Challenges in assessing outcomes for pediatric asthma

Effect of the Telemedicine Enhanced Asthma Management Through the Emergency Department (TEAM-ED) Program on Asthma Morbidity: A Randomized Controlled Trial

OBJECTIVE

To test the effectiveness of a telemedicine-based program in reducing asthma morbidity among children who present to the emergency department (ED) for asthma, by facilitating primary care follow-up and promoting delivery of guideline-based care.

STUDY DESIGN

We included children (3-12 years of age) with persistent asthma who presented to the ED for asthma, who were then randomly assigned to Telemedicine Enhanced Asthma Management through the Emergency Department (TEAM-ED) or enhanced usual care. TEAM-ED included (1) school-based telemedicine follow-ups, completed by a primary care provider, (2) point-of-care prompting to promote guideline-based care, and 3) an opportunity for 2 additional telemedicine follow-ups. The primary outcome was the mean number of symptom-free days (SFDs) over 2 weeks at 3, 6, 9, and 12 months.

RESULTS

We included 373 children from 2016 through 2021 (participation rate 68%; 54% Black, 32% Hispanic, 77% public insurance; mean age, 6.4 years). Demographic characteristics and asthma severity were similar between groups at baseline. Most (91%) TEAM-ED children had ≥1 telemedicine visit and 41% completed 3 visits. At 3 months, caregivers of children in TEAM-ED reported more follow-up visits (66% vs 48%; aOR, 2.07; 95% CI, 1.28-3.33), preventive asthma medication actions (90% vs 79%; aOR, 3.28; 95% CI, 1.56-6.89), and use of a preventive medication (82% vs 69%; aOR, 2.716; 95% CI, 1.45-5.08), compared with enhanced usual care. There was no difference between groups in medication adherence or asthma morbidity. When only prepandemic data were included, there was greater improvement in SFDs over time for children in TEAM-ED vs enhanced usual care.

CONCLUSIONS

TEAM-ED significantly improved follow-up and preventive care after an ED visit for asthma. We also saw improved SFDs with prepandemic data. The lack of overall improvement in morbidity and adherence indicates the need for additional ongoing management support.

TRIAL REGISTRATION

NCT02752165.

Results of an asthma education program delivered via telemedicine in rural schools

BACKGROUND

Asthma morbidity is high in low-income children living in rural US regions, yet few interventions have been designed to decrease the asthma burden in rural populations.

OBJECTIVE

To examine the effect of a school-based asthma education program delivered by telemedicine in children living in an impoverished rural region.

METHODS

We conducted a cluster randomized trial with rural children 7 to 14 years old by comparing a school-based telemedicine asthma education intervention with usual care. The intervention provided comprehensive asthma education by telemedicine to participants and provided evidence-based treatment recommendations to primary care providers.

RESULTS

Of the 393 enrolled children, median age was 9.6 years, 81% were African American, and 47% lived in households with an annual income less than $14,999. At enrollment, 88% of children reported uncontrolled asthma symptoms. At the end of the intervention, there were no statistically significant differences in reported symptom-free days (primary outcome) for the intervention or usual-care group. Participants in the intervention group reported significantly higher use of peak flow meters to monitor asthma and reported taking their asthma medications as prescribed more frequently compared with the usual-care group. There were no changes in other outcome measures, including quality of life, self-efficacy, asthma knowledge, or lung function, between groups.

CONCLUSION

Although there was some evidence of behavior change among intervention participants, these changes were inadequate to overcome the significant morbidity experienced by this highly symptomatic rural impoverished population. Future interventions should be designed with a multifaceted approach that considers caregiver engagement, distance barriers, and inadequate access to asthma providers in rural regions.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT01167855.

Prompting asthma intervention in Rochester-uniting parents and providers (PAIR-UP): a randomized trial

IMPORTANCE

A disproportionate number of impoverished and minority children have asthma and receive suboptimal preventive care.

OBJECTIVE

To evaluate whether the Prompting Asthma Intervention in Rochester-Uniting Parents and Providers (PAIR-UP) intervention, administered in primary care offices, improves the delivery of preventive care and reduces morbidity for urban children with asthma.

