic factors of bronchial asthma and triggering factors the onset of
BA attack. The precise role of several factors is unclear. Some other
factors such as allergens are within two above types above. Pathogenic
factors of BA includes factor of subject (mainly genetic factors) and factors
causing BA attack are usually environmental factors.
Factors affecting development and expression
of Bronchial Asthma
- Subject factors
• Gene
- Gene creating atopy allergy
- Gene creating allergic increase response of the airway.
• Obesity


5

• Gender
- Environmental factors
• Allergens
- In the house: house dust, animal hairs (dog, cat, and mouse) and
allergens from cockroaches, mold, fungi, and spores.
- Outside the house: pollen, mold, fungi and spores.
• Infections (predominantly viral)
• Allergens from work

• Tobacco smoke: Passive and active
• Air pollution inside and outside of the house
• Diet
Mechanisms affecting development process and manifestation of
BA of factors are complex and they interact with each other. Many
multi-gene patterns related to susceptibility to asthma and allergies.
Complex interaction between genes and environment seem to play a
key role in formation of the disease.
1.3 Prophylactic treatment (control) of Bronchial Asthma (BA)
1.3.1 The aims of control treatment (prevention) of BA: According to
GINA 2006
- Gaining and maintaining control of symptoms of BA
- Maintaining normal activities, including to make efforts
- Upholding lung function as close as to normal lung function as
possible
- Preventing from a paroxysmal attack of BA
- Avoiding adverse effect of drugs used to treat BA
- To prevent deaths from BA
1.3.2 Treatment of control of Bronchial Asthma (BA)
Novel concepts in prophylaxis treatment of BA: Prophylactic
treatment of BA is mainly with mild and moderate types in
communities. Several and critical types of BA are treated in hospitals.
Drugs for the preventive treatment are used daily prolonged
medications to control of BA primarily through anti-inflammatory
effects of drugs.


6

Prophylaxis drug include glucocorticoid (ICS) for inhaling and

entire body, transformed drug leukotriene, Long Acting β
2
Agonist
combining with ICS, theophylline released slowly, Cromone, anti-IgE,
and treatments of symptoms of other entire body .
ICS is the sole drug inhibiting inflammation in a effective way.
ICS reduces the increase of reaction of the respiratory tract, controls
inflammation, relieves symptoms and paroxysmal attacks leading to
reduce needs of relieve medications. Today, ICS is recommended as the
first choice in controlling Bronchial Asthma.
Recent studies show that BA patients do not controlled by low or
high doses. Combination with LABA (Long Acting β
2
Agonist) has
more effective than increase of ICS dose. Effect of LABA is
bronchodilator for 12 hours and ICS is used twice per day. So, two
combinated drugs are well suited to control better clinical symptoms of
BA patients without increase ICS dose or maintain the control status of
BA symptoms when reduction of ICS dose.
1.3.3 Seretide is a medication of effective coordination in
prophylaxis treatment of Bronchial Asthma (BA)
Ingredients of Sertide composed of Salmeterol and Fluticasone
propionate. Salbutamol Contains Salmeterol (belonging to LABA
group ) and Fluticasone propionate (belonging to ICS group). Both
substances have effects on the various aspects of BA pathogenesis:
Salmeterol is to control symptoms, while Fluticasone propionate
prevents BA recurrent attacks by controlling inflammation.


7

Chapter 2
RESEARCH OBJECTS AND METHODOLOGY

2.4 Phương pháp nghiên cứu
2.1 Subjects of study
Pupils at primary and secondary schools (from 6 to 15 years old).
Parents or careers of pupils (in the case of pupils from 6 to 7 years old).
2.2 Duration of study: From October 2007 to October 2010.
2.3 Research location: Primary and secondary schools of Thai Nguyen city.
2.4 Research Methodology
2.4.1 Research of description: Design of cross-sectional descriptive
study to determine BA percentage of pupils at primary and secondary
schools in Thai Nguyen city in 2008.
Sample size: Applying the formula for sample size for described study

( )
2
2
2
1
d
pq
Zn
α
−
=

n is minimum number of pupils from 6 to 15 years old to research
Z

2
(1-

α/2)
: coefficient of confident limit (with α = 0,05, Z
2
(1-

α/2)
= 1,96)
p : ratio of pupils with BA estimated 10%
q = 1-p; d: desired error = 1%
Since then we have:
34579,0.1,0.
01,0
96,1
2
2
= pupils.
2.4.2 Research of disease symptom: Applying the formula for sample
size of disease symptom study to identify risk factors.
( )
( ) ( ) ( )
{
}
( )
2
21
2
2211)1(2/1

