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Fitzpatrick AM, Huang M, Mohammad AF, Stephenson ST, Kamaleswaran R, Grunwell JR. Dysfunctional neutrophil type 1 interferon responses in preschool children with recurrent wheezing and IL-4-mediated aeroallergen sensitization. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100229. [PMID: 38510797 PMCID: PMC10950716 DOI: 10.1016/j.jacig.2024.100229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 11/25/2023] [Accepted: 12/24/2023] [Indexed: 03/22/2024]
Abstract
Background The innate mechanisms associated with viral exacerbations in preschool children with recurrent wheezing are not understood. Objective We sought to assess differential gene expression in blood neutrophils from preschool children with recurrent wheezing, stratified by aeroallergen sensitization, at baseline and after exposure to polyinosinic:polycytidylic acid (poly(I:C)) and also to examine whether poly(I:C)-stimulated blood neutrophils influenced airway epithelial gene expression. Methods Blood neutrophils were purified and cultured overnight with poly(I:C) and underwent next-generation sequencing with Reactome pathway analysis. Primary human small airway epithelial cells were treated with poly(I:C)-treated neutrophil culture supernatants and were analyzed for type 1 interferon gene expression with a targeted array. Symptoms and exacerbations were assessed in participants over 12 months. Results A total of 436 genes were differently expressed in neutrophils from children with versus without aeroallergen sensitization at baseline, with significant downregulation of type 1 interferons. These type 1 interferons were significantly upregulated in sensitized children after poly(I:C) stimulation. Confirmatory experiments demonstrated similar upregulation of type 1 interferons in IL-4-treated neutrophils stimulated with poly(I:C). Poly(I:C)-treated neutrophil supernatants from children with aeroallergen sensitization also induced a type 1 interferon response in epithelial cells. Children with aeroallergen sensitization also had higher symptom scores during exacerbations, and these symptom differences persisted for 3 days after prednisolone treatment. Conclusions Type 1 interferon responses are dysregulated in preschool children with aeroallergen sensitization, which is in turn associated with exacerbation severity. Given the importance of type 1 interferon signaling in viral resolution, additional studies of neutrophil type 1 interferon responses are needed in this population.
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Affiliation(s)
- Anne M. Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga
- Division of Pulmonary Medicine, Children’s Healthcare of Atlanta, Atlanta, Ga
| | - Min Huang
- Department of Biomedical Informatics, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R. Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga
- Division of Critical Care Medicine, Children’s Healthcare of Atlanta, Atlanta, Ga
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Hamlington KL, Navanandan N. A step toward predicting recurrence in preschool-age severe wheeze. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:1071-1072. [PMID: 38583924 DOI: 10.1016/j.jaip.2024.01.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 01/04/2024] [Indexed: 04/09/2024]
Affiliation(s)
- Katharine L Hamlington
- Section of Pulmonary and Sleep Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colo
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Children's Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, Colo.
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Hardee IJ, Zaniletti I, Tanverdi MS, Liu AH, Mistry RD, Navanandan N. Emergency management and asthma risk in young Medicaid-enrolled children with recurrent wheeze. J Asthma 2024:1-8. [PMID: 38324665 DOI: 10.1080/02770903.2024.2314623] [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: 08/03/2023] [Accepted: 01/31/2024] [Indexed: 02/09/2024]
Abstract
OBJECTIVES To describe clinical characteristics of young children presenting to the emergency department (ED) for early recurrent wheeze, and determine factors associated with subsequent persistent wheeze and risk for early childhood asthma. METHODS Retrospective cohort study of Medicaid-enrolled children 0-3 years old with an index ED visit for wheeze (e.g. bronchiolitis, reactive airway disease) from 2009 to 2013, and at least one prior documented episode of wheeze at an ED or primary care visit. The primary outcome was persistent wheeze between 4 and 6 years of age. Demographics and clinical characteristics were collected from the index ED visit. Logistic regression was used to estimate the association between potential risk factors and subsequent persistent wheeze. RESULTS During the study period, 41,710 children presented to the ED for recurrent wheeze. Mean age was 1.3 years; 59% were male, 42% Black, and 6% Hispanic. At index ED visits, the most common diagnosis was acute bronchiolitis (40%); 77% of children received an oral corticosteroid prescription. Between 4 and 6 years of age, 11,708 (28%) children had persistent wheeze. A greater number of wheezing episodes was associated with an increased odds of ED treatment with asthma medications. Subsequent persistent wheeze was associated with male sex, Black race, atopy, prescription for bronchodilators or corticosteroids, and greater number of visits for wheeze. CONCLUSIONS Young children with persistent wheeze are at risk for childhood asthma. Thus, identification of risk factors associated with persistent wheeze in young children with recurrent wheeze might aid in early detection of asthma and initiation of preventative therapies.
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Affiliation(s)
- Isabel J Hardee
- Department of Pediatrics, University of CO School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | | | - Melisa S Tanverdi
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
| | - Andrew H Liu
- Section of Pulmonary and Sleep Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO
| | - Rakesh D Mistry
- Section of Emergency Medicine, Department of Pediatrics, Yale University School of Medicine, New Haven, CT, USA
| | - Nidhya Navanandan
- Section of Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Children's Hospital Colorado, Aurora, CO, USA
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Serôdio M, Albuquerque C, Figueiredo M, Moscoso J, Serôdio J, Barreira R, Monteiro R, Leiria MJ. Clinical Predictors of Severe Exacerbations in Pediatric Patients With Recurrent Wheezing. Cureus 2024; 16:e52667. [PMID: 38380209 PMCID: PMC10878539 DOI: 10.7759/cureus.52667] [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] [Accepted: 01/21/2024] [Indexed: 02/22/2024] Open
Abstract
Introduction Wheezing is common in preschool-aged children, affecting about half of all children within their first six years of life. Children who have recurrent wheezing experience disease-related morbidity, including increased emergency visits and hospitalizations. Early-life lower respiratory tract viral infections are linked to recurrent wheezing and eventual asthma onset. Identifying high-risk children is crucial, with the frequency and severity of wheezing episodes being good predictors of long-term outcomes. Aim To identify predictors of severe exacerbations in children with recurrent wheezing. Methods We conducted a retrospective cohort study involving 168 pediatric patients with recurrent wheezing followed up at our outpatient clinic. The outcome of interest was the occurrence of a severe exacerbation, defined as any exacerbation requiring hospitalization and the need for supplemental oxygenation or ventilatory support. Results The median age of the first wheezing exacerbation was five months, with a predominance of the male gender. Approximately two-thirds of the patients had a family history of atopy. Comorbid allergic rhinitis and atopic dermatitis were present in 15.4% and 16.7% of patients, respectively. Twenty percent of patients had a severe wheezing exacerbation as the first form of presentation, and 30% presented at least one severe exacerbation from the first presentation to the last follow-up. Patients with severe exacerbations were younger at the first episode (median age 4 months, IQR 2-7, versus 7 months, IQR 4-12, p=0.027) and more frequently had a family history of atopy (71.7% versus 55.6%, p=0.050). In this cohort, patients who initially presented with a severe episode are at increased risk of incident severe exacerbations during follow-up, HR 2.24 (95%CI 1.01-4.95). Conclusions We know that the severity of exacerbations in children with recurrent wheezing correlates with the long-term outcomes of the disease. Therefore, preventing severe exacerbations can positively impact the prognosis of these patients. In this analysis, we found independent predictors of severe exacerbations to be the first clinical episode before the age of three months and a family history of atopy. We also found that patients whose initial presentation was severe have a higher risk of new severe exacerbations. Therefore, these subgroups of patients should be closely monitored by pediatricians.
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Affiliation(s)
- Margarida Serôdio
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - Catarina Albuquerque
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - Marta Figueiredo
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - Joana Moscoso
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - João Serôdio
- Internal Medicine, Hospital Professor Doutor Fernando Fonseca, Amadora, PRT
| | - Rita Barreira
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - Rita Monteiro
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
| | - Maria João Leiria
- Pediatrics, Hospital de São Francisco Xavier, Centro Hospitalar de Lisboa Ocidental, Lisbon, PRT
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Mallet MC, Pedersen ESL, Makhoul R, Blanchon S, Hoyler K, Jochmann A, Latzin P, Moeller A, Regamey N, Goutaki M, Spycher BD, Kuehni CE. Phenotypes of cough in children: A latent class analysis. Clin Exp Allergy 2023; 53:1279-1290. [PMID: 37997173 DOI: 10.1111/cea.14416] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2023] [Revised: 09/29/2023] [Accepted: 10/19/2023] [Indexed: 11/25/2023]
Abstract
INTRODUCTION Distinguishing phenotypes among children with cough helps understand underlying causes. Using a statistical data-driven approach, we aimed to identify and validate cough phenotypes based on measurable traits, physician diagnoses, and prognosis. METHODS We used data from the Swiss Paediatric Airway Cohort and included 531 children aged 5-16 years seen in outpatient clinics since 2017. We included children with any parent-reported cough (i.e. cough without a cold, cough at night, cough more than other children, or cough longer than 4 weeks) without current wheeze. We applied latent class analysis to identify phenotypes using nine symptoms and characteristics and selected the best model using the Akaike information criterion. We assigned children to the most likely phenotype and compared the resulting groups for parental atopy history, comorbidities, spirometry, fractional exhaled nitric oxide (FeNO), skin prick tests and specific IgE, physician diagnoses, and 1-year prognosis. RESULTS We identified four cough phenotypes: non-specific cough (26%); non-allergic infectious and night cough with snoring and otitis (4%); chronic allergic dry night cough with snoring (9%); and allergic non-infectious cough with rhino-conjunctivitis (61%). Children with the allergic phenotype often had family or personal history of atopy and asthma diagnosis. FeNO was highest for the allergic phenotype [median 17.9 parts per billion (ppb)] and lowest for the non-allergic infectious phenotype [median 7.0 parts per billion (ppb)]. Positive allergy test results differed across phenotypes (p < .001) and were most common among the allergic (70%) and least common among the non-specific cough (31%) phenotypes. Subsequent wheeze was more common among the allergic than the non-specific phenotype. CONCLUSION We identified four clinically relevant cough phenotypes with different prognoses. Although we excluded children with current wheeze, most children with cough belonged to allergy-related phenotypes.
