151
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Beigelman A, Rosas-Salazar C, Hartert TV. Childhood Asthma: Is It All About Bacteria and Not About Viruses? A Pro/Con Debate. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:719-725. [PMID: 29339131 PMCID: PMC5948130 DOI: 10.1016/j.jaip.2017.11.020] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2017] [Revised: 11/14/2017] [Accepted: 11/18/2017] [Indexed: 12/18/2022]
Affiliation(s)
- Avraham Beigelman
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine, St Louis, Mo.
| | - Christian Rosas-Salazar
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, Department of Pediatrics, Vanderbilt University School of Medicine, Nashville, Tenn
| | - Tina V Hartert
- Division of Allergy, Pulmonary, and Critical Care Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tenn.
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152
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Naja AS, Permaul P, Phipatanakul W. Taming Asthma in School-Aged Children: A Comprehensive Review. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2018; 6:726-735. [PMID: 29747980 PMCID: PMC5953205 DOI: 10.1016/j.jaip.2018.01.023] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2017] [Revised: 01/23/2018] [Accepted: 01/24/2018] [Indexed: 12/14/2022]
Abstract
Asthma is the most common chronic disease of childhood and the leading cause of childhood morbidity as measured by school absences, emergency department visits, and hospitalizations. Multiple factors play a role in the development, treatment and prevention of childhood asthma including racial/ethnic and socioeconomic disparities, both the home and school environments, and medication use. The goals of this review are to summarize these aspects of asthma in school-aged children and to present an updated review of medications as it relates to treatment strategies that will help in the care of these children. We conclude that phenotypic heterogeneity and appropriate environmental assessments and interventions are important considerations in the management of childhood asthma.
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Affiliation(s)
- Ahmad Salaheddine Naja
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Lebanese American University, Beirut, Lebanon
| | - Perdita Permaul
- Harvard Medical School, Boston, Mass; Division of Pediatric Allergy and Immunology, Massachusetts General Hospital for Children, Boston, Mass
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, Boston, Mass; Harvard Medical School, Boston, Mass.
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153
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Chipps BE, Bacharier LB, Farrar JR, Jackson DJ, Murphy KR, Phipatanakul W, Szefler SJ, Teague WG, Zeiger RS. The pediatric asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for children with inadequately controlled asthma. Ann Allergy Asthma Immunol 2018; 120:559-579.e11. [PMID: 29653238 DOI: 10.1016/j.anai.2018.04.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/31/2018] [Accepted: 04/03/2018] [Indexed: 12/29/2022]
Abstract
Current asthma guidelines recommend a control-based approach to management involving assessment of impairment and risk followed by implementation of treatment strategies individualized according to the patient's needs and preferences. However, for children with asthma, achieving control can be elusive. Although tools are available to help children (and families) track and manage day-to-day symptoms, when and how to implement a longer-term step-up in care is less clear. Furthermore, treatment is challenged by the 3 age groups of childhood-adolescence (12-18 years old), school age (6-11 years old), and young children (≤5 years old)-and what works for 1 age group might not be the best approach for another. The Pediatric Asthma Yardstick provides an in-depth assessment of when and how to step-up therapy for the child with not well or poorly controlled asthma. Development of this tool follows others in the Yardstick series, presenting patient profiles and step-up strategies based on current guidance documents, but modified according to newer data and the authors' combined clinical experience. The objective is to provide clinicians who treat children with asthma practical and clinically relevant recommendations for each step-up and each intervention, with the intent of helping practitioners better treat their pediatric patients with asthma, particularly those who do not always respond to recommended therapies.
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Affiliation(s)
- Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Missouri
| | | | - Daniel J Jackson
- University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin
| | - Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - Wanda Phipatanakul
- Allergy, Asthma, Immunology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Stanley J Szefler
- Breathing Institute, Children's Hospital of Colorado and Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colorado
| | - W Gerald Teague
- Division of Pediatric Respiratory Medicine and Allergy, University of Virginia Children's Hospital, Charlottesville, Virginia
| | - Robert S Zeiger
- Department of Allergy and Research and Evaluation, Kaiser Permanente Southern California Region, San Diego and Pasadena, California
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154
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Khetan R, Hurley M, Neduvamkunnil A, Bhatt JM. Fifteen-minute consultation: An evidence-based approach to the child with preschool wheeze. Arch Dis Child Educ Pract Ed 2018; 103:7-14. [PMID: 28667045 DOI: 10.1136/archdischild-2016-311254] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2016] [Revised: 12/02/2016] [Accepted: 04/04/2017] [Indexed: 11/04/2022]
Abstract
Preschool wheeze is very common and its prevalence is increasing. It consumes considerable healthcare resources and has a major impact on children and their families due to significant morbidity associated with acute episodes.History taking is the main diagnostic instrument in the assessment of preschool wheeze. Diagnosis and management is complicated by a broad differential and associations with many other diseases and conditions that give rise to noisy breathing, which could be misinterpreted as wheeze. Several clinical phenotypes have been described but they have limitations and do not clearly inform therapeutic decisions. New insights in aetiopathogenesis modify treatment options and lay foundation for further research. An understanding of the approach and available evidence to assess and manage wheeze informs best patient care and use of resources.Our objective is to demonstrate a focused history, examination and management options in a preschool child with wheeze.
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Affiliation(s)
- Renu Khetan
- Department of Paediatrics, Nottingham Children's Hospital, Nottingham, UK
| | - Matthew Hurley
- Department of Paediatrics, Nottingham Children's Hospital, Nottingham, UK.,Division of Child Health, University of Nottingham, Nottingham, UK
| | | | - Jayesh Mahendra Bhatt
- Department of Paediatrics, Nottingham Children's Hospital, Nottingham, UK.,Nottingham Children's Hospital, National Paediatric Ataxia Telangiectasia Clinic, Nottingham, UK
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155
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Edwards MR, Walton RP, Jackson DJ, Feleszko W, Skevaki C, Jartti T, Makrinoti H, Nikonova A, Shilovskiy IP, Schwarze J, Johnston SL, Khaitov MR. The potential of anti-infectives and immunomodulators as therapies for asthma and asthma exacerbations. Allergy 2018; 73:50-63. [PMID: 28722755 PMCID: PMC7159495 DOI: 10.1111/all.13257] [Citation(s) in RCA: 38] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2017] [Indexed: 12/30/2022]
Abstract
Asthma is responsible for approximately 25,000 deaths annually in Europe despite available medicines that maintain asthma control and reduce asthma exacerbations. Better treatments are urgently needed for the control of chronic asthma and reduction in asthma exacerbations, the major cause of asthma mortality. Much research spanning >20 years shows a strong association between microorganisms including pathogens in asthma onset, severity and exacerbation, yet with the exception of antibiotics, few treatments are available that specifically target the offending pathogens. Recent insights into the microbiome suggest that modulating commensal organisms within the gut or lung may also be a possible way to treat/prevent asthma. The European Academy of Allergy & Clinical Immunology Task Force on Anti-infectives in Asthma was initiated to investigate the potential of anti-infectives and immunomodulators in asthma. This review provides a concise summary of the current literature and aimed to identify and address key questions that concern the use of anti-infectives and both microbe- and host-based immunomodulators and their feasibility for use in asthma.
