Micheal Jackson
2 years ago
Thursday, June 25, 2009
Asthma is the most common respiratory tract illness. Discuss its causes and evaluate available asthma treatment
Asthma is an important public health disease and is associated with recent increase in illness and death rates. Asthma affects approximately 5 percent of the population. Men and women appear to be equally affected. Each year 300 million people worldwide suffer from asthma and an additional 100 million may be diagnosed with asthma by 2025 (Chesnutt & Prendergast, 2003, p.225). Asthma is a common chronic inflammation disorder of the airway in which many cells and cellular elements play a role, in particular mast cells, esinophil and T-lymphocytes.
Clinical features of asthma vary because asthma is not a uniform disease but a dynamic clinical syndrome with a variety of features. Typical symptoms are recurrent episodes of wheezing, chest tightness, breathlessness, chronic airway inflammation, hyper-responsiveness and air way obstruction (Innes & Reid, 2006, p. 671). Also asthma characteristically displays a diurnal pattern, which causes an increase in symptoms and Peak Expiratory Flow (PEF) particularly early in the morning (Innes & Reid, 2006, p. 671).
In addition, asthma has been divided according to its prevalence into three degrees, mild, moderate and severe. Patients with mild intermittent asthma are usually asymptomatic between exacerbations, which occur during viral respiratory tract infections or after exposure to allergens (Chesnutt & Prendergast, 2003, p.225).
There are different factors involved causing asthma and it has a complex aetiology. For example, immune system disorders, environmental factors (cold weather, air pollution), smoking, pets and medication can cause asthma through different mechanisms (Asthma Foundation, 2009, para. 1).
The hygiene hypothesis suggests that decreased infection in early life predisposes the immune system toward an allergic reaction. T lymphocytes may differentiate in two different distinct sub types Th1 and Th2. In infancy, a shift occurs from the in utero Th2 bias towards Th1 (a response necessary for bacterial and viral fighting). A reduction in childhood infections helps persistence of a Th2 bias, directing the immune system toward an allergic type of response. This causes asthma (Innes & Reid, 2006, p. 670).
Furthermore, environmental factors (weather and air pollution) are another cause of asthma. For example, sudden changes in temperature, cold air, windy days, poor air quality and hot humid days are all known important triggers of asthma. Also thunderstorms can release large quantities of pollen, and it causes air pollution, which include very small particle of irritants such as sulphur dioxide, nitrogen oxide, and ozone (Asthma Foundation, 2009, para. 2). . The sources of particle in air can be natural (pollen, bacteria, and fungi) or man-made (motor vehicle, emission, wood heaters); smoke from bushfires is also another source of airborne particles. Pollens are also spread in the air by wind from grasses, weeds, and tress. Also the ozone layer in the upper atmosphere protect us from harmful ultrasound rays, but if present in the air we breathe, ozone can irritate the lungs and make breathing difficult and this can trigger asthma attack (Chesnutt & Prendergast, 2003, p. 225).
In addition, smoking is another cause of asthma. Particularly, people with asthma have extra sensitive airways which are inflamed (red and swollen) and it increases mucus secretion. Therefore, people who smoke tobacco damage the cilia which are little hair-like structures that move dust, pollen, and other irritants from the lungs and these elements can trigger asthma attacks (Asthma Foundation, 2009, para. 2).
Another important factor which causes asthma is pets, particularly cats, dogs and horses (Innes & Reid, 2006, p. 670). Cats and dogs are a major source of allergens, coming from the sweat glands in the cats and salivary glands in dogs. These allergens get stuck to the hair and skin of pets and while they shed their hair and skin the allergens spread and remain airborne for sometime. Therefore, it can cause asthma (Asthma Foundation, 2009, para. 2).
Moreover, Asthma can be caused by some medications that are available over the counter or by doctor’s prescriptions, especially medications which contain Aspirin (Salicylic acid), Aspirin- like substances, beta-blockers, pain relievers or steroidal anti-inflammatory agents ‘NSAID’ (Innes & Reid, 2006, p. 671).