DESIGN, SETTING, AND PARTICIPANTS

Cluster randomized trial in which 12 urban primary care practices were matched based on size and type and randomly allocated to the PAIR-UP intervention or usual care (UC). We enrolled 638 children aged 2 to 12 years with persistent or poorly controlled asthma in the waiting room prior to a visit with a clinician for any reason from October 2009 to January 2013. Blinded interviewers called caregivers within 2 weeks to inquire about preventive measures taken at the visit and called them 2 and 6 months later to assess symptoms.

INTERVENTIONS

Children enrolled at PAIR-UP practices received prompts for the caregiver and clinician at the time of the visit that outlined the child's asthma severity or control as well as specific guideline-based recommendations to enhance preventive care. These practices also received educational resources and periodic feedback on their asthma care performance. The UC practices received copies of the asthma guidelines.

MAIN OUTCOMES AND MEASURES

The primary outcome was symptom-free days (SFDs) per 2 weeks at the 2-month follow-up.

RESULTS

We enrolled 638 children (participation rate of 80%; 36% were black, 36% were Hispanic, and 68% had Medicaid insurance). Groups were similar in demographic characteristics and asthma severity at baseline. At the index visit, more children in the PAIR-UP group received a preventive medication action (new medication, increased dose, recommendation to restart preventive medication) than in the UC group (58% vs 33%; odds ratio [OR] = 2.8; 95% CI, 1.9 to 3.9). More children in the PAIR-UP group than in the UC group received an asthma action plan (61% vs 23%; OR = 8.3; 95% CI, 3.7 to 18.7), discussions regarding asthma (93% vs 78%; OR = 4.5; 95% CI, 2.8 to 7.2), and secondhand smoke counseling (80% vs 63%; OR = 2.6; 95% CI, 1.2 to 5.5). At the 2-month follow-up, children in the PAIR-UP group had more SFDs per 2 weeks than those in the UC group (mean difference, 0.78 days; 95% CI, 0.29 to 1.27). At 6 months, the improvement in SFDs was no longer statistically significant (mean difference, 0.56; 95% CI, -0.14 to 1.25).

CONCLUSIONS AND RELEVANCE

The PAIR-UP intervention improved the delivery of preventive asthma care and reduced asthma morbidity for high-risk urban children with persistent asthma at 2 months, but the improvement in SFDs was no longer significant at 6 months.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01105754.

Discrepancies between medical record data and parent reported use of preventive asthma medications

OBJECTIVE

To assess whether medical record documentation reflects actual home practices regarding the administration of preventive medications to urban children with persistent asthma.

METHODS

Baseline data from a prompting asthma intervention were used for this cross-sectional analysis. As part of the larger study, we enrolled children (2-12 years) with persistent asthma in the waiting room at 12 primary care offices (2009-2012). Prior to their visit with a healthcare provider, caregivers reported information regarding their child's asthma symptom severity and current preventive medications (i.e. name and frequency of use). We compared caregiver-reported medication information with medical record data to determine the rate of complete concordance, defined as total consistency between the prescribed medication data documented in the medical record and parent report describing how the child is actually using the medication at home.

RESULTS

According to 310 completed medical record reviews, 194 (62%) children had a current prescription for a daily preventive asthma medication. Of these children, 110 (57%) had caregivers who reported complete concordance. Those reporting complete concordance were more likely to have children with greater symptom severity, including fewer symptom-free days in the prior two weeks (6.9 vs. 8.7, p = 0. 018), and ≥1 asthma-related hospitalization in the prior year (16% vs. 6%, p = 0. 042).

CONCLUSIONS

Medical records may poorly reflect actual home practices and providers should specifically inquire about medication use and barriers to adherence at the time of an office visit to promote guideline-based, consistent treatment for children with persistent asthma.

Preventive asthma care delivery in the primary care office: missed opportunities for children with persistent asthma symptoms

OBJECTIVE

To describe which National Heart Lung and Blood Institute preventive actions are taken for children with persistent asthma symptoms at the time of a primary care visit and determine how care delivery varies by asthma symptom severity.

METHODS

We approached children (2 to 12 years old) with asthma from Rochester, NY, in the waiting room at their doctor's office. Eligibility required current persistent symptoms. Caregivers were interviewed via telephone within 2 weeks after the visit regarding specific preventive care actions delivered. Bivariate and regression analyses assessed the relationship between asthma symptom severity and actions taken during the visit.