1112
pp
ppppZppZ
n
−
−+−+−
=
−−
βα

n is sample size needed in each group
α = 0,05 , Z
1-α/2
= 1,96, β = 0,2, Z
1-β
= 0,84


8

( ) ( )
75,0
1
.
22
2
1
=
−+
=

ppOR
pOR
p


67,0
2
21
=
+
=
pp
p

p
1
is the rate of exposure to risk factors of BA group
p
2
is the rate of exposure to risk factors in the control group
(about 60% of exposure to tobacco smoke without BA).
OR odds ratio expected is 2

(
)
(
)
(
)
}

{
( )
2
2
6,075,0
6,016,075,0175,084,067,0167,0.296,1
−
−+−+−
=n

Replacing the formula, we calculate 152 students
To fix BA groups/ control group is 1/2, we have a sample size to
study: BA group is 152 pupils and the control group is 304 pupils
(sampling rate at schools are 161 pupils of BA group and 322 pupils of
the control group).
2.4.3 Intervention study: formula for calculating sample size of
intervention.

(
)
(
)
( )
2
21
2211
2
),(
11
pp

pppp
Zn
−
−
+
−
=
βα

n is the minimum sample size to calculate
α is statistical significance and probability of a error type 2. it is
estimated 0.01.
Z
2
is looked up the table of value with α= 0,01, β = 0.1;
( )
9,14
2
,
=
βα
Z
β is probability of a error type 2. It is estimated 0.01.
p
1
is the rate of patients estimated asthma control of pretreatment. It is
estimated 30%
p
2
is proportion of patients estimated after treatment. Estimation is 30%

(
)
(
)
( )
2
3,005,0
3,013,005,0105,0
9,14
−
−
+
−
=n



9

- From then, it is calculated n = 61 (estimated 10% give up, n
chosen is 68).
2.5 The studied criteria
- The group of criteria on the status of BA
- The group of criteria on risk factors
- The group of criteria on intervention effect
+ Assessing effectiveness of asthma control according to GINA criteria
+ Assessing the effectiveness of BA control according to tools of
assessment of asthma controlling ACT (Asthma Control Test), the
acceptance of patients.

2.6 Diagnostic criteria of Bronchial Asthma (BA) according to
GINA 2004.
2.7 Methods and techniques of data collection
Collecting screened information through forms of surveys: All
pupils (or parents) are given a questionnaire and instructed answer to
questions (Appendix 1).
Interview, examination, measurement of respiratory function:
pupils, having one of six questions to be answered “yes”, are invited to
visit medical doctor, asked disease history, measurement of respiratory
function (PEF) to diagnose BA (the Appendix 2).
Những học sinh ở nhóm nghiên cứu bệnh chứng ñược phỏng vấn
theo phiếu ñiều tra (phụ lục 3 và 4).
Những bệnh nhân can thiệp: Khám làm bệnh án, khám lại sau 2
tuần, 4 tuần, 8 tuần, 12 tuần (phụ lục 5).
Pupils in the disease group were interviewed by questionnaire
(Appendix 3 and 4).
The patients of intervention: Take medical records and re- examine
after 2 weeks, 4 weeks, 8 weeks and 12 weeks (Appendix 5).
2.8 Data processing
Analysis and data processing by in medical statistical methods using
the software of Epi-Info 6.04 and SPSS 13.0 version.


10

Chapter 3
RESULTS OF STUDY
3.1 Percentage of Bronchial Asthma (BA)
Table 3.1 Percentage of Bronchial Asthma (BA) by gender: Number
of questionnaires forms distributed are 4329 and these collected are 4329.

