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Udoko M, De Keyser H, Szefler SJ. Should children with asthma simply be treated as little adults? Ann Allergy Asthma Immunol 2021; 127:520-521. [PMID: 34260900 DOI: 10.1016/j.anai.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Revised: 07/06/2021] [Accepted: 07/08/2021] [Indexed: 12/01/2022]
Affiliation(s)
- Mfonobong Udoko
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Heather De Keyser
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado
| | - Stanley J Szefler
- The Breathing Institute, Children's Hospital Colorado, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado; Department of Pediatrics, University of Colorado School of Medicine, Anschutz Medical Campus, Aurora, Colorado.
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2
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Coverstone AM, Seibold MA, Peters MC. Diagnosis and Management of T2-High Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 8:442-450. [PMID: 32037108 DOI: 10.1016/j.jaip.2019.11.020] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 11/07/2019] [Accepted: 11/24/2019] [Indexed: 12/15/2022]
Abstract
Type 2 (T2) inflammation plays a key role in the pathogenesis of asthma. IL-4, IL-5, and IL-13, along with other inflammatory mediators, lead to increased cellular eosinophilic inflammation. It is likely that around half of all patients with asthma have evidence of T2-high inflammation. Sputum and blood eosinophils, exhaled nitric oxide, blood IgE levels, and airway gene expression markers are frequently used biomarkers of T2-high asthma. Individuals with T2-high asthma tend to have several features of increased asthma severity, including reduced lung function and increased rates of asthma exacerbations, and T2-high patients demonstrate distinct pathologic features including increased airway remodeling and alterations in airway mucus production. Several monoclonal antibodies are now available to treat individuals with T2-high asthma and these medications significantly reduce asthma exacerbation rates.
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Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Division of Allergy, Immunology and Pulmonary Medicine, Washington University School of Medicine in Saint Louis, St Louis, Mo.
| | - Max A Seibold
- National Jewish Health, Department of Pediatrics, Center for Genes, Environment, and Health, Denver, Colo
| | - Michael C Peters
- Department of Medicine, San Francisco School of Medicine, University of California, San Francisco, Calif
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3
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Munoz FA, Benton LD, Kops SA, Kowalek KA, Seckeler MD. Greater length of stay and hospital charges for severe asthma in children with depression or anxiety. Pediatr Pulmonol 2020; 55:2908-2912. [PMID: 32902930 DOI: 10.1002/ppul.25061] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Revised: 08/23/2020] [Accepted: 09/03/2020] [Indexed: 11/11/2022]
Abstract
RATIONALE Asthma is one of the most common chronic disorders of childhood and is associated with significant healthcare utilization and costs. Comorbid psychiatric illnesses, specifically depression and anxiety, are more prevalent in patients with asthma and associated with worse asthma control, more emergency department visits, and increased hospitalization rates. OBJECTIVES We aimed to compare hospital outcomes and charges for children with severe asthma with and without comorbid depression and anxiety, hypothesizing that those with depression and anxiety would have longer hospitalizations and higher charges. METHODS Retrospective review of the 2000-2012 Healthcare Cost and Utilization Project's Kids' Inpatient Databases for admissions of patients aged 10-21 years with an ICD-9 code severe asthma (status asthmaticus or any asthma diagnosis with a procedure code for endotracheal intubation). Depression and Anxiety subgroups were created based on ICD-9 codes. Data collected included demographics, hospital outcomes and charges and comparisons made between groups. RESULTS There were 52,485 admissions for severe asthma: 45,094 (86%) with No Comorbid Psychiatric Illnesses, 1284 (2.4%) with depression, and 1297 (2.5%) with anxiety. Patients with depression or anxiety were older, had longer hospitalizations, and higher hospital charges (p < .001 for all). CONCLUSIONS Comorbid depression or anxiety is associated with significantly longer hospitalizations and higher charges for children with severe asthma. These findings add to prior reports of worse outcomes for children with asthma and comorbid depression or anxiety and suggest that improved screening for and management of these conditions in children with asthma could improve hospital outcomes and reduce costs.
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Affiliation(s)
- Fernando A Munoz
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
| | - Lauren D Benton
- Department of Pediatrics (Pulmonology), University of Arizona, Tucson, Arizona, USA
| | - Samantha A Kops
- Department of Pediatrics, University of Arizona, Tucson, Arizona, USA
| | - Katie A Kowalek
- Department of Pediatrics (Critical Care), University of Arizona, Tucson, Arizona, USA
| | - Michael D Seckeler
- Department of Pediatrics (Cardiology), University of Arizona, Tucson, Arizona, USA
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4
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Three Major Efforts to Phenotype Asthma: Severe Asthma Research Program, Asthma Disease Endotyping for Personalized Therapeutics, and Unbiased Biomarkers for the Prediction of Respiratory Disease Outcome. Clin Chest Med 2020; 40:13-28. [PMID: 30691708 DOI: 10.1016/j.ccm.2018.10.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The SARP, ADEPT, and U-BIOPRED programs are all significant efforts in characterizing asthma and reporting clusters that will assist in designing personalized therapies for asthma, and especially severe asthma. Key aspects of the design of these programs are summarized and major findings are reported in this review.
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5
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Ramadan AA, Gaffin JM, Israel E, Phipatanakul W. Asthma and Corticosteroid Responses in Childhood and Adult Asthma. Clin Chest Med 2020; 40:163-177. [PMID: 30691710 DOI: 10.1016/j.ccm.2018.10.010] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Corticosteroids are the most effective treatment for asthma; inhaled corticosteroids (ICSs) are the first-line treatment for children and adults with persistent symptoms. ICSs are associated with significant improvements in lung function. The anti-inflammatory effects of corticosteroids are mediated by both genomic and nongenomic factors. Variation in the response to corticosteroids has been observed. Patient characteristics, biomarkers, and genetic features may be used to predict response to ICSs. The existence of multiple mechanisms underlying glucocorticoid insensitivity raises the possibility that this might indeed reflect different diseases with a common phenotype.
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Affiliation(s)
- Amira Ali Ramadan
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Beth Israel Deaconess Center, Cardiovascular institute, 330 Brookline Avenue, Boston, MA 02215, USA
| | - Jonathan M Gaffin
- Division of Respiratory Diseases, Boston Children's Hospital, Boston, MA, USA
| | - Elliot Israel
- Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA; Brigham and Women's Hospital, 15 Francis Street, Boston, MA 02115, USA
| | - Wanda Phipatanakul
- Division of Allergy and Immunology, Boston Children's Hospital, 300 Longwood Avenue, Boston, MA 02115, USA; Harvard Medical School, 25 Shattuck Street, Boston, MA 02115, USA.
