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Peri F, Amaddeo A, Badina L, Maschio M, Barbi E, Ghirardo S. T2-Low Asthma: A Discussed but Still Orphan Disease. Biomedicines 2023; 11:biomedicines11041226. [PMID: 37189844 DOI: 10.3390/biomedicines11041226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Revised: 04/16/2023] [Accepted: 04/18/2023] [Indexed: 05/17/2023] Open
Abstract
Asthma affects 10% of the worldwide population; about 5% of cases are severe with the need for target therapies such as biologics. All the biologics approved for asthma hit the T2 pathway of inflammation. T2-high asthma is classified as allergic and non-allergic, whereas T2-low asthma can be further defined as paucigranulocytic asthma, Type 1 and Type-17 inflammation and the neutrophilic form that accounts for 20-30% of all patients with asthma. Neutrophilic asthma's prevalence is even higher in patients with severe or refractory asthma. We searched Medline and PubMed archives from the past ten years for articles with the subsequent titles: "neutrophilic asthma", "non-type 2 asthma" and "paucigranulocytic asthma". We identified 177 articles; 49 were considered relevant by the title and 33 by the reading of the abstract. Most of these articles are reviews (n = 19); only 6 are clinical trials. No study identified an effective treatment. We used the literature reported by these articles to search for further biologic treatments that target pathways different from T2. We identified 177 articles, 93 of which were considered relevant for the review and included in the present article. In conclusion, T2-low asthma remains poorly investigated in terms of biomarkers, especially as a therapeutic orphan disease.
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Affiliation(s)
- Francesca Peri
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
| | - Alessandro Amaddeo
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137 Trieste, Italy
| | - Laura Badina
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137 Trieste, Italy
| | - Massimo Maschio
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137 Trieste, Italy
| | - Egidio Barbi
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137 Trieste, Italy
| | - Sergio Ghirardo
- Department of Medical, Surgical and Health Sciences, University of Trieste, 34127 Trieste, Italy
- Institute for Maternal and Child Health-IRCCS "Burlo Garofolo", 34137 Trieste, Italy
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2
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Xepapadaki P, Adachi Y, Pozo Beltrán CF, El-Sayed ZA, Gómez RM, Hossny E, Filipovic I, Le Souef P, Morais-Almeida M, Miligkos M, Nieto A, Phipatanakul W, Pitrez PM, Wang JY, Wong GW, Papadopoulos NG. Utility of biomarkers in the diagnosis and monitoring of asthmatic children. World Allergy Organ J 2022; 16:100727. [PMID: 36601259 PMCID: PMC9791923 DOI: 10.1016/j.waojou.2022.100727] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 11/17/2022] [Accepted: 11/17/2022] [Indexed: 12/23/2022] Open
Abstract
Asthma imposes a heavy morbidity burden during childhood; it affects over 10% of children in Europe and North America and it is estimated to exceed 400 million people worldwide by the year 2025. In clinical practice, diagnosis of asthma in children is mostly based on clinical criteria; nevertheless, assessment of both physiological and pathological processes through biomarkers, support asthma diagnosis, aid monitoring, and further lead to better treatment outcomes and reduced morbidity. Recently, identification and validation of biomarkers in pediatric asthma has emerged as a top priority across leading experts, researchers, and clinicians. Moreover, the implementation of non-invasive biomarkers for the assessment and monitoring of paediatric patients with asthma, has been prioritized; however, only a proportion of them are currently included in the clinical practise. Although, the use of non-invasive biomarkers is highly supported in recent asthma guidelines for documenting diagnosis and supporting monitoring of asthmatic patients, data on the Pediatric population are limited. In the present report, the Pediatric Asthma Committee of the World Allergy Organization (WAO), aims to summarize and discuss available data for the implementation of non-invasive biomarkers in the diagnosis and monitoring in children with asthma. Information on the most studied biomarkers, including spirometry, oscillometry, markers of allergic sensitization, fractional exhaled nitric oxide, and the most recent exhaled breath markers and "omic" approaches, will be reviewed. Practical limitations and considerations based on both experts' opinion and critical review of the literature, on the utility of all "well-known" and newly introduced non-invasive biomarkers will be presented. A critical commentary on biomarkers' use in diagnosing and monitoring asthma during the COVID-19 pandemic, cost and availability of biomarkers in different settings and in developing countries, the differences on the biomarkers use between Primary Practitioners, Pediatricians, and Specialists and their role on the longitudinal aspect of asthma is provided.
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Affiliation(s)
- Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
- Corresponding author.