There are 4292 questionnaires forms full enough information processed.
Overall morbidity rate was 9.5%. The rate of BA in boy pupils is 10.4%
and is higher than that girl pupils (8.6%) with p <0.05.
Table 3.2 Percentage of Bronchial Asthma (BA) by age: The rate of
BA of the groups of 6-10 yeas old and the 11-15 years old group are
10.1% and 9.0% (p> 0.05) consecutively.
Table 3.3 The rate of asthma according to asthma status
The rates of BA at level 1, level 2, level 3 are 66.7%, 20.8% and 12.5%
consecutively.
Table 3.6 Knowledge of patients with BA on BA control and BA
control status: Rates of patients knowing drugs cutting BA attacks, BA
being a disease able to be controlled are 64.9% and 3.4% consecutively.
The rate of patients has been treated control by physicians is 1.9%.
18,8
4,8
74,1
29,4
84,3
49
38,5
15,4
0
10
20
30
40
50
60
70
80

90
Asthma level 1 Asthma level 2 Asthma level 3 General
Rate of patients off shool Rate of patients admitted ICU

Figure 3.2 The rate of pupils being off school and admitted ICU due to
asthma in last year
3.2 Some risk factors cause Bronchial Asthma (BA)
Table 3.8 Family history has persons with BA


11

Status of BA


Family history
BA
(n=161)
Without
BA
(n=322)
OR 95% CI p
With BA 64 25
Without BA 97 297
7.84 4.55-13.59 <0.05
Table 3.9 Family history has persons with allergy
Status of BA


Family history

BA
(n=161)
Without
(n=322) OR 95% CI p
With allergy 49 47
Without allergy 112 275
2.56 1.58-4.15 <0.05

Table 3.10 History of patients with allergy
Status

History of
patients
BA
(n=161)
Without
BA
(n=322)
OR 95% CI p
With allergy
95 48
Without allergy
66 274
8.22 5.18-13.07 <0.05

Table 3.11 History of pupils with allergic rhinitis (AR)
Status

History of patients

BA
(n=161)
Without
BA
(n=322)
OR 95% CI p
With AR 99 30
Without AR 62 292
15.54 9.25-26.25 <0.05

Table 3.12 Factors causing the onset of BA
Frequency

Factors causing BA
n (161) Frequency
- Inflammation of respiratory system 128 79.5
- Change of weather 124 77.0
- Allergens 122 75.8
- Tobacco smoke, coal smoke, smoke of
factory
103 64.0
- Making in effort 78 48.4


12

- Tar odor substances: aromatic oils, paint 30 18.6
- Removers and washing substances with smelly 22 13.7

- Medication 11 6.8
Table 3.13 Allergens causing onset of BA attacks: Allergens causing
onset of BA attack: house dusts (34.8%) and animal hairs (30.4%)
account for high percentage.
3.3 Effect of BA control with ICS + LABA HPQ (seretide):
Through studying 68 patients with BA together with 12-week
intervention with ICS + LABA, we obtain following results:
3.3.1 Characteristics of studied subjects
Table 3.14 General characteristics of studied subjects

Rate
Characteristics
n (68) Ratio %
Boys 45 66.2 Sex
Girls 23 33.8
6-10 43 63.2
11-15 25 36.8
Age
Age in average (years) 9.8 ± 2.4
Height in average (meter) 1.3 ± 0.14
< 5 year 33 48.5
≥ 5 year 35 51.5
Age of BA
Age of BA in average (year) 4.6 ± 2.2
3 33 48.5 BA level
2 35 51.5

3.3.3 Effects of interventions
Table 3.17 Percentage of patients with the symptoms within days
after treated days

Before treatment, there are 100% of patients manifesting symptoms in
the days from both BA levels. After 2 weeks and 4 weeks of treatment,


13

symptoms of those patients decrease 39, 7% and 91.2% consecutively.
The difference is statistically significant with p <0.05.
Table 3.18 Number of days with symptoms in average per patient

Point of time

BA level
Pretreatment
(
)
SDX ±
(1)
After 2
weeks
(
)
SDX ±
(2)
After 4 weeks
(
)
SDX ±
(3)
Changes

(1&2)
p
1&2
Leve 2 (n=35) 9.0 ± 1.8 1.0 ± 1.5 0 8.0 < 0.05
Leve 3 (n=33) 13.3 ± 3.4 4.5 ± 2.5 0.5 ± 1.1 8.8 < 0.05
Total (68) 11.1 ± 3.4 2.7 ± 2.7 0.2 ± 0.8 8.4 < 0.05

Table 3.19 Percentage of BA patients with symptoms at the night
after treatment
Pretreatment of BA, after two weeks and 4 weeks, there are 69.1%,
27.9 % and not any patients having symptoms at night consecutively.
The difference is statistically significant with p<0.05.
Table 3.20 Average number of nights with symptoms per patient
Point of time