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6
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Abstract
Severe asthma is broadly defined as asthma requiring a high level of therapy, usually high doses of inhaled corticosteroids, to bring under control. Children who remain symptomatic despite such treatment are a heterogeneous population, and bear a high burden of disease and require high resource utilization. Children with severe asthma require a comprehensive evaluation, careful consideration of alternative diagnoses and comorbid conditions, assessment of medication adherence and environmental conditions, and frequent disease monitoring.
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7
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Coverstone AM, Bacharier LB, Wilson BS, Fitzpatrick AM, Teague WG, Phipatanakul W, Wenzel SE, Gaston BM, Bleecker ER, Moore WC, Ramratnam S, Jarjour NN, Ly NP, Fahy JV, Mauger DT, Schechtman KB, Yin-DeClue H, Boomer JS, Castro M. Clinical significance of the bronchodilator response in children with severe asthma. Pediatr Pulmonol 2019; 54:1694-1703. [PMID: 31424170 PMCID: PMC7015037 DOI: 10.1002/ppul.24473] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 07/12/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Our objective was to determine those characteristics associated with reversibility of airflow obstruction and response to maximal bronchodilation in children with severe asthma through the Severe Asthma Research Program (SARP). METHODS We performed a cross-sectional analysis evaluating children ages 6 to 17 years with nonsevere asthma (NSA) and severe asthma (SA). Participants underwent spirometry before and after 180 µg of albuterol to determine reversibility (≥12% increase in FEV1 ). Participants were then given escalating doses up to 720 µg of albuterol to determine their maximum reversibility. RESULTS We evaluated 230 children (n = 129 SA, n = 101 NSA) from five centers across the United States in the SARP I and II cohorts. SA (odds ratio [OR], 2.08, 95% confidence interval [CI], 1.05-4.13), second-hand smoke exposure (OR, 2.81, 95%CI, 1.23-6.43), and fractional exhaled nitric oxide (FeNO; OR, 1.97, 95%CI, 1.35-2.87) were associated with increased odds of airway reversibility after maximal bronchodilation, while higher prebronchodilator (BD) FEV1 % predicted (OR, 0.91, 95%CI, 0.88-0.94) was associated with decreased odds. In an analysis using the SARP III cohort (n = 186), blood neutrophils, immunoglobulin E (IgE), and FEV1 % predicted were significantly associated with BD reversibility. In addition, children with BD response have greater healthcare utilization. BD reversibility was associated with reduced lung function at enrollment and 1-year follow-up though less decline in lung function over 1 year compared to those without reversibility. CONCLUSIONS Lung function, that is FEV1 % predicted, is a predictor of BD response in children with asthma. Additionally, smoke exposure, higher FeNO or IgE level, and low peripheral blood neutrophils are associated with a greater likelihood of BD reversibility. BD response can identify a phenotype of pediatric asthma associated with low lung function and poor asthma control.
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Affiliation(s)
- Andrea M Coverstone
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Leonard B Bacharier
- Department of Pediatrics, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Bradley S Wilson
- Department of Ophthalmology and Visual Sciences, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Georgia
| | - William Gerald Teague
- Department of Pediatrics, University of Virginia School of Medicine, Charlottesville, Virginia
| | - Wanda Phipatanakul
- Department of Pediatrics, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Sally E Wenzel
- Department of Medicine, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Benjamin M Gaston
- Department of Pediatrics, Rainbow Babies and Children's Hospital, Case Western Reserve University, Cleveland, Ohio
| | | | - Wendy C Moore
- Department of Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina
| | - Sima Ramratnam
- Department of Pediatrics, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Nizar N Jarjour
- Department of Medicine, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Ngoc P Ly
- Department of Pediatrics, University of California, San Francisco, San Francisco, California
| | - John V Fahy
- Department of Medicine, University of California, San Francisco, San Francisco, California
| | - David T Mauger
- Department of Public Health Sciences, Pennsylvania State University, Hershey, Pennsylvania
| | - Kenneth B Schechtman
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Huiqing Yin-DeClue
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Jonathan S Boomer
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
| | - Mario Castro
- Department of Medicine, Washington University School of Medicine in Saint Louis, St. Louis, Missouri
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8
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Schoettler N, Strek ME. Recent Advances in Severe Asthma: From Phenotypes to Personalized Medicine. Chest 2019; 157:516-528. [PMID: 31678077 DOI: 10.1016/j.chest.2019.10.009] [Citation(s) in RCA: 92] [Impact Index Per Article: 18.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 09/15/2019] [Accepted: 10/18/2019] [Indexed: 12/31/2022] Open
Abstract
This review focuses on recent clinical and translational discoveries in severe and uncontrolled asthma that now enable phenotyping and personalized therapies in these patients. Although asthma is common in both children and adults and typically responds to standard therapies, a subset of individuals with asthma experience severe and/or persistent symptoms despite appropriate therapies. Airflow obstruction leading to frequent symptoms requiring higher levels of controller therapy is the cardinal feature of severe asthma, but the underlying molecular mechanisms, or endotypes, are diverse and variable between individuals. Two major risk factors that contribute to severe asthma are genetics and environmental exposures that modulate immune responses, and although these often interact in complex manners that are not fully understood, certain endotypes converge in severe asthma. A number of studies have evaluated various features of patients with severe asthma and classified patients into phenotypes with clinical relevance. This phenotyping is now incorporated into clinical practice and can be used to guide advanced biological therapies that target specific molecules and inflammatory pathways that contribute to asthma pathogenesis.
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Affiliation(s)
- Nathan Schoettler
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL.
| | - Mary E Strek
- Department of Medicine, Section of Pulmonary and Critical Care, University of Chicago, Chicago, IL
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9
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Ross KR, Teague WG, Gaston BM. Life Cycle of Childhood Asthma: Prenatal, Infancy and Preschool, Childhood, and Adolescence. Clin Chest Med 2018; 40:125-147. [PMID: 30691707 DOI: 10.1016/j.ccm.2018.10.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Asthma is a heterogeneous developmental disorder influenced by complex interactions between genetic susceptibility and exposures. Wheezing in infancy and early childhood is highly prevalent, with a substantial minority of children progressing to established asthma by school age, most of whom are atopic. Adolescence is a time of remission of symptoms with persistent lung function deficits. The transition to asthma in adulthood is not well understood.