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Affiliation(s)
- M. R. Edwards
- Airway Disease Infection Section National Heart Lung Institute Imperial College London London UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma London UK
| | - R. P. Walton
- Airway Disease Infection Section National Heart Lung Institute Imperial College London London UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma London UK
| | - D. J. Jackson
- Airway Disease Infection Section National Heart Lung Institute Imperial College London London UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma London UK
- Division of Asthma, Allergy & Lung Biology King's College London & Guy's and St Thomas' NHS Trust London UK
| | - W. Feleszko
- Department of Pediatric Respiratory Diseases and Allergy The Medical University of Warsaw Warsaw Poland
| | - C. Skevaki
- Institute of Laboratory Medicine and Pathobiochemistry, Molecular Diagnostics Philipps University Marburg & University Hospital Giessen Marburg Germany
| | - T. Jartti
- The Department of Pediatrics Turku University Hospital Turku Finland
| | - H. Makrinoti
- Airway Disease Infection Section National Heart Lung Institute Imperial College London London UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma London UK
| | - A. Nikonova
- National Research Center Institute of Immunology of Federal Medicobiological Agency Moscow Russia
- Mechnikov Research Institute of Vaccines and Sera Moscow Russia
| | - I. P. Shilovskiy
- National Research Center Institute of Immunology of Federal Medicobiological Agency Moscow Russia
| | - J. Schwarze
- Centre for Inflammation Research University of Edinburgh The Queens Medical Research Institute Edinburgh Edinburgh UK
| | - S. L. Johnston
- Airway Disease Infection Section National Heart Lung Institute Imperial College London London UK
- MRC and Asthma UK Centre for Allergic Mechanisms of Asthma London UK
| | - M. R. Khaitov
- National Research Center Institute of Immunology of Federal Medicobiological Agency Moscow Russia
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156
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Abstract
Asthma is the most common chronic disease in children. As suggested by international guidelines, the main goals of asthma treatment are symptoms control and lung function preservation, through a stepwise and control-based approach. The first line therapy based on inhaled corticosteroids may fail to reach control in more than one third of patients, especially adolescents, and in these lung function and quality of life may progressively worsen. Treatment with omalizumab, the first anti-immunoglobulin E recombinant humanized monoclonal antibody, has been definitely approved in pediatric uncontrolled asthma. In this review, we discuss the mechanisms and potential roles of emerging therapies for pediatric severe asthma. Novel biologic drugs (i.e., dupilumab, mepolizumab, reslizumab, and benralizumab) seem to be promising in reducing annual exacerbation rates and steroid-use in glucocorticoid-dependent cases, but available data are few and limited to adolescents and adults. Evidences on the use of the muscarinic antagonist tiotropium as controller medication in pediatric settings are progressively growing, sustaining an application as asthma maintenance treatment in children aged >6 years and in preschool children with persistent asthmatic symptoms, but well powered trials are needed to confirm its safety and efficacy. New inhaled corticosteroids (i.e., ciclesonide and mometasone) are effective as once-daily controller therapy, but long-term studies in the different pediatric ages are needed to compare effectiveness and safety to usual treatments. At present, the role of macrolides in pediatric severe asthma is controversial and their administration is not recommended routinely, but may be considered in children with neutrophilic asthma for reducing daily oral steroids administration and improving lung function. Despite the availability of several novel therapeutic strategies for uncontrolled asthma, future trials targeted at specific pediatric age subgroups are needed to support evidences of safety and efficacy also in children.
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Affiliation(s)
- Marco Maglione
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
| | - Marco Poeta
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Naples, Italy.,Department of Pediatrics, Federico II University, Naples, Italy
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157
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Gur M, Hakim F, Bentur L. Better understanding of childhood asthma, towards primary prevention - are we there yet? Consideration of pertinent literature. F1000Res 2017; 6:2152. [PMID: 29333254 PMCID: PMC5749133 DOI: 10.12688/f1000research.11601.1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/14/2017] [Indexed: 12/24/2022] Open
Abstract
Asthma is a chronic disease, characterized by reversible airway obstruction, airway inflammation and hyper-reactivity. The prevalence of asthma has risen dramatically over the past decade, affecting around 300,000,000 people. The etiology is multifactorial, with genetic, epigenetic, developmental and environmental factors playing a role. A complex interaction between the intrauterine environment, the developing immune system, the infant's microbiome and infectious organisms may lead to the development of allergic sensitization and asthma. Thus, a large number of studies have investigated the risk factors for childhood asthma, with a meticulous search of modifiable factors that could aid in primary prevention. We present a current literature review from 2014-2017, as well as older classic publications, on the pathogenesis and the potential modifiable factors for primary prevention of asthma. No ideal preventive measure has yet been found. Rather, creating favorable prenatal and postnatal environments, minimal exposure to hostile environmental factors, prevention of infections in early life, allergic desensitization and nutritional modifications could possibly reduce asthma inception. In the era of personalized medicine, identifying individual risk factors and tailoring specific preventive measures is warranted.
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Affiliation(s)
- Michal Gur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Fahed Hakim
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Lea Bentur
- Pediatric Pulmonary Institute and CF Center, Rappaport Children's Hospital, Rambam Health Care Campus, Haifa, Israel.,Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
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158
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Benefits and Risks of Long-Term Asthma Management in Children: Where Are We Heading? Drug Saf 2017; 40:201-210. [PMID: 27928727 DOI: 10.1007/s40264-016-0483-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
International guidelines provide recommendations for a stepwise approach to the management of asthma in children 0-4 years old, 5-11 years old, and adolescents who are treated as adults. Therapy is aimed at two domains of control: current impairment and future risk. The long-term controller medications, inhaled corticosteroids (ICSs), ICSs in combination with long-acting β2 agonists, leukotriene receptor antagonists, and immunomodulators, exhibit different efficacies for these domains. The risk:benefit ratios of the available medications need to be carefully assessed. This review briefly presents the benefits and the potential risks of available asthma medications in children to assist the practitioner in the optimal use of asthma medications. Specifically, the systemic activity of the ICSs and how to minimize their effects on growth and adrenal activity are reviewed as well as other potential adverse effects. Dosing strategies such as intermittent therapy are also assessed.
