Healthcare Management Research Proposal

1. Introduction/ Background to the review: 

Asthma is a health hazard condition regarding long-term inflammation in the airways of the lungs. This process manifests the narrowing, swelling and producing the extra mucus. This causes breathing problems triggering coughing, wheezing and more importantly shortness of breath. Many types of asthma are present involving adult-onset asthma, allergic asthma, asthma-COPD overlap type, Exercise-induced Bronchoconstriction, asthma response from a non-allergic reaction, occupational asthma, etc. In this research methodology, the topic mainly involves regular physical exercise on asthma control for adults (Lopes and Desai, 2019). There is no cure and no established treatment for this condition. But, there are several measures and remedies are present that can reduce the flare-up reactions or symptoms temporarily. This is generally a chronic respiratory disease. Above the age of 50, a serious condition may kill a person.

Various researches were performed to understand the cause of the disease and minimizing the effect. Some current research measures the investigation process regarding the important role of the immune system in asthma. As the inflammation is a signature symptom for an inflammatory reaction, the concern is justified in this regard. Moreover, the studies are also trying to know the effect of mold on severe forms of asthma and most importantly genetic reasons as well as any gene-specific cause behind this condition. The role of those particular genes and respective controlling mechanisms can also be evaluated from this kind of approach. One study showed that a chemical component from red wine also helps to control inflammation in the case of induced bacterial pathogens in the upper respiratory tract (Tanaka et al., 2019). Previous researches also have some interesting findings regarding the issue. One study found that the links of innate as well as adaptive immunity systems with the host genetics and environmental stimuli regarding viral infection on asthma conditions (Li et al, 2019). Moreover, the effects of regular exercise on controlling asthma conditions were also discussed in young adults. In this regard, this is also important to know some form of exercise can worsen the condition leading to wheezing or chest tightness.

2. Literature review:

The relation between asthma and health hazards (political.legal and social issues). The rationale for the proposed review.

 This chronic reaction in a serious condition may kill a person above the age of 50. According to the World Health Organization or WHO, most asthma-related deaths occur in low or lower-middle-income countries or developing countries (Nunes et al., 2017). Statistics also provided information that mainly women are more susceptible to this condition than men.  The chances of death mainly increase with age and also involves the other health condition, mainly respiratory diseases. Asthma is a long-term disease of the lung which may affect the everyday lives of people. Treating asthma means taking medications daily, even though there are no symptoms. It can be tricky. More than half of the patients do not have any control over their asthma. To achieve a higher quality of life, we need ways to enhance that power. The World Health Organization reports that asthma affects 235–250 million people worldwide. About 4.3 percent of the world’s adult population has asthma. Despite advancements in pharmaceutical treatment, inadequate management of asthma tends to lead to a large number of visits as well as hospitalizations to health care and poorer quality of life (Heikkinen et al. 2018).

Asthma is a chronic airway inflammatory condition characterized by an obstruction of the respiratory tract and bronchial hyperresponsiveness (BHR). The most increasing asthma symptoms include coughing, wheezing, tightness in the chest and shortness of breath/breathing. Aerobic exercise also triggers symptoms linked to asthma and can also lead to resistance to asthmatic physical activity. Previously doctors recommended patients with asthma to stop exercise. Regular aerobic exercise, however, has been shown to offer important health benefits to healthy individuals (Jaakkola et al. 2020). However, because of these results, concern has emerged more recently in whether exercise may also be helpful for patients with asthma.

The literature review presented in the study gives an outline of the fact that routine physical activity enhances adult asthma’s physical health; however, the impact of workout on asthma management and quality of life can be huge. The purpose of the study is to throw light on the improvement of asthma control in adults of the United Kingdom by regular physical activities. The study produces a rationale that justifies the fact of how exercise helps in improving the condition of asthma patients along with sound evidence.

According to Jaakkola et al. (2019), globally, it is estimated that more than 300 million individuals of all age groups have asthma disease, a chronic condition marked by inflammation of the airways and symptoms of the breathing. Asthma symptoms vary in character and severity between individuals and over time. Given comprehensive asthma management techniques and available medications, approximately half of the people with asthma are reported to have impaired asthma control. Jalbert, Lavoie, and Bacon (2018) argued that one important way to improve results is to provide a collaborative conversation on diagnosis and asthma management among health care professionals, often abbreviated as HCPs, and patients.