BA level
Pretreatment
(
)
SDX ±

After 2
weeks
(
)
SDX ±

After 2
weeks

Chan
ges
p
BA level2 (n=35) 1.5 ± 1.9 0.1 ± 0.2 0 1.4 <0.05
BA level3 (n=33) 5.2 ± 2.5 0.9 ± 1.1 0 4.3 <0.05
Total (n =68 ) 3.3 ± 2.9 0.5 ± 0.9 0 2.8 <0.05

Table 3.21 The percentage of patients using drugs to cut BA attacks
Before treatment, 100% of patients have to use drugs for cutting BA
attacks, after 2 weeks and 4 weeks, there are 52.9% and after 4 weeks
of treatment , there are not any patient taking medicine to cut BA
attacks with p <0.05.
Table 3.22 Average number of medicine used to cut BA attack per
patient per day


14

Point of time
BA level
Pretreatment
(
)
SDX±

After 2
weeks
(
)
SDX ±

After 4
weeks
(
)
SDX ±

Chan
ges
p
BA level 2 (n=35) 0.51 ± 0.14 0.03 ± 0.04

0 0.48 <0.05
BA level 3 (n=33) 0.89 ± 0.25 0.16 ± 0.12 0 0.73 <0.05
Total (n=68) 0.69 ± 0.28 0.09 ± 0.11

0 0.6 <0.05
63,2
48,5
13,6
22,1
0
0
0
0
0
0
10
20
30

40
50
60
70
Pretreatement After 2 weeks After 4 weeks
Rate affecting
physical body
Rate pupils school
off
Rate of pupils
admitted ICU

Figure 3.4 The rate of pupils affecting physical body, off school,
admission to ICU before and after 4 weeks of treatment
95,8
91,987,3
75,7
101,3
113,5109,7106,2
105,7
104,2
0
20
40
60
80
100
120
Pretreatment After 2 weeks of
Treament

After 4 weeks of
treament
After 8 weeks of
treament
After 12 weeks of
treament
PEF morning index PEF evening index

Figure 3.5 Changes of PEF morning - evening indexes
before and after treatment



15

Table 3.25 Changes of PEF morning - evening indexes
BAlevel
Time

BA level 2
(
)
SDX ±

BA level 3
(
)
SDX±

General

(
)
SDX ±

Change
(L/minute)

Start n=68)(1) 187.1 ± 44.4 151.5 ± 38.3 169.9 ± 44.9


After 2h(n=68)(2) 205.4 ± 48.8 186.4 ± 46.6 196.2 ± 48.3 26.3
After 4h (n=68)(3) 215.4± 50.5 196.7 ± 48.9 206.3 ± 50.3 36.4
After 8h (n=68)(4) 224.0 ± 53.1 206.7 ± 54.4 215.6 ± 54.0 45.7
After12h(n=68)(5) 235.1 ± 55.6 219.7 ± 57.1 227,7 ± 56.5 57.8
Table 3.27 Changes of number value of PEF Morning - evening
indexes before and after treatment

After 2 weeks, 2 weeks and 8 weeks of treatment, PEF index
increases slowly and after 12 weeks of treatment, PEF index increases
20.6 l per minute
Table 3.28 Variation of PEF morning - evening before and after
treatment
Before treatment, variation of PEF morning and night indexes is 27.6%.
After 2 weeks and 4 weeks of treatment, PEF variation decreases
rapidly. After 12 weeks of treatment, PEF variation is 10.8%. It is
statistically significant with p <0.05.
27,9
29,4
42,7
0

5,9
94,1
4,4
0
95,6
1,5 0
98,5
0
10
20
30
40
50
60
70
80
90
100
Sau ñiều trị 2 tuần After 4 weeks of
treatment
After 8 weeks of
treatment
After 12 weeks of
treatment
Without antibiotics
A part of antibiotics
Control

Figure 3.7 Effect of BA control after treatment

16

Table 3.30 Effect of BA control via ACT Score
ACT

Times
<20 points ≥ 20 and <25 ≥ 25 points
After 4 weeks 4 (5.9%) 64 (94.1%) 0
After 8 weeks 3 (4.4%) 46 (67.7%) 19 (27.9%)
After 12 weeks 1 (1.5%) 7 (10.3%) 60 (88.2%)
Table 3.31 The number of asthma exacerbation attack during 12
weeks of treatment: After 12 weeks, there are 5.9% of patients with
one recurrent asthma of Bronchial Asthma.
Table 3.34 The acceptance of patients for prophylactic medications:
94.1% of patients evaluating a very effective drug, 100% of patients say
that drugs are to be easy to use and convenient, 85.3% of patients are
accepted price. 14.7% of patients say that drugs are expensive. 95.6%
of patients respond that the preventional price is cheaper than therapy.
95.6% of patients feel assuring treatment.
Table 3:35 The compliance of patients in treatment: 100% of
patients changing lifestyle behaviors, avoiding risk factors causing
asthma, 91.2% of patients with full dose spray 100%.