| | - Yuichi Adachi
- Department of Pediatrics, Faculty of Medicine, University of Toyam, Japan
| | | | - Zeinab A. El-Sayed
- Pediatric Allergy, Immunology and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | | | - Elham Hossny
- Pediatric Allergy, Immunology and Rheumatology Unit, Children's Hospital, Ain Shams University, Cairo, Egypt
| | - Ivana Filipovic
- University Hospital Center Dr Dragiša Mišović Hospital Pediatric Department, Serbia
| | - Peter Le Souef
- Faculty of Health and Medical Sciences, Dept of Respiratory Medicine, Child and Adolescent Health Service, University of Western Australia, Perth, Australia
| | | | - Michael Miligkos
- Allergy Department, 2nd Pediatric Clinic, University of Athens, Athens, Greece
| | - Antonio Nieto
- Pediatric Pulmonology & Allergy Unit Children's. Health Research Institute. Hospital La Fe, 46026, Valencia, Spain
| | - Wanda Phipatanakul
- Pediatric Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA
| | - Paulo M. Pitrez
- School of Medicine, Pontifícia Universidade Católica do Rio Grande do Sul (PUCRS), Porto Alegre, Brazil
| | - Jiu-Yao Wang
- Center for Allergy and Clinical Immunology Research, College of Medicine, National Cheng Kung University Hospital, Tainan, Taiwan
| | - Gary W.K. Wong
- Department of Paediatrics, The Chinese University of Hong Kong, China
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3
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Pembrey L, Brooks C, Mpairwe H, Figueiredo CA, Oviedo AY, Chico M, Ali H, Nambuya I, Tumwesige P, Robertson S, Rutter CE, van Veldhoven K, Ring S, Barreto ML, Cooper PJ, Henderson J, Cruz AA, Douwes J, Pearce N. Asthma inflammatory phenotypes on four continents: most asthma is non-eosinophilic. Int J Epidemiol 2022; 52:611-623. [PMID: 36040171 PMCID: PMC10114118 DOI: 10.1093/ije/dyac173] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2021] [Accepted: 08/14/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Most studies assessing pathophysiological heterogeneity in asthma have been conducted in high-income countries (HICs), with little known about the prevalence and characteristics of different asthma inflammatory phenotypes in low-and middle-income countries (LMICs). This study assessed sputum inflammatory phenotypes in five centres, in Brazil, Ecuador, Uganda, New Zealand (NZ) and the United Kingdom (UK). METHODS We conducted a cross-sectional study of 998 asthmatics and 356 non-asthmatics in 2016-20. All centres studied children and adolescents (age range 8-20 years), except the UK centre which involved 26-27 year-olds. Information was collected using questionnaires, clinical characterization, blood and induced sputum. RESULTS Of 623 asthmatics with sputum results, 39% (243) were classified as eosinophilic or mixed granulocytic, i.e. eosinophilic asthma (EA). Adjusted for age and sex, with NZ as baseline, the UK showed similar odds of EA (odds ratio 1.04, 95% confidence interval 0.37-2.94) with lower odds in the LMICs: Brazil (0.73, 0.42-1.27), Ecuador (0.40, 0.24-0.66) and Uganda (0.62, 0.37-1.04). Despite the low prevalence of neutrophilic asthma in most centres, sputum neutrophilia was increased in asthmatics and non-asthmatics in Uganda. CONCLUSIONS This is the first time that sputum induction has been used to compare asthma inflammatory phenotypes in HICs and LMICs. Most cases were non-eosinophilic, including in settings where corticosteroid use was low. A lower prevalence of EA was observed in the LMICs than in the HICs. This has major implications for asthma prevention and management, and suggests that novel prevention strategies and therapies specifically targeting non-eosinophilic asthma are required globally.
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Affiliation(s)
- Lucy Pembrey
- Corresponding author. Department of Medical Statistics, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK. E-mail:
| | - Collin Brooks
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | | | - Camila A Figueiredo
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - Aida Y Oviedo
- Fundacion Ecuatoriana Para Investigacion en Salud, Quito, Ecuador
| | - Martha Chico
- Fundacion Ecuatoriana Para Investigacion en Salud, Quito, Ecuador
| | - Hajar Ali
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Irene Nambuya
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Pius Tumwesige
- MRC/UVRI and LSHTM Uganda Research Unit, Entebbe, Uganda
| | - Steven Robertson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Charlotte E Rutter
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Karin van Veldhoven
- Department of Non-communicable Disease Epidemiology, London School of Hygiene & Tropical Medicine, London, UK
| | - Susan Ring
- Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- MRC Integrative Epidemiology Unit at University of Bristol, Bristol, UK
| | - Mauricio L Barreto
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
- Center for Data and Knowledge Integration for Health (CIDACS), Fiocruz, Bahia, Brazil
| | - Philip J Cooper
- Fundacion Ecuatoriana Para Investigacion en Salud, Quito, Ecuador
- School of Medicine, Universidad Internacional del Ecuador, Quito, Ecuador
- Institute of Infection and Immunity, St George’s University of London, London, UK
| | | | - Alvaro A Cruz
- ProAR, Federal University of Bahia, Salvador, Brazil
- Institute for Health Sciences, Federal University of Bahia, Salvador, Brazil
| | - Jeroen Douwes
- Centre for Public Health Research, Massey University, Wellington, New Zealand
| | - Neil Pearce
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
- Centre for Public Health Research, Massey University, Wellington, New Zealand
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Nakamuta JS, Puglia ALP, Meireles P, Blanco DC, Lima MA, Birck MG, Braga MC, Oliveira RWD, Julian GS, Forestiero FJ. Asthma control in Brazil: a systematic review. J Asthma 2022; 60:868-880. [PMID: 35896311 DOI: 10.1080/02770903.2022.2107537] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
Objectives: To explore asthma control in patients undergoing pharmacotherapy on studies in the last 20 years in Brazil. Asthma is a chronic airway inflammation disease with a high prevalence worldwide. Even with a variety of drug treatment improvements, attaining asthma control is challenging, since it should have a personalized approach. In Brazil, studies on the prevalence of asthma control are scarce and usually from a small sample size.Data Sources: A systematic review was performed to assess asthma control in Brazilian population. Terms related to "asthma", "asthma control" and "Brazil" were used in the search strategies in PubMed, BVSalud, Embase and Cochrane Library, including Brazilian Journal of Allergy and Immunology as data sources. A narrative synthesis was performed to report key outcome.Study Selections: In total, 23 studies were included. Most of them were conducted in the Southeastern and Northeast regions, in a short duration.Results: Pediatric and non-pediatric population were assessed, with a higher proportion of female. In pediatric population, those with poorly controlled asthma usually had severe or persistent disease. In elderly, an increased asthma severity was found, although proper treatment might be effective. Most studies (70%) also described exacerbations, hospitalizations (48%), quality of life (39%), and emergency visits (30%). Despite heterogeneity of outcomes and population, studies show an important prevalence of uncontrolled asthma even in patients being treated, with better disease control with treatment improvements.Conclusions: Studies in Brazil have shown that asthma control remains a challenge and there is still a need for improvement on disease management.