Regulated asthma is characterized by limited to no symptoms at the day and night. No attacks of asthma, no emergency visits to hospitals or physicians, limited need for medications for relief, no restrictions on physical activity and exercise. This has nearly normal functioning of lungs and minimal to no side effects of treatment according to Majd et al. (2018). On the other hand, Lang (2019) states that the global control levels of asthma are suboptimal. It is unclear how daily exercise affects asthma regulation.

A study conducted by Jalbert, Lavoie, and Bacon (2018) reveals that a twelve-week controlled exercise intervention resulted in changes in asthma control including quality of life in partly controlled, exercisable asthmatics. Such results were sustained, while physical health and perceived management of asthma improved dramatically over another twelve weeks of self-administered workout. This suggests that structured exercise can help improve control of the levels of asthma. However, there is no cure for asthma, on the other hand, pharmacological interventions have shown that exercise can regulate and control the levels of asthma.

As per Jaakkola et al. (2020), the severity of daytime symptoms is movement restriction, nocturnal symptoms, need for relief medication, lung function or exacerbations assess asthma control. Therefore patients are categorized as having asthma regulated, partially regulated, or unregulated. Recent statistics indicate that only 23 percent of asthmatics are monitored and 50 percent are not well received, despite specialist treatment. Poor asthma management has been correlated with more trips to emergency departments, doctor visits as well as days spent in hospitals. Heikkinen et al. (2018) stated that healthcare use in physically inactive asthmatics is higher than in physically active asthmatics. This suggests that the active asthmatic patients have better control of asthma, with proper healthcare.

Moreover, Jaakkola et al. (2019) mentioned that exercise interventions help adults improve their asthma control in measures like breathlessness, controller therapy, lung function, quality of life and other factors. However, no direct correlation has yet been identified between asthma control and exercise. Côté, Turmel, and Boulet (2018) opined that the most powerful contributor to asthma control is the activity limitation factor, which involves both physical as well as non-physical activity, indicating that enhancements in aerobic fitness can improve control in partly regulated but physically ineffective asthmatics. To date, scientifically controlled programs have shown the benefits of fitness programs.

Lang (2019) argues that the impacts of these interventions on potential physical activity behaviors are unclear; besides, the effects of exercise programs that are self-administered remain uncertain. For the general section of adults with asthma, self-administered activity may be more budget-effective as well as readily available therapy. If exercise has a beneficial effect on asthma regulation, it could be an effective alternative therapy to prescription medicine for adults in the United Kingdom with poorly controlled asthma and inadequate compliance. Therefore, a greater understanding of the impact of daily exercise on asthma management is imperative and whether or not there is any clinically significant benefit.

 

 

 

3. Aim of the research/ Research question:

 Does regular exercise improve asthma control among young adults?

 

4. Research epistemology/ Methodology:

 The study was conducted with the collaboration of NHS As per NHS, improving health or maintaining it properly adults need to do aerobic and strength exercises every week. As a minimum aged 19-64 should try to be active daily and should do(Janssens et al., 2018). Moreover, 2 and hours of moderate aerobics or cycling or fast walking help in this process. 

In this case, a 24 weeks exercise plan was implemented taking the age group between 18- 37 young adults.  The sample size or the number of patients was 250. Asthma control was assessed by the occurrence of asthma-related symptoms including wheezing, coughing or sometimes shortness of breath and phlegm production during a total period of 1 year. Asthma symptoms score was calculated based on the reported frequency of occurrence of the above-mentioned symptoms. Exercise follower hours/ week format. In the case of a population group, adults with mild or moderate levels were selected in this regard. One group was considered as IG group or intervention group or the reference group (control) RG. In the case of the exercise protocol, at least three times a week for more than 30 minutes were proposed. The protocol was standardized for 2-3 hours/week for the control group and four and a half hours for an experimental reference group per week basis. Then the calculation was converted in hours/week(Teach et al., 2016).  Aerobic exercise, muscle stretching, muscle training, walking were implemented. The asthma control test (ACT) was performed. Moreover, asthma-related symptoms with proper detection and peak of expiratory flow or PEF activity were measured.

In this regard, the risk of improvement or health hazards in asthma control or the risk difference between IG and Rg was also investigated.