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Affiliation(s)
- Kristie R Ross
- Division of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
| | - W Gerald Teague
- Pediatric Asthma Center of Excellence, Department of Pediatrics, University of Virginia School of Medicine, 409 Lane Road, Building MR4, Room 2112, PO Box 801349, Charlottesville, VA 22908, USA
| | - Benjamin M Gaston
- Division of Pediatric Pulmonology, Allergy, Immunology and Sleep Medicine, Rainbow Babies and Children's Hospital, Case Western Reserve University School of Medicine, Children's Lung Foundation, 2109 Adelbert Road, BRB 827, Cleveland, OH 44106, USA
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10
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Grunwell JR, Travers C, Fitzpatrick AM. Inflammatory and Comorbid Features of Children Admitted to a PICU for Status Asthmaticus. Pediatr Crit Care Med 2018; 19:e585-e594. [PMID: 30106766 PMCID: PMC6218278 DOI: 10.1097/pcc.0000000000001695] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES To determine risk factors associated with admission to a PICU with or without endotracheal intubation for an asthma exacerbation. We hypothesized that children with critical and near-fatal asthma would have distinguishing clinical features but varying degrees of asthma severity and measures of type 2 inflammation. DESIGN Retrospective analysis of prospectively collected data of children with asthma recruited into outpatient asthma clinical research studies at Emory University between 2004 and 2015. SETTING Large, free-standing academic quaternary care children's hospital in Atlanta, GA. PATIENTS Children 6-18 years old with physician-diagnosed and confirmed asthma. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS A total of 579 children were analyzed with 170 children (29.4%) being admitted to the PICU for an asthma exacerbation in their lifetime. Of these 170 children with a history of critical asthma, 24.1% were classified as having mild-to-moderate asthma, and 83 of 170 children (48.8%) had been intubated and experienced near-fatal asthma. Multiple logistic regression was used to identify risk factors associated with increased odds of PICU admission with or without endotracheal intubation. Hospitalization within the prior 12 months of survey (odds ratio, 8.19; 95% CI, 4.83-13.89), a history of pneumonia (odds ratio, 2.56; 95% CI, 1.52-4.29), having a designation of increased chronic asthma severity on high-dose inhaled corticosteroids (odds ratio, 2.76; 95% CI, 1.62-4.70), having a father with asthma (odds ratio, 2.15; 95% CI, 1.23-3.76), living in a region with a higher burden of poverty (odds ratio, 1.28; 95% CI, 1.02-1.61), and being of black race (odds ratio, 2.01; 95% CI, 1.05-3.84) were all associated with increased odds of PICU admission with or without intubation. CONCLUSIONS Our findings suggest that there are factors associated with critical and near-fatal asthma, distinct from the chronic asthma severity designations, that should be the focus of future investigation.
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Affiliation(s)
- Jocelyn R Grunwell
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
| | - Curtis Travers
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
- Division of Pediatric Critical Care Medicine, Children's Healthcare of Atlanta at Egleston, Atlanta, GA
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11
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Bonner K, Roberts G. Does allergy explain why some children have severe asthma? Clin Exp Allergy 2018; 48:1594-1605. [PMID: 30019503 DOI: 10.1111/cea.13234] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 06/30/2018] [Accepted: 07/15/2018] [Indexed: 12/13/2022]
Abstract
Asthma is a common disease in childhood with a minority of affected children having severe therapy-resistant asthma (STRA). Children with STRA can be differentiated from those with mild-moderate disease by greater allergic sensitization, increased eosinophilic airway inflammation, increased airway remodelling and reduced corticosteroid responsiveness. The aetiology of STRA in children is multifactorial but allergy seems to play a key role. Many children with asthma have coexisting allergic disease, and severe rhinitis seems to be an important driver of STRA in children. Allergies to foods, moulds, pollen and pets have also been associated with severe asthma exacerbations. Identifying allergens that are driving asthma symptoms in children with STRA may provide additional strategies for improving their disease control. Avoidance strategies may be possible. Additional monoclonal antibody therapy with Omalizumab or Mepolizumab may be helpful in children with clinically important polysensitization.
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Affiliation(s)
- Katie Bonner
- Wexham Park Hospital, Frimley Health NHS Foundation Trust, Slough, UK.,Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
| | - Graham Roberts
- Clinical and Experimental Sciences and Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK.,NIHR Southampton Biomedical Research Centre, University Hospital Southampton NHS Foundation Trust, Southampton, UK.,The David Hide Asthma and Allergy Research Centre, St Mary's Hospital, Isle of Wight, UK
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12
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Ullmann N, Mirra V, Di Marco A, Pavone M, Porcaro F, Negro V, Onofri A, Cutrera R. Asthma: Differential Diagnosis and Comorbidities. Front Pediatr 2018; 6:276. [PMID: 30338252 PMCID: PMC6178921 DOI: 10.3389/fped.2018.00276] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2018] [Accepted: 09/12/2018] [Indexed: 12/26/2022] Open
Abstract
Childhood asthma remains a multifactorial disease with heterogeneous clinical phenotype and complex genetic inheritance. The primary aim of asthma management is to achieve control of symptoms, in order to reduce the risk of future exacerbations and progressive loss of lung function, which results especially challenging in patients with difficult asthma. When asthma does not respond to maintenance treatment, firstly, the correct diagnosis needs to be confirmed and other diagnosis, such as cystic fibrosis, primary ciliary dyskinesia, immunodeficiency conditions or airway and vascular malformations need to be excluded. If control remains poor after diagnostic confirmation, detailed assessments of the reasons for asthma being difficult-to-control are needed. Moreover, all possible risk factors or comorbidities (gastroesophageal reflux, rhinosinusitis, dysfunctional breathing and/or vocal cord dysfunction, obstructive sleep apnea and obesity) should be investigated. At the same time, the possible reasons for poor symptom control need to be find in all modifiable factors which need to be carefully assessed. Non-adherence to medication or inadequate inhalation technique, persistent environmental exposures and psychosocial factors are, currently, recognized as the more common modifiable factors. Based on these premises, investigation and management of asthma require specialist multidisciplinary expertise and a systematic approach to characterizing patients' asthma phenotypes and delivering individualized care. Moreover, since early wheezers are at higher risk of developing asthma, we speculate that precocious interventions aimed at early diagnosis and prevention of modifiable factors might affect the age at onset of wheezing, reduce the prevalence of persistent later asthma and determine long term benefits for lung health.
