Association between Blood Absolute Eosinophil Count with the

Degree of Controlled Asthma

Desi Maghfirah

, T. Mamfaluti

, Islamuddin

Department of internal medicine, Faculty of medicine, University of Syiah Kuala, dr. Zainoel Abidin General Hospital,

Daud bereuh St, Banda aceh, Indonesia

Division of Alergy Immunology, dr. Zainoel Abidin General Hospital, Daud bereuh St, Banda aceh, Indonesia

Division of Pulmonology, dr. Zainoel Abidin General Hospital, Daud bereuh St, Banda aceh, Indonesia

Keyword: Absolute eosinophil count, ACT, PEFR

Abstract: Controlled asthma is the goal of asthma management. Blood eosinophils are known to be an indirect

marker of airway inflammation, it reflects asthmatic activity, but association with asthma control not clearly

understood. This study aims to investigate the association between blood absolute eosinophil count with the

degree of controlled asthma. An analysis observasional cross sectional study in 49 subject obtained through

out a consecutive sampling. The subject was examined physically, fill in ACT queistionnaire, and followed

PEFR test and blood test. The result were analysed using one way annova and unpaired T test. The 49

subjects were divided into three group based on ACT, 17 patients with uncontrolled, 16 not well controlled,

16 controlled and into two group based on PEFR, 38 with uncontrolled and 11 controlled. Mean differences

absolute eosinophil count between groups based on ACT is controlled vs not well controlled 212,6 (14,2-

411,1: p 0,003), controlled vs uncontrolled 373,9 (178,5-569,4: p <0,001), not well controlled vs

uncontrolled 161,3 (34,2-356,8: p 0,104). Mean differences absolute eosinophil count between groups based

on PEFR is controlled vs uncontrolled 419,8 (289,9-548,4: p <0,001). There were significant differences in

blood absolute eosinophil count between asthma control groups, better asthma control result in lower blood

absolute eosinophil count.

1 INTRODUCTION

Asthma is chronic inflammation disease that impact

social life, controlled asthma is the goal of asthma

management. The World Health Organization

(WHO) estimates 100-150 million people is

suffering from asthma, even this number is expected

to continue to grow up to 180,000 people every year.

Asthma prevalence increased by 50% every decade.

If not prevented and handled properly, then it is

expected that there will be a higher increase in

prevalence and disrupt the process of child growth

and quality of life of patients.

Blood eosinophils are known to be an indirect

marker of airway inflammation in asthma. It has

been suggested that blood eosinophil count reflects

asthmatic activity, but association with asthma

control not clearly understood. This study aims to

investigate the association between absolute

eosinophil count with the degree of controlled

asthma in asthma patient.

2 METHOD

We hypothesized there is a correlation between

blood absolute eosinophils count and the degree of

asthma control, the better the control of asthma, the

lower the number of blood absolute eosinophils.

An analysis observasional cross sectional study

in 49 subject obtained through out a consecutive

sampling since agustus -september 2015 in dr.

Zainoel Abidin Hospital Banda Aceh. Inclusion

criteria are age above 18 years, have been diagnosed

with asthma and willing to follow the research.

Parasitic infestation and acute pulmonary infection

were excluded. Patients who have been diagnosed

with outpatient asthma must perfomed stool

examination and chest radiographs. The subject was

examined physically, fill in ACT queistionnaire, and

followed PEFR test and blood test. If the subject has

value ACT ≤ 19 then is called uncontrolled asthma,

a value of 20-24 partially controlled asthma , the

value of 25 is totally controlled asthma.

Maghﬁrah, D., Mamfaluti, T. and Islamuddin, .

Association between Blood Absolute Eosinophil Count with the Degree of Controlled Asthma.