Due to asthma’s complex aetiology, its management needs a combination of some medicines. There are many medications being used together to treat asthma.
Firstly, for patients with mild intermittent asthma (symptoms less than once a week for 3 months and fewer than two nocturnal attacks/month) inhaled short acting beta-agonists are usually sufficient to prescribe for patients. Regular use of beta-agonists such as Fenoterol, Albeterol and Terbutalin has been shown to increase bronchial hyperactivity, despite maintainance of some degree of bronchodilation in asthma and COPD (Salpeter et al 2006, para. 30). A recent meta-analysis of these types of drugs pooled the results of 22 randomised trials and found there was some improvement of lung function and asthma symptoms in 15000 participants (Salpeter et al 2006, para. 25)
However, inhaled short acting beta-2 agonists are less effective than inhaled corticosteroids ICS such as Ipratropium and Tiotropium (Rodrigo, 2001, p. 7) because inhaled corticosteroids have a great effect on lung functions, improve asthma symptoms and reduce respiratory deaths (Salpeter et al, 2006, para. 30). A monotherapy with short acting beta-2 agonist has consistently been shown to be less effective in chronic asthma due to accumulating evidence suggesting a loss of control and excess mortality in asthma (Virchow et al 2008, para, 4).
Secondly, adding (ICS) is important with inhaled beta-2 agonists and should be considered for patients who:
- Have suffered an asthma exacerbation attack in the last two years
- Use inhaled beta-2 agonist three times a week or more
- Report symptoms three times a week or more
- Are awakened by asthma one night per week (Innes & Reid, 2006, p. 676).
ICS especially Beclometasone Dipropionate (BDP) in 400 micro grams is a reasonable starting dose. BDP and Budesonide (BUD) are approximately the same in clinical usage (Innes & Reid, 2006, p. 676).
ICS with inhaled short acting beta-2 agonists are the best choice as the first line treatment for patients with mild to moderate asthma and result in an improved control of asthma symptoms and improved lung function, giving better results than doubling ICS dose. ICS increases PEF and causes bronchodilatation, which reduces asthma symptoms (Molen, 1997, para. 1). A four week group study demonstrated that only a combination therapy of ICS such as beclometasone dipropionate with short acting beta-2 agonist demonstrated significant improvement in morning PEF and improvement in asthma symptoms (Spears et al, 2009, para. 14).
However, many patients consume ICS in both lower and higher doses but continue to have asthma symptoms and need additional treatment (Pauwels, Lofdahl, Postma, Tattersfield, O’Byrue & Barnes, 1997, para. 5).In a study it was demonstrated that ICS monotherapy does not have enough efficacy on asthma symptoms and exacerbates mild or moderate asthma it can also cause severe asthma (Rodrigo, 2002, para. 1). In a controlled group of smokers with asthma, ICS did not reduce but rather increased asthma symptoms (Spears et al, 2009, para. 5).
Thirdly, there are patients who remain poorly controlled despite regular use of inhaled short acting beta-2 agonist with ICS. Therefore, a review of the patients should be made with particular attention to adherence and inhaler technique.