RESULTS

We identified 171 children with persistent asthma symptoms (34% black, 64% Medicaid) from October 2009 to January 2011 at 6 pediatric offices. Overall delivery of guideline-based preventive actions during visits was low. Children with mild persistent symptoms were least likely to receive preventive care. Regression analyses controlling for demographics and visit type (acute or follow-up asthma visit vs non-asthma-related visit) confirmed that children with mild persistent asthma symptoms were less likely than those with more severe asthma symptoms to receive preventive medication action (odds ratio [OR] 0.34, 95% confidence interval [CI] 0.14-0.84), trigger reduction discussion (OR 0.39, 95% CI 0.19-0.82), recommendation of follow-up (OR 0.40, 95% CI 0.19-0.87), and receipt of action plan (OR 0.37, 95% CI 0.16-0.86).

CONCLUSIONS

Many children with persistent asthma symptoms do not receive recommended preventive actions during office visits, and children with mild persistent symptoms are the least likely to receive care. Efforts to improve guideline-based asthma care are needed, and children with mild persistent asthma symptoms warrant further consideration.

Is Clinical Judgment of Asthma Control Adequate?: A prospective survey in a tertiary hospital pulmonary clinic

OBJECTIVES

Asthma control is often difficult to measure. The aim of this study was to compare physicians' personal clinical assessments of asthma control with the Global Initiative for Asthma (GINA) scoring.

METHODS

Physicians in the adult pulmonary clinics of a tertiary hospital in Oman first documented their subjective judgment of asthma control on 157 consecutive patients. Immediately after that and in the same proforma, they selected the individual components from the GINA asthma control table as applicable to each patient.

RESULTS

The same classification of asthma control was achieved by physicians' clinical judgment and GINA classification in 106 cases (67.5%). In the other 32.5% (n = 51), the degree of control by clinical judgment was one level higher than the GINA classification. The agreement was higher for the pulmonologists (72%) as compared to non-pulmonologists (47%; P = 0.009). Physicians classified 76 patients (48.4%) as well-controlled by clinical judgment compared to 48 (30.6%) using GINA criteria (P <0.001). Conversely, they classified 34 patients (21.7%) as uncontrolled as compared to 57 (36.3%) by GINA criteria (P <0.001). In the 28 patients who were clinically judged as well-controlled but, by GINA criteria, were only partially controlled, low peak expiratory flow rate (PEFR) (46.7%) and limitation of activity (21.4%) were the most frequent parameters for downgrading the level of control.

CONCLUSION

Using clinical judgment, physicians overestimated the level of asthma control and underestimated the uncontrolled disease. Since management decisions are based on the perceived level of control, this could potentially lead to under-treatment and therefore sub-optimal asthma control.

A pilot study to enhance preventive asthma care among urban adolescents with asthma

BACKGROUND

Low-income, minority teens have disproportionately high rates of asthma morbidity and are at high risk for nonadherence to preventive medications.

OBJECTIVE

To assess the feasibility and preliminary effectiveness of an innovative school-based asthma program to enhance the delivery of preventive care for 12-15 year olds with persistent asthma. We hypothesized that this intervention would (1) be feasible and acceptable among this population and (2) yield reduced asthma morbidity.

DESIGN/METHODS

SUBJECTS/SETTING

Teens with persistent asthma and a current preventive medication prescription in Rochester, NY.

DESIGN

Single group pre-post pilot study during the 2009-2010 school year.

INTERVENTION

Teens visited the school nurse daily for 6-8 weeks at the start of the school year to receive directly observed therapy (DOT) of preventive asthma medications; 2-4 weeks following DOT initiation, they received three counseling sessions (one in-home and two via telephone) using motivational interviewing (MI) to explore attitudes about asthma management, build motivation for medication adherence, and support transition to independent preventive medication use.

PRIMARY OUTCOME

Number of symptom-free days (SFDs)/2 weeks; outcome data were collected 2 months after baseline and at the end of school year.