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159
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Gern JE. Respiratory Syncytial Virus Bronchiolitis: Enter the Microbiome. Am J Respir Crit Care Med 2017; 194:1044-1045. [PMID: 27797613 DOI: 10.1164/rccm.201605-1018ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- James E Gern
- 1 School of Medicine and Public Health University of Wisconsin-Madison Madison, Wisconsin
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160
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McConnell K, Shields M. Azithromycin for episodes with asthma-like symptoms in young children aged 1-3 years. Arch Dis Child Educ Pract Ed 2017; 102:336. [PMID: 28735295 DOI: 10.1136/archdischild-2016-311409] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Affiliation(s)
- Katy McConnell
- Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, UK
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161
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Williams DJ, Edwards KM, Self WH, Zhu Y, Arnold SR, McCullers JA, Ampofo K, Pavia AT, Anderson EJ, Hicks LA, Bramley AM, Jain S, Grijalva CG. Effectiveness of β-Lactam Monotherapy vs Macrolide Combination Therapy for Children Hospitalized With Pneumonia. JAMA Pediatr 2017; 171:1184-1191. [PMID: 29084336 PMCID: PMC6583650 DOI: 10.1001/jamapediatrics.2017.3225] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
IMPORTANCE β-Lactam monotherapy and β-lactam plus macrolide combination therapy are both common empirical treatment strategies for children hospitalized with pneumonia, but few studies have evaluated the effectiveness of these 2 treatment approaches. OBJECTIVE To compare the effectiveness of β-lactam monotherapy vs β-lactam plus macrolide combination therapy among a cohort of children hospitalized with pneumonia. DESIGN, SETTING, AND PARTICIPANTS We analyzed data from the Etiology of Pneumonia in the Community Study, a multicenter, prospective, population-based study of community-acquired pneumonia hospitalizations conducted from January 1, 2010, to June 30, 2012, in 3 children's hospitals in Nashville, Tennessee; Memphis, Tennessee; and Salt Lake City, Utah. The study included all children (up to 18 years of age) who were hospitalized with radiographically confirmed pneumonia and who received β-lactam monotherapy or β-lactam plus macrolide combination therapy. Data analysis was completed in April 2017. MAIN OUTCOMES AND MEASURES We defined the referent as β-lactam monotherapy, including exclusive use of an oral or parenteral second- or third-generation cephalosporin, penicillin, ampicillin, ampicillin-sulbactam, amoxicillin, or amoxicillin-clavulanate. Use of a β-lactam plus an oral or parenteral macrolide (azithromycin or clarithromycin) served as the comparison group. We modeled the association between these groups and patients' length of stay using multivariable Cox proportional hazards regression. Covariates included demographic, clinical, and radiographic variables. We further evaluated length of stay in a cohort matched by propensity to receive combination therapy. Logistic regression was used to evaluate secondary outcomes in the unmatched cohort, including intensive care admission, rehospitalizations, and self-reported recovery at follow-up. RESULTS Our study included 1418 children (693 girls and 725 boys) with a median age of 27 months (interquartile range, 12-69 months). This cohort was 60.1% of the 2358 children enrolled in the Etiology of Pneumonia in the Community Study with radiographically confirmed pneumonia in the study period; 1019 (71.9%) received β-lactam monotherapy and 399 (28.1%) received β-lactam plus macrolide combination therapy. In the unmatched cohort, there was no statistically significant difference in length of hospital stay between children receiving β-lactam monotherapy and combination therapy (median, 55 vs 59 hours; adjusted hazard ratio, 0.87; 95% CI, 0.74-1.01). The propensity-matched cohort (n = 560, 39.5%) showed similar results. There were also no significant differences between treatment groups for the secondary outcomes. CONCLUSIONS AND RELEVANCE Empirical macrolide combination therapy conferred no benefit over β-lactam monotherapy for children hospitalized with community-acquired pneumonia. The results of this study elicit questions about the routine empirical use of macrolide combination therapy in this population.
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Affiliation(s)
- Derek J. Williams
- Division of Hospital Medicine, Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center, Nashville, Tennessee,The Vanderbilt Vaccine Research Program, Department of Pediatrics, Vanderbilt University Medical Center, Nashville
| | - Kathryn M. Edwards
- Division of Infectious Diseases, Monroe Carell Jr. Children’s Hospital, Vanderbilt University Medical Center, Nashville, Tennessee,The Vanderbilt Vaccine Research Program, Department of Pediatrics, Vanderbilt University Medical Center, Nashville
| | - Wesley H. Self
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Yuwei Zhu
- Division of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sandra R. Arnold
- Division of Infectious Diseases, Le Bonheur Children’s Hospital, Memphis, Tennessee,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis
| | - Jonathan A. McCullers
- Division of Infectious Diseases, Le Bonheur Children’s Hospital, Memphis, Tennessee,Department of Pediatrics, University of Tennessee Health Sciences Center, Memphis
| | - Krow Ampofo
- Division of Infectious Diseases, Primary Children’s Medical Center, Salt Lake City, Utah
| | - Andrew T. Pavia
- Division of Infectious Diseases, Primary Children’s Medical Center, Salt Lake City, Utah,Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Evan J. Anderson
- Division of Infectious Diseases, Departments of Medicine and Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - Lauri A. Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Anna M. Bramley
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Seema Jain
- Centers for Disease Control and Prevention, Atlanta, Georgia
| | - Carlos G. Grijalva
- Department of Health Policy, Vanderbilt University Medical Center, Nashville, Tennessee
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162
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Bashir H, Grindle K, Vrtis R, Vang F, Kang T, Salazar L, Anderson E, Pappas T, Gangnon R, Evans MD, Jackson DJ, Lemanske RF, Bochkov YA, Gern JE. Association of rhinovirus species with common cold and asthma symptoms and bacterial pathogens. J Allergy Clin Immunol 2017; 141:822-824.e9. [PMID: 29111214 DOI: 10.1016/j.jaci.2017.09.027] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Revised: 08/23/2017] [Accepted: 09/04/2017] [Indexed: 11/29/2022]
Affiliation(s)
- Hiba Bashir
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Kristine Grindle
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Rose Vrtis
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Fue Vang
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Teresa Kang
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Lisa Salazar
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | | | - Tressa Pappas
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Ronald Gangnon
- Department of Biostatistics, University of Wisconsin-Madison, Madison, Wis
| | - Michael D Evans
- Department of Biostatistics, University of Wisconsin-Madison, Madison, Wis
| | - Daniel J Jackson
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Robert F Lemanske
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - Yury A Bochkov
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis
| | - James E Gern
- Department of Pediatrics, University of Wisconsin-Madison, Madison, Wis.
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163
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Kwong CG, Bacharier LB. Microbes and the Role of Antibiotic Treatment for Wheezy Lower Respiratory Tract Illnesses in Preschool Children. Curr Allergy Asthma Rep 2017; 17:34. [PMID: 28456910 DOI: 10.1007/s11882-017-0701-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
PURPOSE OF REVIEW Antibiotics are commonly used to treat wheezy lower respiratory tract illnesses in preschoolers, although these infections have been traditionally thought to be predominantly of viral origin. Our purpose is to review recent research pertaining to the role of antibiotics in lower respiratory tract illnesses and on subsequent asthma development, as well as the possible mechanisms of their effects. RECENT FINDINGS Increasing evidence suggests that asthma pathogenesis is associated with events during infancy and early childhood, particularly respiratory tract infections. While viruses are frequently detected in children with lower respiratory tract infections, the presence of potentially pathogenic bacteria is also often detected and may play a role in asthma pathogenesis. Recent evidence suggests that use of macrolides, particularly azithromycin, may decrease the risk of and duration of lower respiratory tract illnesses and prevent future episodes in specific high-risk populations. Infants and preschoolers who have wheezy lower respiratory tract illnesses have a higher risk of asthma development. Alterations in the microbiome are thought to be influential. While several recent studies identify azithromycin as a therapeutic option in these illnesses, additional research is needed.