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Affiliation(s)
- Nicola Ullmann
- Paediatric Pulmonology & Respiratory Intermediate Care Unit, Sleep and Long Term Ventilation Unit, Department of Paediatrics, Paediatric Hospital “Bambino Gesù” Research Institute, Rome, Italy
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13
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Guilbert T, Zeiger RS, Haselkorn T, Iqbal A, Alvarez C, Mink DR, Chipps BE, Szefler SJ. Racial Disparities in Asthma-Related Health Outcomes in Children with Severe/Difficult-to-Treat Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:568-577. [PMID: 30172020 DOI: 10.1016/j.jaip.2018.07.050] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Revised: 07/22/2018] [Accepted: 07/29/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND There are limited data that examine differences in asthma etiology between black and white children with severe or difficult-to-treat asthma. OBJECTIVE To describe demographic, clinical, and asthma-related outcomes in black and white children and examine whether differences in outcomes are explained by confounding factors in sequential multivariable models. METHODS Black (n = 86) and white (n = 262) children aged 6-11 years from The Epidemiology and Natural History of Asthma: Outcomes and Treatment Regimens 3-year observational study were analyzed. Baseline demographics and clinical characteristics were described for both cohorts, and outcomes at month 12 were analyzed using statistical models, sequentially adjusting for potential confounders. RESULTS Black children were more likely to be male (79.1% vs 66.4%; P < .05), obese (12.8% vs 1.5%; P < .001), and from a lower income stratum (USD43,400 vs 55,770; P < .001) than white children. Black children had higher geometric mean IgE levels (434.8 vs 136.8 IU/mL; P < .001), were more likely to have very poorly controlled asthma (72.1% vs 53.4%), use long-term systemic corticosteroids (30.2% vs 9.2%; P < .001), have poorer quality of life (5.5 vs 6.1; P < .001), and have an emergency department visit (27.4% vs 7.7%, P < .001) in the 3 months before month 12. Differences in asthma control and the severity of exacerbations persisted even after accounting for all confounding factors. CONCLUSIONS Among children with severe or difficult-to-treat asthma, asthma burden is greater in black than white children particularly related to several clinical and patient-reported outcome measures that are not explained by differences in background or clinical characteristics.
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Affiliation(s)
- Theresa Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio.
| | - Robert S Zeiger
- Departments of Allergy and Research and Evaluation, Kaiser Permanente Southern California, San Diego and Pasadena, Calif
| | | | - Ahmar Iqbal
- US Medical Affairs, Genentech, Inc., South San Francisco, Calif
| | | | | | | | - Stanley J Szefler
- Department of Pediatrics, Children's Hospital Colorado and University of Colorado School of Medicine, Aurora, Colo
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14
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Translating Asthma: Dissecting the Role of Metabolomics, Genomics and Personalized Medicine. Indian J Pediatr 2018; 85:643-650. [PMID: 29185231 DOI: 10.1007/s12098-017-2520-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/27/2017] [Indexed: 01/26/2023]
Abstract
The management of asthma has largely stagnated over the last 25 years, but we are at the dawning of a new age wherein -omics technology can help us manage the disease objectively and rationally. Even in this new scientific age, getting the basics of asthma management right remains essential. The new technologies which can be applied to multiple biological samples include genomics (study of the genome), transcriptomics (gene transcription), lipidomics, proteomics and metabolomics (lipids, proteins and metabolites, respectively) and breathomics, using exhaled breath as a source of biomarkers, which is of particular interest in view of its non-invasive nature in pediatrics. Important applications will include the diagnosis of airways disease, including its components; the pathways driving airway pathology; monitoring the response to treatment; and measuring future risk (asthma attacks, poor lung growth trajectory). With the advent of a wide range of novel biologicals to treat asthma, -omics technology to personalize therapy will be especially important. The U-BIOPRED (Europe) and SARP (USA) groups have been most active in this field, especially using bronchoscopically obtained samples to perform cluster analyses to define new asthma endotypes. However, stability over time and consistency between investigators is imperfect. This is perhaps unsurprising; results of biomarker studies in asthma will be a composite of the underlying disease, the (variable) effects of adverse drivers such as allergen exposure and pollution, the effects of treatment, and the effects of adherence or otherwise to treatment. Ultimately, the aim should be an exhaled breath based tool with a rapid result that can be used as a routine in the clinic. However, at the moment, there are as yet no clinical applications in children of -omics technology.
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15
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Microbial Insights into Asthmatic Immunopathology. A Forward-Looking Synthesis and Commentary. Ann Am Thorac Soc 2018; 14:S316-S325. [PMID: 29161080 DOI: 10.1513/annalsats.201707-534aw] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Asthma is an aberrant inflammatory condition of the airways affecting approximately 1 in 10 children in affluent countries. An increasing body of evidence suggests that microbial exposures during a "critical window" of development in early life play a central role in determining future asthma susceptibility. However, like the disease itself, considerable heterogeneity exists among studies in which researchers have investigated the associations between particular microbial taxa and asthma immunology. As our understanding of asthmatic pathology evolves to enable clearer definition of asthma endotypes, it will be important to consider the impact of various environmental factors on each endotype. Given the strong evidence in support of the hypothesis that early-life microbial exposures predict later disease states such as asthma, consideration of these endotypes when establishing experimental outcomes in epidemiological studies could allow for increased precision when determining exposure-outcome associations and engaging in more focused follow-up mechanistic investigations.
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16
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Abstract
The growth and maturity of the peripheral immune system and subsequent development of pulmonary immunity in early life is dictated by host, environmental and microbial factors. Dysregulation during the critical window of immune development in the postnatal years results in disease which impacts on lifelong lung health. Asthma is a common disease in childhood and is often preceded by wheezing illnesses during the preschool years. However, the mechanisms underlying development of wheeze and how and why only some children progress to asthma is unknown. Human studies to date have generally focused on peripheral immune development, with little assessment of local tissue pathology in young children. Moreover, mechanisms underlying the interactions between inflammation and tissue repair at mucosal surfaces in early life remain unknown. Disappointingly, mechanistic studies in mice have predominantly used adult models. This review will consider the aspects of the neonatal immune system which might contribute to the development of early life wheezing disorders and asthma, and discuss the external environmental factors which may influence this process.
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Affiliation(s)
- Clare M Lloyd
- Inflammation, Repair & Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK
| | - Sejal Saglani
- Inflammation, Repair & Development Section, National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, Royal Brompton Harefield NHS Foundation Trust, London, UK
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17
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Mirra V, Montella S, Santamaria F. Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment. BMC Pediatr 2018; 18:73. [PMID: 29466963 PMCID: PMC5820802 DOI: 10.1186/s12887-018-1019-9] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 01/29/2018] [Indexed: 12/22/2022] Open
Abstract
Background The primary goal of asthma management is to achieve disease control for reducing the risk of future exacerbations and progressive loss of lung function. Asthma not responding to treatment may result in significant morbidity. In many children with uncontrolled symptoms, the diagnosis of asthma may be wrong or adherence to treatment may be poor. It is then crucial to distinguish these cases from the truly “severe therapy-resistant” asthmatics by a proper filtering process. Herein we report on four cases diagnosed as difficult asthma, detail the workup that resulted in the ultimate diagnosis, and provide the process that led to the prescription of omalizumab. Case presentation All children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β2-agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma. Three out four patients were treated with omalizumab, which improved asthma control and patients’ quality of life. We reviewed the current literature on the diagnostic approach to the disease and on the comorbidities associated with difficult asthma and presented the perspectives on omalizumab treatment in children and adolescents. Based on the evidence from the literature review, we also proposed an algorithm for the diagnosis of pediatric difficult-to-treat and severe asthma. Conclusions The management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma. The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism in the management of children and adolescents with atopic severe asthma.