Inhaled long-acting agonists and corticosteroids (ICS) are considered as a choice treatment in patients with moderate and severe asthma (Innes & Reid 2006, p. 676). Increasing ICS doses are beneficial for most patients, but in general add- on therapy should be considered beyond an ICS dose of 80 micro grams of BDP, BUP (Innes & Reid 2006, p. 676). Long acting beta-2 agonists (LABAs) Salmeterol and Formoterol should also be added. They have consistently demonstrated improvement in symptoms and reduce the frequency and severity of exacerbation. Also they improved lung functions when compared to increasing the dose of short acting ICS (Innes & Reid 2006, p. 676). Combining inhaled long acting beta-2 agonist with an inhaled ICS results in a greater improvement in controlling asthma symptoms and lung function than doubling the dose of the ICS (Molen, 2004, para. 1). However, the precise amount of Formoterol in the maintenance of asthma is still under debate (Molen, 2004). In a study evaluating the safety and efficacy of Formoterol and Salmeterol, Patients who used long acting beta 2 agonist (S, F, 100-3200micro grams/ day) still needed at least five inhalations of long acting beta-2 agonist ( Ipratropium bromide) per week, and this was effective in treating mild to moderate and even persistent asthma. There were significant improvements in lung function with no apparent increased evidence about side effects (Molen et al 1997, para. 1).
Another class of asthma treatments consists of adding a fourth drug. Patients particularly who remain poorly controlled on moderate dose of inhaled steroid and add on therapy need the addition of a fourth drug. Therefore, increasing the dose of long-acting inhaled corticosteroid (ICS) Beclometasone dipropionate and Budesonide up to 2000 micro grams might be useful (Salpeter et al 2006, para. 1). Oral therapy with leukotriene receptor antagonists (theophylline, montelukast 10 mg) or a slow-release beta-2 agonist should also be considered (Innes & Reid 2006, p. 676). The result of studies show that the risk factor for life-threatening and fatal asthma exacerbations are reduced by using ICS in combination with beta-agonist and leukotriene receptor antagonist ( Salpeter et al 2006, para. 29). Also montelukasts are less effective than long-acting beta-agonists. In a study, montelukast with high-dose ICS was prescribed for smokers with asthma and there was less improvement seen in PEF, FVC, while long acting beta agonists (Salmeterol and Formoterol) produced significant improvement in combination with long-acting beta-2 agonist (Spears et al, 2009, para. 2).Therefore, monotherapy with ICS increases the risk for hospitalization due to asthma life threatening exacerbations and asthma related deaths. A similar risk was found for Salmeterol and Formoterol in children and adults (Salpeter, et al 2006, para. 2).
The last type of asthma therapy is to use the systemic corticosteroid and inhaled beta-2 agonist with prednisolone (40mg/ day, or in two divided dose 30-60mg for 10 days. (Innes, Reid 2006, p. 676). Prednisolone has demonstrated the fastest resolution of air way obstruction, reducing the rate of relapse. Also it is more effective in treating severe asthma (Chesnutt & Prendergast 2003, p. 235). In a study on severe asthmatic patients, prednisolone taken in doses of 40 mg/ day reduced asthma exacerbation, improved lung functions, decreased systemic parameters such as eosinophils, serum cortisol ( Chesnutt & Prendergast 2003, p. 235).
In conclusion asthma is an important public health disease and is associated with a recent increase in illness and death rates. It is characterized with recurrent episode of wheezing, chest pain, breathlessness, and pain. There are many different factors involved causing asthma such as imbalanced immune system, environmental factors, smoking, pets and medications. In its treatment, short acting beta agonists with ICS have a great effect treating mild to moderate asthma and long acting beta agonists with ICS and leukotriene plus or with Prednisolone have a great effect on severe asthma.
References
Asthma Foundation, 2009, ‘About Asthma Basics’, Asthma Foundation New South Wales, Viewed 27 May 2009, from http://www.asthmasnw.org.au/content.cfmid=2188
Chesnutt, MS & Prendergast, TJ 2003, ‘Common Manifestations of Lung Disease’ ,in T. Lawrence, M, Stephen & P, Maxine (Eds), Current Medical Diagnosis and Treatment, 42 edition, McGraw Hill, USA.