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Affiliation(s)
| | | | | | | | - Marina Andrade Lima
- Departamento de Pesquisas Clínicas, Hospital Dia do Pulmão, Blumenau, Brazil
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Eller MCN, Pierantozzi Vergani K, Saraiva-Romanholo BM, de Souza Xavier Costa N, de Brito JM, Antonangelo L, Faria CS, Rodrigues JC, Mauad T. Bronchial eosinophils, neutrophils, and CD8 + T cells influence asthma control and lung function in schoolchildren and adolescents with severe treatment-resistant asthma. Respir Res 2022; 23:335. [PMID: 36494835 PMCID: PMC9733356 DOI: 10.1186/s12931-022-02259-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Studies in adult severe treatment-resistant asthma (STRA) have demonstrated heterogeneous pathophysiology. Studies in the pediatric age group are still scarce, and few include bronchial tissue analysis. OBJECTIVE We investigated 6-18-year-old patients diagnosed with STRA in Sao Paulo, Brazil, by characterizing the different lung compartments and their correlations with asthma control and lung function. METHODS Inflammatory profiles of 13 patients with a confirmed diagnosis of STRA were analyzed using blood, induced sputum, bronchoalveolar lavage, viral and bacterial screens and endobronchial biopsy. Inflammatory cells, cytokines, and basement membrane thickening were tested for correlations with the asthma control test (ACT) and spirometry and plethysmography parameters. RESULTS Endobronchial biopsy specimens from 11 patients were viable for analysis. All biopsies showed eosinophilic infiltration. Submucosal (SM) eosinophils and neutrophils were correlated with worse lung function (pre-BD FEV1), and SM neutrophils were correlated with fixed obstruction (post-BD FEV1). Intraepithelial (IE) neutrophils were positively correlated with lung function (pre-BD sGaw). CD8 + T cells had the highest density in the IE and SM layers and were positively correlated with ACT and negatively correlated with the cytokines IL1β, IL2, IL5, IL7, IL10, IL12, IL17, GCSF, MCP-1, INF-δ, and TNFα in sputum supernatant. The ASM chymase + mast cell density correlated positively with quality-of-life score (pAQLQ) and ACT. CONCLUSION Eosinophils and SM neutrophils correlated with worse lung function, while IE neutrophils correlated with better lung function. Most importantly, CD8 + T cells were abundant in bronchial biopsies of STRA patients and showed protective associations, as did chymase + mast cells.
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Affiliation(s)
- Miriam Cardoso Neves Eller
- grid.11899.380000 0004 1937 0722Unidade de Pneumologia Pediátrica, Instituto da Criança, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneias de Carvalho Aguiar, 647, São Paulo, SP CEP 05403-000 Brazil
| | - Karina Pierantozzi Vergani
- grid.11899.380000 0004 1937 0722Unidade de Pneumologia Pediátrica, Instituto da Criança, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneias de Carvalho Aguiar, 647, São Paulo, SP CEP 05403-000 Brazil
| | | | - Natália de Souza Xavier Costa
- grid.11899.380000 0004 1937 0722Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
| | - Jôse Mára de Brito
- grid.11899.380000 0004 1937 0722Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil ,grid.411180.d0000 0004 0643 7932Departamento de Patologia E Parasitologia, Universidade Federal de Alfenas, Alfenas, MG Brazil
| | - Leila Antonangelo
- grid.11899.380000 0004 1937 0722Divisao de Patologia Clinica, Departamento de Patologia, Faculdade de Medicina, Hospital das Clinicas HCFMUSP, Universidade de São Paulo, São Paulo, SP Brazil ,grid.11899.380000 0004 1937 0722Laboratorio de Investigacao Clinica (LIM03), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
| | - Caroline Silvério Faria
- grid.11899.380000 0004 1937 0722Laboratorio de Investigacao Clinica (LIM03), Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
| | - Joaquim Carlos Rodrigues
- grid.11899.380000 0004 1937 0722Unidade de Pneumologia Pediátrica, Instituto da Criança, Hospital das Clínicas HCFMUSP, Faculdade de Medicina, Universidade de São Paulo, Av. Dr. Eneias de Carvalho Aguiar, 647, São Paulo, SP CEP 05403-000 Brazil
| | - Thais Mauad
- grid.11899.380000 0004 1937 0722Departamento de Patologia, Faculdade de Medicina, Universidade de São Paulo, São Paulo, SP Brazil
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Pijnenburg MW, Frey U, De Jongste JC, Saglani S. Childhood asthma- pathogenesis and phenotypes. Eur Respir J 2021; 59:13993003.00731-2021. [PMID: 34711541 DOI: 10.1183/13993003.00731-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/15/2021] [Indexed: 11/05/2022]
Abstract
In the pathogenesis of asthma in children there is a pivotal role for a type 2 inflammatory response to early life exposures or events. Interactions between infections, atopy, genetic susceptibility, and environmental exposures (such as farmyard environment, air pollution, tobacco smoke exposure) influence the development of wheezing illness and the risk for progression to asthma. The immune system, lung function and the microbiome in gut and airways develop in parallel and dysbiosis of the microbiome may be a critical factor in asthma development. Increased infant weight gain and preterm birth are other risk factors for development of asthma and reduced lung function. The complex interplay between these factors explains the heterogeneity of asthma in children. Subgroups of patients can be identified as phenotypes based on clinical parameters, or endotypes, based on a specific pathophysiological mechanism. Paediatric asthma phenotypes and endotypes may ultimately help to improve diagnosis of asthma, prediction of asthma development and treatment of individual children, based on clinical, temporal, developmental or inflammatory characteristics. Unbiased, data-driven clustering, using a multidimensional or systems biology approach may be needed to better define phenotypes. The present knowledge on inflammatory phenotypes of childhood asthma has now been successfully applied in the treatment with biologicals of children with severe therapy resistant asthma, and it is to be expected that more personalized treatment options may become available.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Urs Frey
- University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Johan C De Jongste
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College, London, UK