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Affiliation(s)
- Maria Christina Mallet
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Eva S L Pedersen
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Ronny Makhoul
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Graduate School for Health Sciences, University of Bern, Bern, Switzerland
| | - Sylvain Blanchon
- Pediatric Pulmonology and Cystic Fibrosis Unit, Service of Pediatrics, Department Woman-Mother-Child, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Karin Hoyler
- Kinderpneumologie Horgen, Private Practice for Pediatric Pneumology, Horgen, Switzerland
| | - Anja Jochmann
- Department of Paediatric Pulmonology, University Children's Hospital Basel, Basel, Switzerland
| | - Philipp Latzin
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Alexander Moeller
- Department of Respiratory Medicine, University Children's Hospital Zurich and Children's Research Centre, University of Zurich, Zurich, Switzerland
| | - Nicolas Regamey
- Division of Paediatric Pulmonology, Children's Hospital, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | - Myrofora Goutaki
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Ben D Spycher
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
| | - Claudia E Kuehni
- Institute of Social and Preventive Medicine, University of Bern, Bern, Switzerland
- Division of Paediatric Respiratory Medicine and Allergology, Department of Paediatrics, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Fitzpatrick AM, Mohammad AF, Huang M, Stephenson ST, Patrignani J, Kamaleswaran R, Grunwell JR. Functional immunophenotyping of blood neutrophils identifies novel endotypes of viral response in preschool children with recurrent wheezing. J Allergy Clin Immunol 2023; 152:1433-1443. [PMID: 37604313 PMCID: PMC10841272 DOI: 10.1016/j.jaci.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/07/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Preschool children with recurrent wheezing are heterogeneous, with differing responses to respiratory viral infections. Although neutrophils are crucial for host defense, their function has not been studied in this population. OBJECTIVE We performed functional immunophenotyping on isolated blood neutrophils from 52 preschool children with recurrent wheezing (aeroallergen sensitization, n = 16; no sensitization, n = 36). METHODS Blood neutrophils were purified and cultured overnight with polyinosinic:polycytidylic acid [poly(I:C)] as a viral analog stimulus. Neutrophils underwent next-generation sequencing with Reactome pathway analysis and were analyzed for cytokine secretion, apoptosis, myeloperoxidase, and extracellular DNA release. CD14+ monocytes were also exposed to neutrophil culture supernatant and analyzed for markers of M1 and M2 activation. RESULTS A total of 495 genes, related largely to the innate immune system and neutrophil degranulation, were differently expressed in children with versus without aeroallergen sensitization. Functional experiments identified more neutrophil degranulation and extracellular trap formation (ie, more myeloperoxidase and extracellular DNA) and less neutrophil proinflammatory cytokine secretion in children with aeroallergen sensitization. Neutrophils also shifted CD14+ monocytes to a more anti-inflammatory (ie, M2) phenotype in sensitized children and a more proinflammatory (ie, M1) phenotype in nonsensitized children. Although both groups experienced viral exacerbations, annualized exacerbation rates prompting unscheduled health care were also higher in children without aeroallergen sensitization after enrollment. CONCLUSIONS Systemic neutrophil responses to viral infection differ by allergic phenotype and may be less effective in preschool children without allergic inflammation. Further studies of neutrophil function are needed in this population, which often has less favorable therapeutic responses to inhaled corticosteroids and other therapies directed at type 2-high inflammation.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | | | - Min Huang
- Department of Biomedical Informatics, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
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Jensen SK, Melgaard ME, Pedersen CET, Yang L, Vahman N, Thyssen JP, Schoos AMM, Stokholm J, Bisgaard H, Chawes B, Bønnelykke K. Limited clinical role of blood eosinophil levels in early life atopic disease: A mother-child cohort study. Pediatr Allergy Immunol 2023; 34:e14050. [PMID: 38010010 DOI: 10.1111/pai.14050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Blood eosinophil count is a well-established biomarker of atopic diseases in older children and adults. However, its predictive role for atopic diseases in preschool children is not well established. OBJECTIVE To investigate the association between blood eosinophil count in children and development of atopic diseases up to age 6 years. METHODS We investigated blood eosinophil count at age 18 months and 6 years in relation to recurrent wheeze/asthma, atopic dermatitis, allergic rhinitis, and allergic sensitization during the first 6 years of life in the two Copenhagen Prospective Studies on Asthma in Childhood cohorts (n = 1111). Blood eosinophil count was investigated in association with remission of existing atopic disease, current atopic disease, and later development of atopic disease. RESULTS Blood eosinophil count at 18 months was not associated with current wheezing/asthma or atopic dermatitis, while blood eosinophil count at age 6 years was associated with increased occurrence of current wheezing/asthma (OR = 1.1; 1.04-1.16, p = .0005), atopic dermatitis (OR = 1.06; 1.01-1.1, p = .02), and allergic rhinitis (OR = 1.11; 1.05-1.18, p = .0002). Blood eosinophil count at 18 months did not predict persistence or development of recurrent wheeze/asthma or atopic dermatitis at age 6 years. CONCLUSION Blood eosinophil count at 18 months was not associated with current wheezing/asthma or atopic dermatitis and did not predict persistence or development of disease. This implies a limited clinical role of blood eosinophil levels in early-life atopic disease and questions the clinical value of blood eosinophil counts measured in toddlers as a predictive biomarker for subsequent atopic disease in early childhood.
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Affiliation(s)
- Signe Kjeldgaard Jensen
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Elsner Melgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Casper-Emil Tingskov Pedersen
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Luo Yang
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nilo Vahman
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jacob P Thyssen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ann-Marie M Schoos
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
- Section of Microbiology and Fermentation, Department of Food Science, University of Copenhagen, Copenhagen, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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Rodríguez-Martínez CE, Sossa-Briceño MP, Forno E. Composite predictive models for asthma exacerbations or asthma deterioration in pediatric asthmatic patients: A systematic review of the literature. Pediatr Pulmonol 2023; 58:2703-2718. [PMID: 37403820 DOI: 10.1002/ppul.26584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/11/2023] [Revised: 06/05/2023] [Accepted: 06/24/2023] [Indexed: 07/06/2023]
Abstract
A variety of factors have shown to be useful in predicting which children are at high risk for future asthma exacerbations, some of them combined into composite predictive models. The objective of the present review was to systematically identify all the available published composite predictive models developed for predicting which children are at high risk for future asthma exacerbations or asthma deterioration. A systematic search of the literature was performed to identify studies in which a composite predictive model developed for predicting which children are at high risk for future asthma exacerbations or asthma deterioration was described. Methodological quality assessment was performed using accepted criteria for prediction rules and prognostic models. A total of 18 articles, describing a total of 17 composite predictive models were identified and included in the review. The number of predictors included in the models ranged from 2-149. Upon analyzing the content of the models, use of healthcare services for asthma and prescribed or dispensed asthma medications were the most frequently used items (in 8/17, 47.0% of the models). Seven (41.2%) models fulfilled all the quality criteria considered in our evaluation. The identified models may help clinicians dealing with asthmatic children to identify which children are at a higher risk for future asthma exacerbations or asthma deterioration, therefore targeting and/or reinforcing specific interventions for these children in an attempt to prevent exacerbations or deterioration of the disease.
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Affiliation(s)
- Carlos E Rodríguez-Martínez
- Department of Pediatrics, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Department of Pediatric Pulmonology, School of Medicine, Universidad El Bosque, Bogota, Colombia
| | - Monica P Sossa-Briceño
- Department of Internal Medicine, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
| | - Erick Forno
- Division of Pulmonary Medicine, Department of Pediatrics, Indiana University School of Medicine and Riley Children's Hospital, Indianapolis, Indiana, USA
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9
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Fitzpatrick AM, Lee T, Vickery BP, Corace EA, Mason C, Norwood J, Caldwell C, Grunwell JR. Social determinants of health influence preschool and caregiver experiences during symptoms and exacerbations of wheezing. Ann Allergy Asthma Immunol 2023; 131:75-81.e3. [PMID: 37100275 PMCID: PMC10330199 DOI: 10.1016/j.anai.2023.04.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 03/28/2023] [Accepted: 04/14/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Social determinants of health have been inadequately studied in preschool children with wheezing and their caregivers but may influence the care received. OBJECTIVE To evaluate the symptom and exacerbation experiences of wheezing preschool children and their caregivers, stratified by risk of social vulnerability, over 1 year of longitudinal follow-up. METHODS A total of 79 caregivers and their preschool children with recurrent wheezing and at least 1 exacerbation in the previous year were stratified by a composite measure of social vulnerability into "low" (N = 19), "intermediate" (N = 27), and "high" (N = 33) risk groups. Outcome measures at the follow-up visits included child respiratory symptom scores, asthma control, caregiver-reported outcome measures of mental and social health, exacerbations, and health care utilization. The severity of exacerbations reflected by symptom scores and albuterol use and exacerbation-related caregiver quality of life were also assessed. RESULTS Preschool children at high risk of social vulnerability had greater day-to-day symptom severity and more severe symptoms during acute exacerbations. High-risk caregivers were also distinguished by lower general life satisfaction at all visits and lower global and emotional quality of life during acute exacerbations which did not improve with exacerbation resolution. Rates of exacerbation or emergency department visits did not differ, but intermediate- and high-risk families were significantly less likely to seek unscheduled outpatient care. CONCLUSION Social determinants of health influence wheezing outcomes in preschool children and their caregivers. These findings argue for routine assessment of social determinants of health during medical encounters and tailored interventions in high-risk families to promote health equity and improve respiratory outcomes.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia.