To perform this experiment initially enrollment of patients was done maintaining every aspect and ethical factor. The inclusion and exclusion process was implemented to maintain the proper protocol. Eligible candidates were random based on sex, location, and types of asthma. Basic treatment was there to avoid any critical condition or handle an emergency(Jaakkola te al., 2020). Besides, a compulsory follow up was implemented after every week to assess fitness.  Asthma is a heterogeneous condition having several symptoms in a collaborative manner. In this aspect, anti-medication asthmatic medication impairment prohibited to affect the method. Danish personal Identification Number or CPR number format was used to extract the information regarding a patient's history of the disease. Past exposure to any kind of anti-asthmatic medicine was also recorded. As this is a physiological condition so numerous internal and external factors would be involved. This would be different for different kinds of patients and is an inflammatory reaction, several cofactors, and inflammatory cytokines, signaling molecules, are involved with the help of T helper cells and macrophages(Pelton et al., 2019). They are also different patterns for every individual. These concerns were eliminated to make the process uniform(Heikkinen et al., 2018). Only physical aspects were considered no gene-level expression and internal factors were assessed for this. Further experiments can be conducted from the help of this study. Airway limitation and airway reactivity were also controlled involving breathing issues. Their basic lung functions and lifestyle parameters were also recorded as reference. To establish the outcomes a blood test with eosinophil and neutrophil can be counted as mutually exclusive subtypes in asthma with the excess amount.

 

5. Research Design:

5.1 Data sourcing/ search strategy

In the case of the ACT test, a patient was provided with a self-administered tool with basic questions initially. The questions were as follows:

  1. In the past week how much of the time was occupied for asthma symptoms and relative health trouble?
  2.  During the past week, how often was shortness of breath felt?
  3. What was the approximate duration of the above-mentioned condition?
  4. During the past one week how often did any asthma symptoms like wheezing, coughing, shortness of breath, chest tightness, or chest pain wake the patient up at night or earlier than usual morning awakening?
  5. During the past week, how often did patients use any kind of nebulizer or inhaler?
  6. Based on self-perception, what was the rate of asthma control during last week?
  7. As per the regular exercise did the condition worsen with time or get better from the patient's point of view?

These were the basic questions to follow with a five-point scale for symptoms and activities from low condition =5 to severe condition all time hazards =1 (Segura-Navas et l., 2018). Not controlled cases signified the number 1 and significantly controlled cases would be number 5 .

PEF activity mainly followed the measurement of how fast air came out of the lungs after one full cycle of forceful exhalation as well as inhalation. But this process was not standardized properly. It is affected by variable parameters. So prior to proceeding over the experiment a proper standardization was conducted involving the patient's height, age, and gender. All factors were involved in that due course.

In the case of a differential blood count test, the blood sample was collected at the initial stage of experiments and after the completion of the experimental phase. That was a lab-based technique with stains to differentiate the types of white blood cells in the sample. Using a microscope the number could be counted(Johnston et al., 2016). To avoid the error statistical approaches could be involved and at least three times counting with choosing different filed form slides would be followed.

 

5.2 Justification of the method

The method and the experimental process were standardized protocols in case of asthma studies. For regular exercise procedures, ACT surveys were considered as a basic informal approach to getting the outline. But a formal approach was applied using the blood test count and the PEF activity(Hancox et al., 2016). These patterns of methods are generally followed and popular in the case of various asthma studies worldwide. Moreover, the ethical concern can be easily implemented to follow this process. This process with a limited sample size (initially n=250) is very effective to understand the process. Though some consideration was followed to avoid the complexity and interference of those parameters.

5.3 Included format and excluded format. (The reason behind the exclusion)

 Inclusion Criteria

Inclusion criteria were initially focused on the age group. The target age group was selected between 18-37 years for this study. Higher age groups are more susceptible to severe forms of the disease. As the severe form was not considered for the involvement of many medications. The age group was suitable for the desired criteria.  Moreover, the diagnosis was performed for a lung condition in the case of individual patients to know and understand their lung functionality and condition for exercise as well as that state. A mild or moderate form of asthma was included. Both genders were considered except pregnant women. The reimbursement right for asthma medication from NHS guideline was followed as per the Health and Social care Act, 2012.  In the case of a newly diagnosed form of asthma, the NHS outline was implemented for further investigation considering the severity. In this regard, proper actions were taken to maintain the temperature and pollution measure in the surrounding atmosphere(Greenberg et al., 2016). Reliever inhaler and preventer inhaler involvement were also considered in this aspect. The NICE quality standard was maintained throughout the process.