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Affiliation(s)
- Christina G Kwong
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis Children's Hospital, One Children's Place, St. Louis, MO, 63110, USA
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine in St. Louis, St. Louis Children's Hospital, One Children's Place, St. Louis, MO, 63110, USA.
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164
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Abrams EM, Szefler SJ, Becker AB. Does inhaled steroid therapy help emerging asthma in early childhood? THE LANCET RESPIRATORY MEDICINE 2017; 5:827-834. [DOI: 10.1016/s2213-2600(17)30295-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/15/2017] [Accepted: 06/27/2017] [Indexed: 11/26/2022]
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165
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Papadopoulos NG, Megremis S, Kitsioulis NA, Vangelatou O, West P, Xepapadaki P. Promising approaches for the treatment and prevention of viral respiratory illnesses. J Allergy Clin Immunol 2017; 140:921-932. [PMID: 28739285 PMCID: PMC7112313 DOI: 10.1016/j.jaci.2017.07.001] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2017] [Revised: 07/11/2017] [Accepted: 07/14/2017] [Indexed: 02/09/2023]
Abstract
Viral respiratory tract infections are the most common human ailments, leading to enormous health and economic burden. Hundreds of viral species and subtypes have been associated with these conditions, with influenza viruses, respiratory syncytial virus, and rhinoviruses being the most frequent and with the highest burden. When considering prevention or treatment of viral respiratory tract infections, potential targets include the causative pathogens themselves but also the immune response, disease transmission, or even just the symptoms. Strategies targeting all these aspects are developing concurrently, and several novel and promising approaches are emerging. In this perspective we overview the entire range of options and highlight some of the most promising approaches, including new antiviral agents, symptomatic or immunomodulatory drugs, the re-emergence of natural remedies, and vaccines and public health policies toward prevention. Wide-scale prevention through immunization appears to be within reach for respiratory syncytial virus and promising for influenza virus, whereas additional effort is needed in regard to rhinovirus, as well as other respiratory tract viruses.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, United Kingdom; Allergy Department, 2nd Pediatric Clinic, National & Kapodistrian University of Athens, Athens, Greece.
| | - Spyridon Megremis
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Nikolaos A Kitsioulis
- Allergy Department, 2nd Pediatric Clinic, National & Kapodistrian University of Athens, Athens, Greece
| | - Olympia Vangelatou
- Department of Nutritional Physiology & Feeding, Agricultural University of Athens, Athens, Greece
| | - Peter West
- Division of Infection, Immunity & Respiratory Medicine, University of Manchester, Manchester, United Kingdom
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National & Kapodistrian University of Athens, Athens, Greece
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166
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Management of preschool recurrent wheezing and asthma: a phenotype-based approach. Curr Opin Allergy Clin Immunol 2017; 17:131-138. [PMID: 28118241 DOI: 10.1097/aci.0000000000000344] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the recent evidence on the management of preschool children with wheezing and asthma, and to propose a phenotype-based approach to the management of these children. RECENT FINDINGS Recent studies have begun to identify populations of preschool children that are likely to benefit from inhaled corticosteroids (ICS) therapy and defined ICS regimens: daily ICS in preschool children with persistent asthma, and pre-emptive high-dose intermittent ICS among preschool children with intermittent disease reduce the risk of exacerbation. In addition, among preschool children with mild persistent asthma, the presence of aeroallergen sensitivity and/or blood eosinophil counts of 300/μL or greater are predictors of good response to daily ICS therapy. Other studies identified intermittent azithromycin as a therapy to prevent, and potentially to treat, acute exacerbations.The uncertainty of the role of oral corticosteroids (OCS) as a therapy for acute exacerbations continues, as a recent meta-analysis showed that OCS did not prevent hospitalizations or urgent visits, and did not reduce the need for additional courses of OCS. Whereas previous epidemiologic studies suggested acetaminophen may increase risk of exacerbations, a clinical trial clearly demonstrated acetaminophen use, compared to ibuprofen use,does not increase exacerbation risk among preschool children with mild-persistent asthma. SUMMARY Recent studies have shown potential for phenotypic-driven therapies for the management of preschool children with asthma. Targeting airway bacteria has emerged as a promising therapeutic approach, but its effect on antibiotic resistance still needs to be investigated. Finally, more studies are required to evaluate if oral corticosteroids provide any benefits for acute episodic wheeze.
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167
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Current and future management of the young child with early onset wheezing. Curr Opin Allergy Clin Immunol 2017; 17:146-152. [PMID: 28092287 DOI: 10.1097/aci.0000000000000341] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW In this review, we discuss current thinking in relation to available guidelines for the care of preschool-aged children with recurrent wheezing, while highlighting the gaps in our knowledge and discussing changes that could occur over the next 5 years. RECENT FINDINGS The Asthma Predictive Index as well as allergen-specific IgE, peripheral eosinophil count and exhaled nitric oxide are perhaps underutilized sources of information that can assist in predicting progression to asthma and response to therapies. Inhaled corticosteroids and leukotriene receptor antagonists decrease impairment and exacerbation frequency in wheezing children but are not disease modifying. Macrolides may be useful during acute wheezing episodes for preventing progression to more severe symptoms. Monoclonal antibodies targeting IgE and TH2 cytokines have been successful in trials of adults and older children with asthma, but trials in younger children are needed. SUMMARY Establishing the phenotype and endotype of young wheezing children can be useful for prognostication of future asthma risk as well as for selection of the most appropriate treatment. Primary asthma prevention strategies are needed during the critical developmental window in early life prior to the onset of irrecoverable loss of lung function.
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168
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Messinger AI, Kupfer O, Hurst A, Parker S. Management of Pediatric Community-acquired Bacterial Pneumonia. Pediatr Rev 2017; 38:394-409. [PMID: 28864731 DOI: 10.1542/pir.2016-0183] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Affiliation(s)
| | | | - Amanda Hurst
- Department of Pharmacy, Children's Hospital Colorado, Aurora, CO
| | - Sarah Parker
- Infectious Diseases, Department of Pediatrics, University of Colorado Denver School of Medicine, Aurora, CO
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Abstract
PURPOSE OF REVIEW In terms of immune regulating functions, analysis of the microbiome has led the development of therapeutic strategies that may be applicable to asthma management. This review summarizes the current literature on the gut and lung microbiota in asthma pathogenesis with a focus on the roles of innate molecules and new microbiome-mediated therapeutics. RECENT FINDINGS Recent clinical and basic studies to date have identified several possible therapeutics that can target innate immunity and the microbiota in asthma. Some of these drugs have shown beneficial effects in the treatment of certain asthma phenotypes and for protection against asthma during early life. Current clinical evidence does not support the use of these therapies for effective treatment of asthma. The integration of the data regarding microbiota with technologic advances, such as next generation sequencing and omics offers promise. Combining comprehensive bioinformatics, new molecules and approaches may shape future asthma treatment.