RESULTS

We enrolled 30 teens; 28 participated in the intervention. All teens initiated a trial of school-based DOT. All in-home MI visits were completed successfully, and 89% completed both follow-up sessions. Teens experienced an overall reduction of symptoms with more SFDs/2 weeks from baseline to 2-month and final (end of school year) assessments (8.71 vs. 10.79 vs. 12.89, respectively, p = .046 and p = .004). Teens also reported fewer days with symptoms, less activity limitation, and less rescue medication use (all p < .05). Exhaled nitric oxide levels decreased (p = .012), suggesting less airway inflammation. At the final assessment, teens reported significantly higher motivation to take their preventive medication every day (p = .043). At the end of the study, 79% of teens stated that they were better at managing asthma on their own, and 93% said they would participate in a similar program again.

CONCLUSIONS

This pilot study provides preliminary evidence of the feasibility and effectiveness of a novel school-based intervention to promote independence in asthma management and improve asthma outcomes in urban teens.

Randomized controlled trial to improve care for urban children with asthma: results of the School-Based Asthma Therapy trial

OBJECTIVE

To evaluate the impact of the School-Based Asthma Therapy trial on asthma symptoms among urban children with persistent asthma.

DESIGN

Randomized trial, with children stratified by smoke exposure in the home and randomized to a school-based care group or a usual care control group.

SETTING

Rochester, New York.

PARTICIPANTS

Children aged 3 to 10 years with persistent asthma.

INTERVENTIONS

Directly observed administration of daily preventive asthma medications by school nurses (with dose adjustments according to National Heart, Lung, and Blood Institute Expert Panel guidelines) and a home-based environmental tobacco smoke reduction program for smoke-exposed children, using motivational interviewing.

MAIN OUTCOME MEASURE

Mean number of symptom-free days per 2 weeks during the peak winter season (November-February), assessed by blinded interviews.

RESULTS

We enrolled 530 children (74% participation rate). During the peak winter season, children receiving preventive medications through school had significantly more symptom-free days compared with children in the control group (adjusted difference = 0.92 days per 2 weeks; 95% confidence interval, 0.50-1.33) and also had fewer nighttime symptoms, less rescue medication use, and fewer days with limited activity (all P < .01). Children in the treatment group also were less likely than those in the control group to have an exacerbation requiring treatment with prednisone (12% vs 18%, respectively; relative risk = 0.64; 95% confidence interval, 0.41-1.00). Stratified analyses showed positive intervention effects even for children with smoke exposure (n = 285; mean symptom-free days per 2 weeks: 11.6 for children in the treatment group vs 10.9 for those in the control group; difference = 0.96 days per 2 weeks; 95% confidence interval, 0.39-1.52).

CONCLUSIONS

The School-Based Asthma Therapy intervention significantly improved symptoms among urban children with persistent asthma. This program could serve as a model for improved asthma care in urban communities.

Predictors of Health-Related Quality of Life in Asthmatic Children

For children with asthma, their perceived health-related quality of life (HRQL) is viewed as a valid outcome measure with which to evaluate care and guide clinical interventions. Numerous clinical variables have been associated with HRQL, but few studies have addressed the role of family functioning in relationship to this outcome. The current study extends the findings of an earlier meta-analysis that indicated that family functioning and illness severity were significant predictors of health-related quality of life in children with asthma. Sixty children and 60 parents or guardians participated in this study of school-age asthmatic children who, over the preceding year, received regular care at a pediatric respiratory clinic for their asthma symptoms. Demographic information was obtained from the adults, who also completed standard measures assessing family stress, adaptation, and cohesion. The children were interviewed by the investigator and completed scales to assess HRQL. The major outcome of interest was the child’s HRQL. The child’s level of control over symptoms and the accumulation of family demands, particularly those related to loss, transition, and illness/family care, negatively affected the child’s quality of life. Multiple regression analysis further revealed that level of control and transitions within the family accounted for 23% of the variance of scores measuring HRQL. Family cohesion emerged as a potential mediating factor that may buffer the negative effects of family stress and the lack of control that an asthmatic child may experience in symptom management. An appreciation of the relationships between family stress, cohesion, and HRQL for children with asthma will directly inform clinical practice. Additional family-centered clinical research that fully incorporates HRQL into a theoretical model of health outcomes will continue to refine effective clinical interventions for asthmatic children.