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7
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Campisi ES, Reyna ME, Brydges M, Dubeau A, Moraes TJ, Campisi P, Subbarao P. Adenotonsillectomy, bronchoscopy and bronchoalveolar lavage in the management of preschool children with severe asthma: pilot study. Eur Arch Otorhinolaryngol 2021; 279:319-326. [PMID: 34542655 DOI: 10.1007/s00405-021-07084-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/10/2021] [Indexed: 11/28/2022]
Abstract
PURPOSE This is a pilot study that describes the feasibility and clinical course of a cohort of preschool children with severe asthma undergoing a combined adenotonillectomy (TA), bronchoscopy (B), and bronchoalveolar lavage (BAL) procedure. METHODS A retrospective cohort study of preschool patients with severe asthma who underwent a combined TA-B-BAL procedure between 2012 and 2019. Subjects were treated at a tertiary care asthma clinic and had a diagnosis of preschool asthma according to the Canadian Thoracic Society Guidelines. Data on demographics, clinical characteristics, medication use, virology and microbiology from bronchoalveolar lavage, and asthma control questionnaires were collected. Variables were analyzed using paired t test. RESULTS Eighteen preschool subjects (mean age 3.19 ± 1.13 years) with severe asthma were identified through the asthma clinic. Patients treated with standard asthma care and a combined TA-B-BAL procedure experienced a decrease in the number of oral steroid courses (p = 0.017), emergency department visits (p = 0.03) and wheezing exacerbations (p = 0.026) following the procedure. Ten patients experienced clinically meaningful improvements in TRACK scores after the procedure (p < 0.001). CONCLUSION This pilot study provides early evidence that a combined TA-B-BAL procedure is feasible in preschool children with severe asthma and that the procedure may reduce asthma medication use and hospital visits.
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Affiliation(s)
- Emma S Campisi
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada
| | - Myrtha E Reyna
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - May Brydges
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - Aimee Dubeau
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - Theo J Moraes
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada
| | - Paolo Campisi
- Department of Otolaryngology-Head & Neck Surgery, Hospital for Sick Children and University of Toronto, 555 University Avenue, Toronto, ON, M5G 1X8, Canada.
| | - Padmaja Subbarao
- Division of Respiratory Medicine, Department of Paediatrics, and Program in Translational Medicine, SickKids Research Institute, The Hospital for Sick Children, 555 University Avenue, Toronto, Canada.,Dalla Lana School of Public Health, Division of Epidemiology, University of Toronto, 27 King's College Circle, Toronto, Canada
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Characteristics and Role of Neutrophil Extracellular Traps in Asthma. Inflammation 2021; 45:6-13. [PMID: 34480251 PMCID: PMC8803764 DOI: 10.1007/s10753-021-01526-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 07/22/2021] [Indexed: 12/12/2022]
Abstract
Asthma is a common chronic respiratory disease that affects millions of people worldwide. The incidence of asthma has continued to increase every year. Bronchial asthma involves a variety of cells, including airway inflammatory cells, structural cells, and neutrophils, which have gained more attention because they secrete substances that play an important role in the occurrence and development of asthma. Neutrophil extracellular traps (NETs) are mesh-like structures composed of DNA, histones, and non-histone molecules that can be secreted from neutrophils. NETs can enrich anti-bacterial substances and limit pathogen migration, thus having a protective effect in case of inflammation. However, despite of their anti-inflammatory properties, NETs have been shown to trigger allergic asthma and worsen asthma progression. Here, we provide a systematic review of the roles of NETs in asthma.
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Crisford H, Sapey E, Rogers GB, Taylor S, Nagakumar P, Lokwani R, Simpson JL. Neutrophils in asthma: the good, the bad and the bacteria. Thorax 2021; 76:thoraxjnl-2020-215986. [PMID: 33632765 PMCID: PMC8311087 DOI: 10.1136/thoraxjnl-2020-215986] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2020] [Revised: 01/12/2021] [Accepted: 01/18/2021] [Indexed: 12/30/2022]
Abstract
Airway inflammation plays a key role in asthma pathogenesis but is heterogeneous in nature. There has been significant scientific discovery with regard to type 2-driven, eosinophil-dominated asthma, with effective therapies ranging from inhaled corticosteroids to novel biologics. However, studies suggest that approximately 1 in 5 adults with asthma have an increased proportion of neutrophils in their airways. These patients tend to be older, have potentially pathogenic airway bacteria and do not respond well to classical therapies. Currently, there are no specific therapeutic options for these patients, such as neutrophil-targeting biologics.Neutrophils comprise 70% of the total circulatory white cells and play a critical defence role during inflammatory and infective challenges. This makes them a problematic target for therapeutics. Furthermore, neutrophil functions change with age, with reduced microbial killing, increased reactive oxygen species release and reduced production of extracellular traps with advancing age. Therefore, different therapeutic strategies may be required for different age groups of patients.The pathogenesis of neutrophil-dominated airway inflammation in adults with asthma may reflect a counterproductive response to the defective neutrophil microbial killing seen with age, resulting in bystander damage to host airway cells and subsequent mucus hypersecretion and airway remodelling. However, in children with asthma, neutrophils are less associated with adverse features of disease, and it is possible that in children, neutrophils are less pathogenic.In this review, we explore the mechanisms of neutrophil recruitment, changes in cellular function across the life course and the implications this may have for asthma management now and in the future. We also describe the prevalence of neutrophilic asthma globally, with a focus on First Nations people of Australia, New Zealand and North America.