| | - Tricia Lee
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | - Carrie Mason
- Children's Healthcare of Atlanta, Atlanta, Georgia
| | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Georgia; Children's Healthcare of Atlanta, Atlanta, Georgia
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10
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Navanandan N, Florin TA, Leonard J, Ramgopal S, Cotter JM, Shah SS, Ruddy RM, Ambroggio L. Impact of Adjunct Corticosteroid Therapy on Quality of Life for Children With Suspected Pneumonia. Pediatr Emerg Care 2023; 39:482-487. [PMID: 37306694 PMCID: PMC10351650 DOI: 10.1097/pec.0000000000002984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Abstract
OBJECTIVE To determine the association between adjunct corticosteroid therapy and quality of life (QoL) outcomes in children with signs and symptoms of lower respiratory tract infection and clinical suspicion for community-acquired pneumonia (CAP) in the emergency department (ED). METHODS Secondary analysis from a prospective cohort study of children aged 3 months to 18 years with signs and symptoms of LRTI and a chest radiograph for suspected CAP in the ED, excluding children with recent (within 14 days) systemic corticosteroid use. The primary exposure was receipt of corticosteroids during the ED visit. Outcomes were QoL measures and unplanned visits. Multivariable regression was used to evaluate the association between corticosteroid therapy and outcomes. RESULTS Of 898 children, 162 (18%) received corticosteroids. Children who received corticosteroids were more frequently boys (62%), Black (45%), had history of asthma (58%), previous pneumonia (16%), presence of wheeze (74%), and more severe illness at presentation (6%). Ninety-six percent were treated for asthma as defined by report of asthma or receipt of ß-agonist in the ED. Receipt of corticosteroids was not associated with QoL measures: days of activity missed (adjusted incident rate ratio [aIRR], 0.84; 95% confidence interval [CI], 0.63-1.11) and days of work missed (aIRR, 0.88; 95% CI, 0.60-1.27). There was a statistically significant interaction between age (>2 years) and corticosteroids receipt; the patients had fewer days of activity missed (aIRR, 0.62; 95% CI, 0.46-0.83), with no effect on children 2 years or younger (aIRR, 0.83; 95% CI, 0.54-1.27). Corticosteroid treatment was not associated with unplanned visit (odds ratio, 1.37; 95% CI, 0.69-2.75). CONCLUSIONS In this cohort of children with suspected CAP, receipt of corticosteroids was associated with asthma history and was not associated with missed days of activity or work, except in a subset of children aged older than 2 years.
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Affiliation(s)
- Nidhya Navanandan
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Todd A. Florin
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jan Leonard
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jillian M. Cotter
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
| | - Samir S. Shah
- Division of Hospital Medicine and Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Richard M. Ruddy
- Division of Emergency Medicine, Cincinnati Children’s Hospital Medical Center and the University of Cincinnati College of Medicine, Cincinnati, OH
| | - Lilliam Ambroggio
- Section of Emergency Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
- Section of Pediatric Hospital Medicine, Children’s Hospital Colorado, Department of Pediatrics, University of Colorado, Aurora, CO
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11
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Salehian S, Fleming L, Saglani S, Custovic A. Phenotype and endotype based treatment of preschool wheeze. Expert Rev Respir Med 2023; 17:853-864. [PMID: 37873657 DOI: 10.1080/17476348.2023.2271832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Preschool wheeze (PSW) is a significant public health issue, with a high presentation rate to emergency departments, recurrent symptoms, and severe exacerbations. A heterogenous condition, PSW comprises several phenotypes that may relate to a range of pathobiological mechanisms. However, treating PSW remains largely generalized to inhaled corticosteroids and a short acting beta agonist, guided by symptom-based labels that often do not reflect underlying pathways of disease. AREAS COVERED We review the observable features and characteristics used to ascribe phenotypes in children with PSW and available pathobiological evidence to identify possible endotypes. These are considered in the context of treatment options and future research directions. The role of machine learning (ML) and modern analytical techniques to identify patterns of disease that distinguish phenotypes is also explored. EXPERT OPINION Distinct clusters (phenotypes) of severe PSW are characterized by different underlying mechanisms, some shared and some unique. ML-based methodologies applied to clinical, biomarker, and environmental data can help design tools to differentiate children with PSW that continues into adulthood, from those in whom wheezing resolves, identifying mechanisms underpinning persistence and resolution. This may help identify novel therapeutic targets, inform mechanistic studies, and serve as a foundation for stratification in future interventional therapeutic trials.
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Affiliation(s)
- Sormeh Salehian
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Adnan Custovic
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
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12
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Ngo SY, Venter C, Anderson WC, Picket K, Zhang H, Arshad SH, Kurukulaaratchy RJ. Clinical features and later prognosis of replicable early-life wheeze clusters from two birth cohorts 12 years apart. Pediatr Allergy Immunol 2023; 34:e13999. [PMID: 37492911 PMCID: PMC10372879 DOI: 10.1111/pai.13999] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/09/2023] [Revised: 07/01/2023] [Accepted: 07/10/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Clustering techniques can define the heterogeneity of asthma and wheezing. Defining early-life wheezing clusters and associated asthma risk could potentially inform patient management strategies. Clustering models that yield replicable cluster groups will have greater validity and clinical utility. This study sought to identify early-life wheezing clusters that are translatable into clinical practice and assess their stability over time in two whole-population birth cohorts established a decade apart from the same geographical location. METHODS Nonparametric K-means cluster analysis was performed separately on two birth cohorts from the Isle of Wight, UK; the Isle of Wight Birth Cohort (IOWBC) and Food Allergy and Intolerance Research Cohort (FAIR), using clinically defining variables in wheezing subjects in the first 3-4 years. Associations of resulting clusters with potential early-life risk factors and 10-year asthma outcomes were further assessed. RESULTS Five clusters were identified in both cohorts: (1) infantile-onset-transient-non-atopic-wheeze, (2) infantile-onset-persistent-non-atopic-wheeze, (3) infantile-onset-atopic-wheeze, (4) early-childhood-onset-non-atopic-wheeze, and (5) early-childhood-onset-atopic-wheeze. Two atopic wheezing clusters (3 and 5) were associated with greatest early-life wheeze frequency, highest wheeze persistence, and asthma prevalence at 10 years. Cluster 1 was commonest but had lowest early-life wheeze frequency and asthma prevalence at 10 years. Cluster 2, characterized by limited atopy but recurrent infantile respiratory infections and ongoing early-life wheezing, had high 10-year asthma prevalence only in IOWBC. CONCLUSIONS Early-life wheeze comprises several disease clusters (two more severe and three mild-moderate) with differing relationships to later childhood asthma, which can be replicated over time supporting their potential validity and clinical utility.
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Affiliation(s)
- Suzanne Y Ngo
- Section of Allergy and Immunology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo
- Division of Allergy and Clinical Immunology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO
| | - Carina Venter
- Section of Allergy and Immunology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo
| | - William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo
| | - Kaci Picket
- Section of Allergy and Immunology, Department of Pediatrics, University of Colorado School of Medicine, Children’s Hospital Colorado, Aurora, Colo
| | - Hongmei Zhang
- Division of Epidemiology, Biostatistics, and Environmental Health, School of Public Health, University of Memphis, Memphis, TN
| | - S Hasan Arshad
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
- The David Hide Asthma & Allergy Centre, St Mary’s Hospital, Newport, Isle of Wight, UK
| | - Ramesh J Kurukulaaratchy
- School of Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, UK
- National Institute for Health Research (NIHR) Southampton Biomedical Research Centre at University Hospital Southampton NHS Foundation Trust, Southampton, UK
- The David Hide Asthma & Allergy Centre, St Mary’s Hospital, Newport, Isle of Wight, UK
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13
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Fitzpatrick AM, Diani B, Kavalieratos D, Corace EA, Mason C, Van Dresser M, Grunwell JR. Poorer Caregiver Mental and Social Health Is Associated With Worse Respiratory Outcomes in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1814-1822. [PMID: 36868472 PMCID: PMC10258161 DOI: 10.1016/j.jaip.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Mental and social health in caregivers of preschool children has been inadequately studied, but it may influence respiratory symptom recognition and management. OBJECTIVE To identify preschool caregivers at highest risk for poor mental and social health outcomes on the basis of patient-reported outcome measures. METHODS Female caregivers 18 to 50 years old (N = 129) with a preschool child aged 12 to 59 months with recurrent wheezing and at least 1 exacerbation in the previous year completed 8 validated patient-reported outcome measures of mental and social health. k-means cluster analysis was performed using the T score for each instrument. Caregiver/child dyads were followed for 6 months. Primary outcomes included caregiver quality of life and wheezing episodes in their preschool children. RESULTS Three clusters of caregivers were identified: low risk (n = 38), moderate risk (n = 56), and high risk (n = 35). The high-risk cluster had the lowest life satisfaction, meaning and purpose, and emotional support and the highest social isolation, depression, anger, perceived stress, and anxiety that persisted for more than 6 months. This cluster had the poorest quality of life and marked disparities in social determinants of health. Preschool children from caregivers in the high-risk cluster had more frequent respiratory symptoms and a higher occurrence of any wheezing episode, but a lower outpatient physician utilization for wheezing management. CONCLUSIONS Caregiver mental and social health is associated with respiratory outcomes in preschool children. Routine assessment of mental and social health in caregivers is warranted to promote health equity and improve wheezing outcomes in preschool children.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Badiallo Diani
- Department of Biomedical Engineering, Emory University, Atlanta, Ga; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Ga
| | - Dio Kavalieratos
- Department of Family and Preventative Medicine, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
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14
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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15
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Fayon M, Beaufils F, Esteves P, Campagnac M, Maurat E, Michelet M, Siao-Him-Fa V, Lavrand F, Simon G, Begueret H, Berger P. Bronchial Remodeling-based Latent Class Analysis Predicts Exacerbations in Severe Preschool Wheezers. Am J Respir Crit Care Med 2023; 207:416-426. [PMID: 36108144 DOI: 10.1164/rccm.202205-0913oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Children with preschool wheezing represent a very heterogeneous population with wide variability regarding their clinical, inflammatory, obstructive, and/or remodeling patterns. We hypothesized that assessing bronchial remodeling would help clinicians to better characterize severe preschool wheezers. Objectives: The main objective was to identify bronchial remodeling-based latent classes of severe preschool wheezers. Secondary objectives were to compare cross-sectional and longitudinal clinical and biological data between classes and to assess the safety of bronchoscopy. Methods: This double-center prospective study (NCT02806466) included severe preschool wheezers (1-5 yr old) requiring fiberoptic bronchoscopy. Bronchial remodeling parameters (i.e., epithelial integrity, reticular basement membrane [RBM] thickness, mucus gland, fibrosis and bronchial smooth muscle [BSM] areas, the density of blood vessels, and RBM-BSM distance) were assessed and evaluated by latent class analysis. An independent cohort of severe preschool wheezers (NCT04558671) was used to validate our results. Measurements and Main Results: Fiberoptic bronchoscopy procedures were well tolerated. A two-class model was identified: Class BR1 was characterized by increased RBM thickness, normalized BSM area, the density of blood vessels, decreased mucus gland area, fibrosis, and RBM-BSM distance compared with Class BR2. No significant differences were found between classes in the year before fiberoptic bronchoscopy. By contrast, Class BR1 was associated with a shorter time to first exacerbation and an increased risk of both frequent (3 or more) and severe exacerbations during the year after bronchoscopy in the two cohorts. Conclusions: Assessing bronchial remodeling identified severe preschool wheezers at risk of frequent and severe subsequent exacerbations with a favorable benefit to risk ratio.