Exclusion Criteria:

Exclusion criteria were initially measured based on age. As much documentation supports the fact that the above age of 50, the condition may get worse with other physiological states. So the age group was chosen form 18-37 considering the active young age to get the best value from exercise(Selberg et al., 2019). Again, any pregnant female candidate was not entertained as medication and pregnant conditions can impair the asthma symptoms. Moreover, the exercise may be a difficult course for target candidates. In this regard, the exclusion criteria also involved the magnitude of the asthma condition. Severe cases were not included. Not only that patients with other physiological diseases were not selected as that condition could interfere with the process. In this regard, the FEVI baseline < 60>30% at least 2 times during a week monitoring period. The use of short-acting bronchodilator medications at least 4 times per day was not included and permanent daily oral steroid treatment was not encouraged to be involved in this process(White et al., 2017). Forced expiratory volume or forced vital capacity were measured 10 min following the aerobic test with the PEF test. The data was collected just as a reference value and was not used for analysis. The PEF rate was only considered with the obtained data.

6.  Data analysis

Ethical considerations were followed properly. The patients were selected as per their consent. Their agreements were considered based on the experimental protocol. No data was revealed without their permission. They were fully aware of the process and they know the whole procedure was conducted for an experimental purpose. It was assured that no harm was caused due to these experiments. A proper medical team would be present throughout the process. Among 250 whole sample size, 164 candidates selected based on the desired criteria. Effective sample size 164. They were divided into a control and experimental group. Moreover, the first stage diagnosis proceeded to screen out disqualified candidates  So, the value was determined as n1=67 and n2=64 finally.  Every time the stage was involved a spirometry testing to evaluate their physical condition.  The mean amount of exercise during this study period was at least 2 to 3 hours in case of control group nad 4 and half hours for reference experimental groups, where Sd value was 3.03 and 3.12 respectively (p=0.049). The Asthma score was reduced by 0.09 points per 1 hour of exercise/ week (95% CI: 0 to 0.17).  The low exercise showed not so improvement in the case of their respective physiological condition. The improvement was temporary, not standardized, having a good value of the PEF test and blood count test. They were considered as references. The control group with 3hours exercise showed a moderate elevation in their physical aspects score by 0.66 (CI 95%: -0.39 to 1.72) and the experimental group resulted in expected beneficial ways and asthma condition was reduced significantly by 1.13 (0.33 to 2.22). The value was recorded for further analysis. The effective differential blood count was determined to support the value to make the process effective.

BMI was also measured in this regard to show the effectiveness of the protocol. The results from every experiment showed positive results as per the procedure. Regular exercise and the baseline ACT showed generalized linear form with statistical significant value (0.256, 85% CI 0.047 -0.489, p=0.016). No asthma rescue medication was provided so that no interference occurred. The emergency situation was opposite and exceptional, those cases were not considered in this regard. ACT, self-administered tool value showed near about 15 (nor more than 15 ) for the control group of patients. In the case of the experimental group, the values were between 15-20. In the case of peak flow, the rate was in between 80-100 liter/minute in the case of the reference group. Eosinophil and neutrophil value was a little higher than the normal value. That was not so significant in the moderate case of asthma patients.

 