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Affiliation(s)
- Virginia Mirra
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Silvia Montella
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy
| | - Francesca Santamaria
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pansini 5, 80131, Naples, Italy.
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18
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Goldman DL, Chen Z, Shankar V, Tyberg M, Vicencio A, Burk R. Lower airway microbiota and mycobiota in children with severe asthma. J Allergy Clin Immunol 2017; 141:808-811.e7. [PMID: 29031597 DOI: 10.1016/j.jaci.2017.09.018] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2017] [Revised: 08/31/2017] [Accepted: 09/13/2017] [Indexed: 12/16/2022]
Affiliation(s)
- David L Goldman
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY; Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY.
| | - Zigui Chen
- Department of Microbiology, Chinese University of Hong Kong, Hong Kong, China
| | - Viswanathan Shankar
- Department of Epidemiology and Population Health, Albert Einstein College of Medicine, Bronx, NY
| | - Michael Tyberg
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY
| | - Alfin Vicencio
- Department of Pediatrics, the Cohen's Children Medical Center, Queens, NY
| | - Robert Burk
- Department of Pediatrics, Children's Hospital at Montefiore, Bronx, NY; Department of Microbiology and Immunology, Albert Einstein College of Medicine, Bronx, NY
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Iordanidou M, Loukides S, Paraskakis E. Asthma phenotypes in children and stratified pharmacological treatment regimens. Expert Rev Clin Pharmacol 2016; 10:293-303. [PMID: 27936975 DOI: 10.1080/17512433.2017.1271322] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Asthma is the most common inflammatory disease in childhood. The interaction of genetic, environmental and host factors may contribute to the development of childhood asthma and defines its progress, including persistence and severity. Until now, various classifications of childhood asthma phenotypes have been suggested based on patient's age during onset of symptoms, type of inflammatory cells, response to treatment and disease severity. Many efforts have been carried out to identify childhood asthma phenotypes and to clarify which are the risk factors that define asthma prediction and the response to therapy. The identification of asthma phenotypes has not only prognostic but also therapeutic role. However, the classification of asthma phenotypes is complex due to the heterogeneity of the disease. Areas covered: The current childhood asthma phenotypes and the new therapeutic strategies for each phenotype are reviewed. Expert commentary: There are multiple phenotypes in childhood asthma and it is crucial to define them before the initiation of personalized treatment. Both the therapeutic strategy and monitoring should follow the recent guidelines.
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Affiliation(s)
- Maria Iordanidou
- a Paediatric Respiratory Unit, Department of Pediatrics , University Hospital of Alexandroupolis , Alexandroupolis , Greece
| | - Stelios Loukides
- b 2nd Respiratory Medicine Department , National and Kapodistrian University of Athens Medical School, Attiko University Hospital , Athens , Greece
| | - Emmanouil Paraskakis
- a Paediatric Respiratory Unit, Department of Pediatrics , University Hospital of Alexandroupolis , Alexandroupolis , Greece
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20
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Fitzpatrick AM. Severe Asthma in Children: Lessons Learned and Future Directions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2016; 4:11-9; quiz 20-1. [PMID: 26772923 DOI: 10.1016/j.jaip.2015.10.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/10/2015] [Revised: 10/14/2015] [Accepted: 10/16/2015] [Indexed: 01/02/2023]
Abstract
Severe asthma in children is a complicated and heterogeneous disorder that is extremely challenging to treat. Although most children with asthma derive clinical benefit from daily administration of low-to-medium-dose inhaled corticosteroid (ICS) therapy, a small subset of children with "severe" or "refractory" asthma require high doses of ICS and even systemic corticosteroids to maintain symptom control. These children with severe asthma are at increased risk for adverse outcomes including medication-related side effects and recurrent and life-threatening exacerbations that significantly impair quality of life. This review highlights findings on severe asthma in school-age children (age 6-17 years) from the National Heart, Lung and Blood Institute's Severe Asthma Research Program (SARP) over a 10-year period, between 2001 and 2011. Although SARP has advanced knowledge of the unique clinical, biological, and molecular attributes of severe asthma in children, considerable gaps remain for which additional studies are needed.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta Center for Cystic Fibrosis and Airways Disease Research, Atlanta, Ga.
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21
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Bossley CJ, Fleming L, Ullmann N, Gupta A, Adams A, Nagakumar P, Bush A, Saglani S. Assessment of corticosteroid response in pediatric patients with severe asthma by using a multidomain approach. J Allergy Clin Immunol 2016; 138:413-420.e6. [PMID: 27061250 DOI: 10.1016/j.jaci.2015.12.1347] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Revised: 12/12/2015] [Accepted: 12/28/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND There is no agreed upon definition of systemic corticosteroid response in asthmatic children. Moreover, pediatric severe therapy-resistant asthma (STRA) is heterogeneous, and thus response to steroids is unlikely to be uniform in all patients. OBJECTIVE We sought to evaluate the utility of a multidomain approach incorporating symptoms, lung function, and inflammation to determine steroid responsiveness in pediatric patients with STRA. METHODS Eighty-two children (median age, 12 years) with STRA received a clinically indicated dose of intramuscular steroid. Changes in 4 separate domains were assessed 4 weeks after intramuscular triamcinolone acetonide: normalization of (1) symptoms (Asthma Control Test score, >19/25 or 50% increase), (2) spirometric results (FEV1 ≥80% of predicted value or ≥15% increase), (3) fraction of exhaled nitric oxide levels (<24 ppb), and (4) sputum eosinophil counts (<2.5%). Fifty-four of 82 children had complete data in all 4 domains. RESULTS Twenty-three (43%) of 54 children had a symptom response, 29 (54%) of 54 had a lung function response, 28 (52%) of 54 had a fraction of exhaled nitric oxide response, and 29 (54%) of 54 had a sputum eosinophil response. Although a similar proportion of children responded to systemic corticosteroids in each domain, there were no reliable predictors of a response pattern. Seven (13%) of 54 were complete responders (response in all domains), 8 (15%) of 54 were nonresponders (no response in any domain), and 39 (72%) of 54 were partial responders (response in ≥1 domain). CONCLUSIONS A multidomain evaluation of systemic steroid responsiveness using pragmatic clinical assessments confirms childhood STRA is heterogeneous and that a complete response in symptoms and inflammatory and physiologic parameters is rare. Individual response patterns to systemic steroids might be useful in guiding the choice of add-on therapies in each child as a step toward achieving personalized medicine.