DOI: 10.5220/0008790000170022

In Proceedings of the 2nd Syiah Kuala International Conference on Medicine and Health Sciences (SKIC-MHS 2018), pages 17-22

ISBN: 978-989-758-438-1

Researchers explain how to use the HS755

peak flow meter and the patient is shown a video

recording how to use it and ensure that the patient

understands how to use the device. The patient

stands upright, inspire and place the mouth in the

mouthpiece tightly, the patient expires by blowing

strong and fast. The researcher assesses the number

in the indicator's place to stop, the examination is

repeated up to 3 times and the highest value is

recorded. The PEFR value of the patient is compared

with the predicted PEFR value. PEFR value <80%

prediction shows uncontrolled asthma.

Informed consent was requested in writing from

research subjects who were willing to participate in

the study after getting an explanation of the purpose

and objectives of this study.

The feasibility of research ethics was obtained

from the Faculty Ethics Feasibility Committee

Medicine Syiah Kuala University.

The analysis of the relationship of blood absolute

eosinophil count with the degree of asthma control

using ACT was done using one way anova, analysis

of the relationship of blood absolute eosinophil

count with the degree of asthma control using PEFR

was done using unpaired T test.

3. RESULT

In this study the proportion of asthma patients

aged at most 18-45 years (91.8%), female is 57.1%,

most of the subjects the study got the first attack of

asthma at the age of 0-11 years (55.1%), most

patients did not smoke (83.7%), with a history of

tendency most atopy (38.8%), with the most history

of drug use (49%) SABA (table 1).

Table 1: Baseline Characteristic

Characteristic n (%)

Age

- 18-45 years old

- ≥ 46 years old

Sex

- Man

- Women

First attack

- 0-11 years old

- 12-65 years old

Smoking

- Yes

- No

Atopy

- Rhinitis

- Dermatitis

- Mixed

- None

Dru

45 (91,8)

4(8,2)

21 (42,9)

28 (57,1)

27 (55,1)

22 (44,9)

8 (16,3)

41(83,7)

19 (38,8)

3 (6,1)

18 (36,7)

9 (18,4)

- SABA

- LABACS

- Metylxanthine

- SABA+ LABACS

- None

24 (49)

15 (30,6)

1 (2)

8 (16,3)

Characteristics of research samples when

grouped by degree asthma control using ACT, it was

found that the distribution of characteristics the

sample is the same in three asthma degree groups,

while if grouped based on the PEFR value, it was

found that in the uncontrolled asthma group it was

found older, had longer asthma, with an age of

attack first, younger, but this difference was not

statistically significant

Absolute eosinophil counts in the lower total

controlled asthma group compared to the partially

controlled asthma group and uncontrolled asthma

(figure 1).

Figure 1: The Absolute eosinophil count of asthmatics

grouped by asthma control degree using ACT

One way annova test to see the correlation

between absolute eosinophil count and degree of

asthma control based on ACT found that there were

significant differences in mean eosinophil counts at

least in two asthma control degree groups, the better

the degree of asthma control, the lower the absolute

number of eosinophils (table.2 )

Table. 2 Mean Differences Absolute Eosinophil Count

Between Groups Based on ACT

N Means ± SD

Controlled

Asthma

16 305 ± 236,3 <

0,002

Partially

controlled

Asthma

518 ± 322

Uncontrolled

Asthma

17 679,3 ± 271,8

Absolute eo

sinophil count

Uncontroll

Partially

Controlled

Degree of asthma control (ACT)

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

There were significant differences in blood

absolute eosinophil count in the total controlled and

partially controlled asthma group, in the total and

uncontrolled controlled group, but the mean absolute

eosinophil count in the controlled group did not have

a significant difference compared to the uncontrolled

asthma group (table 3).

Table 3: One way Annova after post hoc LSD test Mean Differences Absolute Eosinophil Count Between Groups Based

on ACT

Mean

Differences

CI 95 % p

Minimu

Maximu

Controlled Asthma vs Partially controlled Asthma 212,6 14,2 411,1 0,003

Controlled Asthma vs Uncontrolled Asthma 373,9 178,5 569,4 < 0,001

Partially controlled Asthma vs Uncontrolled Asthma 161,3 34,2 356,8 0,104

Table 4: Association Between Absolute Eosinophil Count With The Degree Of Controlled Asthma based on PEFR

N Means ± SD Mean Differences ( CI 95 % )

Uncontrolled

Asthma

38 598,6 ± 285,9 419,8 (289,9-548,4) < 0,001

Controlled Asthma 11 179,4 ±144,2

The blood absolute eosinophils count in the

controlled asthma group was lower compared to

the uncontrolled asthma group assessed according to

PEFR (figure 2).