Chapter 4
DISCUSSION
4.1. Status of Bronchial Asthma (BA)
Through screening 4292 pupils at primary and secondary schools
in Thai Nguyen city, the rate of BA is 9.5%. Of which, the rate of BA

in male pupils is 10.4% and is higher than that of female pupils (8.6%)
(p<0.05). The rates of BA of the pupil groups of 6-10 years old and 11 -
15 years old are 10.1% and 9.0% (p> 0.05) consecutively. Relatively
high morbidity rate herein reflects status of BA increasing in Vietnam
as well as countries around the world due to many different factors. BA
prevalence in men is higher rate than that in women. It means BA
affects male. The results of our study are consistent with the findings of
researchers in Asia - Pacific Region and Vietnam. Researcher Wang X.
S and et al in 2001 in Singapore, the rates of asthma in pupils at 6-7 and
2-15 years old ware 10.2% and 11.9% consecutively. Wong and et al
study in Hong Kong (2002), the rate of pupils at the age of 13-14


17

diagnosed by physician is 10.2%. Study Pham Le Tuan carrying in
local and suburban in Hanoi city showed that the rate of BA pupils is
10.42%. There was a difference between men and women. Studies of
Ton Kim Long in 2003 in Hanoi city, the rate of BA in Ha Noi city was
10.3%, variation among are 7.8% -15.05% and a percentage of men
was higher than that of women. In table 3.3 the rate of BA level 1 was
66.7%, BA level 2 was 20.8%, BA level 3 was 12.5%. These results are
consistent with findings of Lai CKW study in Asia Thailand Pacific
region and the study of Le Thi Hong Hanh to research at Children's
Hospital Central.
The table 3.6 and the chart 3.2 show that 38.5% of pupils are off
school, 15.4% of BA pupils treated at ICU in the last year and 1.9% of
patients controlled BA. This result is consistent with studies of Lai
CKW studied in Asia Pacific Region.
4.2 Risk factors causing Bronchial Asthma (BA)

Factors of studied subjects: Risk of BA for pupils with the family
history of BA is 7.84 times higher than pupils without family history of
BA (p <0.05). Risk of BA for pupils with allergic family history is 2.56
times higher than without allergic family history (p <0.05). The results
of our study are equivalent to the authors’ results:
Leung and et al studying in Hong Kong show that pupils with
the family history available persons with asthma, risk of asthma is 6.8
times (95% CI: 3.3 to 13.9) than pupils available the family history
without any person of asthma. Study of Dong G.H and et al show that
risk for children from their parents with allergic asthma is 3.2 times
(OR, 3.12; 95% CI, 2.61-3.73). Phan Quang Doan studying some
causes of BA in 2001 found that 39.7% of BA patients available a
family history having person with BA. In 2006, Do Thuy Huong
identified some epidemiological factors of BA in children, there are 40
% of BA family history of patients.
The risk of BA for pupils with allergic history is 8.22 times higher
than that of pupils without allergic history (p <0.05). The risk of BA for
pupils with a history of allergic rhinitis is 15.54 times higher than that of


18

pupils without a history of allergic rhinitis (p <0.05). Study of Leung et al
showed that the risk of asthma for allergic pupils themselves is 10.3 times
higher than that of pupils without allergic history. Research of Sun Kim
Long indicated that the risk of BA for persons with family history of
allergic diseases is 16 times higher than that of person without allergic
family history. Do Thuy Huong determining some epidemiological factors
of BA in children in 2006 showed that personal allergic history of BA
patients is 56.4%. Duong Thuy Nga (2008) identifying the relationship of