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Affiliation(s)
- Cara J Bossley
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom; Respiratory Paediatrics, Kings College Hospital, London, United Kingdom
| | - Louise Fleming
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom; Leukocyte Biology, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Nicola Ullmann
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom; Leukocyte Biology, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Atul Gupta
- Leukocyte Biology, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Alexandra Adams
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Prasad Nagakumar
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Andrew Bush
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom; Leukocyte Biology, National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Sejal Saglani
- Respiratory Paediatrics, Royal Brompton Hospital and National Heart & Lung Institute, Imperial College London, London, United Kingdom; Leukocyte Biology, National Heart & Lung Institute, Imperial College London, London, United Kingdom.
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22
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O'Brien CE, Tsirilakis K, Santiago MT, Goldman DL, Vicencio AG. Heterogeneity of lower airway inflammation in children with severe-persistent asthma. Pediatr Pulmonol 2015; 50:1200-4. [PMID: 25739748 DOI: 10.1002/ppul.23165] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2014] [Revised: 01/15/2015] [Accepted: 01/21/2015] [Indexed: 12/21/2022]
Abstract
RATIONALE The treatment of children with severe-persistent asthma remains problematic. Recent studies suggest that stratification of this cohort by inflammatory type may be useful in designing effective treatment strategies. In this study, we examined the inflammatory profile in bronchoalveolar lavage fluid from children with severe-persistent asthma and compared this profile with serum IgE levels. METHODS The inflammatory profile in the bronchoalveolar fluid from 32 children who met criteria for severe-persistent asthma as defined by the Severe Asthma Research Program (SARP) were analyzed retrospectively. Inflammatory patterns were classified as neutrophilic, eosinophilic, mixed, or pauci-granulocytic. Serum total IgE was measured prior to bronchoscopy and determined by ELISA at each hospital's lab by standard procedures. RESULTS The most common pattern of inflammation in this cohort was neutrophilic (37.5%) followed by eosinophilic (28.1%), mixed (21.9%), and pauci-granulocytic (11.1%). The odds ratio of an eosinophilic BAL pattern for patients with an elevated serum IgE was 4.67 (CI 0.78-28, P = 0.12). A correlation between serum IgE levels and BAL eosinophil percentages was present (P = 0.04). CONCLUSIONS To our knowledge, ours is one of few studies to systematically investigate the pattern of lower airway inflammation in children with severe-persistent asthma. Our results differ from a recent investigation in children, showing more heterogeneity and a greater proportion of neutrophilic inflammation. Further investigation is required to determine whether specific inflammatory patterns are associated with specific etiologies, and whether individualized therapy is warranted.
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Affiliation(s)
- Caitlin E O'Brien
- Department of Pediatrics, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York
| | - Kalliope Tsirilakis
- Department of Pediatrics, Cohen Children's Medical Center of New York, Hofstra University School of Medicine, New Hyde Park, New York
| | - Maria Teresa Santiago
- Department of Pediatrics, Cohen Children's Medical Center of New York, Hofstra University School of Medicine, New Hyde Park, New York
| | - David L Goldman
- Divisions of Pediatrics and Microbiology, Albert Einstein College of Medicine and Children's Hospital at Montefiore, Bronx, New York
| | - Alfin G Vicencio
- Department of Pediatrics, Kravis Children's Hospital, Icahn School of Medicine at Mount Sinai, New York City, New York
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23
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Anderson WC, Szefler SJ. New and future strategies to improve asthma control in children. J Allergy Clin Immunol 2015; 136:848-59. [PMID: 26318072 DOI: 10.1016/j.jaci.2015.07.007] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2015] [Revised: 07/09/2015] [Accepted: 07/09/2015] [Indexed: 12/13/2022]
Abstract
Symptomatic asthma in childhood has lifelong effects on lung function and disease severity, emphasizing the need for improved pediatric asthma control. Control of pediatric risk and impairment domains can be achieved through increased medication adherence or new therapeutic strategies. Developing electronic monitoring device technology with reminders might be a key noninvasive resource to address poor adherence in children and adolescents in a clinical setting. In patients who have persistently poor control despite optimal medication compliance, newly emerging pharmaceuticals, including inhaled therapies and biologics, might be key to their treatment. However, barriers exist to their development in the pediatric population, and insights must be drawn from adult studies, which has its own unique limitations. Biomarkers to direct the use of such potentially expensive therapies to those patients most likely to benefit are imperative. In this review the current literature regarding strategies to improve pediatric asthma control is addressed with the goal of exploring the potential and pitfalls of strategies that might be available in the near future.
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Affiliation(s)
- William C Anderson
- Section of Allergy and Immunology, Department of Pediatrics, Children's Hospital Colorado, Aurora, Colo; Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo
| | - Stanley J Szefler
- Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo; Pediatric Asthma Research Program, Section of Pediatric Pulmonary Medicine, Breathing Institute, Department of Pediatrics, Children's Hospital Colorado, and the Department of Pediatrics, University of Colorado School of Medicine, Aurora, Colo.
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24
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Guilbert TW, Bacharier LB, Fitzpatrick AM. Severe asthma in children. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2015; 2:489-500. [PMID: 25213041 DOI: 10.1016/j.jaip.2014.06.022] [Citation(s) in RCA: 99] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Received: 05/01/2014] [Revised: 06/27/2014] [Accepted: 06/30/2014] [Indexed: 11/19/2022]
Abstract
Severe asthma in children is characterized by sustained symptoms despite treatment with high doses of inhaled corticosteroids or oral corticosteroids. Children with severe asthma may fall into 2 categories, difficult-to-treat asthma or severe therapy-resistant asthma. Difficult-to-treat asthma is defined as poor control due to an incorrect diagnosis or comorbidities, or poor adherence due to adverse psychological or environmental factors. In contrast, treatment resistant is defined as difficult asthma despite management of these factors. It is increasingly recognized that severe asthma is a highly heterogeneous disorder associated with a number of clinical and inflammatory phenotypes that have been described in children with severe asthma. Guideline-based drug therapy of severe childhood asthma is based primarily on extrapolated data from adult studies. The recommendation is that children with severe asthma be treated with higher-dose inhaled or oral corticosteroids combined with long-acting β-agonists and other add-on therapies, such as antileukotrienes and methylxanthines. It is important to identify and address the influences that make asthma difficult to control, including reviewing the diagnosis and removing causal or aggravating factors. Better definition of the phenotypes and better targeting of therapy based upon individual patient phenotypes is likely to improve asthma treatment in the future.