Innes, JA & Reid, PT 2003, ‘ Respiratory disease’, in B Nicholas, C Nickir, W Brain, H John (Eds) 2006, in Principles and Practices of Medicine, 28 edition, Churchhill Livingstone, UK
Lommatzsch, M, Lindner, Y, Edner, A, Bratke, K & Kuepper, M, Virchow, J 2009, , ‘Adverse effects of Salmeterol in asthma: a neuronal Perspective’, in Thorax, doi:10.1136/thx.2008.110916, 24 May 2009, form http://thorax.bmj.com/cgi/content/abstract/thx.2008.110916v1.
Molen, T 2004, ‘Formoterol And Asthma Exacerbations’, Chest, vol. 125, no. 4, p.1591, viewed 24 May from http://www.chestjournal.org/site/misc/reprints.xhtml.
Molen, T, Postma, DS, Turner, MO, Jong, BM, Malo, JL 1997, ‘Effects of the long acting beta agonist Formoterol of asthma control in asthmatic patients using ICS; The Netherlands and Canadian Formoterol Study investigation’, in Thorax, vol. 52, pp. 535-539, viewed 20 May 2009, http://thorax.bmj.com/cgi/content/abstract.
Pauwels, R, Lofdahl, C, Postma, D, Tatterfield, A, O’Byrne, P & Barnes, P 1998, ‘ Effect of Inhaled Formoterol and Budesonide on Exacerbations of Asthma’, The New England Journal of Medicine, vol. 338, no. 2, p. 139, viewed 4 May 2009, http:// www.thorax.bmj.com/cgi/respiratory-products.
Rodrigo, G & Rodrigo, C 2 002, ‘The Role of Anticholinergics in Acute Asthma Treatment’, Pediatrics, vol. 121, pp1977-1987, viewed 12 May 2009, http://www.chestjournal.org/content/121/6/1977.full.html.
Salpeter S, Buckley, N, Ormiston, T & Salpeter, E 2006, ‘ Meta-Analysis: Effect of Long-Acting B-Agonists on Severe Asthma Exacerbations and Asthma-Related Deaths’, Annals of Internal Medicine, vol. 144, no. 12, pp. 904-912, viewed 10 May 2009, http://www.annals.org/cgi/content/full/1441/12/904.
Spears, M, Donnelly, I, Jolly, L, Brannigan, M, Ito, K, McSharry, C, Lafferty, J, Chaudhuri, R, Braganza, G, Adcock, I, Barnes, P, Wood, S, and Thomson, N 2009, ‘Effect of low-dose theophylline plus beclometasone on lung function in smokers with asthma: a Pilot study’, European Respiratory Journal, vol. 33, pp. 1010-1017, viewed 2 May 2009, http://erj.ersjournals.com/cgi/reprint/33/5/1010
Asthma is an important public health disease and is associated with recent increase in illness and death rates. Asthma affects approximately 5 percent of the population. Men and women appear to be equally affected. Each year 300 million people worldwide suffer from asthma and an additional 100 million may be diagnosed with asthma by 2025 (Chesnutt & Prendergast, 2003, p.225). Asthma is a common chronic inflammation disorder of the airway in which many cells and cellular elements play a role, in particular mast cells, esinophil and T-lymphocytes.
Clinical features of asthma vary because asthma is not a uniform disease but a dynamic clinical syndrome with a variety of features. Typical symptoms are recurrent episodes of wheezing, chest tightness, breathlessness, chronic airway inflammation, hyper-responsiveness and air way obstruction (Innes & Reid, 2006, p. 671). Also asthma characteristically displays a diurnal pattern, which causes an increase in symptoms and Peak Expiratory Flow (PEF) particularly early in the morning (Innes & Reid, 2006, p. 671).
In addition, asthma has been divided according to its prevalence into three degrees, mild, moderate and severe. Patients with mild intermittent asthma are usually asymptomatic between exacerbations, which occur during viral respiratory tract infections or after exposure to allergens (Chesnutt & Prendergast, 2003, p.225).
There are different factors involved causing asthma and it has a complex aetiology. For example, immune system disorders, environmental factors (cold weather, air pollution), smoking, pets and medication can cause asthma through different mechanisms (Asthma Foundation, 2009, para. 1).