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Affiliation(s)
- Michael Fayon
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Fabien Beaufils
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Pauline Esteves
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Maryline Campagnac
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Elise Maurat
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Marine Michelet
- CHU Toulouse, Hôpital des Enfants, Service de pneumologie-allergologie pédiatrique, Service d'Anatomopathologie; and.,University Toulouse Paul Sabatier, INSERM U1043 (CPTP), F-31059 Toulouse, France
| | - Valerie Siao-Him-Fa
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Frederic Lavrand
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Guillaume Simon
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Hugues Begueret
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Patrick Berger
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
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16
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Standardization of Reporting Obstructive Airway Disease in Children: A National Delphi Process. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:187-194.e6. [PMID: 36108926 DOI: 10.1016/j.jaip.2022.08.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Revised: 07/17/2022] [Accepted: 08/30/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Pediatric pulmonologists report asthma and obstructive bronchitis in medical records in a variety of ways, and there is no consensus for standardized reporting. OBJECTIVE We investigated which diagnostic labels and features pediatric pulmonologists use to describe obstructive airway disease in children and aimed to reach consensus for standardized reporting. METHODS We obtained electronic health records from 562 children participating in the Swiss Pediatric Airway Cohort from 2017 to 2018. We reviewed the diagnosis section of the letters written by pediatric pulmonologists to referring physicians and extracted the terms used to describe the diagnosis. We grouped these terms into diagnostic labels (eg, asthma) and features (eg, triggers) using qualitative thematic framework analysis. We also assessed how frequently the different terms were used. Results were fed into a modified Delphi process to reach consensus on standardized reporting. RESULTS Pediatric pulmonologists used 123 different terms to describe the diagnosis, which we grouped into 6 diagnostic labels and 17 features. Consensus from the Delphi process resulted in the following recommendations: (i) to use the diagnostic label "asthma" for children older than 5 years and "obstructive bronchitis" or "suspected asthma" for children younger than 5 years; (ii) to accompany the diagnosis with relevant features: diagnostic certainty, triggers, symptom control, risk of exacerbation, atopy, treatment adherence, and symptom perception. CONCLUSION We found great heterogeneity in the reporting of obstructive airway disease among pediatric pulmonologists. The proposed standardized reporting will simplify communication among physicians and improve quality of research based on electronic health records.
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17
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Sirianansopa K, Ruangnapa K, Prasertsan P, Saelim K, Intusoma U, Anuntaseree W. Probability of successful inhaled corticosteroids cessation in preschool wheezers: a predictive score. Eur J Pediatr 2023; 182:237-244. [PMID: 36289097 DOI: 10.1007/s00431-022-04679-2] [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: 08/12/2022] [Revised: 10/15/2022] [Accepted: 10/24/2022] [Indexed: 01/12/2023]
Abstract
UNLABELLED Nearly all asthma predictive tools estimate the future risk of asthma development. However, there is no tool to predict the probability of successful ICS cessation at an early age. Therefore, we aimed to determine the predictors of successful ICS cessation in preschool wheezers, and developed a simple predictive tool for clinical practice. This was a retrospective cohort study involving preschool wheezers who had undergone an ICS therapeutic trial during 2015-2020 at the University Hospital, Southern, Thailand. A predictive scoring system was developed using a nomogram to estimate the probability of successful ICS cessation. We calculated area under ROC curve and used a calibration plot for assessing the tool's performance. A total of 131 medical records were eligible for analysis. Most of the participants were male (68.9%). More than half of the preschool wheezers had successful ICS cessation after an initial therapeutic trial regimen. The predictors of less successful ICS cessation were perinatal oxygen use [OR 0.10 (0.01, 0.70), P = 0.02], allergic rhinitis [OR 0.20 (0.08, 0.56), P = 0.002], blood eosinophil count > 500 cell/mm3 [OR 0.20 (0.06, 0.67), P = 0.008], and previous ICS use > 6 months [OR 0.30 (0.09, 0.72), P = 0.009]. CONCLUSIONS Predictors of less successful ICS cessation were the following: perinatal oxygen use, allergic rhinitis, blood eosinophil count > 500 cell/mm3, and previous ICS use > 6 months. A simple predictive score developed in this study may help general practitioners to be more confident in making a decision regarding the discontinuation of ICS after initial therapeutic trials. WHAT IS KNOWN • Early allergic sensitization is associated with reduced chances of inhaled corticosteroid cessation at school age. • Prolonged ICS is associated with the emergence of adverse effect and discontinuing too early can result in recurrence symptoms. WHAT IS NEW • Requirement of oxygen support within 7 days after birth in term neonate is a postnatal factor associated with less successful ICS cessation. • We propose a simple predictive tool with easily available clinical parameters (perinatal oxygen use, allergic rhinitis, blood eosinophil count, parental asthma history, and duration of previous ICS use) to determine the timing of inhalational corticosteroid cessation in preschool wheezers.
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Affiliation(s)
- Kantisa Sirianansopa
- Department of Pediatrics Pulmonology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand.
| | - Kanokpan Ruangnapa
- Department of Pediatrics Pulmonology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Pharsai Prasertsan
- Department of Pediatrics Pulmonology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Kantara Saelim
- Department of Pediatrics Pulmonology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
| | - Utcharee Intusoma
- Department of Pediatrics Neurology, Faculty of Medicine, Prince of Songkla University, Songkhla, Thailand
| | - Wanaporn Anuntaseree
- Department of Pediatrics Pulmonology, Faculty of Medicine, Prince of Songkla University, Songkhla, 90110, Thailand
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18
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Viral Infections and Wheezing in Preschool Children. Immunol Allergy Clin North Am 2022; 42:727-741. [DOI: 10.1016/j.iac.2022.05.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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19
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Haider S, Granell R, Curtin J, Fontanella S, Cucco A, Turner S, Simpson A, Roberts G, Murray CS, Holloway JW, Devereux G, Cullinan P, Arshad SH, Custovic A. Modeling Wheezing Spells Identifies Phenotypes with Different Outcomes and Genetic Associates. Am J Respir Crit Care Med 2022; 205:883-893. [PMID: 35050846 PMCID: PMC9838626 DOI: 10.1164/rccm.202108-1821oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale: Longitudinal modeling of current wheezing identified similar phenotypes, but their characteristics often differ between studies. Objectives: We propose that a more comprehensive description of wheeze may better describe trajectories than binary information on the presence/absence of wheezing. Methods: We derived six multidimensional variables of wheezing spells from birth to adolescence (including duration, temporal sequencing, and the extent of persistence/recurrence). We applied partition-around-medoids clustering on these variables to derive phenotypes in five birth cohorts. We investigated within- and between-phenotype differences compared with binary latent class analysis models and ascertained associations of these phenotypes with asthma and lung function and with polymorphisms in asthma loci 17q12-21 and CDHR3 (cadherin-related family member 3). Measurements and Main Results: Analysis among 7,719 participants with complete data identified five spell-based wheeze phenotypes with a high degree of certainty: never (54.1%), early-transient (ETW) (23.7%), late-onset (LOW) (6.9%), persistent (PEW) (8.3%), and a novel phenotype, intermittent wheeze (INT) (6.9%). FEV1/FVC was lower in PEW and INT compared with ETW and LOW and declined from age 8 years to adulthood in INT. 17q12-21 and CDHR3 polymorphisms were associated with higher odds of PEW and INT, but not ETW or LOW. Latent class analysis- and spell-based phenotypes appeared similar, but within-phenotype individual trajectories and phenotype allocation differed substantially. The spell-based approach was much more robust in dealing with missing data, and the derived clusters were more stable and internally homogeneous. Conclusions: Modeling of spell variables identified a novel intermittent wheeze phenotype associated with lung function decline to early adulthood. Using multidimensional spell variables may better capture wheeze development and provide a more robust input for phenotype derivation.