Figure 2: The Absolute eosinophil count of asthmatics

grouped by asthma control degree using PEFR

In the unpaired T test to see the relationship

between blood absolute eosinophil count and asthma

control level based on PEFR, it was found that there

was a significant difference in the mean blood

absolute eosinophil count between controlled and

uncontrolled asthma groups, where the mean

absolute eosinophil count in the uncontrolled asthma

group was significantly lower than controlled

asthma group (table 4).

4. DISCUSSION

Thymus involution begins immediately after birth,

thymus involution causes the thymus volume to

decrease significantly after 45 years old and turn

into fat tissue, it finished approaching 60 years old.

As a result of this involution there is a decrease in

naiv T cells gradually and more memory T cells,

decreased activity T helper cell. The aging process

can also reduce the proliferative response, decreased

levels of CD8 + T cells, and changes in Th1 to Th2.

Changes to this immune system closely resembles

the effects of aging, so asthma progression in older

age it stands out and is heavier. In this study the

proportion of patients at 18-45 years (91.8%), and

those aged ≥ 46 (8.2%), it because asthma symptoms

at the age of ≥46 years heavier and the possibility of

the patient going to the emergency room,

temporarily the study was conducted in polyclinics.

Francisco et al's in 2010 was found that

proportion female asthma patients are > 65% with

aged 15-34 years. Research by Agarwal in 2006

concluded that women, old age, low socio-economic

status, history Atopy tendency, history of parents

with asthma, and smokers are risk factors for the

occurrence of asthma. Puberty is associated with

increased incidence of asthma in women while after

menopause the incidence of asthma is reduced, this

proves that the influence of endogenous hormones

and exogenous roles in asthma. In this study the

Absolute eosinophil count

Controlled

Uncontrolle

Degree of asthma control (PEFR)

Association between Blood Absolute Eosinophil Count with the Degree of Controlled Asthma

proportion of female is 57.1% and most patients do not smoking (83.7%).

Most patients get the first attack before 6 years

old. Boys get more asthma than girls, however at 11

years the prevalence is the same, while after 16

years of age, women (6.2%) were more likely to

suffer from asthma than boys (4.3%). The main risk

factors for asthma in children are, genetic

predisposition, history families with asthma or

allergies, history of parents with atopic disease,

respiratory infections, bacterial colonization, allergic

sensitization and exposure to cigarette race. Asthma

with adult onset varies from 12-65 years, compared

with the onset of children, adult onset still needs

investigation prevalence and risk factors In this

study most patients experienced the first asthma

attack before 12 years of age (55.1%).

One third to half of cases of asthma are caused

by atopy. Atopy can be proven by skin puncture

examination or examination IgE. In this study no

skin pricking tests were carried out IgE examination

so that the tendency of atopy is assessed based on

history history of complaints of patients associated

with atopy. In this research proportion of history of

atopy tendencies of 81% with most complaints of

rhinitis 38.8%, followed by rhinitis accompanied by

dermatitis by 36.7%, and 18.4% patients have never

had atopic complaints. Charpin et al and Wieringa et

al said that a history of atopy was associated with

asthma.

The absolute eosinophils counts increases in

circulation and is associated with asthma severity.

Research conducted by Yousry et al in 2012

Lonnkvist et al in 2001 showed that the absolute

eosinophils counts significantly higher in the asthma

group than in the group of people healthy (p

<0.001). A typical picture of asthma is an increase in

eosinophils peripheral blood. Peripheral blood

eosinophils correlate with the severity of symptoms,

levels limited air flow, and airway hypereactivity.