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170
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Treatment of preschool children presenting to the emergency department with wheeze with azithromycin: A placebo-controlled randomized trial. PLoS One 2017; 12:e0182411. [PMID: 28771627 PMCID: PMC5542589 DOI: 10.1371/journal.pone.0182411] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Accepted: 07/17/2017] [Indexed: 12/18/2022] Open
Abstract
Background Antibiotics are frequently used to treat wheezing children. Macrolides may be effective in treating bronchiolitis and asthma. Method We completed a prospective, double-blinded, randomized placebo-control trial of azithromycin among pre-school children (12 to 60 months of age) presenting to the emergency department with wheeze. Patients were randomized to receive either five days of azithromycin or placebo. Primary outcome was time to resolution of respiratory symptoms after treatment initiation. Secondary outcomes included the number of days children used a Short-Acting Beta-Agonists during the 21 day follow-up and time to disease exacerbation during the following six months (unscheduled health care visit or treatment with an oral corticosteroid for acute respiratory symptoms). Results Of the 300 wheezing children recruited, 222 and 169 were analyzed for the primary and secondary outcomes, respectively. The treatment groups had similar demographics and clinical parameters at baseline. Median time to resolution of respiratory symptoms was four days for both treatment arms (interquartile range (IQR) 3,6; p = 0.28). Median number of days of Short-Acting Beta-Agonist use among those who received azithromycin was four and a half days (IQR 2, 7) and five days (IQR 2, 9; p = 0.22) among those who received placebo. Participants who received azithromycin had a 0.91 hazard ratio for time to six-month exacerbation compared to placebo (95% CI 0.61, 1.36, p = 0.65). A pre-determined subgroup analysis showed no differences in outcomes for children with their first or repeat episode of wheezing. There was no significant difference in the proportion of participants experiencing an adverse event. Conclusion Azithromycin neither reduced duration of respiratory symptoms nor time to respiratory exacerbation in the following six months after treatment among wheezing preschool children presenting to an emergency department. There was no significant effect among children with either first-time or prior wheezing.
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171
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Waites KB, Xiao L, Liu Y, Balish MF, Atkinson TP. Mycoplasma pneumoniae from the Respiratory Tract and Beyond. Clin Microbiol Rev 2017; 30:747-809. [PMID: 28539503 PMCID: PMC5475226 DOI: 10.1128/cmr.00114-16] [Citation(s) in RCA: 380] [Impact Index Per Article: 54.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Mycoplasma pneumoniae is an important cause of respiratory tract infections in children as well as adults that can range in severity from mild to life-threatening. Over the past several years there has been much new information published concerning infections caused by this organism. New molecular-based tests for M. pneumoniae detection are now commercially available in the United States, and advances in molecular typing systems have enhanced understanding of the epidemiology of infections. More strains have had their entire genome sequences published, providing additional insights into pathogenic mechanisms. Clinically significant acquired macrolide resistance has emerged worldwide and is now complicating treatment. In vitro susceptibility testing methods have been standardized, and several new drugs that may be effective against this organism are undergoing development. This review focuses on the many new developments that have occurred over the past several years that enhance our understanding of this microbe, which is among the smallest bacterial pathogens but one of great clinical importance.
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Affiliation(s)
- Ken B Waites
- Department of Pathology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Li Xiao
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Yang Liu
- Institute of Antibiotics, Huashan Hospital, Fudan University, Shanghai, China, and Key Laboratory of Clinical Pharmacology of Antibiotics, Ministry of Health, Shanghai, China
| | | | - T Prescott Atkinson
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, Alabama, USA
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172
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Lee N, Wong CK, Chan MCW, Yeung ESL, Tam WWS, Tsang OTY, Choi KW, Chan PKS, Kwok A, Lui GCY, Leung WS, Yung IMH, Wong RYK, Cheung CSK, Hui DSC. Anti-inflammatory effects of adjunctive macrolide treatment in adults hospitalized with influenza: A randomized controlled trial. Antiviral Res 2017; 144:48-56. [PMID: 28535933 DOI: 10.1016/j.antiviral.2017.05.008] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2017] [Revised: 05/16/2017] [Accepted: 05/18/2017] [Indexed: 12/18/2022]
Abstract
INTRODUCTION - Macrolides can ameliorate inflammation in respiratory diseases, providing clinical benefits. Data in influenza is lacking. METHOD - A randomized, open-label, multicenter trial among adults hospitalized for laboratory-confirmed influenza was conducted. Study treatments of oseltamivir and azithromycin (500 mg/day), or oseltamivir alone, both for 5 days, were allocated at 1:1 ratio. The primary outcome was plasma cytokine/chemokine concentration change over time (Day 0-10); secondary outcomes were viral load and symptom score changes. Generalized Estimating Equation (GEE) models were used to analyze longitudinal data. RESULTS - Fifty patients were randomized to the oseltamivir-azithromycin or oseltamivir groups, with comparable baseline characteristics (age, 57 ± 18 years; A/H3N2, 70%), complications (72%), and viral load. Pro-inflammatory cytokines IL-6 (GEE: β -0.037, 95%CI-0.067,-0.007, P = 0.016; reduction from baseline -83.4% vs -59.5%), CXCL8/IL-8 (β -0.018, 95%CI-0.037,0.000, P = 0.056; -80.5% vs -58.0%), IL-17 (β -0.064, 95%CI-0.117,-0.012, P = 0.015; -74.0% vs -34.3%), CXCL9/MIG (β -0.010, 95%CI-0.020,0.000, P = 0.043; -71.3% vs -56.0%), sTNFR-1, IL-18, and CRP declined faster in the oseltamivir-azithromycin group. There was a trend toward faster symptom resolution (β -0.463, 95%CI-1.297,0.371). Viral RNA decline (P = 0.777) and culture-negativity rates were unaffected. Additional ex vivo studies confirmed reduced induction of IL-6 (P = 0.017) and CXCL8/IL-8 (P = 0.005) with azithromycin. CONCLUSION - We found significant anti-inflammatory effects with adjunctive macrolide treatment in adults with severe influenza infections. Virus control was unimpaired. Clinical benefits of a macrolide-containing regimen deserve further study. [ClinicalTrials.gov NCT01779570].
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Affiliation(s)
- Nelson Lee
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong.
| | - Chun-Kwok Wong
- Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong
| | - Martin C W Chan
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong
| | - Esther S L Yeung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Department of Chemical Pathology, The Chinese University of Hong Kong, Hong Kong
| | - Wilson W S Tam
- Alice Lee Centre for Nursing Studies, National University of Singapore, Singapore
| | - Owen T Y Tsang
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Kin-Wing Choi
- Department of Medicine, Alice Ho Miu Ling Nethersole Hospital, Hong Kong
| | - Paul K S Chan
- Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong; Department of Microbiology, The Chinese University of Hong Kong, Hong Kong
| | - Angela Kwok
- Department of Microbiology, The Chinese University of Hong Kong, Hong Kong
| | - Grace C Y Lui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Wai-Shing Leung
- Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Irene M H Yung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - Rity Y K Wong
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Department of Medicine and Geriatrics, Princess Margaret Hospital, Hong Kong
| | - Catherine S K Cheung
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong
| | - David S C Hui
- Department of Medicine and Therapeutics, Prince of Wales Hospital, The Chinese University of Hong Kong, Hong Kong; Stanley Ho Center for Emerging Infectious Diseases, The Chinese University of Hong Kong, Hong Kong.