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Affiliation(s)
- Sadia Haider
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Raquel Granell
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - John Curtin
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alex Cucco
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephen Turner
- Royal Aberdeen Children’s Hospital National Health Service Grampian, Aberdeen, United Kingdom;,Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Graham Roberts
- Human Development and Health and,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom;,David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Clare S. Murray
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - John W. Holloway
- Human Development and Health and,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Graham Devereux
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Syed Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom;,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom;,David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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Feleszko W, Jartti T, Bacharier LB. Current strategies for phenotyping and managing asthma in preschool children. Curr Opin Allergy Clin Immunol 2022; 22:107-114. [PMID: 35197432 DOI: 10.1097/aci.0000000000000819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Half of all children will experience an episode of wheezing by 6 years. Recurrent preschool wheezing is associated with early lung function loss and has a lifelong impact on airway health, so deciding which children should be treated to prevent exacerbations while also avoiding irreversible health consequences is crucial. The purpose of this review is to provide a practical approach to the pediatric patient under 5 years of age with asthma, with particular attention to the recent enhanced identification of wheeze phenotypes. RECENT FINDINGS Here, we note the difficulty of defining 'asthma' for this age group and advocate that it be determined by the set of respiratory symptoms presented, without assumptions about the underlying mechanisms of the disease. In addition, we propose a forward-looking approach, what treatment to apply to particular phenotypes, which child should be treated, and, if so, which treatment strategy to choose. No clear recommendation exists for the management of nonallergic preschool wheezing, a substantial clinical and research gap. SUMMARY We recommend an empathetic approach to parent anxiety and considering objective markers: timing, severity, and frequency of symptoms, along with an assessment of other biomarkers, including viral etiology, aeroallergen sensitization, and blood eosinophils, that contribute to successful decision-making.
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Affiliation(s)
- Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku
- Department of Pediatrics, Oulu University Hospital and the University of Oulu
- Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Leonard B Bacharier
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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Asthma and Allergy: Unravelling a Tangled Relationship with a Focus on New Biomarkers and Treatment. Int J Mol Sci 2022; 23:ijms23073881. [PMID: 35409241 PMCID: PMC8999577 DOI: 10.3390/ijms23073881] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/21/2022] [Accepted: 03/21/2022] [Indexed: 12/19/2022] Open
Abstract
Asthma is a major driver of health care costs across ages. Despite widely disseminated asthma-treatment guidelines and a growing variety of effective therapeutic options, most patients still experience symptoms and/or refractoriness to standard of care treatments. As a result, most patients undergo a further intensification of therapy to optimize symptom control with a subsequent increased risk of side effects. Raising awareness about the relevance of evaluating aeroallergen sensitizations in asthmatic patients is a key step in better informing clinical practice while new molecular tools, such as the component resolved diagnosis, may be of help in refining the relationship between sensitization and therapeutic recommendations. In addition, patient care should benefit from reliable, easy-to-measure and clinically accessible biomarkers that are able to predict outcome and disease monitoring. To attain a personalized asthma management and to guide adequate treatment decisions, it is of paramount importance to expand clinicians' knowledge about the tangled relationship between asthma and allergy from a molecular perspective. Our review explores the relevance of allergen testing along the asthma patient's journey, with a special focus on recurrent wheezing children. Here, we also discuss the unresolved issues regarding currently available biomarkers and summarize the evidence supporting the eosinophil-derived neurotoxin as promising biomarker.
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Watkinson RL, Looi K, Laing IA, Cianferoni A, Kicic A. Viral Induced Effects on a Vulnerable Epithelium; Lessons Learned From Paediatric Asthma and Eosinophilic Oesophagitis. Front Immunol 2021; 12:773600. [PMID: 34912343 PMCID: PMC8666438 DOI: 10.3389/fimmu.2021.773600] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Accepted: 11/05/2021] [Indexed: 01/07/2023] Open
Abstract
The epithelium is integral to the protection of many different biological systems and for the maintenance of biochemical homeostasis. Emerging evidence suggests that particular children have epithelial vulnerabilities leading to dysregulated barrier function and integrity, that resultantly contributes to disease pathogenesis. These epithelial vulnerabilities likely develop in utero or in early life due to various genetic, epigenetic and environmental factors. Although various epithelia are uniquely structured with specific function, prevalent allergic-type epithelial diseases in children potentially have common or parallel disease processes. These include inflammation and immune response dysregulation stemming from atypical epithelial barrier function and integrity. Two diseases where aetiology and pathogenesis are potentially linked to epithelial vulnerabilities include Paediatric Asthma and Eosinophilic Oesophagitis (EoE). For example, rhinovirus C (RV-C) is a known risk factor for paediatric asthma development and is known to disrupt respiratory epithelial barrier function causing acute inflammation. In addition, EoE, a prevalent atopic condition of the oesophageal epithelium, is characterised by similar innate immune and epithelial responses to viral injury. This review examines the current literature and identifies the gaps in the field defining viral-induced effects on a vulnerable respiratory epithelium and resulting chronic inflammation, drawing from knowledge generated in acute wheezing illness, paediatric asthma and EoE. Besides highlighting the importance of epithelial structure and barrier function in allergic disease pathogenesis regardless of specific epithelial sub-types, this review focuses on the importance of examining other parallel allergic-type disease processes that may uncover commonalities driving disease pathogenesis. This in turn may be beneficial in the development of common therapeutics for current clinical management and disease prevention in the future.
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Affiliation(s)
- Rebecca L Watkinson
- Division of Paediatrics, Medical School, The University of Western Australia, Nedlands, WA, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia
| | - Kevin Looi
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia
| | - Ingrid A Laing
- Division of Paediatrics, Medical School, The University of Western Australia, Nedlands, WA, Australia.,Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA, United States
| | - Anthony Kicic
- Wal-Yan Respiratory Research Centre, Telethon Kids Institute, Perth, WA, Australia.,School of Public Health, Curtin University, Bentley, WA, Australia.,Centre for Cell Therapy and Regenerative Medicine, School of Medicine, The University of Western Australia, Nedlands, WA, Australia
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Severcan EU, Bal CM, Gülen F, Tanaç R, Demir E. Identifying wheezing phenotypes in a pediatric Turkish cohort. J Asthma 2021; 59:1298-1304. [PMID: 33906564 DOI: 10.1080/02770903.2021.1922916] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Characterization of wheezing phenotypes in children might help to identify the underlying mechanisms through which asthma occurs. In our study, we aimed to describe wheezing phenotypes in Turkish children and to identify risk factors according to phenotypes. METHODS 651 wheezy children were evaluated and 5 wheezing phenotypes were described according to age of onset, atopy and persistence at 6 years of age and risk factors were identified. RESULTS Distribution of wheezing phenotypes was transient early wheeze (TEW)(34.9%) non-atopic wheeze (NAW) (18%), atopic wheeze (AW) (22.3%), intermediate onset wheeze (IOW) (11.1%), late onset wheeze (LOW) (11.7%). LOW, AW, and IOW were associated with, father's, sibling's and family's atopy (p:0.001) whereas LOW and AW were associated with mother's asthma and atopy as well as family's asthma (p < 0.05). Atopic dermatitis and allergic rhinitis were common of patients with LOW, AW, and IOW (p < 0.05). İnfection was the major trigger for TEW and NAW whereas multiple triggers were common of AW, LOW, and IOW. Allergens were mostly associated with AW, IOW and LOW. Aeroallergen-specific IgE positivity was mostly with AW, IOW, and LOW phenotype. Skin prick tests showed multiple allergen sensitivity in IOW, LOW groups and mostly single allergen in AW phenotype. Modified asthma predictive index (mAPI) positivity was high in all groups except TEW and NAW. CONCLUSIONS With this study we classified five wheeze phenotypes and found that atopy and family's atopy history, maternal asthma were strongly associated with AW, LOW, and IOW phenotypes which were usually effected by allergens or multiple triggers.
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Affiliation(s)
- Ezgi Ulusoy Severcan
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Cem Murat Bal
- Department of Pediatrics, Division of Pediatric Pulmonology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Figen Gülen
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Remziye Tanaç
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
| | - Esen Demir
- Department of Pediatrics, Division of Pediatric Allergy and Immunology, Ege University Faculty of Medicine, İzmir, Turkey
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Fitzpatrick AM, Chipps BE, Holguin F, Woodruff PG. T2-"Low" Asthma: Overview and Management Strategies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:452-463. [PMID: 32037109 DOI: 10.1016/j.jaip.2019.11.006] [Citation(s) in RCA: 84] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 11/11/2019] [Accepted: 11/11/2019] [Indexed: 02/07/2023]
Abstract
Although the term "asthma" has been applied to all patients with airway lability and variable chest symptoms for centuries, phenotypes of asthma with distinct clinical and molecular features that may warrant different treatment approaches are well recognized. Patients with type 2 (T2)-"high" asthma are characterized by upregulation of T2 immune pathways (ie, IL-4 and IL-13 gene sets) and eosinophilic airway inflammation, whereas these features are absent in patients with T2-"low" asthma and may contribute to poor responsiveness to corticosteroid treatment. This review details definitions and clinical features of T2-"low" asthma, potential mechanisms and metabolic aspects, pediatric considerations, and potential treatment approaches. Priority research questions for T2-"low" asthma are also discussed.