Comparison of doctor and patient assessments of asthma control

INTRODUCTION

The objective of asthma management is to control the condition. However, world-wide surveys reveal that only 5% of asthmatics are well controlled. One reason for this phenomenon is the fact that patients and doctors consistently over-estimate control. This study compared patient and doctor assessment of asthma control.

METHODS

A random sample of asthmatics was identified by practitioners in South Africa. Patients completed an Asthma Control Test (ACT) and provided a list of medications currently being taken. The doctor also provided an assessment of control which was summarised into the categories - 'not controlled' and 'controlled' and listed all medications prescribed.

RESULTS

The mean ACT score was 12.8 where doctors assessed the patients as being 'not controlled' and 20.7 where doctors assessed the patients as being 'controlled'. Half of the patients classified themselves as being 'not controlled' (ACT score <20, category 1), while doctors classified only 33% of patients as being 'not controlled'. Although only 7% of patients disagreed with the doctor's classification of 'not controlled', 29% disagreed with the doctor's assessment of being 'controlled'. There was a significant difference in ACT score between the sexes (p < 0.0001). Most therapeutic interventions (with the exception of combination products [ICS + LABA]) performed poorly with regard to level of control.

CONCLUSION

This study suggests that asthma still appears to be relatively poorly controlled in South Africa, although levels of patient control appear to have improved compared to previous surveys, and confirms that physicians and patients differ in their assessments of asthma control.

Experience with use of extracorporeal life support for severe refractory status asthmaticus in children

Introduction

Severe status asthmaticus (SA) in children may require intubation and mechanical ventilation with a subsequent increased risk of death. In the patient with SA and refractory hypercapnoeic respiratory failure, use of extracorporeal life support (ECLS) has been anecdotally reported for carbon dioxide removal and respiratory support. We aimed to review the experience of a single paediatric centre with the use of ECLS in children with severe refractory SA, and to compare this with international experience from the Extracorporeal Life Support Organization (ELSO) registry.

Methods

All paediatric patients (aged from 1 to 17 years) with primary International Classification of Diseases (ICD)-9 diagnoses of SA receiving ECLS for respiratory failure from both the Children's Healthcare of Atlanta at Egleston (Children's at Egleston) database and the ELSO registry were reviewed.

Results

Thirteen children received ECLS for refractory SA at the Children's at Egleston from 1986 to 2007. The median age of the children was 10 years (range 1 to 16 years). Patients generally received aggressive use of medical and anaesthetic therapies for SA before cannulation with a median partial pressure of arterial carbon dioxide (PaCO₂) of 130 mmHg (range 102 to 186 mmHg) and serum pH 6.89 (range 6.75 to 7.03). The median time of ECLS support was 95 hours (range 42 to 395 hours). All 13 children survived without neurological sequelae. An ELSO registry review found 64 children with SA receiving ECLS during the same time period (51 excluding the Children's at Egleston cohort). Median age, pre-ECLS PaCO₂ and pH were not different in non-Children's ELSO patients. Overall survival was 60 of 64 (94%) children, including all 13 from the Children's at Egleston cohort. Survival was not significantly associated with age, pre-ECLS PaCO₂, pH, cardiac arrest, mode of cannulation or time on ECLS. Significant neurological complications were noted in 3 of 64 (4%) patients; patients with neurological complications were not significantly more likely to die (P = 0.67).

Conclusions

Single centre and ELSO registry experience provide results of a cohort of children with refractory SA managed with ECLS support. Further study is necessary to determine if use of ECLS in this setting produces better outcomes than careful mechanical ventilation and medical therapy alone.

Improving care for urban children with asthma: design and methods of the School-Based Asthma Therapy (SBAT) trial

The School Based Asthma Therapy (SBAT) trial builds on a pilot study in which we found that school-based administration of preventive asthma medications for inner-city children reduced asthma symptoms. However, the beneficial effects of this program were seen only among children not exposed to environmental tobacco smoke (ETS). The current study is designed to establish whether this intervention can be enhanced by more stringent adherence to asthma guidelines through the addition of symptom-based medication dose adjustments, and whether smoke-exposed children benefit from the intervention when it is combined with an ETS reduction program. The intervention consists of both administration of preventive asthma medications in school (with dose adjustments according to NHLBI guidelines) and a home-based ETS reduction program utilizing motivational interviewing principles. This paper describes the methodology, conceptual framework, and lessons learned from the SBAT trial. Results of this study will help to determine whether this type of comprehensive school-based program can serve as a model to improve care for urban children and reduce disparities.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Tobacco as an allergen in bronchial disease

BACKGROUND

Skin testing and sera measurements have verified the existence of tobacco specific IgE. However, the few published studies on this matter report conflicting results concerning their clinical significance.