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Edwards MR, Saglani S, Schwarze J, Skevaki C, Smith JA, Ainsworth B, Almond M, Andreakos E, Belvisi MG, Chung KF, Cookson W, Cullinan P, Hawrylowicz C, Lommatzsch M, Jackson D, Lutter R, Marsland B, Moffatt M, Thomas M, Virchow JC, Xanthou G, Edwards J, Walker S, Johnston SL. Addressing unmet needs in understanding asthma mechanisms: From the European Asthma Research and Innovation Partnership (EARIP) Work Package (WP)2 collaborators. Eur Respir J 2017; 49:49/5/1602448. [PMID: 28461300 DOI: 10.1183/13993003.02448-2016] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2016] [Accepted: 03/13/2017] [Indexed: 12/27/2022]
Abstract
Asthma is a heterogeneous, complex disease with clinical phenotypes that incorporate persistent symptoms and acute exacerbations. It affects many millions of Europeans throughout their education and working lives and puts a heavy cost on European productivity. There is a wide spectrum of disease severity and control. Therapeutic advances have been slow despite greater understanding of basic mechanisms and the lack of satisfactory preventative and disease modifying management for asthma constitutes a significant unmet clinical need. Preventing, treating and ultimately curing asthma requires co-ordinated research and innovation across Europe. The European Asthma Research and Innovation Partnership (EARIP) is an FP7-funded programme which has taken a co-ordinated and integrated approach to analysing the future of asthma research and development. This report aims to identify the mechanistic areas in which investment is required to bring about significant improvements in asthma outcomes.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Rene Lutter
- Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Benjamin Marsland
- University of Lausanne, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | | | | | | | - Georgina Xanthou
- Biomedical Research Foundation, Academy of Athens, Athens, Greece
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Guiddir T, Saint-Pierre P, Purenne-Denis E, Lambert N, Laoudi Y, Couderc R, Gouvis-Echraghi R, Amat F, Just J. Neutrophilic Steroid-Refractory Recurrent Wheeze and Eosinophilic Steroid-Refractory Asthma in Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:1351-1361.e2. [PMID: 28363401 DOI: 10.1016/j.jaip.2017.02.003] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/15/2016] [Revised: 01/21/2017] [Accepted: 02/03/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Little is known about inflammatory pathways of severe recurrent wheeze in preschool children and severe asthma in children. OBJECTIVES The aim of the Severe Asthma Molecular Phenotype cohort was to characterize phenotypes of severe recurrent wheeze and severe asthma during childhood in terms of triggers (allergic or not), involved cells (eosinophil or neutrophil), and corticoid responsiveness. METHODS Children with moderate-to-severe asthma and preschool children with moderate-to-severe recurrent wheeze were enrolled prospectively. They underwent standardized clinical and blood workup, and bronchoalveolar lavage (BAL) evaluation. Cluster analysis was applied to 350 children with 34 variables. RESULTS Three clusters were identified: cluster 1, Neutrophilic steroid-refractory recurrent wheeze phenotype, with 138 children uncontrolled despite high-dose inhaled corticosteroids (ICS) (92%, P < .001), with more history of pneumonia (31%, P < .001), more gastroesophageal reflux disease (37%, P < .001), and the highest blood neutrophil count (mean 4.524 cells/mm3, P = .05); cluster 2, Severe recurrent wheeze with sensitization to a single aeroallergen (12%, P = .002), with 104 children controlled with high-dose ICS (63%, P < .001); cluster 3, Eosinophilic steroid-refractory asthma phenotype, with 108 children uncontrolled despite high-dose ICS (76%, P < .001) with more allergic rhinitis, atopic dermatitis, and food allergies (82%, 40%, 31%, P < .001, respectively). They also had a higher blood eosinophil count and a higher percentage of BAL eosinophil (506/mm3, 2.6%, P < .001 respectively). CONCLUSIONS Inflammation pathway of asthma and recurrent wheeze are related to eosinophil cells in older children and neutrophil cells in younger children. These results could improve personalized treatments.
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Affiliation(s)
- Tamazoust Guiddir
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; University Paris 06, Sorbonne University, Paris, France
| | | | - Elsa Purenne-Denis
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Nathalie Lambert
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; University Paris 06, Sorbonne University, Paris, France
| | - Yacine Laoudi
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Rémy Couderc
- Biochemistry Laboratory, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Rahelé Gouvis-Echraghi
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Flore Amat
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; University Paris 06, Sorbonne University, Paris, France
| | - Jocelyne Just
- Allergology Department, Armand Trousseau Children Hospital, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France; University Paris 06, Sorbonne University, Paris, France.
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Abstract
Viral bronchiolitis is a common clinical syndrome affecting infants and young children. Concern about its associated morbidity and cost has led to a large body of research that has been summarised in systematic reviews and integrated into clinical practice guidelines in several countries. The evidence and guideline recommendations consistently support a clinical diagnosis with the limited role for diagnostic testing for children presenting with the typical clinical syndrome of viral upper respiratory infection progressing to the lower respiratory tract. Management is largely supportive, focusing on maintaining oxygenation and hydration of the patient. Evidence suggests no benefit from bronchodilator or corticosteroid use in infants with a first episode of bronchiolitis. Evidence for other treatments such as hypertonic saline is evolving but not clearly defined yet. For infants with severe disease, the insufficient available data suggest a role for high-flow nasal cannula and continuous positive airway pressure use in a monitored setting to prevent respiratory failure.
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Affiliation(s)
- Todd A Florin
- Division of Pediatric Emergency Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA; Department of Pediatrics, University of Cincinnati College of Medicine, Cincinnati, OH, USA.