The hygiene hypothesis suggests that decreased infection in early life predisposes the immune system toward an allergic reaction. T lymphocytes may differentiate in two different distinct sub types Th1 and Th2. In infancy, a shift occurs from the in utero Th2 bias towards Th1 (a response necessary for bacterial and viral fighting). A reduction in childhood infections helps persistence of a Th2 bias, directing the immune system toward an allergic type of response. This causes asthma (Innes & Reid, 2006, p. 670).
Furthermore, environmental factors (weather and air pollution) are another cause of asthma. For example, sudden changes in temperature, cold air, windy days, poor air quality and hot humid days are all known important triggers of asthma. Also thunderstorms can release large quantities of pollen, and it causes air pollution, which include very small particle of irritants such as sulphur dioxide, nitrogen oxide, and ozone (Asthma Foundation, 2009, para. 2). . The sources of particle in air can be natural (pollen, bacteria, and fungi) or man-made (motor vehicle, emission, wood heaters); smoke from bushfires is also another source of airborne particles. Pollens are also spread in the air by wind from grasses, weeds, and tress. Also the ozone layer in the upper atmosphere protect us from harmful ultrasound rays, but if present in the air we breathe, ozone can irritate the lungs and make breathing difficult and this can trigger asthma attack (Chesnutt & Prendergast, 2003, p. 225).
In addition, smoking is another cause of asthma. Particularly, people with asthma have extra sensitive airways which are inflamed (red and swollen) and it increases mucus secretion. Therefore, people who smoke tobacco damage the cilia which are little hair-like structures that move dust, pollen, and other irritants from the lungs and these elements can trigger asthma attacks (Asthma Foundation, 2009, para. 2).
Another important factor which causes asthma is pets, particularly cats, dogs and horses (Innes & Reid, 2006, p. 670). Cats and dogs are a major source of allergens, coming from the sweat glands in the cats and salivary glands in dogs. These allergens get stuck to the hair and skin of pets and while they shed their hair and skin the allergens spread and remain airborne for sometime. Therefore, it can cause asthma (Asthma Foundation, 2009, para. 2).
Moreover, Asthma can be caused by some medications that are available over the counter or by doctor’s prescriptions, especially medications which contain Aspirin (Salicylic acid), Aspirin- like substances, beta-blockers, pain relievers or steroidal anti-inflammatory agents ‘NSAID’ (Innes & Reid, 2006, p. 671).
Due to asthma’s complex aetiology, its management needs a combination of some medicines. There are many medications being used together to treat asthma.
Firstly, for patients with mild intermittent asthma (symptoms less than once a week for 3 months and fewer than two nocturnal attacks/month) inhaled short acting beta-agonists are usually sufficient to prescribe for patients. Regular use of beta-agonists such as Fenoterol, Albeterol and Terbutalin has been shown to increase bronchial hyperactivity, despite maintainance of some degree of bronchodilation in asthma and COPD (Salpeter et al 2006, para. 30). A recent meta-analysis of these types of drugs pooled the results of 22 randomised trials and found there was some improvement of lung function and asthma symptoms in 15000 participants (Salpeter et al 2006, para. 25)
However, inhaled short acting beta-2 agonists are less effective than inhaled corticosteroids ICS such as Ipratropium and Tiotropium (Rodrigo, 2001, p. 7) because inhaled corticosteroids have a great effect on lung functions, improve asthma symptoms and reduce respiratory deaths (Salpeter et al, 2006, para. 30). A monotherapy with short acting beta-2 agonist has consistently been shown to be less effective in chronic asthma due to accumulating evidence suggesting a loss of control and excess mortality in asthma (Virchow et al 2008, para, 4).
