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Roberts G, Valovirta E, Halken S, Eng PA, Mäkelä MJ, Lødrup Carlsen KC, Knecht R, Malmberg LP. Diagnosing new-onset asthma in a paediatric clinical trial setting in school-age children. FRONTIERS IN ALLERGY 2024; 5:1418922. [PMID: 39081649 PMCID: PMC11287659 DOI: 10.3389/falgy.2024.1418922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Accepted: 05/21/2024] [Indexed: 08/02/2024] Open
Abstract
Asthma is a common chronic disease in children. It is a dynamic condition-symptoms change over time, and the outcome of diagnostic tests can vary. Consequently, evaluating the onset of asthma at a single point in time, perhaps when patients are asymptomatic with limited impairment of the lung function, may result in false diagnostic conclusions. The absence of consistent gold-standard diagnostic criteria in children challenges the ability of any study to ascertain an effect of treatment on asthma prevention. A comprehensive review of the diagnostic criteria used for new-onset asthma in school-age children was conducted based on existing recommendations from published clinical guidance, alongside evidence from paediatric asthma prevention trials. Findings from the review were used to propose suggestions for diagnosing new-onset asthma in future asthma prevention trials. Despite an overall lack of consensus in the published clinical guidance, there are similarities between the various recommendations for diagnosing asthma in children, which typically involve assessing the variable symptoms and supplementing the medical history with objective measures of lung function. For future paediatric asthma prevention trials, we suggest that paediatric clinical trials should use a new-onset asthma definition that incorporates the concepts of "possible", "probable" and "confirmed" asthma. "Possible" asthma would capture self-reported features of chronic symptoms and symptom relief with β2-agonist bronchodilator (suggesting reversibility). "Probable" asthma would include symptom chronicity, self-reported symptom relief with β2-agonist bronchodilator, and objective features of asthma (reversibility or bronchial hyper-responsiveness). A "confirmed" diagnosis would be made only if there is a positive response to controller therapy. These suggestions aim to improve the diagnosis of new-onset childhood asthma in clinical trials, which will be useful in the design and conduct of future paediatric asthma prevention trials.
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Affiliation(s)
- Graham Roberts
- The David Hide Asthma and Allergy Research Centre, St Mary’s Hospital, Newport, Isle of Wight, United Kingdom
- NIHR Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Erkka Valovirta
- Terveystalo Allergy Clinic, Department of Lung Diseases and Clinical Immunology, University of Turku, Turku, Finland
| | - Susanne Halken
- Hans Christian Andersen Children’s Hospital, Odense University Hospital, Odense, Denmark
| | - Peter A. Eng
- Section of Paediatric Pulmonology and Allergy, Children’s Hospital, Aarau, Switzerland
| | - Mika J. Mäkelä
- Skin and Allergy Hospital, Helsinki University Central Hospital and University of Helsinki, Helsinki, Finland
| | - Karin C. Lødrup Carlsen
- Department of Paediatrics, Oslo University Hospital, Oslo, Norway
- Faculty of Medicine, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - L. Pekka Malmberg
- Unit of Clinical Physiology, Skin and Allergy Hospital, Helsinki University and Helsinki University Hospital, Helsinki, Finland
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Bradding P, Porsbjerg C, Côté A, Dahlén SE, Hallstrand TS, Brightling CE. Airway hyperresponsiveness in asthma: The role of the epithelium. J Allergy Clin Immunol 2024; 153:1181-1193. [PMID: 38395082 DOI: 10.1016/j.jaci.2024.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Revised: 02/02/2024] [Accepted: 02/20/2024] [Indexed: 02/25/2024]
Abstract
Airway hyperresponsiveness (AHR) is a key clinical feature of asthma. The presence of AHR in people with asthma provides the substrate for bronchoconstriction in response to numerous diverse stimuli, contributing to airflow limitation and symptoms including breathlessness, wheeze, and chest tightness. Dysfunctional airway smooth muscle significantly contributes to AHR and is displayed as increased sensitivity to direct pharmacologic bronchoconstrictor stimuli, such as inhaled histamine and methacholine (direct AHR), or to endogenous mediators released by activated airway cells such as mast cells (indirect AHR). Research in in vivo human models has shown that the disrupted airway epithelium plays an important role in driving inflammation that mediates indirect AHR in asthma through the release of cytokines such as thymic stromal lymphopoietin and IL-33. These cytokines upregulate type 2 cytokines promoting airway eosinophilia and induce the release of bronchoconstrictor mediators from mast cells such as histamine, prostaglandin D2, and cysteinyl leukotrienes. While bronchoconstriction is largely due to airway smooth muscle contraction, airway structural changes known as remodeling, likely mediated in part by epithelial-derived mediators, also lead to airflow obstruction and may enhance AHR. In this review, we outline the current knowledge of the role of the airway epithelium in AHR in asthma and its implications on the wider disease. Increased understanding of airway epithelial biology may contribute to better treatment options, particularly in precision medicine.