Suspected that blood eosinophils is an indirect

marker for airway inflammation in asthma. In this

study blood absolute eosinophil counts in the total

controlled group asthma lower than in the partially

controlled asthma group and are not controlled.

The results of this study are in accordance with

previous studies. Sele et al in 2001 found the

absolute eosinophils counts in uncontrolled asthma

hingher than patients with asthma controlled. Yousri

et al in 2012 was found that the absolute eosinophils

counts was significantly higher in patients asthma

with severe attacks compared with mild attack

patients. There is a relationship between the severity

of the asthma attack and the high number peripheral

absolute eosinophils. Fujitaka et all got that the

absolute eosinophils counts is significantly higher in

patients severe asthma compared to mild asthma.

Anna et al stated that asthma patients with high

absolute eosinophil counts have more treatment

background, more frequent exacerbations and worse

asthma control than patients with low blood absolute

eosinophils. Trung et al got the results showed that

patients who had high levels of blood absolute

eosinophils experience more asthma attacks often

compared to patients with absolute blood eosinophil

counts low. In this study it was found that there were

significant mean differences the blood absolute

eosinophils in the group of asthma was totally

controlled and controlled in part, in a total and

uncontrolled controlled group, but the average the

absolute eosinophils counts in a part of the

controlled group does not have significant difference

compared to uncontrolled asthma group.

There is a difference in the blood absolute

eosinophils between controlled and uncontrolled

asthma groups assessed using PEFR, where the

mean absolute eosinophil count in the asthma group

was not controlled more significantly lower than the

controlled asthma group. This discovery showed

that changes in blood eosinophils showed activity

diseases and the number of absolute eosinophils play

an important role in determine the degree of asthma

control.

5. CONCLUSION

There are significant differences in the number of

blood absolute eosinophils counts in asthma totally

controlled group and partially controlled, and

between total controlled and uncontrolled groups

assessed using ACT, the better the degree of asthma

control, the absolute number of eosinophils Getting

lower. There are differences in the number of

absolute eosinophils that are meaningful between a

group of controlled and uncontrolled asthma

assessed using PEFR, where the absolute number of

eosinophils in the asthma group is more controlled

significantly lower than uncontrolled asthma groups.

Increased numbers of absolute blood eosinophils are

associated with asthma not controlled.

REFERENCES

Ardinata D. Eosinofil dan patogenesa asma. Allergy Asthma

Clin Immunol.

2008;2(4):84-90.

Ballweg T, Bufford J, Busse W, Fliegel J, Jackson D, Kim M et

all. Diagnosis

and Management of Asthma -

Adult/Pediatric - Clinical Practice Guideline.

USA. 2013.

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences

Barnes PJ. Pathophysiology of asthma. Eur Respir Mon, 2003, 23,

84-113.

Bernstein JA. Asthma in handbook of allergic disorders.

Philadelphia: Lipincott Williams & Wilkins. USA.

2003.73-102.

Bradding P. Asthma: eosinophil disease, mast cell disease, or

both? Allergy

Asthma Clin Immunol. 2008; 4(2): 84-90.

Busse W, Lemanske FR. Asthma, N Engl J Med, 344, 2001: 350-

62.

Davoodi P, Mahesh PA, Holla AD, Ramachandra NB.

Association of socio-

economic status with family history

in adult patients with asthma. Indian J Med Res

2013;138:497-503.

Departemen Kesehatan RI. Pedoman Pengendalian Penyakit

Asma. Depkes RI.

Jakarta. 2009.

Fujitaka M, Kawaguchi H, Kato Y, Sakura N, Ueda K, Abe Y.

Significance of

the eosinophil cationic protein/eosinophil

count ratio in asthmatic patients: its

relationship to disease

severity. Ann. Allergy Asthma Immunol. 2001; 86: 323 -9.

Gay BG, Parker K. Understanding the Complete Blood Count

With Differential. J of Peri Anesthesia Nursing.