OBJECTIVE

To verify if a specific clinical allergenic response against tobacco might be possible in allergenic and nonallergenic bronchial diseases.

METHODS

We performed a cross-sectional observational case-control analysis on 180 patients with asthma, chronic obstructive pulmonary disease (COPD), and bronchial carcinoma and controls who were randomly chosen. Skin prick tests and serum specific IgE to tobacco and related allergens, bronchial challenge with cigarettes and tobacco extract, patch tests with tobacco and nicotine, sodium dodecyl sulfate-polyacrylamide gel electrophoresis immunoblotting, and Enzyme AllergoSorbent Test (EAST) inhibition were performed.

RESULTS

Twenty-eight patients had positive tobacco skin prick test results. The association among positive skin prick test results, IgE, and bronchial challenge was strong (P < .001). Tobacco sensitivity was higher in patients with pollen asthma than in patients with COPD and carcinoma and negative in patients with intrinsic asthma and controls. A positive bronchial challenge result was related to the length of habit (P < .001) and the tobacco index in patients who had stopped smoking (P < .001). Delayed bronchial and patch response was more common in patients with COPD (P < .001). Tobacco IgE response (EAST) was related to sensitivity to Lolium perenne (rye grass) pollen (P < .001) but not to other vegetables that belong to the Solanaceae family. EAST inhibition showed cross-reactivity between tobacco and Lolium pollen.

CONCLUSIONS

Tobacco may be responsible for a specific IgE response. Patients with pollen asthma were those with more positive responses to tobacco due to cross-reactivity between Lolium and tobacco allergens.

Interleukin-1R antagonist gene and pre-natal smoke exposure are associated with childhood asthma

The interleukin-1 receptor antagonist (IL1RN) is a potent anti-inflammatory cytokine. In the present study, association of the human IL1RN gene polymorphisms with asthma, bronchial hyperresponsiveness and forced expiratory volume in one second/forced vital capacity ratio was tested and the data was stratified by environmental tobacco smoke exposure in order to investigate a gene-smoking interaction. In an unselected subset (n = 921) of the Isle of Wight birth (UK) cohort, which has previously been evaluated for asthma and related manifestations at ages 1, 2, 4 and 10 yrs, three IL1RN single nucleotide polymorphisms (SNP) were genotyped. Logistic regression and repeated measurement models for tests of association using a representative SNP rs2234678 were used, as all SNPs tested were in strong linkage disequilibrium. In the overall analysis, the SNP rs2234678 was not associated with asthma. However, in the stratum with maternal smoking during pregnancy the rs2234678 GG genotype significantly increased the relative risk of asthma in children, both in analyses of repeated asthma occurrences and persistent asthma. In conclusion, the present results show that in the first decade of life, the gene-environment interaction of the interleukin-1 receptor antagonist gene polymorphism rs2234678 and maternal smoking during pregnancy increased the risk for childhood asthma.

Efficacy and safety of inhaled fluticasone propionate chlorofluorocarbon in 2- to 4-year-old patients with asthma: results of a double-blind, placebo-controlled study

BACKGROUND

Current asthma guidelines recommend inhaled glucocorticoids administered via pressurized metered-dose inhaler (MDI) with a holding chamber as the preferred therapy for young children with asthma.

OBJECTIVE

To evaluate the efficacy and safety of fluticasone propionate chlorofluorocarbon MDI use in preschool-aged children with asthma.

METHODS

Randomized, double-blind, placebo-controlled, parallel-group study of 332 children aged 24 to 47 months with asthma. Fluticasone propionate chlorofluorocarbon, 44 or 88 microg twice daily, or placebo (chlorofluorocarbon propellant alone) administered for 12 weeks via MDI with a valved holding chamber and an attached face mask. The primary efficacy measure was average change in 24-hour daily asthma symptom scores. Safety assessments included adverse events, 12-hour urinary cortisol excretion, and growth.