allergic rhinitis with BA generation showed that patients with a history of
allergic rhinitis is 60%.
When finding out factors causing onset of BA attacks, results are
due to respiratory infections (79.5%), climate change (77%), allergens
(75.8%), types of smoke (64%). The leading reason causing onset of
BA attacks is types of smoke. In allergens causing BA, house dusts
(34.8%) and animal furs (30.4%) are more common allergens than all.
Results are similar as researches in Viet Nam and abroad.
4.3 Control effect of Bronchial Asthma (BA) with Seretide
Through 68 patients treated intervention by seretide and monitored and
controlled until 12
th
weeks, we obtained the following results:
The percentage of patients still having symptoms within day
(Table 3.17) and the number of days of symptoms in average per
patient (Table 3.18) are significantly reduced after two weeks and 4
weeks (p <0.05). Results of the study of Strand AM and Luckow A.
also found that percentages of number of days and nights without
symptoms have increased significantly in group treated by Seretide (20
to 64%), compared with those only treated by Fluticasone propionate
(24 to 51%). The differential treatment is 15.3% with p = 0.008.
Research of Mai Huong Lan about number of days with symptoms in
average ( 8.33 with BA level 2; 12.7 with BA level 3) and after 4 weeks
of treatment, patients with BA level 2 have without symptoms at the
day, after 8 weeks of treatment, patients with BA level 3 have without
symptoms at the day. The study of Nguyen Thu Ha monitoring the
effectiveness of Seretide in the prevention of 31 BA patients at Ha Noi


19

Club of BA prevention and protection also showed that after 2 weeks of
treatment, symptoms at the day of patients reduced 53.12% . The study
of Le Anh Tuan and Nguyen Nang An on preventive treatment with
Seretide. Before treatment, 71.9% of patients have symptoms at the
day, but after 2 weeks, those decrease 9.4%.
Table 3.19. The percentage of patients with symptoms at night,
after two weeks, improved 59.6%. Number of nights with symptoms
per patient within 4 weeks (Table 3.20) decreased on average is 2.9
nights. The difference is statistically significant with p <0.05. After 4
weeks, the patients have no symptoms at night.
The percentage of patients using medications to cut BA attacks
after two weeks (Table 3.21) reaches to 47.1% efficiency. Average
number of times using medications to cut BA attacks (Table 3.22),
before treatment, is 0.69 times per patient per month. After 2 weeks, it
changes 0.6 times. After 4 weeks, there is not any patient needing to
using medications to cut BA attacks. The difference is statistically
significant with p <0.05. Barnes et al studied four initial trials with
randomized, double-blind and parallel studies. Results improved
significantly that are without symptoms at the day, without waking up
at night and it should use medications to cut BA attacks at group treated
combination compared with the treatment group with Flutication
propionat.
The percentage of patients affected physical activity, off school,
intensive care due to asthma in four weeks (Chart 3.4). Before
intervention, rates of pupils affected physical activity, off school and
intensive care due to asthma are 63.2% , 48.5% and 13.6%
consecutively. After 2 weeks of intervention, 22.1% of pupils affected
physical activity (index of efficiency reached 65%), no pupils off
school and intensive care due to asthma. After 4 weeks, there is not any

pupils affect physical activity (p <0.05).
We use the peak flow meter and apply a distinctive calculation
method of the lowest PEF measured in the morning before taking
bronchodilator and the highest PEF in the evening after using


20

bronchodilator. It takes 2 times of measurement with a 12-hour interval
and compares with theoretical PEF to evaluate variation of peak flow
morning and evening and improvement of PEF morning index after
intervention. This method is convenient and feasible for school pupils.
We obtained the following results: At the chart 3.5%. Changes% PEF
morning index before and after intervention. Before intervention, PEF
value is 80%, which is lower than that of the theoretical value. It
indicates ventilatory obstructive disorders. After 2 weeks, percentage
of PEF increases over 10%. The difference is statistically significant
with p <0.05. After 4 weeks, 8 weeks and 12 weeks, PEF values
continue to increase, but the speed is slower. After 12 weeks, PEF
reached to 101.3%.
At Table 3.25, Table 3.27 and Table 3.28, PEF morning index,
after 2 weeks, increases 26.3 liters per minute; after 12 weeks that
increases 57.8 liters per min. PEF evening index increases 20.6 liters
per min after 12 weeks. Before treatment, variation of PEF morning and
evening indexes is 27.6%. This means that asthma has not been
controlled. After 2 weeks and 4 weeks, PEF variation decreases rapidly
with statistical significance p <0.05. After 12 weeks, PEF variation is
10.8% corresponding to index of normal health people. It is compared
with the study of Bergmannn KC, after 12 weeks of treatment
combined by Salmeterol / Fluticasone propionate. The average increase