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Affiliation(s)
| | - Bradley E Chipps
- Capital Allergy and Respiratory Disease Center, Sacramento, Calif
| | - Fernando Holguin
- University of Colorado, Pulmonary Sciences and Critical Care Medicine, Denver, Colo
| | - Prescott G Woodruff
- Department of Medicine, Division of Pulmonary and Critical Care Medicine, and the Cardiovascular Research Institute, University of California, San Francisco, Calif
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Teague WG, Lawrence MG, Williams S, Garrod AS, Froh D, Early SV, Brand W, Middleton JP, Mendoza MV, Hollis KA, Wavell K, Heymann PW, Steinke JW, Borish L. Novel Treatment-Refractory Preschool Wheeze Phenotypes Identified by Cluster Analysis of Lung Lavage Constituents. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2792-2801.e4. [PMID: 33905917 DOI: 10.1016/j.jaip.2021.03.059] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/01/2020] [Revised: 02/25/2021] [Accepted: 03/24/2021] [Indexed: 01/28/2023]
Abstract
BACKGROUND Preschool children with treatment-refractory wheeze often require unscheduled acute care. Current guidelines advise treatment of persistent wheeze with inhaled corticosteroids. Alternative treatments targeting structural abnormalities and specific inflammatory patterns could be more effective. OBJECTIVE To apply unsupervised analysis of lung lavage (bronchoalveolar lavage [BAL]) variables to identify clusters of preschool children with treatment-refractory wheeze. METHODS A total of 155 children 6 years or younger underwent bronchoscopy with BAL for evaluation of airway structure, inflammatory markers, and pathogens. Variables were screened with factor analysis and sorted into clusters by Ward's method, and membership was confirmed by discriminant analysis. RESULTS The model was repeatable in a 48-case validation sample and accurately classified 86% of cases. Cluster 1 (n = 60) had early-onset wheeze, 85% with structural abnormalities, mostly tracheamalacia, with low total IgE and agranulocytic BAL. Cluster 2 (n = 42) had later-onset wheeze, the highest prevalence of gastroesophageal reflux, little atopy, and two-third had increased BAL lipid-laden macrophages. Cluster 3 (n = 46) had mid-onset wheeze, low total IgE, and two-third had BAL viral transcripts, predominately human rhinovirus, with BAL neutrophilia. Cluster 4 (n = 7) was older, with high total IgE, blood eosinophilia, and mixed BAL eosinophils and neutrophils. CONCLUSIONS Preschool children with recurrent wheeze refractory to inhaled corticosteroid treatment include 4 clusters: airway malacia, gastroesophageal reflux, indolent human rhinovirus bronchoalveolitis, and type-2high inflammation. The results support the risk and cost of invasive bronchoscopy to diagnose causes of treatment-refractory wheeze and develop novel therapies targeting airway malacia, human rhinovirus infection, and BAL neutrophilia in preschool children.
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Affiliation(s)
- W Gerald Teague
- Child Health Research Center, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va; Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va.
| | - Monica G Lawrence
- Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va; Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Sanford Williams
- Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va; Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Andrea S Garrod
- Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Deborah Froh
- Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Stephen V Early
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - William Brand
- Department of Otolaryngology, Head and Neck Surgery, University of Virginia School of Medicine, Charlottesville, Va
| | - Jeremy P Middleton
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Michael V Mendoza
- Division of Gastroenterology and Hepatology, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - Kerry A Hollis
- Department of Respiratory Therapy and Sleep Technology, University of Virginia Medical Center, Charlottesville, Va
| | - Kristin Wavell
- Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va; Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Peter W Heymann
- Child Health Research Center, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va; Division of Respiratory Medicine, Allergy, Immunology, and Sleep, Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Va
| | - John W Steinke
- Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va
| | - Larry Borish
- Division of Allergy, Asthma, and Immunology, Department of Medicine, University of Virginia School of Medicine, Charlottesville, Va; Department of Microbiology, University of Virginia School of Medicine, Charlottesville, Va
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Predicting Severe Asthma Exacerbations in Children: Blueprint for Today and Tomorrow. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2619-2626. [PMID: 33831622 DOI: 10.1016/j.jaip.2021.03.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 03/03/2021] [Accepted: 03/22/2021] [Indexed: 12/18/2022]
Abstract
Severe asthma exacerbations are the primary cause of morbidity and mortality in children with asthma. Accurate prediction of children at risk for severe exacerbations, defined as those requiring systemic corticosteroids, emergency department visit, and/or hospitalization, would considerably reduce health care utilization and improve symptoms and quality of life. Substantial progress has been made in identifying high-risk exacerbation-prone children. Known risk factors for exacerbations include demographic characteristics (ie, low income, minority race/ethnicity), poor asthma control, environmental exposures (ie, aeroallergen exposure/sensitization, concomitant viral infection), inflammatory biomarkers, genetic polymorphisms, and markers from other "omic" technologies. The strongest risk factor for a future severe exacerbation remains having had one in the previous year. Combining risk factors into composite scores and use of advanced predictive analytic techniques such as machine learning are recent methods used to achieve stronger prediction of severe exacerbations. However, these methods are limited in prediction efficiency and are currently unable to predict children at risk for impending (within days) severe exacerbations. Thus, we provide a commentary on strategies that have potential to allow for accurate and reliable prediction of children at risk for impending exacerbations. These approaches include implementation of passive, real-time monitoring of impending exacerbation predictors, use of population health strategies, prediction of severe exacerbation responders versus nonresponders to conventional exacerbation management, and considerations for preschool-age children who can be especially high risk. Rigorous prediction and prevention of severe asthma exacerbations is needed to advance asthma management and improve the associated morbidity and mortality.
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Shah SN, Grunwell JR, Mohammad AF, Stephenson ST, Lee GB, Vickery BP, Fitzpatrick AM. Performance of Eosinophil Cationic Protein as a Biomarker in Asthmatic Children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2761-2769.e2. [PMID: 33781764 DOI: 10.1016/j.jaip.2021.02.053] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 02/07/2021] [Accepted: 02/25/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND Although blood eosinophils are a frequently used marker of type 2 inflammation in children with asthma, their sensitivity is relatively poor. Additional markers of type 2 inflammation are needed. OBJECTIVE We hypothesized that plasma concentrations of eosinophil cationic protein (ECP), a marker of eosinophil activation, would be useful for detection of type 2 inflammation and would predict poorer asthma outcomes over 1 year. METHODS Children and adolescents 6 through 17 years (N = 256) with confirmed asthma completed a baseline visit and a follow-up visit at 12 months. A subset also underwent systemic corticosteroid responsiveness testing with intramuscular triamcinolone. Outcome measures at 12 months included uncontrolled asthma, lung function, and asthma exacerbations treated with systemic corticosteroids. RESULTS Plasma ECP concentrations ranged from 0.03 to 413.61 ng/mL (median, 6.95 ng/mL) and were consistently associated with other markers of type 2 inflammation. At baseline, children in the highest ECP tertile had poorer asthma control, more airflow limitation, and more exacerbations, but also had greater symptom improvement with intramuscular triamcinolone. At 12 months, associations between the highest ECP tertile and exacerbations, but not lung function or asthma control, persisted after covariate adjustment. However, the sensitivity of ECP was modest and was not markedly different from that of blood eosinophil counts. CONCLUSION Plasma ECP concentrations may be a useful marker of type 2 inflammation in children and may help identify those children at highest risk for recurrent exacerbations who could benefit from corticosteroid treatment. However, additional markers may be needed to improve sensitivity for outcome detection.
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Affiliation(s)
- Sheel N Shah
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | | | - Gerald B Lee
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Brian P Vickery
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Center for Cystic Fibrosis and Airways Disease Research, Children's Healthcare of Atlanta, Atlanta, Ga.
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Which Wheezing Preschoolers Should be Treated for Asthma? THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:2611-2618. [PMID: 33677078 DOI: 10.1016/j.jaip.2021.02.045] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 02/05/2021] [Accepted: 02/20/2021] [Indexed: 11/23/2022]
Abstract
Wheezing disorders in children younger than 5 years are common, but lack of clarity remains about which children should be treated to prevent symptoms and acute episodes. The aim of this review was to discuss a practical approach to deciding which children younger than 5 years with asthma should be treated, and if so, with which strategy. The importance of having a clear definition of "asthma" for this age group, determined by a collection of presenting respiratory symptoms, without assumptions about underlying mechanisms is addressed. Subsequent consideration should be given to timing, severity, and frequency of symptoms, together with assessment of objective biomarkers, including aeroallergen sensitization and blood eosinophils, to inform whether or not a preschooler with recurrent wheezing requires treatment. Numerous unanswered questions remain about the optimal management of nonallergic preschool wheezing and asthma, and areas of specific unmet need and future directions for research are highlighted.
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Donath H, Kluge S, Sideri G, Trischler J, Jerkic SP, Schulze J, Zielen S, Blumchen K. Hospitalization, Asthma Phenotypes, and Readmission Rates in Pre-school Asthma. Front Pediatr 2020; 8:562843. [PMID: 33330266 PMCID: PMC7716437 DOI: 10.3389/fped.2020.562843] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Accepted: 10/13/2020] [Indexed: 01/19/2023] Open
Abstract
Objective: Children with pre-school asthma suffer disproportionally more often from severe asthma exacerbations with emergency visits and hospital admissions compared to school children. Despite this high disease burden, there are only a few reports looking at this particular severe asthma cohort. Similarly, there is little real-life research on the distribution of asthma phenotypes and personalized treatment at discharge in this age group. Patients and Methods: Retrospective analysis of the electronic charts of all children aged 1-5 years with asthma hospitalizations (ICD J45) at the Frankfurt University between 2008 and 2017. An acute severe asthma exacerbation was defined as dyspnea, oxygen demand, and/or systemic steroid therapy. Age, gender, duration of hospitalization, asthma phenotype, treatment, and readmission rate were analyzed. Results: Of 572 patients, 205 met the definition of acute severe asthma. The phenotypic characterization showed 56.1% had allergic asthma, 15.2% eosinophilic asthma and 28.7% non-allergic asthma. Of these patients, 71.7% were discharged with inhaled corticosteroids (ICS) or ICS + long-acting-beta-agonists (LABA), 15.1% with leukotriene antagonists (LTRA) and 7.3% salbutamol on demand. The rate of emergency presentations (emergency department and readmission) within 12 months after discharge was high (n = 42; 20.5%). No phenotype tailored treatment was detectable. Neither the number of eosinophils (>300/μl) nor the treatment at discharge had an effect on emergency visits and readmission rate. Conclusion: Despite protective therapy with ICS, ICS + LABA, or LTRA, the readmission rate was high. Thus, current care and treatment strategies should be reevaluated continuously, in order to better control asthma in pre-school children and prevent hospitalization.