7. Discussion

The act test reliability was 0.77. Validation has proceeded with other diagnoses and FEV1 protocol. The value, in this case, showed that marginally less than the effectively controlled condition as 23-25. The value was limited under 20 so the condition was considered a well-controlled group. Moreover in the case of the control group the values were not effective with the performance as expected. So they showed below the control level. In the case of value 5, it is generally considered as poorly controlled. But no patient showed that in terms of moderate asthma condition with variable time on exercise exposure. In case PEF values the range 80-100 with the desired value considering the condition. Few persons show a value of higher than 100 but that was not under statistical significant analysis. Hence it was not considered. The normal value for PEF in healthy humans is generally measured as 400-700 liter/ minute where men have the value on the little higher side than the women. These women have a value of 80 liters/min. This condition can also be said under control. The effectivity also performed with a medical check-up and considering other physiological factors. The differential white blood cell count was performed. The normal range for healthy adult eosinophil - 1-4% and neutrophil 40-60%. But the resulting value for the reference group and controlled group did not have any statistical significance with all the persons or considering the majority. In the case of a few people, the value was elevated to 6-7% in the case of eosinophil and 65-75% for neutrophil. In case of severe neutrophilic or eosinophilic asthma the condition gets worse and causes severe harm. The normal range of neutrophil has a count of 2,500-6000 cells /dl of blood. In the case of neutrophilic and eosinophilic asthma conditions, the tracheal aspirates showed a huge elevation of 10 times higher than normal. That showed the severity or intensity of the condition. However, in this case, such an occurrence was not noticed. Not only that but also in case of patient questionnaire format they also provided positive answers concerning the improvement with times. In case of PEF peak the green zone for asthma patients implies the value of 80-100% of normal peak flow and is considered as reasonably good control. In the control group of patients the value was under the yellow group having 50-80 with moderately controlled. Generally the value below 50 is considered as severe and falls under the red zone. The early postexercise response generally showed a fall in the value but late response was satisfactory in this measure. In this regard, the peak expiratory (or inspiratory) flow rate signifies the maximum flow  at which a tidal volume breath is delivered or considering the expiration it can be said how fast one person can exhale. This peak flow in this regard can show ealy result or low result depending on particular circumstances

 

8. The timescale of the research

 

First month - first 4 weeks

Second month- 4 weeks

Third month-4 weeks

Fourth month - 4 weeks

Fifth month - 4 weeks 

Sixth month- last 4 weeks

Task1- standardization of protocol

           

Task2- Basic diagnosis

           

Task3- First screening out

           

Task4- Exercise process started

           

Task-5 

The end of experiment and data analysis

           

Table1: Gnatt Chart for experiment schdeule

Source: (created by learner)

9. The estimated cost of the research

Generally asthma case study needs to invest $2000 to $45000 considering the protocol, the sample size , medicational support, incubation period, exercise types, additional health hazard condition, basic necessity for patients and experimental expense.

 

Event 

 Cost ($)

Standardized protocol with ethical  permission from authorized institution

 550

Medicinal support

7500

Experimental expense

8000

Emergency health service

2000

Basic necessity

7200

Exercise protocol

1000

Total Expense

26250

Table2: Research Budget

Source: (created by learner)

 10. Conclusion

 The study helped to understand the condition concerning a chronic inflammatory disease, asthma. The study also analyzed factors such as the age based condition or severity. The study mainly helped to understand the role of regular exercise in the asthma patients. By providing positive outcomes and various results supporting the hypothetical fact that  a regular and proper exercise has  beneficial side in case of asthma condition. From the above condition it can easily be concluded that regular exercise should be considered as self management clinical practice in asthma. Moreover, further analysis can be done based on the outcome from this study. The practice of regular exercise not only takes care of the asthma condition but also boosts up the physical condition. Better BMI level and better heart condition also can be resulted. The detailed analysis should be performed in terms of physiological factors concerning the actual factor behind this result. As a chronic condition, that can be controlled with such good practice implementing in daily life. Such measures can be implemented considering other physiological conditions.

 

 

Referemce

Janssens, T., Dupont, L. and Von Leupoldt, A., 2018. Exercise fear-avoidance beliefs and self-reported physical activity in young adults with asthma and healthy controls.

Hancox, R.J., Gray, A.R., Poulton, R. and Sears, M.R., 2016. The effect of cigarette smoking on lung function in young adults with asthma. American journal of respiratory and critical care medicine194(3), pp.276-284.

Heikkinen, S.A., Mäkikyrö, E.M., Hugg, T.T., Jaakkola, M.S. and Jaakkola, J.J., 2018. Effects of regular exercise on asthma control in young adults. Journal of Asthma55(7), pp.726-733.

Selberg, S., Hedman, L., Jansson, S.A., Backman, H. and Stridsman, C., 2019. Asthma control and acute healthcare visits among young adults with asthma—A population?based study. Journal of advanced nursing75(12), pp.3525-3534.

White, E.C., de Klerk, N., Hantos, Z., Priston, M., Hollams, E.M., James, A., Sly, P.D., Holt, P.G. and Hall, G.L., 2017. Mannitol challenge testing for asthma in a community cohort of young adults. Respirology22(4), pp.678-683.