of PEF morning index is 48.4 liters per minute after 6 weeks and 51.3
liters/min after 12 weeks. Woodcock et al have results of study after 52
weeks, PEF morning index improves 58.2 liters per minute
(Salmeterol/Fluticasone propionate) compared with 33.9 liters / min
(when use only Fluticasone propionate); Phan Quang Doan's study,
when monitoring the preventional effect of Seretide on 55 pupils with
BA, after 4 weeks showed improvement of respiratory functional index
is statistically significant (p <0.05). After treatment, PEF value
increases 60.4 liters / min. Nguyen Thu Ha's study on 31 patients found
that after 14 days of BA treatment, PEF value increases 37.6 liters/min.


21

There are many different methods to assess level of asthma control. In
addition to the GINA criteria evaluated, we also evaluate level of asthma
control with the asthma controlled kit (ACT). At Table 3.30, after 4 weeks of
intervention, 94.1% of asthma controlled patients achieving criteria. After 12
weeks, 88.2% of patients controlled completely asthma and 10.3% of asthma
controlled patients achieving criteria.
Effectiveness of BA control and rate of onset of BA (Chart 3.7;
Table 3.32) are namely. After 2 weeks of treatment, there are 42.7% of
patients controlled asthma, 27.9% of patients uncontrolled asthma and
29.4% of patients controlled partly. After 4 weeks, rates of patients
controlled asthma and patients controlled partly asthma are 94.1% and
5.9% consecutively. In Table 3.31, at the 8
th
week, there are 3 patients
uncontrolled of BA due to respiratory infections which makes onset of
BA attack. At the 12

th
week, a patient, being in a good asthma control,
gets influenza and BA attack begins and fail to asthma control. After 12
weeks, it is re-evaluation, there are 98.5% of controlled patients. A total
of four asthma relapse/4 patients and no patient had recurrence of two
asthma attacks. So, percentage of patients uncontrolled is 5.9%. So, BA
attacks (also called onset factor) are a main cause due to acute
respiratory infections, these patients are required to treat the symptoms
of co-disease with maintaining asthma control. After 5 - 7 days,
symptoms of infection are relief and asthma control for patients is
good.
The acceptance of patients for prophylactic medication shows
that most patients evaluate good efficacy of medication (94.1%), ease
to use, convenience (100%) and high safety. When asked about the
cost, 85.3% of patients accepting cost. 14.7% of patients show that
medications are expensive, but when compared to the treatment
process, 95.6% of patients show that prevention costs are cheaper than
that of the treatment cost. 95.6% of patients are comfortable to be
treated. 4.4% of patients do not assured and show that long duration of
treatment affecting the health. Thus, Seretide is evaluated weekly by
community. Patients believe of treatment and acceptance of treatment


22

costs. The results of our study are consistent with findings of Bergmann
KC and Mai Lan Huong. When assessing on the compliance of patients
in treatment (Table 3:35), we found 100% of patients changing lifestyle
behaviors, prevention of risk factors causing onset of asthma attacks
under physician's advice, 91.2% of patients inhaling medication

regularly and fully 100% , only 8.8% of patients forgetting to inhale
medication from 4 to 6 doses at 2
nd
month and 3
rd
month. Patients often
forget to inhale 2 doses of medication in the evening, 2 inhaled doses
are sprayed in the morning and in three months patients just forget 4-6
inhaled doses at the evening. Therefore, we saw doses forgetting to
inhale do not large to affect treatment’s outcomes. But, we also discuss
with the regular treatment compliance and adequate doses, changes in
lifestyle behavior and avoid risk factors are good, results achieve
optimal treatment.
Thus, combination of ICS with LABA in inhaler has brought
significant improvements available clinical meaning and improve respiratory
functions and improvement of life quality of patients as well as economic
efficiency better than drugs for other treatments. Combination of two above
medications in one inhaler having effectiveness of mutually complementary
and synergistic and, improve well the physiologic abnormalities of increase
obstruction and increase breath respiratory response. Coordinating these two
drugs has proper role in the treatment from mild to moderate bronchial
asthma, increase of convenience, and improvement of compliance by
patients, increase control results and reduce incidence of severe attack of BA,
reduce the cost of treatment.