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Affiliation(s)
- Peter Bradding
- Department of Respiratory Sciences, Leicester Respiratory National Institute for Health and Care Research Biomedical Research Centre, Glenfield Hospital, University of Leicester, Leicester, United Kingdom
| | - Celeste Porsbjerg
- Department of Respiratory Medicine and Infectious Diseases, Copenhagen University Hospital Bispebjerg, Copenhagen, Denmark
| | - Andréanne Côté
- Quebec Heart and Lung Institute, Université Laval, Laval, Quebec, Canada; Department of Medicine, Université Laval, Laval, Quebec, Canada
| | - Sven-Erik Dahlén
- Department of Medicine Huddinge, Karolinska Institutet, Stockholm, Sweden; Department of Respiratory Medicine and Allergy, Karolinska University Hospital, Stockholm, Sweden
| | - Teal S Hallstrand
- Department of Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, University of Washington, Seattle, Wash; Center for Lung Biology, University of Washington, Seattle, Wash.
| | - Christopher E Brightling
- Department of Respiratory Sciences, Leicester Respiratory National Institute for Health and Care Research Biomedical Research Centre, Glenfield Hospital, University of Leicester, Leicester, United Kingdom.
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Stewart L, Miyazawa N, Covar R, Mjaanes C, Shimamoto R, Gleason M, Peroni D, Spahn JD, Comberiati P. Wheeze is an unreliable endpoint for bronchial methacholine challenges in preschool children. Pediatr Allergy Immunol 2022; 33:e13767. [PMID: 35470941 PMCID: PMC9325539 DOI: 10.1111/pai.13767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 03/14/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Onset of wheeze is the endpoint often used in the determination of a positive bronchial challenge test (BCT) in young children who cannot perform spirometry. We sought to assess several clinical endpoints at the time of a positive BCT in young children with recurrent wheeze compared to findings in school-aged children with asthma. METHODS Positive BCT was defined in: (1) preschool children (n = 22) as either persistent cough, wheeze, fall in oxygen saturation (SpO2 ) of ≥5%, or ≥50% increase in respiratory rate (RR) from baseline; and (2) school-aged children (n = 22) as the concentration of methacholine (MCh) required to elicit a 20% decline in FEV1 (PC20 ). RESULTS All preschool children (mean age 3.4 years) had a positive BCT (median provocative MCh concentration 1.25 mg/ml [IQR, 0.62, 1.25]). Twenty (91%) school-aged children (mean age 11.3 years) had a positive BCT (median PC20 1.25 mg/ml [IQR, 0.55, 2.5]). At the time of the positive BCT, the mean fall in SpO2 (6.9% vs. 3.8%; p = .001) and the mean % increase in RR (61% vs. 22%; p < .001) were greater among preschool-aged than among school-aged children. A minority of children developed wheeze at time of positive BCT (23% preschool- vs. 15% school-aged children; p = .5). CONCLUSIONS The use of wheeze as an endpoint for BCT in preschool children is unreliable, as it rarely occurs. The use of clinical endpoints, such as ≥25% increase in RR or fall in SpO2 of ≥3%, captured all of our positive BCT in preschool children, while minimizing undue respiratory distress.
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Affiliation(s)
- Lora Stewart
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA
| | - Naomi Miyazawa
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA.,Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Ronina Covar
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA.,Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Christopher Mjaanes
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA
| | - Reed Shimamoto
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA
| | - Melanie Gleason
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA.,Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Diego Peroni
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Joseph D Spahn
- Divisions of Allergy-Clinical Immunology and Clinical Pharmacology, National Jewish Health, Denver, Colorado, USA.,Department of Pediatrics, National Jewish Health, Denver, Colorado, USA
| | - Pasquale Comberiati
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
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Papadopoulos NG, Miligkos M, Xepapadaki P. A Current Perspective of Allergic Asthma: From Mechanisms to Management. Handb Exp Pharmacol 2021; 268:69-93. [PMID: 34085124 DOI: 10.1007/164_2021_483] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Asthma is a result of heterogenous, complex gene-environment interactions with variable clinical phenotypes, inflammation, and remodeling. It affects more than 330 million of people worldwide throughout their educational and working lives, while exacerbations put a heavy cost/burden on productivity. Childhood asthma is characterized by a predominance of allergic sensitization and multimorbidity, while in adults polysensitization has been positively associated with asthma occurrence. Despite significant improvements in recent decades, asthma management remains challenging. Recently, a group of specialists suggested that the term "asthma" should be preferably used as a descriptive term for symptoms. Moreover, type 2 inflammation has emerged as a pivotal disease mechanism including overlapping endotypes of specific IgE production, while type 2-low asthma includes several disease endotypes. Optimal asthma control requires both appropriate pharmacological interventions, tailored to each patient, as well as trigger avoidance measures. Regular monitoring for maintenance of symptom control, preservation of lung function, and detection of treatment-related adverse effects are warranted. Allergen-specific immunotherapy and the advent of new targeted therapies for patients with difficult to control asthma offer diverse treatment options. The current review summarizes up-to-date knowledge on epidemiology, definitions, diagnosis, and current therapeutic strategies.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece. .,Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK.
| | - Michael Miligkos
- First Department of Pediatrics, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
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