Secondly, adding (ICS) is important with inhaled beta-2 agonists and should be considered for patients who:
- Have suffered an asthma exacerbation attack in the last two years
- Use inhaled beta-2 agonist three times a week or more
- Report symptoms three times a week or more
- Are awakened by asthma one night per week (Innes & Reid, 2006, p. 676).
ICS especially Beclometasone Dipropionate (BDP) in 400 micro grams is a reasonable starting dose. BDP and Budesonide (BUD) are approximately the same in clinical usage (Innes & Reid, 2006, p. 676).
ICS with inhaled short acting beta-2 agonists are the best choice as the first line treatment for patients with mild to moderate asthma and result in an improved control of asthma symptoms and improved lung function, giving better results than doubling ICS dose. ICS increases PEF and causes bronchodilatation, which reduces asthma symptoms (Molen, 1997, para. 1). A four week group study demonstrated that only a combination therapy of ICS such as beclometasone dipropionate with short acting beta-2 agonist demonstrated significant improvement in morning PEF and improvement in asthma symptoms (Spears et al, 2009, para. 14).
However, many patients consume ICS in both lower and higher doses but continue to have asthma symptoms and need additional treatment (Pauwels, Lofdahl, Postma, Tattersfield, O’Byrue & Barnes, 1997, para. 5).In a study it was demonstrated that ICS monotherapy does not have enough efficacy on asthma symptoms and exacerbates mild or moderate asthma it can also cause severe asthma (Rodrigo, 2002, para. 1). In a controlled group of smokers with asthma, ICS did not reduce but rather increased asthma symptoms (Spears et al, 2009, para. 5).
Thirdly, there are patients who remain poorly controlled despite regular use of inhaled short acting beta-2 agonist with ICS. Therefore, a review of the patients should be made with particular attention to adherence and inhaler technique.
Inhaled long-acting agonists and corticosteroids (ICS) are considered as a choice treatment in patients with moderate and severe asthma (Innes & Reid 2006, p. 676). Increasing ICS doses are beneficial for most patients, but in general add- on therapy should be considered beyond an ICS dose of 80 micro grams of BDP, BUP (Innes & Reid 2006, p. 676). Long acting beta-2 agonists (LABAs) Salmeterol and Formoterol should also be added. They have consistently demonstrated improvement in symptoms and reduce the frequency and severity of exacerbation. Also they improved lung functions when compared to increasing the dose of short acting ICS (Innes & Reid 2006, p. 676). Combining inhaled long acting beta-2 agonist with an inhaled ICS results in a greater improvement in controlling asthma symptoms and lung function than doubling the dose of the ICS (Molen, 2004, para. 1). However, the precise amount of Formoterol in the maintenance of asthma is still under debate (Molen, 2004). In a study evaluating the safety and efficacy of Formoterol and Salmeterol, Patients who used long acting beta 2 agonist (S, F, 100-3200micro grams/ day) still needed at least five inhalations of long acting beta-2 agonist ( Ipratropium bromide) per week, and this was effective in treating mild to moderate and even persistent asthma. There were significant improvements in lung function with no apparent increased evidence about side effects (Molen et al 1997, para. 1).
Another class of asthma treatments consists of adding a fourth drug. Patients particularly who remain poorly controlled on moderate dose of inhaled steroid and add on therapy need the addition of a fourth drug. Therefore, increasing the dose of long-acting inhaled corticosteroid (ICS) Beclometasone dipropionate and Budesonide up to 2000 micro grams might be useful (Salpeter et al 2006, para. 1). Oral therapy with leukotriene receptor antagonists (theophylline, montelukast 10 mg) or a slow-release beta-2 agonist should also be considered (Innes & Reid 2006, p. 676). The result of studies show that the risk factor for life-threatening and fatal asthma exacerbations are reduced by using ICS in combination with beta-agonist and leukotriene receptor antagonist ( Salpeter et al 2006, para. 29). Also montelukasts are less effective than long-acting beta-agonists. In a study, montelukast with high-dose ICS was prescribed for smokers with asthma and there was less improvement seen in PEF, FVC, while long acting beta agonists (Salmeterol and Formoterol) produced significant improvement in combination with long-acting beta-2 agonist (Spears et al, 2009, para. 2).Therefore, monotherapy with ICS increases the risk for hospitalization due to asthma life threatening exacerbations and asthma related deaths. A similar risk was found for Salmeterol and Formoterol in children and adults (Salpeter, et al 2006, para. 2).