| | - Amy C Plint
- Division of Emergency Medicine, Children's Hospital of Eastern Ontario, Ottawa, ON, Canada; Department of Pediatrics, University of Ottawa, Ottawa, ON, Canada
| | - Joseph J Zorc
- Division of Emergency Medicine, The Children's Hospital of Philadelphia, Philadelphia, PA, USA; Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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176
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Mallol J. ASMA DEL LACTANTE: ACTUALIZACIÓN. REVISTA MÉDICA CLÍNICA LAS CONDES 2017. [DOI: 10.1016/j.rmclc.2017.02.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
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177
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Hussein HR, Gupta A, Broughton S, Ruiz G, Brathwaite N, Bossley CJ. A meta-analysis of montelukast for recurrent wheeze in preschool children. Eur J Pediatr 2017; 176:963-969. [PMID: 28567533 PMCID: PMC5486554 DOI: 10.1007/s00431-017-2936-6] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2017] [Revised: 05/10/2017] [Accepted: 05/15/2017] [Indexed: 11/25/2022]
Abstract
UNLABELLED There is conflicting evidence of the effectiveness of montelukast in preschool wheeze. A recent Cochrane review focused on its use in viral-induced wheeze; however, such subgroups are unlikely to exist in real life and change with time, recently highlighted in an international consensus report. We have therefore sought to investigate the effectiveness of montelukast in all children with preschool wheeze (viral-induced and multiple-trigger wheeze). The PubMed, Cochrane Library, Ovid Medline and Ovid EMBASE were screened for randomised controlled trials (RCTs), examining the efficacy of montelukast compared with placebo in children with the recurrent preschool wheeze. The primary endpoint examined was frequency of wheezing episodes. Five trials containing 3960 patients with a preschool wheezing disorder were analysed. Meta-analyses of studies of intermittent montelukast showed no benefit in preventing episodes of wheeze (mean difference (MD) 0.07, 95% confidence interval (CI) -0.14 to 0.29; mean for montelukast 2.68 vs placebo 2.54 (p = 0.5)), reducing unscheduled medical attendances (MD -0.13, 95% CI -0.33 to 0.07; mean for montelukast 1.62 vs placebo 1.78 (p = 0.21)) and reducing oral corticosteroids (MD -0.06, 95% CI -0.16 to 0.02; mean for montelukast 0.35 vs placebo 0.36 (p = 0.25)). The pooled results of the continuous regimen showed no significant difference in the number of wheezing episodes between the montelukast and placebo groups (MD -0.40, 95% CI -1.00 to 0.19; mean for montelukast 2.05 vs placebo 2.37 (p = 0.18)). CONCLUSIONS This review highlights that the currently available evidence does not support the use of montelukast in preschool children with recurrent wheeze. We recommend further studies to investigate if a 'montelukast responder' phenotype exists, and how these can be easily identified in the clinical setting. What is Known: • Current guidelines recommend montelukast use in preschool children with recurrent wheeze. • A recent Cochrane review has found montelukast to be ineffective at reducing courses of oral corticosteroids for viral-induced wheeze. What is New: • This meta-analysis has examined all children with preschool wheeze and found that montelukast was not effective at preventing wheezing episodes or reducing unscheduled medical attendances. • A specific montelukast responder phenotype may exist, but such patients should be sought in larger multicentre RCTs.
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Affiliation(s)
- Hasan R. Hussein
- Faculty of Life Sciences & Medicine, Kings College London, London, UK
- Department of Respiratory Paediatrics, Kings College Hospital, Denmark Hill, London, SE5 9RS UK
| | - Atul Gupta
- Faculty of Life Sciences & Medicine, Kings College London, London, UK
- Department of Respiratory Paediatrics, Kings College Hospital, Denmark Hill, London, SE5 9RS UK
| | - Simon Broughton
- Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Gary Ruiz
- Faculty of Life Sciences & Medicine, Kings College London, London, UK
- Department of Respiratory Paediatrics, Kings College Hospital, Denmark Hill, London, SE5 9RS UK
| | - Nicola Brathwaite
- Faculty of Life Sciences & Medicine, Kings College London, London, UK
| | - Cara J. Bossley
- Faculty of Life Sciences & Medicine, Kings College London, London, UK
- Department of Respiratory Paediatrics, Kings College Hospital, Denmark Hill, London, SE5 9RS UK
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178
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Johnston SL, Szigeti M, Cross M, Brightling C, Chaudhuri R, Harrison T, Mansur A, Robison L, Sattar Z, Jackson D, Mallia P, Wong E, Corrigan C, Higgins B, Ind P, Singh D, Thomson NC, Ashby D, Chauhan A. Azithromycin for Acute Exacerbations of Asthma : The AZALEA Randomized Clinical Trial. JAMA Intern Med 2016; 176:1630-1637. [PMID: 27653939 DOI: 10.1001/jamainternmed.2016.5664] [Citation(s) in RCA: 75] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
IMPORTANCE Guidelines recommend against antibiotic use to treat asthma attacks. A study with telithromycin reported benefit, but adverse reactions limit its use. OBJECTIVE To determine whether azithromycin added to standard care for asthma attacks in adults results in clinical benefit. DESIGN, SETTING, AND PARTICIPANTS The Azithromycin Against Placebo in Exacerbations of Asthma (AZALEA) randomized, double-blind, placebo-controlled clinical trial, a United Kingdom-based multicenter study in adults requesting emergency care for acute asthma exacerbations, ran from September 2011 to April 2014. Adults with a history of asthma for more than 6 months were recruited within 48 hours of presentation to medical care with an acute deterioration in asthma control requiring a course of oral and/or systemic corticosteroids. INTERVENTIONS Azithromycin 500 mg daily or matched placebo for 3 days. MAIN OUTCOMES AND MEASURES The primary outcome was diary card symptom score 10 days after randomization, with a hypothesized treatment effect size of -0.3. Secondary outcomes were diary card symptom score, quality-of-life questionnaires, and lung function changes, all between exacerbation and day 10, and time to a 50% reduction in symptom score. RESULTS Of 4582 patients screened at 31 centers, 199 of a planned 380 were randomized within 48 hours of presentation. The major reason for nonrecruitment was receipt of antibiotics (2044 [44.6%] screened patients). Median time from presentation to drug administration was 22 hours (interquartile range, 14-28 hours). Exacerbation characteristics were well balanced across treatment arms and centers. The primary outcome asthma symptom scores were mean (SD), 4.14 (1.38) at exacerbation and 2.09 (1.71) at 10 days for the azithromycin group and 4.18 (1.48) and 2.20 (1.51) for the placebo group, respectively. Using multilevel modeling, there was no significant difference in symptom scores between azithromycin and placebo at day 10 (difference, -0.166; 95% CI, -0.670 to 0.337), nor on any day between exacerbation and day 10. No significant between-group differences were observed in quality-of-life questionnaires or lung function between exacerbation and day 10, or in time to 50% reduction in symptom score. CONCLUSIONS AND RELEVANCE In this randomized population, azithromycin treatment resulted in no statistically or clinically significant benefit. For each patient randomized, more than 10 were excluded because they had already received antibiotics. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01444469.