2003;2(18):96-117.

Ghaffari J, Khademloo M, Saffar MJ, Rafiel A, Masiha E.

Hypersensitivity to

house dust mite and cockroach is the

most common allergy in north Iran. Iran J. Immunol.

2010;7:223-34.

Gibson PG, Saltos N, Borgas T. Airway mastcells and

eosinophils correlatewith clinical severity and airway

hyperresponsiveness in corticosteroid-treated asthma. J

Allergy Clin Immunol. 2000;105:752-9.

GINA. Global strategy for asthma management and

prevention. National

nstitutes of Health. Canada. 2007.

Green RH, Brightling CE, McKenna S, Hargadon B, Parker

D, Bradding P,

Wardlaw AJ, Pavord ID. Asthma

exacerbations and sputum eosinophil counts: a

randomised controlled trial. Lancet. 2002 Nov

30;360(9347):1715-21.

Hamid Q, Tulic MK, Liu MC, Moqbel R. Inflammatory

cells inasthma:

Mechanisms and implications for therapy. J

Allergy Clin Immunol. 2003;1:5-17.

Hamri R, Xenakis JJ, Spencer LA. Eosinophils in innate

immunity: an evolving story. Cell TissueRes. 2012;343:57-

83.

Humbert M, Kay AB. Chronic inflammation in asthma. Eur

Respir Mon,

2003;23:126-37.

Jia CE, Zhang HP, Yan LV, Liang R, Jiang YQ, Powell H et al.

Asthmacontrol

test/quistionnaire for assesing asthma

control: systematic review and meta-

analysis. J Allergy Clin Immunol. 2013 Mar;131(3):695-703.

Juniper EF, Gruffydd JK, Ward S, Svensson K. Validation,

measurement

properties and interpretation of the asthma

controll questionnaire in children. Eur Respir J 2010; 36:

1410-6.

Juniper EF, Bosquet J, Abetz L, Bateman ED. Identifying well

controlled and not

well controlled asthma using the

asthma control quistionnaire. Respir Med

2006;100: 616-

21.

Juniper EF, Svensson K, Mork AC, Stahl E. Measurement

properties and

nterpretation of three shortened version

of the asthma control quistionnaire.

Respir Med 2005; 99:

53-8.

Kikkawa,Y,Sugiyama K, Obara K, Hirata H, Fukushima Y,

Toda M, etal.

Interferon-alpha inhibits airway

eosinophilia and hyperresponsiveness in an

animal asthma

model. AsiaPac.Allergy 2012; 2: 256-63.

Koh I, choi IS. Blood eosinophil counts for the prediction of

the severity of

exercise-induced bronchospasmin asthma. J

resp med 2002;96, 120-5.

Kumar RK, Herbert C, Yang M, Koskinen AM, McKenzie AN,

Foster PS. Role of interleukin-13 in eosinophil

accumulation and airway remodelling in a mouse

model of chronic asthma. Clin Exp Allergy 2002; 32(7):

1104-11.

Lee YS, In KH. Immunopathogenesis of Asthma. Tuberc

Respir Dis. 2006

Apr;60(4):379-90.

Liang Z, Zhao H, Y, Li R, Dong H, Liu L, etal. Moderate

accuracy of peripheral

eosinophil count for predicting

eosinophilic phenotype in steroid naive non-

atopic adult asthmatics. Intern.Med. 2012;51:717-22.

Lonnkvist K, Hellman C, Lundahl J, Hallden G, Hedlin G.

Eosinophil markers in blood, serum, and urine for

monitoring the clinical course in childhood asthma:

impact of budesonide treatment and withdrawal. J.

Allergy Clin. Immunol.

2001;107: 812-7.

Molfino NA. Targeting of eosinophils in asthma. ExpertOpin.

Biol.Ther. 2012;

12:807-9.

Obase Y, Shimoda T, Mitsuta K, Matsuo N, Matsuse H, Kohno

S. Correlation

between airway hyperresponsiveness and

airway inflammation in a young adult

population:

eosinophil, ECP, and cytokine levels in induced

sputum. Ann.