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Affiliation(s)
- Helena Crisford
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - Geraint B Rogers
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
- Microbiome and Host Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Steven Taylor
- SAHMRI Microbiome Research Laboratory, Flinders University College of Medicine and Public Health, Adelaide, South Australia, Australia
- Microbiome and Host Health, South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Prasad Nagakumar
- Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
- Respiratory Medicine, Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Ravi Lokwani
- Faculty of Health and Medicine, Priority Research Centre for Healthy Lungs, The University of Newcastle, Callaghan, New South Wales, Australia
| | - Jodie L Simpson
- Faculty of Health and Medicine, Priority Research Centre for Healthy Lungs, The University of Newcastle, Callaghan, New South Wales, Australia
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Ulrik CS, Lange P, Hilberg O. Fractional exhaled nitric oxide as a determinant for the clinical course of asthma: a systematic review. Eur Clin Respir J 2021; 8:1891725. [PMID: 33708363 PMCID: PMC7919904 DOI: 10.1080/20018525.2021.1891725] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Precision medicine means linking the right patient to the right management strategy including best possible pharmacological therapy, considering the individual variability of the disease characteristics, type of inflammation, genes, environment, and lifestyle. For heterogenous diseases such as asthma, reliable biomarkers are needed to facilitate the best possible disease control and reduce the risk of side effects. The present review examines fractional exhaled nitric oxide (FeNO) as a guide for the management strategy of asthma and predictor of its clinical course. Method: The literature included was identified by searching the PubMed database using specific key words and MeSH terms. Studies were not excluded based on their design alone. The search resulted in 212 hits, of which 35 articles were included in this review. Results: Several studies support a potential role for high FeNO levels as a prognostic biomarker for accelerated lung function decline in adults with newly diagnosed asthma. Furthermore, studies report an association between high FeNO levels and excess decline in FEV1 in adults with long-standing moderate to severe asthma despite optimised therapy, whereas the findings for patients with less severe disease are conflicting. Applying a FeNO-based management algorithm reduces the exacerbation rate in adults with asthma. Similar observations are seen in children, though based on fewer studies. The available studies provide evidence that the level of FeNO may be useful as a predictor of subsequent loss of asthma control in adults, though the evidence is somewhat conflicting in children and young adults. Conclusion: The present review provides evidence of the prognostic value of FeNO as a surrogate biomarker for type 2 inflammation in the airways. FeNO is likely to emerge as an important biomarker in monitoring and tailoring modern asthma treatment, either alone or in combination with other biomarkers.
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Affiliation(s)
- Charlotte Suppli Ulrik
- Department of Respiratory Medicine, Hvidovre University Hospital, DK-2650 Hvidovre, Denmark and Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Peter Lange
- Section of Epidemiology, Department of Public Health, Medical Department, Herlev-Gentofte Hospital, University of Copenhagen, DK-1014 Copenhagen K, Denmark, Herlev, Denmark
| | - Ole Hilberg
- Department of Medicine, Vejle Hospital, Southern Denmark University Hospital, Denmark
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11
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Matsunaga NY, Gianfrancesco L, Mazzola TN, Oliveira MS, Morcillo AM, Ribeiro MÂGO, Ribeiro JD, Hashimoto S, Toro AADC. Differences between patients who achieved asthma control and those who remain uncontrolled after standardized severe asthma care strategy. J Asthma 2020; 59:418-425. [PMID: 33263446 DOI: 10.1080/02770903.2020.1852415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To assess clinical, functional, and inflammatory patterns of children and adolescents with severe uncontrolled asthma, and investigate the differences between patients who achieved asthma control and those who remain uncontrolled after standardized asthma care strategy. METHODS Screening all children and adolescents with asthma from the Pediatric Pulmonology Outpatient Clinic of Unicamp, Brazil, and included those with severe uncontrolled asthma according to GINA guidelines criteria. Patients were assessed at baseline and after by demographic and medication data, questionnaires (Asthma Control Test and Pediatric Asthma Quality of Life Questionnaire), Six-Minute Walk Test, skin prick test, spirometry, induced sputum, and blood collection (total immunoglobulin E and eosinophil count). Cytokine dosage was analyzed in sputum supernatant and serum by Cytometric Bead Array. RESULTS Thirty-three patients with severe uncontrolled asthma were included (median age 10.9 [7.00-17.60] years). All patients presented satisfactory adherence to treatment and 50% of them achieved good asthma control after six-month follow-up (p < 0.001). Patients who achieved asthma control reported higher intervals since their last exacerbation episode (p = 0.008) and higher quality of life scores (p < 0.001) as compared to patients who remained uncontrolled. We found no changes in lung function markers, inflammatory biomarkers, or cytokine levels between patients with uncontrolled and controlled asthma. CONCLUSION Participation of six months in a structured outpatient clinic for children with severe asthma had a notable improvement in control and quality of life of patients. This demonstrates the importance of a global assessment, focused on peculiarities presented by patients with severe uncontrolled asthma.