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Affiliation(s)
- Theresa W Guilbert
- Division of Pulmonology Medicine, Department of Pediatrics, Cincinnati Children's Hospital, Cincinnati, Ohio.
| | - Leonard B Bacharier
- Division of Allergy, Immunology and Pulmonary Medicine, Department of Pediatrics, Washington University School of Medicine and St Louis Children's Hospital, St Louis, Mo
| | - Anne M Fitzpatrick
- Division of Pulmonary, Allergy & Immunology, Cystic Fibrosis, and Sleep, Department of Pediatrics, Emory University, Atlanta, Ga
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25
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Veskitkul J, Ruangchira-urai R, Charuvanij S, Pongtanakul B, Udomittipong K, Vichyanond P. Asthma-like symptoms as a presentation of antiphospholipid syndrome. Pediatr Pulmonol 2015; 50:E1-4. [PMID: 25045120 DOI: 10.1002/ppul.23079] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 05/17/2014] [Accepted: 05/24/2014] [Indexed: 11/06/2022]
Abstract
We herein report a case of antiphospholipid syndrome (APS) primarily presenting with asthma-like symptoms that had been misdiagnosed as severe asthma. Patients presenting with severe asthma symptoms along with systemic thrombosis should be systematically evaluated for APS.
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Affiliation(s)
- J Veskitkul
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
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Valverde-Molina J. Identifying severe asthma in pediatrics: the glass half full or half empty. Allergol Immunopathol (Madr) 2014; 42:507-9. [PMID: 25454925 DOI: 10.1016/j.aller.2014.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2014] [Accepted: 10/27/2014] [Indexed: 11/27/2022]
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Sah PK, Gerald Teague W, Demuth KA, Whitlock DR, Brown SD, Fitzpatrick AM. Poor asthma control in obese children may be overestimated because of enhanced perception of dyspnea. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2014; 1:39-45. [PMID: 23646295 DOI: 10.1016/j.jaip.2012.10.006] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Although studies in adults have shown a non-TH2 obese asthma phenotype, whether a similar phenotype exists in children is unclear. OBJECTIVE We hypothesized that asthmatic children with obesity, defined as a body mass index above the 95th percentile for age and sex, would have poorer asthma control as well as decreased quality of life, increased health care utilization, and decreased pulmonary function measures as a function of increased TH1 versus TH2 polarization. METHODS This study involved a post hoc analysis of cross sectional data from 269 children 6 to 17 years of age enrolled in the National Heart, Lung, and Blood Institute Severe Asthma Research Program. Children answered questionnaires and underwent spirometry, plethysmography, exhaled nitric oxide determination, and venipuncture for TH1/TH2 cytokine determination. Asthma control was defined according to national asthma treatment guidelines that are based on prespecified thresholds for lung function and symptom frequency. RESULTS Fifty-eight children (22%) were overweight and 67(25%) were obese. Obese children did not have poorer asthma control but were more likely to report nonspecific symptoms such as dyspnea and nocturnal awakenings. Obese children did have decreased asthma-related quality of life and increased health care utilization, but this was not associated with airflow limitation. Instead, obese children had decreased functional residual capacity. A unique pattern of TH1 or TH2 polarization was not observed. CONCLUSIONS Poor asthma control in obese children with asthma may be overestimated because of enhanced perception of nonspecific symptoms such as dyspnea that results from altered mechanical properties of the chest wall. Careful assessment of physiologic as well as symptom-based measures is needed in the evaluation of obese children with respiratory symptoms.
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Yang HJ, Kim BS, Kim WK, Kim J, Kim JT, Suh DI, Koh YY, Shin YH, Lee SY, Lim DH, Choung JT, Kim HB. Phenotype and endotype in pediatric asthma. ALLERGY ASTHMA & RESPIRATORY DISEASE 2014. [DOI: 10.4168/aard.2014.2.2.85] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- Hyeon-Jong Yang
- Department of Pediatrics, Soonchunhyang University Hospital, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Bong-Seong Kim
- Department of Pediatrics, GangNeung Asan Hospital, University of Ulsan College of Medicine, Gangneung, Korea
| | - Woo Kyung Kim
- Department of Pediatrics, Inje University Seoul Paik Hospital, Inje University College of Medicine, Seoul, Korea
| | - Jakyoung Kim
- Department of Pediatrics, Kangwon National University School of Medicine, Chunchon, Korea
| | - Jin Tack Kim
- Department of Pediatrics, The Catholic University of Korea College of Medicine, Seoul, Korea
| | - Dong In Suh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Young Yull Koh
- Department of Pediatrics, Seoul National University College of Medicine, Seoul, Korea
| | - Youn Ho Shin
- Department of Pediatrics, CHA University College of Medicine, Pocheon, Korea
| | - So-Yeon Lee
- Department of Pediatrics, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Dae Hyun Lim
- Department of Pediatrics, Inha University School of Medicine, Incheon, Korea
- Environmental Health Center for Allergic Rhinitis, Inha University Hospital, Ministry of Environment, Incheon, Korea
| | - Ji Tae Choung
- Department of Pediatrics, Korea University College of Medicine, Seoul, Korea
- Environmental Health Center for Asthma, Korea University Anam Hospital, Ministry of Environment, Seoul, Korea
| | - Hyo-Bin Kim
- Department of Pediatrics, Inje University Sanggye Paik Hospital, Inje University College of Medicine, Seoul, Korea
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Vicencio AG, Santiago MT, Tsirilakis K, Stone A, Worgall S, Foley EA, Bush D, Goldman DL. Fungal sensitization in childhood persistent asthma is associated with disease severity. Pediatr Pulmonol 2014; 49:8-14. [PMID: 23401301 DOI: 10.1002/ppul.22779] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 11/03/2012] [Indexed: 11/09/2022]
Abstract
RATIONALE Recent observations, especially in adults, suggest that asthma severity may be associated with fungal sensitization. Other studies suggest that some patients with severe asthma and fungal sensitization may benefit from anti-fungal therapy. Currently, the prevalence of fungal sensitization among children with severe asthma is not well characterized. METHODS We determined prevalence of fungal sensitization among children with moderate to severe persistent asthma and compared clinical characteristics between sensitized and non-sensitized children, including asthma severity, serum immunoglobulin E, and pulmonary function. RESULTS Of the 64 children enrolled, 25 (39%) had evidence of sensitization to one or more fungi. Nineteen of 25 (76%) children with fungal sensitization were categorized as severe persistent compared to 13 of 39 (33%) children without evidence of fungal sensitization (odds ratio = 6.33, 95% confidence interval 2.04-19.68, P = 0.0014). Of 32 severe persistent asthmatics, 19 (59%) demonstrated evidence of fungal sensitization. Serum immunoglobulin E was significantly higher (P < 0.001), and pulmonary function (including FEV1, FEV1/FVC, and FEF25-75%) significantly lower in the fungal-sensitized patients (P = 0.016, 0.0004, and 0.002, respectively). Bronchial biopsy of sensitized children revealed basement membrane thickening and eosinophil infiltration. CONCLUSIONS Fungal sensitization in children with persistent asthma is associated with disease severity. Almost 60% of our severe persistent asthma patients had evidence of fungal sensitization and, based on our previous studies, may be potential candidates for anti-fungal therapy.