The last type of asthma therapy is to use the systemic corticosteroid and inhaled beta-2 agonist with prednisolone (40mg/ day, or in two divided dose 30-60mg for 10 days. (Innes, Reid 2006, p. 676). Prednisolone has demonstrated the fastest resolution of air way obstruction, reducing the rate of relapse. Also it is more effective in treating severe asthma (Chesnutt & Prendergast 2003, p. 235). In a study on severe asthmatic patients, prednisolone taken in doses of 40 mg/ day reduced asthma exacerbation, improved lung functions, decreased systemic parameters such as eosinophils, serum cortisol ( Chesnutt & Prendergast 2003, p. 235).
In conclusion asthma is an important public health disease and is associated with a recent increase in illness and death rates. It is characterized with recurrent episode of wheezing, chest pain, breathlessness, and pain. There are many different factors involved causing asthma such as imbalanced immune system, environmental factors, smoking, pets and medications. In its treatment, short acting beta agonists with ICS have a great effect treating mild to moderate asthma and long acting beta agonists with ICS and leukotriene plus or with Prednisolone have a great effect on severe asthma.
References
Asthma Foundation, 2009, ‘About Asthma Basics’, Asthma Foundation New South Wales, Viewed 27 May 2009, from http://www.asthmasnw.org.au/content.cfmid=2188
Chesnutt, MS & Prendergast, TJ 2003, ‘Common Manifestations of Lung Disease’ ,in T. Lawrence, M, Stephen & P, Maxine (Eds), Current Medical Diagnosis and Treatment, 42 edition, McGraw Hill, USA.
Innes, JA & Reid, PT 2003, ‘ Respiratory disease’, in B Nicholas, C Nickir, W Brain, H John (Eds) 2006, in Principles and Practices of Medicine, 28 edition, Churchhill Livingstone, UK
Lommatzsch, M, Lindner, Y, Edner, A, Bratke, K & Kuepper, M, Virchow, J 2009, , ‘Adverse effects of Salmeterol in asthma: a neuronal Perspective’, in Thorax, doi:10.1136/thx.2008.110916, 24 May 2009, form http://thorax.bmj.com/cgi/content/abstract/thx.2008.110916v1.
Molen, T 2004, ‘Formoterol And Asthma Exacerbations’, Chest, vol. 125, no. 4, p.1591, viewed 24 May from http://www.chestjournal.org/site/misc/reprints.xhtml.
Molen, T, Postma, DS, Turner, MO, Jong, BM, Malo, JL 1997, ‘Effects of the long acting beta agonist Formoterol of asthma control in asthmatic patients using ICS; The Netherlands and Canadian Formoterol Study investigation’, in Thorax, vol. 52, pp. 535-539, viewed 20 May 2009, http://thorax.bmj.com/cgi/content/abstract.
Pauwels, R, Lofdahl, C, Postma, D, Tatterfield, A, O’Byrne, P & Barnes, P 1998, ‘ Effect of Inhaled Formoterol and Budesonide on Exacerbations of Asthma’, The New England Journal of Medicine, vol. 338, no. 2, p. 139, viewed 4 May 2009, http:// www.thorax.bmj.com/cgi/respiratory-products.
Rodrigo, G & Rodrigo, C 2 002, ‘The Role of Anticholinergics in Acute Asthma Treatment’, Pediatrics, vol. 121, pp1977-1987, viewed 12 May 2009, http://www.chestjournal.org/content/121/6/1977.full.html.