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Affiliation(s)
- Natasha Yumi Matsunaga
- Child and Adolescent Health Postgraduate Program, State University of Campinas, Campinas, São Paulo, Brazil.,Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil
| | - Lívea Gianfrancesco
- Child and Adolescent Health Postgraduate Program, State University of Campinas, Campinas, São Paulo, Brazil.,Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil
| | - Taís Nitsch Mazzola
- Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil
| | - Marina Simões Oliveira
- Child and Adolescent Health Postgraduate Program, State University of Campinas, Campinas, São Paulo, Brazil.,Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil
| | - André Moreno Morcillo
- Department of Paediatric Respiratory Medicine, Emma Children's hospital and Department of Respiratory Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Maria Ângela Gonçalves Oliveira Ribeiro
- Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil
| | - José Dirceu Ribeiro
- Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil.,Department of Pediatrics, School of Medical Sciences, State University of Campinas, Campinas, São Paulo, Brazil
| | - Simone Hashimoto
- Department of Paediatric Respiratory Medicine, Emma Children's hospital and Department of Respiratory Medicine, University of Amsterdam, Amsterdam, Netherlands
| | - Adyleia Aparecida Dalbo Contrera Toro
- Faculty of Medical Sciences, Laboratory of Pulmonary Physiology, Center for Investigation in Pediatrics, State University of Campinas, Campinas, São Paulo, Brazil.,Department of Pediatrics, School of Medical Sciences, State University of Campinas, Campinas, São Paulo, Brazil
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12
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Pijnenburg MW, Fleming L. Advances in understanding and reducing the burden of severe asthma in children. THE LANCET RESPIRATORY MEDICINE 2020; 8:1032-1044. [PMID: 32910897 DOI: 10.1016/s2213-2600(20)30399-4] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 01/16/2023]
Abstract
Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College, London, UK
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13
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Licari A, Manti S, Castagnoli R, Leonardi S, Marseglia GL. Measuring inflammation in paediatric severe asthma: biomarkers in clinical practice. Breathe (Sheff) 2020; 16:190301. [PMID: 32494300 PMCID: PMC7249787 DOI: 10.1183/20734735.0301-2019] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Severe asthma in children is a highly heterogeneous disorder, encompassing different clinical characteristics (phenotypes) and immunopathological pathways (endotypes). Research is focusing on the identification of noninvasive biomarkers able to predict treatment response and assist in designing personalised therapies for severe asthma. Blood and sputum eosinophils, serum IgE and exhaled nitric oxide fraction mostly reflect type 2 airway inflammation in children. However, in the absence of available point-of-care biomarkers, the diagnosis of non-type 2 asthma is still reached by exclusion. In this review, we present the most recent evidence on biomarkers for severe asthma and discuss their implementation in clinical practice. We address the methods for guiding treatment decisions and patient identification, focusing on the paediatric age group. Noninvasive biomarkers should be integrated with clinical findings to assist in diagnosing and guiding personalised therapies for severe asthma in childrenhttp://bit.ly/2JPvKFV
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Affiliation(s)
- Amelia Licari
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy.,These authors contributed equally
| | - Sara Manti
- Dept of Clinical and Experimental Medicine, University of Catania, Catania, Italy.,These authors contributed equally
| | - Riccardo Castagnoli
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
| | - Salvatore Leonardi
- Dept of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Gian Luigi Marseglia
- Pediatric Clinic, Fondazione IRCCS Policlinico San Matteo, University of Pavia, Pavia, Italy
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14
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Abstract
PURPOSE OF REVIEW Children with poor asthma control despite maximal maintenance therapy have problematic severe asthma (PSA). A step-wise approach including objective adherence monitoring and a detailed multidisciplinary team assessment to identify modifiable factors contributing to poor control is needed prior to considering therapy escalation. Pathophysiological phenotyping in those with true severe therapy-resistant asthma (STRA) and the current array of add-on therapies will be discussed. RECENT FINDINGS Adherence monitoring using electronic devices has shown that only 20-30% of children with PSA have STRA and need additional therapies. Omalizumab and mepolizumab are licensed for children with STRA aged 6 years and older. Although robust safety and efficacy data, with reduced exacerbations, are available for omalizumab, biomarkers predicting response to treatment are lacking. Paediatric safety data are available for mepolizumab, but efficacy data are unknown for those aged 6-11 years and minimal for those 12 years and older. A sub-group of children with STRA have neutrophilia, but the clinical significance and contribution to disease severity remains uncertain. SUMMARY Most children with PSA have steroid sensitive disease which improves with adherence to maintenance inhaled corticosteroids. Add-on therapies are only needed for the minority with STRA. Paediatric efficacy data of novel biologics and biomarkers that identify the optimal add-on for each child are lacking. If we are to progress toward individualized therapy for STRA, pragmatic clinical trials of biologics in accurately phenotyped children are needed.
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15
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Felicio-Júnior EL, Barnabé V, de Almeida FM, Avona MD, de Genaro IS, Kurdejak A, Eller MCN, Vergani KP, Rodrigues JC, Tibério IDFLC, Martins MDA, Saraiva-Romanholo BM. Randomized trial of physiotherapy and hypertonic saline techniques for sputum induction in asthmatic children and adolescents. Clinics (Sao Paulo) 2020; 75:e1512. [PMID: 31994616 PMCID: PMC6970279 DOI: 10.6061/clinics/2020/e1512] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 12/19/2019] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES This study aimed to analyze the efficiency of physiotherapy techniques in sputum induction and in the evaluation of pulmonary inflammation in asthmatic children and adolescents. Although hypertonic saline (HS) is widely used for sputum induction (SI), specific techniques and maneuvers of physiotherapy (P) may facilitate the collection of mucus in some asthmatic children and adolescents. METHODS A randomized crossover study was performed in patients with well-controlled asthma, and 90 sputum samples were collected. Children and adolescents were assessed using spirometry and randomized at entry into one of three sputum induction techniques: (i) 3% hypertonic saline - HS technique; (ii) physiotherapy (oscillatory positive expiratory pressure, forced expiration, and acceleration of expiratory flow) - P technique; and (iii) hypertonic saline + physiotherapy - HSP technique. ClinicalTrials.gov: NCT03136042. RESULTS The total cells (mL) and the percentage (%) of differential inflammatory cells were similar in all techniques. The sputum weight (g) in the HSP technique was significantly higher than that in the HS technique. In all techniques, the percentage of viable cells was >50%, and there was no difference between the HS and P techniques. Moreover, sputum induction did not cause any alterations in the pulmonary function of patients. CONCLUSION The physiotherapy sputum collection technique was effective in obtaining viable cells from mucus samples and yielded the same amount of sputum as the gold standard technique (hypertonic saline). In addition, the physiotherapy maneuvers were both safe and useful for sputum induction in asthmatic children and adolescents with well-controlled asthma.