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Affiliation(s)
| | - Matyas Szigeti
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, England
| | - Mary Cross
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, England
| | | | - Rekha Chaudhuri
- Institute of Infection Immunity and Inflammation, University of Glasgow, Glasgow, Scotland.,Respiratory Medicine, NHS Greater Glasgow and Clyde, Glasgow, Scotland
| | - Timothy Harrison
- Nottingham Respiratory Research Unit, University of Nottingham, Nottingham, England
| | - Adel Mansur
- Respiratory Medicine, Heart of England Foundation Trust, Birmingham, England.,Severe and Brittle Asthma Unit, University of Birmingham, Birmingham, England
| | - Laura Robison
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, England
| | - Zahid Sattar
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, England
| | - David Jackson
- National Heart and Lung Institute, Imperial College London, London, England
| | - Patrick Mallia
- National Heart and Lung Institute, Imperial College London, London, England
| | - Ernie Wong
- National Heart and Lung Institute, Imperial College London, London, England
| | - Christopher Corrigan
- Respiratory Medicine and Allergy, King's College London School of Medicine, London, England.,Department of Asthma, Allergy and Respiratory Science, Guy's and St. Thomas' NHS Foundation Trust, London, England
| | - Bernard Higgins
- Respiratory Medicine, Newcastle University, Newcastle, England
| | - Philip Ind
- National Heart and Lung Institute, Imperial College London, London, England.,Respiratory Medicine, Imperial College Healthcare NHS Trust, London, England
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, Medicines Evaluation Unit, University of Manchester and University Hospital of South Manchester NHS Foundation Trust, Manchester, England
| | - Neil C Thomson
- Institute of Infection Immunity and Inflammation, University of Glasgow, Glasgow, Scotland
| | - Deborah Ashby
- Imperial Clinical Trials Unit, School of Public Health, Imperial College London, London, England
| | - Anoop Chauhan
- Respiratory Medicine, Portsmouth Hospitals NHS Trust, Portsmouth, England
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Jackson DJ, Gern JE, Lemanske RF. The contributions of allergic sensitization and respiratory pathogens to asthma inception. J Allergy Clin Immunol 2016; 137:659-65; quiz 666. [PMID: 26947979 PMCID: PMC4782609 DOI: 10.1016/j.jaci.2016.01.002] [Citation(s) in RCA: 55] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Revised: 01/06/2016] [Accepted: 01/13/2016] [Indexed: 01/10/2023]
Abstract
Of the chronic diseases affecting grade-school children, asthma is the most common and accounts for the greatest number of school days missed. Moreover, it can influence family dynamics and function in other ways, and unfortunately, it can also be associated with mortality, particularly in the inner-city environments of the United States. Thus understanding factors that lead to its development in early life is essential in developing strategies aimed at primary prevention. Two risk factors that have been identified by a number of investigators include the development of allergic sensitization and wheezing respiratory tract illnesses caused by viruses and bacteria, either alone or in combination. Both of these factors appear to exert their influences within the first few years of life, such that asthma becomes established before the child enters grade school at age 5 to 6 years. Therefore, because both allergic sensitization and viral and bacterial illnesses can occur in children who do not have asthma, it is paramount to identify genetic and environmental factors that activate, interact with, and/or direct the immune system and components of the respiratory tract along pathways that allow asthma to become established and expressed clinically.
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Affiliation(s)
- Daniel J Jackson
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis.
| | - James E Gern
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
| | - Robert F Lemanske
- Department of Pediatrics, University of Wisconsin School of Medicine and Public Health, Madison, Wis; Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, Wis
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180
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Deshpande DR, Martinez FD. The dilemma of systemic steroids in preschool children with recurrent wheezing exacerbations. Pediatr Pulmonol 2016; 51:775-7. [PMID: 27158816 DOI: 10.1002/ppul.23465] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2016] [Accepted: 04/25/2016] [Indexed: 01/19/2023]
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181
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Auten R, Schwarze J, Ren C, Davis S, Noah TL. Pediatric Pulmonology year in review 2015: Part 1. Pediatr Pulmonol 2016; 51:733-9. [PMID: 27124279 DOI: 10.1002/ppul.23423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 03/03/2016] [Accepted: 03/12/2016] [Indexed: 02/04/2023]
Abstract
Our journal covers a broad range of research and scholarly topics related to children's respiratory disorders. For updated perspectives on the rapidly expanding knowledge in our field, we will summarize the past year's publications in our major topic areas, as well as selected publications in these areas from the core clinical journal literature outside our own pages. The current review covers articles on neonatal lung disease, pulmonary physiology, and respiratory infection. Pediatr Pulmonol. 2016;51:733-739. © 2016 Wiley Periodicals, Inc.
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Affiliation(s)
| | - Jurgen Schwarze
- Department of Child Life and Health, The University of Edinburgh, Edinburgh, United Kingdom
| | - Clement Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Stephanie Davis
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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182
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Raissy HH, Blake K. Macrolides for Acute Wheezing Episodes in Preschool Children. PEDIATRIC ALLERGY IMMUNOLOGY AND PULMONOLOGY 2016; 29:100-103. [PMID: 27458539 DOI: 10.1089/ped.2016.0663] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The National Asthma Education and Prevention Program's Expert Panel Report 3, Guidelines for the Diagnosis and Management of Asthma does not recommend antibiotics for the management of acute episodes of asthma exacerbation. Macrolides seem to have some potential effect beyond or in addition to their antibacterial effect. It has been reported that macrolides may potentially benefit patients with chronic inflammatory airway diseases due to their antibacterial, antiviral, and/or anti-inflammatory effects. This review presents recent data on use of azithromycin in prevention and management of acute exacerbation of respiratory symptoms in infants and young children.
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Affiliation(s)
- Hengameh H Raissy
- Department of Pediatrics, University of New Mexico , School of Medicine, Albuquerque, New Mexico
| | - Kathryn Blake
- Department of Biomedical Research, Nemours Children's Clinic , Jacksonville, Florida
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183
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Abstract
PURPOSE OF REVIEW Asthma guidelines recognize the presence of different asthma endotypes and phenotypes but treatment recommendations are limited to age groups rather than phenotypes, as the phenotype literature is regarded as emerging evidence. This review will examine the current evidence regarding the management of asthma in school age children (5-18 years old) by endotype and phenotype. RECENT FINDINGS A number of studies have examined the effect of endotypes and phenotypes on response to conventional asthma therapy, omalizumab and specific allergen immunotherapy, and response in children with severe asthma. Emerging therapies, namely biologics and immunomodulators, have attracted considerable attention and appear to have favorable effects in adults with asthma, but additional pediatric studies are needed. SUMMARY The optimal treatment strategy for children with asthma is not yet defined and likely dependent on many patient and disease characteristics. Much of the phenotypic response literature presented in this review was constrained by a limited number of pediatric and adult studies available and as such should be regarded as preliminary. Better definition of asthma phenotypes and better targeting of therapy based on individual patient phenotypes are likely to improve asthma treatment in the future.
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184
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Fleming-Dutra KE, Friedman CR, Hicks LA. Early Azithromycin Treatment to Prevent Severe Lower Respiratory Tract Illnesses in Children. JAMA 2016; 315:2121-2. [PMID: 27187308 PMCID: PMC6457256 DOI: 10.1001/jama.2016.0918] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
| | | | - Lauri A Hicks
- Centers for Disease Control and Prevention, Atlanta, Georgia
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185
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Chronic Chlamydia pneumoniae lung infection: a neglected explanation for macrolide effects in wheezing and asthma? THE LANCET RESPIRATORY MEDICINE 2016; 4:e8. [PMID: 26973164 DOI: 10.1016/s2213-2600(16)00064-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Accepted: 01/20/2016] [Indexed: 12/27/2022]
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186
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Mathew JL, Rai S, Sahi P, Kumar V. Oral azithromycin for acute episodic airway symptoms in young children. Indian Pediatr 2016; 53:244-7. [DOI: 10.1007/s13312-016-0829-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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