RESULTS

Treatment failure (ie, asthma exacerbation) occurred in approximately half as many fluticasone propionate-treated patients (13%-14%) as placebo-treated patients (24%). Compared with placebo users, patients treated with fluticasone propionate, 88 microg twice daily, had a 13% greater improvement in the mean proportion of symptom- and albuterol-free days (P = .02); asthma symptom scores and albuterol use were also significantly reduced. Patients treated with fluticasone propionate, 44 microg twice daily, had greater improvements than placebo-treated patients; however, differences did not reach statistical significance. At end point, the growth velocities of fluticasone propionate-treated patients were within the range of those of placebo-treated patients. No clinically relevant changes in 12-hour overnight urinary cortisol excretion were observed.

CONCLUSION

Compared with placebo use, fluticasone propionate, 88 microg administered twice daily, significantly reduced asthma exacerbations, asthma symptoms, and rescue albuterol use and was well tolerated, with no clinically relevant systemic effects, as measured by growth velocity or 12-hour urinary cortisol excretion levels.

The need for pediatric studies of allergy and asthma medications

For many years, clinicians have accepted the fact that most medications do not have dosing guidelines for children younger than 12 years of age. Recently, there has been a great effort to correct this deficiency. With the introduction of the 1997 Food and Drug Administration Modernization Act, a provision was established to grant additional market exclusivity to pharmaceutical firms that performed the required studies that would lead to improved labeling of medications for children. This effort has resulted in a significant advance for the management of asthma and allergic disorders in children. Several allergy and asthma medications are now approved for use in children as young as 1 year of age, with studies currently being conducted in younger age groups. In this review, we discuss the background for this effort and the continuing impact it will have on the future management of allergy and asthma in children.

Oral prednisolone in the acute management of children age 6 to 35 months with viral respiratory infection-induced lower airway disease: a randomized, placebo-controlled trial

OBJECTIVE

To investigate the efficacy of oral prednisolone in virally induced respiratory distress. Study design Randomized, double-blind, placebo-controlled trial involving 230 children age 6 to 35 months in the emergency department. Each patient received either oral prednisolone (2 mg/kg/d) or placebo for 3 days.

RESULTS

The hospitalization rates were similar between the two groups. For admitted children (n=123), the median length of stay was 1 day shorter in the prednisolone group (2 vs 3 days, P=.060). The proportion of children requiring >or=3 days of hospitalization was 47.5% in the prednisolone group and 67.7% in the placebo group (P=.023). There was less need for additional asthma medication (18.0% vs 37.1%, P=.018) in the prednisolone group. The median duration of symptoms of respiratory distress was 1 day in the prednisolone group versus 2 days in the placebo group both among the hospitalized (P<.001) and nonhospitalized children (P=.006).

CONCLUSION

A 3-day course of oral prednisolone effectively reduced disease severity, length of hospital stay, and the duration of symptoms among children 6 to 35 months old with virally induced respiratory distress.

The impact of a large-scale population-based asthma management program on pediatric asthma patients and their caregivers

BACKGROUND

The consequences of pediatric asthma include missed school attendance, limitations in physical activity, and increased health care utilization and costs. Caregivers of asthmatic children are affected through missed work days and decreased job productivity. In response to these issues, a disease management program encompassing asthmatic children and their caregivers was developed as part of the core services offered to members of a large, national health care plan.

OBJECTIVE

To determine the impact of the asthma management program on pediatric asthma patients and their caregivers over a 12-month period.

METHODS

In this longitudinal study, 401 randomly selected member households with asthmatic children from 17 regional markets completed surveys before and after 12 months of participation in the asthma management program. Program interventions, which were tailored according to risk and need status, included various staggered educational mailings, reminder aids, videos, a peak expiratory flow rate meter, and telephonic case management. The Asthma Quality Assessment System survey, a battery of self-reported quality indicators, was used to solicit information from parents or caregivers of asthmatic children on issues pertaining to quality of life, asthma management skills and knowledge, and lost work/school days related to asthma.

RESULTS

Statistically significant postprogram outcomes were observed in various domains, including a reduction in adverse utilization, symptomatology, and restricted activity days for children and lost work days for adult caretakers.