23

CONCLUSION
1. Status of Bronchial Asthma (BA) of pupils in elementary and

secondary schools in Thai Nguyen city.
Rate of pupils at primary and secondary schools is 9.5%. Of
whom Rate of BA of male pupils is 10.4% and is higher than that in
female pupils (8.6%) (p<0.05). BA rate at the groups of 6-10 years old
and 11-15 years old is 10.1% and 9.0% respectively (p> 0.05).
= Rates of asthma of level 1, level 2 and level 3 are 66.7% ,
20.8% and 12.5% respectively. Rates of pupils off school and intensive
care due to BA in past year are 38.5% and 15.4% consecutively.
Percentage of students treated BA control is 1.9%.

2. Risk factors causing Bronchial Asthma (BA).
In families having BA persons, risk of BA for pupils is higher than
those without BA persons (with OR: 7.84; 95% CI: 4.55 to 13.59).
Families have allergic persons, risk of BA for pupils is high than those
without allergic persons (with OR: 2.56; 95% CI: 1.58 to 4.15). The
risk of BA for pupils themselves with an allergic history is higher than
that of pupils without allergic history (with OR: 8.22; 95% CI: 5.18 to
13.07). Risk of BA for pupils themselves with a history of allergic
rhinitis is higher than that of pupils without allergic rhinitis history
(with OR: 15.54; 95% CI: 9.25 to 26.25).
Factors of onset of BA attacks: acute respiratory infections (79.5%),
weather changes (77.0%) allergens (75.8%), cigarette smoke, coal smoke
and factory smoke (64.0%) are factors that trigger high BA attacks. Factors
in making in effort (48.4%), house dusts (34.8%), animal fur, hairs of dog
and cat (30.4%) cause lower rate of onset of BA attacks.

3. Effectiveness of BA control with Seretide
BA symptoms at the day decrease 39.7% after 2 weeks of
intervention and 91.2% after 4 weeks (p <0.05). Nocturnal symptoms
after two weeks and four weeks of intervention are improved 59.6%

and 100% respectively.


24

Number of days with moderate symptoms decreases significantly.
After 4 weeks of intervention, it reduces 10.9 days in average (p <0.05).
Number of nights with moderate symptoms decreases 2.9 nights after
two weeks. After four weeks, there is not any patient having symptoms
at night (p <0.05).
The percentage of patients, who must use medications to cut BA
attacks improved is 47.1% after 2 weeks of intervention (p <0.05).
Number of times of using medications to cut BA attacks in average
decreased 0.6 times after 2 weeks. After 4 weeks, there is not any
patients having to use medication to cut BA attacks (p <0.05).
Physical activity is improved 65% after 2 weeks of
intervention.
PEF morning value increases after 2 weeks, 4 weeks, 8 weeks, and
12 weeks. After 12 weeks, PEF index in average reaches 101.3%.
PEF morning value in average increase 26.3 liter/min after 2
weeks and 57.8 liters per minute after 12 weeks. PEF evening value
increases 20.6 liters/min after 12 weeks.
42.7% of patients are controlled after 2 weeks of intervention.
After 4 weeks, 8 weeks and 12 weeks, patients controlled asthma
account for 94.1; 95.6% and 98.5% respectively.
Assessing asthma control attacks, there are ACT score, after 4 weeks of
intervention. 94.1% of patients with asthma achieving controlled, there are
asthma controlled patients gaining criteria. After 8 weeks, 27.9% of patients
are controlled completely. 67.6% of patients asthma control, after 12 weeks,
88.2% of patients completely relieve, 10.3% of asthma control patients

achieving criteria.
RECOMMENDATIONS
1. Rate of bronchial asthma (BA) of pupils in school ages is high
percentage. Therefore, it is necessary to have information with the
functional agencies such as Provincial Health Sector, Bureau of
Education City to cooperate in establish BA control program at the
School Health Facilities, to found clubs of prevention and Protection of
BA at schools with BA high rates.


25

2. The acute respiratory tract infection, weather changes, tobacco
smoke, coal smoke, factory smoke are factors causing onset of high
attacks of BA. Hence, it is necessary to strengthen the propaganda
education for pupils with BA to understand how to avoid risk factors,
reduces risks of BA onset and make more serious disease.
3. Enhancement of consultancy of pupils with bronchial asthma and
their families to know that bronchial asthma is a chronic disease able to
controll. ICS + LABA (Seretide) is a good medicine for controlling
BA. Watching indexes and variation of PEF or grading controlling BA
according to ACT Score of BA control. This score is simple,
convenient, easy to use and evaluate BA control in community.