Allergy Asthma Immunol. 2001;86: 304-10.

Pereira LMP, Boodoo S, Dindial KA, Hosein A, Seemungal

TAR, Bekele I.

Evaluation of asthma control using patient

based measures and peak expiratory

flow rate. West Indian Med J 2009; 58 (3): 214

Prussin C, Metcalfe DD. IgE, mast cells, basophils, and

eosinophils. J Allergy

Clin Immunol 2003;111:486 -94.

Quaedvlieg V, Sele J, Henket M, Louis R. Association between

asthma control

and bronchial hyperresponsiveness and

airways inflammation: a cross-sectional study in daily

practice. Clin Exp Allergy. 2009;39(12):1822-9.

Rahmawati I, Yunus F, Wiyono HW. Patogenesis dan

patofisiologi asma. Dalam: Cermin Dunia Kedokteran.

Jakarta. 2003;141:5-10.

Ramlie A, Soemarwoto RAS, Wiyono WH. Korelasi antara

asthma control test

dengan VEP

% dalam menentukan

tingkat kontrol asma. J Respir Indo. 2014;

34(2): 95-101.

Rengganis I, Diagnosis dan tatalaksana asma bronkial. Maj

Kedokt Indon. 2008;58 (11): 444-51.

Rigazio A. Raised blood eosinophil levels as an indicator of

prospective asthma

outcomes. dalam: Hoyle B, editor.

2013 Annual Meeting of the American

College of

Allergy, Asthma & Immunology. 2013 Nov 9-12. America.

2013.p53.

Saeed W, Badar A, Hussain MM, Aslam M. Eosinophils and

eosinophil products in asthma. J Ayub Med Coll

Abbottabad. 2002; 14(4): 49-55.

Spector SL, Tan RA. Is a single blood eosinofil count a

reliable marker for

eosinophilic asthma?. J.Asthma.

2012;49:807-10.

Spencer LA, Szela CT, Perez SA, Kirchhoffer CL, Neves JS,

Radke AL, etal.

Human eosinophils constitutively

express multiple Th1, Th2, and

immunoregulatory cytokines that are secreted rapidly

and differentially. J.

Leukoc. Biol. 2009;85:117-23.

Sundaru H, Sukamto. Asma bronkial. Dalam : Sudoyo AW,

Setiyohadi B. Alwi I. Simadribata M, Setiati S, editor. Buku

ajar ilmu penyakit dalam Jilid I. Edisi V.

Jakarta : Balai penerbit Fakultas Kedokteran Indonesia ;

2010. Hal 404-14.

Tran TN, Khatry DB, Ke X, Ward CK, Gossage D. High blood

eosinophil count is associated with more frequent asthma

Association between Blood Absolute Eosinophil Count with the Degree of Controlled Asthma

attacks in asthma patients. Ann Allergy Asthma Immunol.

2014;113(1):19-24.

Wardlaw AJ, Brightling C, Green R, Woltmann G, Pavord I.

Eosinophils in

asthma and other allergic diseases. Br Med

Bull 2000; 56:985-1003.

Wardlaw AJ. Eosinophil trafficking in asthma. Clin Med

JRCPL.2001;1:214-8.

Youroukova VF, Oddera S, Silvestri M, Spallarossa D,

Rossi GA. Blood

eosinophilia and degree of sensitization

to house-dust mites in preschool and

school children with

asthma. J. Asthma. 1998;35: 489-96.

Zohery YZA, Kenawy MA, Awad AA, Helmi N, Shafei AM,

Hamid YMA.

Levels of five biochemical parameters in

asthmatic patient’s blood as markers for

bronchial asthma induced by the house-dust mite allergy.

Egypt. Acad. J. Biolog. Sci. 2012; 4(1)

SKIC-MHS 2018 - The 2nd Syiah Kuala International Conference on Medicine and Health Sciences