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Affiliation(s)
| | | | | | | | | | | | - Stefan Zielen
- Division of Allergology, Pulmonology and Cystic Fibrosis, Department for Children and Adolescents, Goethe University, Frankfurt, Germany
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Eisenlohr CP, Chartrand EM, Barzaga MR, Lanz MJ. Impact of pneumococcal vaccine response on asthma exacerbation frequency in young children. IMMUNITY INFLAMMATION AND DISEASE 2020; 8:493-496. [PMID: 32677745 PMCID: PMC7654423 DOI: 10.1002/iid3.331] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/20/2020] [Accepted: 07/08/2020] [Indexed: 12/20/2022]
Abstract
INTRODUCTION Chronic asthma is a heterogeneous disease, and increased eosinophils have been shown to predict increased asthma exacerbations, especially in adults. Recent recommendations suggest the need for supplemental PPV-23 vaccination in older children with chronic asthma. METHODS To investigate differences in preschool asthma, our case-cohort study comprised of 127 children, mean age 47 months (32-65), with a history of asthma exacerbations requiring more than three courses of systemic steroid bursts and more than six antibiotics courses in the previous year. RESULTS At baseline, mean antibody titer response to Streptococcus pneumoniae was decreased at 2.6 ± 2 out of 14 serotypes, despite prior complete pneumococcal conjugate vaccine (PCV) vaccinations. All children were readministered pneumococcal vaccinations with PCV-13 booster and/or PPSV-23. Mean postvaccination pneumococcal vaccine (PV) titer response was 16 ± 5 out of 23 serotypes. After contacting 91 parents/caretakers, 75 responded with less frequency of corticosteroids and antibiotic use for asthma exacerbations after PV. This group had baseline eosinophil counts of 211 ± 36/µL, while those without improvement were significantly higher at 371 ± 123/µL,*P < .05. There were no significant differences (P > .05) between the two groups from other baseline measures including demography or atopic status. CONCLUSIONS This subset of children with exacerbation-prone asthma had poor antibody titer response to Streptococcus pneumoniae, even with prior complete PCV-13 immunization. Identification of low antibody responses to PV serotypes may provide a targeted therapeutic approach to reduce wheezing exacerbations in a precise asthma phenotype in children.
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Stokes JR, Bacharier LB. Prevention and treatment of recurrent viral-induced wheezing in the preschool child. Ann Allergy Asthma Immunol 2020; 125:156-162. [PMID: 32454096 DOI: 10.1016/j.anai.2020.05.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2020] [Revised: 05/05/2020] [Accepted: 05/17/2020] [Indexed: 01/24/2023]
Abstract
OBJECTIVE To summarize the recent evidence in the treatment of viral-induced wheezing in the infant and preschool aged child. DATA SOURCES Published literature obtained through PubMed database searches. STUDY SELECTIONS Studies relevant to phenotypes and treatment of wheezing illnesses in infants and preschool children were included. RESULTS Recurrent wheezing in preschool children is common and is frequently triggered by viral respiratory tract infections. Certain phenotypes may respond to treatments differently, depending on the risk factors identified. Inhaled corticosteroids, administered continuously or intermittently, reduce the risk of virus-induced wheezing episodes. The use of leukotriene modifying agents may have a role in wheezing episodes in a select group of preschool children. Early administration of azithromycin reduces the risk of severe lower respiratory tract illnesses in children. The effect of oral corticosteroids on wheezing episodes in young children varies by degree of episode severity. CONCLUSION Recurrent viral-induced wheezing illnesses has been the focus of many clinical trials, which now provide an increasingly robust evidence base for management. Additional research is needed to define optimal strategies, to best match therapies to specific phenotypes and endotypes, and will eventually begin to include therapies directed specifically at the viral triggers.
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Affiliation(s)
- Jeffrey R Stokes
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, St. Louis Children's Hospital, St. Louis, Missouri
| | - Leonard Benjamin Bacharier
- Division of Pediatric Allergy, Immunology, and Pulmonary Medicine, St. Louis Children's Hospital, St. Louis, Missouri.
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Fainardi V, Santoro A, Caffarelli C. Preschool Wheezing: Trajectories and Long-Term Treatment. Front Pediatr 2020; 8:240. [PMID: 32478019 PMCID: PMC7235303 DOI: 10.3389/fped.2020.00240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/20/2020] [Indexed: 12/13/2022] Open
Abstract
Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.
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Affiliation(s)
| | | | - Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Schatz M, Sicherer SH, Khan DA, Zeiger RS. The Journal of Allergy and Clinical Immunology: In Practice 2019 Highlights. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:912-936. [PMID: 31980411 DOI: 10.1016/j.jaip.2020.01.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 01/03/2020] [Accepted: 01/03/2020] [Indexed: 10/25/2022]
Abstract
This article provides highlights of the clinically impactful original studies and reviews published in The Journal of Allergy and Clinical Immunology: In Practice in 2019 on the subjects of anaphylaxis, asthma, dermatitis, drug allergy, food allergy, immunodeficiency, immunotherapy, rhinitis/sinusitis, and urticaria/angioedema/mast cell disorders. Within each topic, practical aspects of diagnosis and management are emphasized. Treatments discussed include lifestyle modifications, allergen avoidance therapy, positive and negative effects of pharmacologic therapy, and various forms of immunologic and desensitization management. We designed this review to help readers consolidate and use this extensive and practical knowledge for the benefit of their patients.
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Affiliation(s)
- Michael Schatz
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif.
| | - Scott H Sicherer
- Jaffe Food Allergy Institute, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David A Khan
- Department of Internal Medicine, Division of Allergy & Immunology, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Robert S Zeiger
- Department of Allergy, Kaiser Permanente Southern California, San Diego, Calif; Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, Calif
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Hoang JA, Mashouri P, Dai R, Brydges MG, Dubeau A, Lépine C, Yin X, Kowalik K, DeLorenzo S, Upton JEM, Moraes TJ, Amin R, Narang I, Boutis K, Schuh S, Maksym GN, Brudno M, Ramani A, Subbarao P, Eiwegger T. Extract and component-specific sensitization patterns in Canadian moderate-to-severe preschool asthmatics. Allergy 2019; 74:2519-2521. [PMID: 31125434 DOI: 10.1111/all.13927] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jennifer A. Hoang
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
- Department of Immunology University of Toronto Toronto Ontario Canada
| | - Pouria Mashouri
- Centre for Computational Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Ruixue Dai
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - May G. Brydges
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Aimée Dubeau
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Claire Lépine
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Xiaojun Yin
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
| | - Krzysztof Kowalik
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
| | - Stephanie DeLorenzo
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
| | - Julia E. M. Upton
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Hospital for Sick Children, Departments of Paediatrics and Immunology University of Toronto Toronto Ontario Canada
| | - Theo J. Moraes
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Reshma Amin
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Indra Narang
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
- Division of Respiratory Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Kathy Boutis
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Research Institute, The Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Suzanne Schuh
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Research Institute, The Hospital for Sick Children University of Toronto Toronto Ontario Canada
| | - Geoffrey N. Maksym
- School of Biomedical Engineering Dalhousie University Halifax Nova Scotia Canada
| | - Michael Brudno
- Centre for Computational Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Arun Ramani
- Centre for Computational Medicine Hospital for Sick Children Toronto Ontario Canada
| | - Padmaja Subbarao
- Division of Respiratory Medicine and Translational Medicine, Departments of Pediatrics & Physiology Hospital for Sick Children & University of Toronto Toronto Ontario Canada
| | - Thomas Eiwegger
- Translational Medicine Program Research Institute, Hospital for Sick Children Toronto Ontario Canada
- Department of Immunology University of Toronto Toronto Ontario Canada
- Division of Immunology and Allergy, Food Allergy and Anaphylaxis Program, The Hospital for Sick Children, Departments of Paediatrics and Immunology University of Toronto Toronto Ontario Canada
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Kitcharoensakkul M, Bacharier LB. A Case-Based Review on the Diagnosis and Treatment Options for Recurrent Wheezing and Asthma in Preschool Children. CURRENT TREATMENT OPTIONS IN ALLERGY 2019. [DOI: 10.1007/s40521-019-00227-w] [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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Denlinger LC, Heymann P, Lutter R, Gern JE. Exacerbation-Prone Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 8:474-482. [PMID: 31765853 DOI: 10.1016/j.jaip.2019.11.009] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Revised: 10/28/2019] [Accepted: 11/12/2019] [Indexed: 02/07/2023]
Abstract
Patients who are prone to exacerbations of asthma experience significant costs in terms of missed work and school, acute care visits, and hospitalizations. Exacerbations are largely driven by environmental exposures including pollutants, stress, and viral and bacterial pathogens. These exposures are most likely to induce acute severe "asthma attacks" in high-risk patients. These personal risk factors for exacerbations can vary with the phenotype of asthma and age of the patient. In children, allergic sensitization is a strong risk factor, especially for those children who develop sensitization early in life. Airway inflammation is an important risk factor, and biomarkers are under evaluation for utility in detecting eosinophilic and type 2 inflammation and neutrophilic inflammation as indicators of risk for recurrent exacerbations. Insights into inflammatory mechanisms have led to new approaches to prevent exacerbations using mAb-based biologics that target specific type 2 pathways. Challenges remain in developing an evidence base to support precision interventions with these effective yet expensive therapies, and in determining whether these treatments will be safe and effective in young children. Unfortunately, there has been less progress in developing treatments for acute exacerbations. Hopefully, greater understanding of mechanisms relating airway viruses, bacteria, mucin production, and neutrophilic inflammatory responses will lead to additional treatment options for patients experiencing acute exacerbations.