CONCLUSIONS

These findings demonstrate that a large-scale population-based intervention program can produce measurable clinical and economic benefits, thereby lessening the burden of asthma on the family unit.

[Difficult asthma in children]

Difficult asthma in children is defined as the persistence of exacerbations or frequent symptoms requiring rescue bronchodilator, or persistent airway obstruction in spite of treatment with inhaled steroid >/= 800 microg/d beclomethasone or equivalent and beta-2 long acting agonist. Management of difficult asthma in children first requires to identify conditions that may mimic asthma, asthma with bad compliance to treatment, and difficult asthma in relation with avoidable factors that worsen symptoms. The pathological bases of genuine difficult asthma remain unknown. Different patterns have been described according to the cells that are involved (eosinophil, neutrophil), the degree of airway remodeling, or the distal localization of the lesions. Difficult asthma requires specialized management including airway inflammation evaluation. Studies on bronchoalveolar lavage and bronchial mucosa biopsies will perhaps help to better understand the pathophysiology and to improve the management.

Agreement among measures of asthma status: a prospective study of low-income children with moderate to severe asthma

BACKGROUND

Because no validated "gold standard" for measuring asthma outcomes exists, asthma interventions are often evaluated using a large number of disease status measures. Some of these measures may be redundant, whereas others may be complementary. Use of multiple outcomes may lead to ambiguous results, increased type I error rates, and be an inefficient use of resources including caregiver and patient/participant time and effort. Understanding the relationship between these measures may facilitate more parsimonious and valid evaluation strategies without loss of information.

OBJECTIVE

To assess the relationships between multiple measures of asthma disease status over time.

DESIGN/METHODS

We used data from a randomized, controlled trial of a comprehensive disease management program involving 119 disadvantaged inner-city children aged 5 to 12 years with moderate to severe asthma. Spearman correlations were calculated between the following asthma disease status measures: parent-reported disease symptoms, parent-reported health care utilization, functional health status using the American Academy of Pediatrics' validated Child Health Survey for Asthma (CHSA), diary data (symptom scores, night wakings, and bronchodilator use), and pulmonary function tests at baseline, 32 weeks, 52 weeks, and changes from baseline to 52 weeks.

RESULTS

Ninety-four (79%) of randomized patients participated at baseline and 52 weeks. Completion rates for outcome measures ranged from 79% (CHSA, spirometry data) to 64% (diary data). At baseline, asthma symptoms, health care utilization, and individual domains from the CHSA were significantly correlated (r = 0.21-0.53). These correlations were stable over the 52-week follow-up. Forced expiratory volume in 1 second and diary data did not correlate to any other measures at baseline, and these measures correlated only inconsistently with other measures at 32 weeks and 52 weeks. Baseline to 52-week changes in asthma symptoms, utilization, and the CHSA domains were significantly correlated (0.22-0.56), as were baseline to 52-week changes in symptom days, night wakings, and the CHSA domains (r = 0.24-0.64). Baseline to 52-week changes in forced expiratory volume in 1 second and diary data did not correlate with other measures.

CONCLUSIONS

These results suggest that asthma status and change in asthma status over time after introduction of a disease management intervention are best characterized by parent-reported symptoms, parent-reported utilization, and functional health status measures. Asthma diaries and pulmonary function tests did not seem to provide additional benefit, although they may play an important role in individual patient management. Our findings suggest a parsimonious evaluation strategy would include collection of key data elements regarding symptoms, utilization, and functional health status only, without loss of vital response information.

The use of inhaled corticosteroids in children with asthma

The inhaled corticosteroids (ICSs) are the most effective long-term controllers for the treatment of childhood asthma. There is now substantial controlled clinical trial data to support the efficacy and safety of ICS therapy in infants and young children (6 months to 4 years of age). These data support the use of nebulizer suspension or metered-dose inhalers with valved holding chambers as effective forms of delivery in this age group. Currently, selection of delivery method depends on the comfort of the parent and the cooperation of the child, as well as on which drug the clinician chooses. The ICSs have a favorable safety profile when administered in currently recommended dosages. A transient 0.5- to 2-cm growth delay occurs in prepubescent children but does not appear to affect attainment of predicted adult height. Long-term trials support the existing recommendations of lowering dosage once control is achieved and stopping therapy when the child's asthma is in remission.