Salpeter S, Buckley, N, Ormiston, T & Salpeter, E 2006, ‘ Meta-Analysis: Effect of Long-Acting B-Agonists on Severe Asthma Exacerbations and Asthma-Related Deaths’, Annals of Internal Medicine, vol. 144, no. 12, pp. 904-912, viewed 10 May 2009, http://www.annals.org/cgi/content/full/1441/12/904.
Spears, M, Donnelly, I, Jolly, L, Brannigan, M, Ito, K, McSharry, C, Lafferty, J, Chaudhuri, R, Braganza, G, Adcock, I, Barnes, P, Wood, S, and Thomson, N 2009, ‘Effect of low-dose theophylline plus beclometasone on lung function in smokers with asthma: a Pilot study’, European Respiratory Journal, vol. 33, pp. 1010-1017, viewed 2 May 2009, http://erj.ersjournals.com/cgi/reprint/33/5/1010
Group Solving Problems
Our survey topic was Vitamin C. there were four students at the beginging in our group: Shermulla, Awailate, Jaqulline and Abdul hasib. while we choose our topic it look very simple topic and essay and our group started to make survey questions, after we prepared vitamin c survey questions, about 40 people surveyed by our group and we really tried to get to the point and unfourtunately one of our classmate 'Awaliate' she left the EAP class during the survey and there were three students left in our group. We use the library in most times and also we emailed to each other and shared our work during the survey we had alot of problems to make a proper table because the EAP demand was very different than our thinking and finally we made the table and the graphs. However, it was very useful and we found experience how to work in a group and how to respect group's member. Also our computer teacher adviced positive clue to help us with our graph and table designe
Sunday, April 5, 2009
Writing:
Paraphrasing a paragraph is an important academicals issue. Also the rules of paraphrasing are more important to be considered while paraphrasing. For example, using the synonyms in a paraphrasing and also using different sentences structures in a paragraph help students while paraphrasing. In addition paraphrasing exercise is very useful because it help the writer a lot regarding plagiarism, but it is important to reference information while copying some data or quotation from someone else.
Another most important in academic field is to consider punctuation. As punctuation help the readers a lot while do reading a text and and article or and kind of informations. As the full stop means in sentences that the sentence finished and the following sentences might be a new piece of information. In addition, a comma will help the readers to think about the position which might be followed by more sufficient evidence .
Reading and listening:
Reading and listening class also were very useful classes. As in the listening classes the trategies of note taking is very important to know and it is useful to learn the different ways of note taking because it helps a student a lot and student may save a lot of time by note taking in a proper way. In addition, reading has some different way of learning a text for example skiming and scaning a text which is very long help a student a lot and student should be focused more in key words and it is better to get and whole idea of the text as reading the whole text sometimes might be useless.
Paraphrasing a paragraph is an important academicals issue. Also the rules of paraphrasing are more important to be considered while paraphrasing. For example, using the synonyms in a paraphrasing and also using different sentences structures in a paragraph help students while paraphrasing. In addition paraphrasing exercise is very useful because it help the writer a lot regarding plagiarism, but it is important to reference information while copying some data or quotation from someone else.
Another most important in academic field is to consider punctuation. As punctuation help the readers a lot while do reading a text and and article or and kind of informations. As the full stop means in sentences that the sentence finished and the following sentences might be a new piece of information. In addition, a comma will help the readers to think about the position which might be followed by more sufficient evidence .
Reading and listening:
Reading and listening class also were very useful classes. As in the listening classes the trategies of note taking is very important to know and it is useful to learn the different ways of note taking because it helps a student a lot and student may save a lot of time by note taking in a proper way. In addition, reading has some different way of learning a text for example skiming and scaning a text which is very long help a student a lot and student should be focused more in key words and it is better to get and whole idea of the text as reading the whole text sometimes might be useless.
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