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Affiliation(s)
- Egberto Luiz Felicio-Júnior
- Hospital do Servidor Publico do Estado de Sao Paulo (IAMSPE), Sao Paulo, SP, BR
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Viviani Barnabé
- Hospital do Servidor Publico do Estado de Sao Paulo (IAMSPE), Sao Paulo, SP, BR
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, BR
| | - Francine Maria de Almeida
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | | | | | - Miriam Cardoso Neves Eller
- Departamento de Pediatria e Pneumologia, Instituto da Criança, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Karina Pierantozzi Vergani
- Departamento de Pediatria e Pneumologia, Instituto da Criança, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Joaquim Carlos Rodrigues
- Departamento de Pediatria e Pneumologia, Instituto da Criança, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | | | - Milton de Arruda Martins
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
| | - Beatriz Mangueira Saraiva-Romanholo
- Hospital do Servidor Publico do Estado de Sao Paulo (IAMSPE), Sao Paulo, SP, BR
- Laboratorio de Terapeutica Experimental (LIM-20), Faculdade de Medicina FMUSP, Universidade de Sao Paulo, Sao Paulo, SP, BR
- Universidade Cidade de Sao Paulo (UNICID), Sao Paulo, SP, BR
- *Corresponding author. E-mail:
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16
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Pajor NM, Guilbert TW. Personalized Medicine and Pediatric Asthma. Immunol Allergy Clin North Am 2019; 39:221-231. [PMID: 30954172 DOI: 10.1016/j.iac.2018.12.009] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Asthma is a heterogeneous disorder described by a large number of clinical features. A growing body of literature on more specific asthma phenotypes provides evidence for a phenotype-based approach to management in which specific therapies are recommended based on patient and disease characteristics. This understanding, coupled with an increase in the number of available therapies for children with asthma, as well as emerging therapies and phenotypic markers, will allow for improved asthma management in the future.
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Affiliation(s)
- Nathan M Pajor
- Department of Pediatrics, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA
| | - Theresa W Guilbert
- Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA; Pulmonary Division, Cincinnati Children's Hospital Medical Center, 3333 Burnet Avenue, MLC 7041, Cincinnati, OH 45229, USA.
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17
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Loughlin CE, Muston HN, Pena MA, Ren CL, Yilmaz O, Noah TL. Pediatric Pulmonology year in review 2018: Asthma, physiology/pulmonary function testing, and respiratory infections. Pediatr Pulmonol 2019; 54:1508-1515. [PMID: 31237426 DOI: 10.1002/ppul.24420] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Accepted: 05/28/2019] [Indexed: 11/06/2022]
Abstract
Pediatric Pulmonology publishes original research, reviews, and case reports related to a wide range of children's respiratory disorders. In our "Year in Review" series, we summarize publications in our major topic areas from 2018, in the context of selected literature in these areas from other journals relevant to our discipline. This review covers selected articles on asthma, physiology/lung function testing, and respiratory infections.
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Affiliation(s)
- Ceila E Loughlin
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Heather N Muston
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Michael A Pena
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Clement L Ren
- Department of Pediatrics, Riley Children's Hospital, Indiana University School of Medicine, Indianapolis, Indiana
| | - Ozge Yilmaz
- Department of Pediatrics, Pediatric Allergy and Pulmonology, Celal Bayar University, Manisa, Turkey
| | - Terry L Noah
- Department of Pediatrics, University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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18
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Lee WY, Suh DI, Song DJ, Baek HS, Shin M, Yoo Y, Kwon JW, Jang GC, Yang HJ, Lee E, Seo JH, Woo SI, Kim HY, Shin YH, Lee JS, Yoon J, Jung S, Han M, Eom E, Yu J, Kim WK, Lim DH, Kim JT, Chang WS, Lee JK, Kim HS. Asthma control test reflects not only lung function but also airway inflammation in children with stable asthma. J Asthma 2019; 57:648-653. [PMID: 30969134 DOI: 10.1080/02770903.2019.1599386] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Objective: Various numerical asthma control tools have been developed to distinguish different levels of symptom control. We aimed to examine whether the asthma control test (ACT) is reflective of objective findings such as lung function, fractional exhaled nitric oxide (FeNO) and laboratory data in patients with stable asthma.Methods: We included patients who were enrolled in the Korean Childhood Asthma Study. ACT, spirometry, blood tests and FeNO were performed in patients after stabilization of their asthma. We examined differences among spirometry parameters, blood tests and FeNO according to control status as determined by ACT and investigated for any significant correlations.Results: The study population consisted of 441 subjects. Spirometry showed that forced expiratory volume in one second (FEV1), forced expiratory flow between 25% and 75% of forced vital capacity and FEV1/forced vital capacity were all significantly higher in the controlled asthma group. Likewise, FeNO and percent-change in FEV1 were both significantly lower in the controlled asthma group. In blood tests, the eosinophil fraction was significantly lower in the controlled asthma group while white blood cell count was significantly higher in the controlled asthma group. Lastly, among the various factors analyzed, only provocative concentration of methacholine causing a 20% fall in FEV1 significantly correlated with ACT score.Conclusion: ACT is useful as part of the routine evaluation of asthmatic children and should be used as a complement to existing tools such as spirometry and FeNO measurement.