Pelton, S.I., Shea, K.M., Bornheimer, R., Sato, R. and Weycker, D., 2019. Pneumonia in young adults with asthma: impact on subsequent asthma exacerbations. Journal of asthma and allergy12, p.95.

Greenberg, N., Carel, R.S., Derazne, E., Bibi, H., Shpriz, M., Tzur, D. and Portnov, B.A., 2016. Different effects of long-term exposures to SO2 and NO2 air pollutants on asthma severity in young adults. Journal of Toxicology and Environmental Health, Part A79(8), pp.342-351.

Segura-Navas, L., Arnedo-Pena, A., Tosca-Segura, R., Romeu-García, M.A., Meseguer-Ferrer, N., Silvestre-Silvestre, E., Conde, F., Fernández-González, S., Dubon, M., Ortuño-Forcada, M. and Fabregat-Puerto, J., 2018. Incidence of asthma in young adults from Castellon, Spain: a prospective cohort study. Allergologia et immunopathologia46(2), pp.112-118.

Johnston, S.L., Szigeti, M., Cross, M., Brightling, C., Chaudhuri, R., Harrison, T., Mansur, A., Robison, L., Sattar, Z., Jackson, D. and Mallia, P., 2016. Azithromycin for acute exacerbations of asthma: the AZALEA randomized clinical trial. JAMA internal medicine176(11), pp.1630-1637.

Teach, S.J., Shelef, D.Q., Fousheé, N., Horn, I.B., Yadav, K., Wang, Y., Rand, C.S. and Streisand, R., 2019. Randomized clinical trial of parental psychosocial stress management to improve asthma outcomes. Journal of Asthma, pp.1-12.

Jaakkola, M.S., Aalto, S.A., Hyrkäs-Palmu, H. and Jaakkola, J.J., 2020. Association between regular exercise and asthma control among adults: The population-based Northern Finnish Asthma Study. PloS one15(1), p.e0227983.

Li, X., Hastie, A.T., Peters, M.C., Hawkins, G.A., Li, H., Moore, W.C., Castro, M., Gaston, B., Israel, E., Jarjour, N.N. and Levy, B.D., 2019. Investigation of IL-6 and IL-6R levels as Biomarkers for Asthma Severity and Asthma Exacerbations. In B21. SEVERE ASTHMA: CLINICAL AND MECHANISTIC STUDIES (pp. A2687-A2687). American Thoracic Society.

Nunes, C., Pereira, A.M. and Morais-Almeida, M., 2017. Asthma costs and social impact. Asthma research and practice3(1), p.1.

Tanaka, T., Iuchi, A., Harada, H. and Hashimoto, S., 2019. Potential beneficial effects of wine flavonoids on allergic diseases. Diseases7(1), p.8.

Lopes, J.P. and Desai, M., 2019. Biologics for Asthma and Risk of Infection: Cause for Concern?. Immunology and Allergy Clinics39(3), pp.429-445.

Côté, A., Turmel, J. and Boulet, L.P., 2018, February. Exercise and asthma. In Seminars in respiratory and critical care medicine (Vol. 39, No. 01, pp. 019-028). Thieme Medical Publishers.

Heikkinen, S.A., Mäkikyrö, E.M., Hugg, T.T., Jaakkola, M.S. and Jaakkola, J.J., 2018. Effects of regular exercise on asthma control in young adults. Journal of Asthma55(7), pp.726-733.

Jaakkola, J.J., Aalto, S.A., Hernberg, S., Kiihamäki, S.P. and Jaakkola, M.S., 2019. Regular exercise improves asthma control in adults: A randomized controlled trial. Scientific reports9(1), pp.1-11.

Jaakkola, M.S., Aalto, S.A., Hyrkäs-Palmu, H. and Jaakkola, J.J., 2020. Association between regular exercise and asthma control among adults: The population-based Northern Finnish Asthma Study. PloS one15(1), p.e0227983.

Jalbert, A.C., Lavoie, K. and Bacon, S., 2018. Effects of aerobic exercise on asthma control in eosinophilic asthma patients: a randomized controlled trial.

Lang, J.E., 2019. The impact of exercise on asthma. Current opinion in allergy and clinical immunology19(2), pp.118-125.

Majd, S., Singh, S., Bradding, P., Hewitt, S., Apps, L., Murphy, A., Green, R. and Evans, R., 2018. Exercise training and airway inflammation in severe-asthma: results from a feasibility study.

 

 

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