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Affiliation(s)
- Loren C Denlinger
- Department of Medicine, University of Wisconsin-Madison School of Medicine and Public Health, Madison, Wis.
| | - Peter Heymann
- Department of Pediatrics, University of Virginia, Charlottesville, Va
| | - Rene Lutter
- Departments of Respiratory Medicine and Experimental Immunology, Amsterdam University Centers, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, The Netherlands
| | - James E Gern
- Department of Pediatrics, University of Wisconsin-Madison, School of Medicine and Public Health, Madison, Wis
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Suh DI, Kang MJ, Park YM, Lee JK, Lee SY, Sheen YH, Kim KW, Ahn K, Hong SJ. The risk of preschool asthma at 2-4 years is not associated with leukocyte telomere length at birth or at 1 year of age. Asia Pac Allergy 2019; 9:e33. [PMID: 31720244 PMCID: PMC6826115 DOI: 10.5415/apallergy.2019.9.e33] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 10/10/2019] [Indexed: 12/28/2022] Open
Abstract
Background Exposure to prenatal stress is associated with offspring allergic-disease development, and oxidative stress may mediate this relationship. Objective We aimed to evaluate whether leukocyte telomere length (LTL) shortening, a marker for exposure to oxidative stress, in early life is associated with increased risk of asthma development during the preschool period. Methods We assessed the follow-up clinical data of a subgroup from a birth cohort whose LTLs had been measured from cord-blood and 1-year peripheral-blood samples. We examined whether the LTLs would be associated with asthma development at the age of 2–4 years. Results The data of 84 subjects were analyzed. LTLs were measured from the cord-blood and 1-year peripheral blood of 75 and 79 subjects, respectively. Among them, 14 subjects (16.7%) developed bronchial asthma between 2–4 years old. Prenatally stressed subjects had marginally increased odds of developing asthma (p = 0.097). There was no significant difference in the odds of preschool-asthma development between the groups with shorter and longer cord-blood LTLs (odds ratio [OR], 0.651; 95% confidence interval [CI], 0.184–2.306) or in the odds between the groups with shorter and longer 1-year peripheral-blood LTLs (OR, 0.448; 95% CI, 0.135–1.483). Finally, subjects with both higher prenatal stress and shorter LTLs did not have significantly higher odds of preschool-asthma development (for cord-blood: OR, 1.242; 95% CI, 0.353–4.368; for 1-year peripheral-blood: OR, 1.451; 95% CI, 0.428–4.919). Conclusion There was no significant association between early life LTLs and higher risk of bronchial-asthma development during the preschool years.
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Affiliation(s)
- Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Mi-Jin Kang
- Department of Pediatrics, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea
| | - Yoon Mee Park
- Department of Pediatrics, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea
| | - Jun-Kyu Lee
- Department of Pediatrics, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea
| | - So-Yeon Lee
- Department of Pediatrics, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea.,Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Youn Ho Sheen
- Department of Pediatrics, CHA University Gangnam CHA Hospital, Seoul, Korea
| | - Kyung Won Kim
- Department of Pediatrics, Yonsei University Severance Children's Hospital, Seoul, Korea
| | - Kangmo Ahn
- Department of Pediatrics, Sungkyunkwan University Samsung Medical Center, Seoul, Korea
| | - Soo-Jong Hong
- Department of Pediatrics, Asan Institute for Life Sciences, University of Ulsan College of Medicine, Seoul, Korea.,Department of Pediatrics, Childhood Asthma Atopy Center, Environmental Health Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Agache I, Lau S, Akdis CA, Smolinska S, Bonini M, Cavkaytar O, Flood B, Gajdanowicz P, Izuhara K, Kalayci O, Mosges R, Palomares O, Papadopoulos NG, Sokolowska M, Angier E, Fernandez‐Rivas M, Pajno G, Pfaar O, Roberts G, Ryan D, Sturm GJ, Ree R, Varga EM, Wijk RG, Yepes‐Nuñez J, Jutel M. EAACI Guidelines on Allergen Immunotherapy: House dust mite-driven allergic asthma. Allergy 2019; 74:855-873. [PMID: 31095767 DOI: 10.1111/all.13749] [Citation(s) in RCA: 158] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2019] [Accepted: 02/12/2019] [Indexed: 12/14/2022]
Abstract
Allergen immunotherapy (AIT) has been in use for the treatment of allergic disease for more than 100 years. Asthma treatment relies mainly on corticosteroids and other controllers recommended to achieve and maintain asthma control, prevent exacerbations, and improve quality of life. AIT is underused in asthma, both in children and in adults. Notably, patients with allergic asthma not adequately controlled on pharmacotherapy (including biologics) represent an unmet health need. The European Academy of Allergy and Clinical Immunology has developed a clinical practice guideline providing evidence-based recommendations for the use of house dust mites (HDM) AIT as add-on treatment for HDM-driven allergic asthma. This guideline was developed by a multi-disciplinary working group using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. HDM AIT was separately evaluated by route of administration and children and adults: subcutaneous (SCIT) and sublingual AIT (SLIT), drops, and tablets. Recommendations were formulated for each. The important prerequisites for successful treatment with HDM AIT are (a) selection of patients most likely to respond to AIT and (b) use of allergen extracts and desensitization protocols of proven efficacy. To date, only AIT with HDM SLIT-tablet has demonstrated a robust effect in adults for critical end points (exacerbations, asthma control, and safety). Thus, it is recommended as an add-on to regular asthma therapy for adults with controlled or partially controlled HDM-driven allergic asthma (conditional recommendation, moderate-quality evidence). HDM SCIT is recommended for adults and children, and SLIT drops are recommended for children with controlled HDM-driven allergic asthma as the add-on to regular asthma therapy to decrease symptoms and medication needs (conditional recommendation, low-quality evidence).
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Affiliation(s)
- Ioana Agache
- Faculty of Medicine Department of Allergy and Clinical Immunology Transylvania University Brasov Brasov Romania
| | - Susanne Lau
- Department for Pediatric Pneumology, Immunology and Intensive Care Charité Universität Medizin Berlin Germany
| | - Cezmi A. Akdis
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | - Sylwia Smolinska
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
| | - Matteo Bonini
- National Heart and Lung Institute (NHLI) Royal Brompton Hospital & Imperial College London UK
| | - Ozlem Cavkaytar
- Faculty of Medicine Department of Pediatric Allergy Istanbul Medeniyet University Goztepe Training and Research Hospital Istanbul Turkey
| | - Breda Flood
- European Federation of Allergy and Airways Diseases, Patients Association Brussels Belgium
| | - Pawe Gajdanowicz
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
| | | | - Omer Kalayci
- Hacettepe University School of Medicine Ankara Turkey
| | - Ralph Mosges
- Universität zu Koln Institute of Medical Statistics, Informatics and Epidemiology (IMSIE) Koln Germany
| | - Oscar Palomares
- Department of Biochemistry and Molecular Biology Complutense University of Madrid Madrid Spain
| | - Nikolaos G. Papadopoulos
- Division of Infection, Immunity and respiratory medicine University of Manchester Manchester UK
- Allergy Department 2nd Pediatric Clinic University of Athens Athens Greece
| | - Milena Sokolowska
- University of Zürich Swiss Institute of Allergy and Asthma Research (SIAF) Davos Switzerland
- Christine Kühne‐Center for Allergy Research and Education (CK‐CARE) Davos Switzerland
| | | | | | - Giovanni Pajno
- Allergy Unit Department of Pediatrics University of Messina Messina Italy
| | - Oliver Pfaar
- Department of Otorhinolaryngology, Head and Neck Surgery Section of Rhinology and Allergy University Hospital Marburg Philipps‐Universität Marburg Marburg Germany
| | - Graham C. Roberts
- The David Hide Asthma and Allergy Research Centre St Mary's Hospital Newport Isle of Wight UK
- NIHR Biomedical Research Centre University Hospital Southampton NHS Foundation Trust Southampton UK
- Faculty of Medicine University of Southampton Southampton UK
| | - Dermot Ryan
- Usher Institute of Population Health Sciences and Informatics University of Edinburgh Edinburgh UK
- Asthma UK Centre for Applied Research The University of Edinburgh Edinburgh UK
| | - Gunter J. Sturm
- Department of Dermatology and Venerology Medical University of Graz Graz Austria
- Outpatient Allergy Clinic Reumannplaz Vienna Austria
| | - Ronald Ree
- Department of Experimental Immunology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
- Department of Otorhinolaryngology Academic Medical Center University of Amsterdam Amsterdam The Netherlands
| | - Eva M. Varga
- Department of Pediatric and Adolescent Medicine Respiratory and Allergic Disease Division Medical University of Graz Graz Austria
| | - Roy Gerth Wijk
- Section of Allergology Department of Internal Medicine Erasmus Medical Center Rotterdam The Netherlands
| | | | - Marek Jutel
- Department of Clinical Immunology Wroclaw Medical University Wroclaw Poland
- “ALL‐MED” Medical Research Institute Wroclaw Poland
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Fitzpatrick AM, Bacharier LB. One step forward, 2 steps back: The enigma of preschool wheeze. J Allergy Clin Immunol 2019; 143:1734-1735. [PMID: 30660640 DOI: 10.1016/j.jaci.2019.01.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/02/2019] [Accepted: 01/08/2019] [Indexed: 12/21/2022]
Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
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