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Affiliation(s)
- Woo Yeon Lee
- Department of Pediatrics, School of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Dae Jin Song
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
| | - Hey-Sung Baek
- Department of Pediatrics, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Meeyong Shin
- Department of Pediatrics, Soonchunhyang University School of Medicine, Bucheon, Korea
| | - Young Yoo
- Department of Pediatrics, Korea University Anam Hospital, Seoul, Korea
| | - Ji-Won Kwon
- Department of Pediatrics, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Gwang Cheon Jang
- Department of Pediatrics, National Health Insurance Service Ilsan Hospital, Ilsan, Korea
| | - Hyeon-Jong Yang
- Department of Pediatrics, Pediatric Allergy and Respiratory Center, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Eun Lee
- Department of Pediatrics, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea
| | - Ju-Hee Seo
- Department of Pediatrics, Dankook University Hospital, Cheonan, Korea
| | - Sung-Il Woo
- Department of Pediatrics, College of Medicine, Chungbuk National University, Cheongju, Korea
| | - Hyung Young Kim
- Department of Pediatrics, Pusan National University Yangsan Hospital, Yangsan, Korea
| | - Youn Ho Shin
- Department of Pediatrics, Gangnam CHA Medical Center CHA University School of Medicine, Seoul, Korea
| | - Ju Suk Lee
- Department of Pediatrics, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Jisun Yoon
- Department of Pediatrics, Mediplex Sejong Hospital, Incheon, Korea
| | - Sungsu Jung
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Minkyu Han
- Department of Clinical Epidemiology and Biostatistics, Asan Medical Center, Seoul, Korea
| | - Eunjin Eom
- Department of Statistics, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea
| | - Jinho Yu
- Department of Pediatrics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Woo Kyung Kim
- Department of Pediatrics, Inje University Seoul Paik Hospital, Seoul, Korea
| | - Dae Hyun Lim
- Department of Pediatrics, School of Medicine, Inha University, Incheon, Korea
| | - Jin Tack Kim
- Department of Pediatrics, School of Medicine, The Catholic University of Korea, Uijeongbu St. Mary's hospital, Uijeongbu, Korea
| | - Woo-Sung Chang
- Division of Allergy and Chronic Respiratory Diseases, Center for Biomedical Sciences, Korea National Institute of Health, Korea Centers for Disease Control and Prevention, Osong, Korea
| | - Jeom-Kyu Lee
- Division of Allergy and Chronic Respiratory Diseases, Center for Biomedical Sciences, Korea National Institute of Health, Korea Centers for Disease Control and Prevention, Osong, Korea
| | - Hwan Soo Kim
- Department of Pediatrics, School of Medicine, The Catholic University of Korea, Bucheon St. Mary's Hospital, Bucheon, Korea
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19
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Haktanir Abul M, Phipatanakul W. Severe asthma in children: Evaluation and management. Allergol Int 2019; 68:150-157. [PMID: 30648539 DOI: 10.1016/j.alit.2018.11.007] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2018] [Revised: 11/19/2018] [Accepted: 11/21/2018] [Indexed: 12/17/2022] Open
Abstract
Severe asthma in children is associated with significant morbidity. Children with severe asthma are at increased risk for adverse outcomes including medication-related side effects, life-threatening exacerbations, and impaired quality of life. It is important to differentiate between severe therapy resistant asthma and difficult-to-treat asthma due to comorbidities. The most common problems that need to be excluded before a diagnosis of severe asthma can be made are poor medication adherence, poor medication technique or incorrect diagnosis of asthma. Difficult to treat asthma is a much more common reason for persistent symptoms and exacerbations and can be managed if comorbidities are clearly addressed. Children with persistent symptoms and exacerbations despite correct inhaler technique and good medical adherence to standard Step 4 asthma therapies according to the guidelines1,2, should be referred to an asthma specialist with expertise in severe asthma.
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Affiliation(s)
- Mehtap Haktanir Abul
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA; Harvard Medical School, Boston, MA, USA
| | - Wanda Phipatanakul
- Harvard Medical School, Boston, MA, USA; Division of Allergy and Immunology, Boston Children's Hospital, Boston, MA, USA.
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20
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Grunwell JR, Travers C, Fitzpatrick AM. Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus. Pediatr Crit Care Med 2018; 19:e585-e594. [PMID: 30106766 PMCID: PMC6218278 DOI: 10.1097/pcc.0000000000001695] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation. DESIGN Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory University between 2004 and 2015. SETTING Large, free-standing academic quaternary care children's hospital in Atlanta, GA. PATIENTS Children 6-18 years old with physician-diagnosed and confirmed asthma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 579 children were analyzed with 170 children (29.4%) being admitted to the PICU for an asthma exacerbation in their lifetime. Of these 170 children with a history of critical asthma, 24.1% were classified as having mild-to-moderate asthma, and 83 of 170 children (48.8%) had been intubated and experienced near-fatal asthma. Multiple logistic regression was used to identify risk factors associated with increased odds of PICU admission with or without endotracheal intubation. Hospitalization within the prior 12 months of survey (odds ratio, 8.19; 95% CI, 4.83-13.89), a history of pneumonia (odds ratio, 2.56; 95% CI, 1.52-4.29), having a designation of increased chronic asthma severity on high-dose inhaled corticosteroids (odds ratio, 2.76; 95% CI, 1.62-4.70), having a father with asthma (odds ratio, 2.15; 95% CI, 1.23-3.76), living in a region with a higher burden of poverty (odds ratio, 1.28; 95% CI, 1.02-1.61), and being of black race (odds ratio, 2.01; 95% CI, 1.05-3.84) were all associated with increased odds of PICU admission with or without intubation. CONCLUSIONS Our findings suggest that there are factors associated with critical and near-fatal asthma, distinct from the chronic asthma severity designations, that should be the focus of future investigation.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
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