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Affiliation(s)
- Alfin G Vicencio
- Department of Pediatrics, Cohen Children's Medical Center, New Hyde Park, New York
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31
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Holgate ST. Stratified approaches to the treatment of asthma. Br J Clin Pharmacol 2013; 76:277-91. [PMID: 23163316 DOI: 10.1111/bcp.12036] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2012] [Accepted: 10/28/2012] [Indexed: 01/01/2023] Open
Abstract
While asthma is a chronic inflammatory disorder that is managed with inhaled controller and reliever drugs, there remains a large unmet need at the severe end of the disease spectrum. Here, a novel stratified approach to its treatment is reviewed, based upon identification of causal pathways, with a focus on biologics. A systematic search of the literature was made using Medline, and publications were selected on the basis of their relevance to the topic. Despite strong preclinical data for many of the more recently identified asthma targets, especially those relating to the T-helper 2 allergic pathway, clinical trials with specific biologics in moderate to severe asthma as a group have been disappointing. However, subgroup analyses based upon pathway-specific biomarkers suggest specific endotypes that are responsive. Application of hypothesis-free analytical approaches (the 'omics') to well-defined phenotypes is leading to the stratification of asthma along causal pathways. Refinement of this approach is likely to be the future for diagnosing and treating this group of diseases, as well as helping to define new causal pathways. The identification of responders and nonresponders to targeted asthma treatments provides a new way of looking at asthma diagnosis and management, especially with biologics that are costly. The identification of novel biomarkers linked to well-phenotyped patients provides a stratified approach to disease management beyond simple disease severity and involving causal pathways. In order to achieve this effectively, a closer interaction will be required between industry (therapeutic and diagnostic), academia and health workers.
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Yoo Y. Phenotypes and endotypes of severe asthma in children. KOREAN JOURNAL OF PEDIATRICS 2013; 56:191-5. [PMID: 23741231 PMCID: PMC3668198 DOI: 10.3345/kjp.2013.56.5.191] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/24/2012] [Accepted: 12/28/2012] [Indexed: 01/10/2023]
Abstract
Severe childhood asthma is a complicated and heterogeneous disorder with distinct phenotypes. Children with severe asthma have more persistent symptoms despite receiving treatment, more atopy, greater airway obstruction, and more air trapping than those with mild-to-moderate asthma. They also have higher morbidity and substantial airflow limitations that persist throughout adulthood. Identification of the phenotype clusters and endotypes of severe asthma can allow further modulation of the natural history of severe asthma and may provide the pathophysiologic rationale for appropriate management strategies.
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Affiliation(s)
- Young Yoo
- Department of Pediatrics, Allergy Immunology Center, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
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33
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Guibas GV, Makris M, Papadopoulos NG. Acute asthma exacerbations in childhood: risk factors, prevention and treatment. Expert Rev Respir Med 2013; 6:629-38. [PMID: 23234449 DOI: 10.1586/ers.12.68] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Asthma is a heterogeneous disease more appropriately seen as a syndrome rather than a single pathologic entity. Although it can remain quiescent for extended time periods, the inflammatory and remodeling processes affect the bronchial milieu and predispose to acute and occasionally severe clinical manifestations. The complexity underlying these episodes is enhanced during childhood, an era of ongoing alterations and maturation of key biological systems. In this review, the authors focus on such sudden-onset events, emphasizing on their diversity on the basis of the numerous asthma phenotypes.
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Affiliation(s)
- George V Guibas
- Allergy Unit D. Kalogeromitros, Attikon University Hospital, University of Athens Medical School, Athens, Greece
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Konradsen JR, James A, Nordlund B, Reinius LE, Söderhäll C, Melén E, Wheelock AM, Wheelock A, Lödrup Carlsen KC, Lidegran M, Verhoek M, Boot RG, Dahlén B, Dahlén SE, Hedlin G. The chitinase-like protein YKL-40: a possible biomarker of inflammation and airway remodeling in severe pediatric asthma. J Allergy Clin Immunol 2013; 132:328-35.e5. [PMID: 23628340 DOI: 10.1016/j.jaci.2013.03.003] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Revised: 03/06/2013] [Accepted: 03/08/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND Problematic severe childhood asthma includes a subgroup of patients who are resistant to therapy. The specific mechanisms involved are unknown, and novel biomarkers are required to facilitate treatment and diagnosis of therapy-resistant asthma. The chitinase-like protein YKL-40 has been related to asthma and airway remodeling. OBJECTIVES To compare serum YKL-40 levels in children with severe, therapy-resistant asthma (n = 34), children with controlled persistent asthma (n = 39), and healthy controls (n = 27), and to investigate correlations with biomarkers of inflammation and airway remodeling. METHODS The study protocol included questionnaires, measurement of exhaled nitric oxide in exhaled air, blood sampling for inflammatory biomarkers, and high-resolution computed tomography of the lungs to identify bronchial wall thickening (therapy-resistant only). Serum YKL-40 levels were measured by ELISA, and all asthmatic children were genotyped for a CHI3L1 promoter single nucleotide polymorphism (rs4950928). RESULTS Serum YKL-40 levels were significantly higher in children with therapy-resistant asthma than in healthy children (19.2 ng/mL vs 13.8 ng/mL, P = .03). Among children with severe, therapy-resistant asthma, YKL-40 levels correlated with fraction of exhaled nitric oxide in exhaled air (r = 0.48, P = .004), blood neutrophils (r = 0.63, P < .001), and bronchial wall thickening on high-resolution computed tomography (r = 0.45, P = .01). Following adjustment for CHI3L1 genotype, significantly greater levels of YKL-40 were found in children with therapy-resistant asthma than in children with controlled asthma. CONCLUSIONS YKL-40 levels are increased in children with severe, therapy-resistant asthma compared to healthy children, and also compared to children with controlled asthma following correction for genotype.
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Affiliation(s)
- Jon R Konradsen
- Astrid Lindgren Children's Hospital, Karolinska University Hospital, Karolinska Institutet, Stockholm, Sweden.
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Severe asthma in childhood: recent advances in phenotyping and pathogenesis. Curr Opin Allergy Clin Immunol 2012; 12:193-201. [PMID: 22249197 DOI: 10.1097/aci.0b013e32835090ac] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
PURPOSE OF REVIEW Children with severe asthma have a high degree of respiratory morbidity despite treatment with high doses of inhaled corticosteroids and are therefore very difficult to treat. This review will discuss phenotypic and pathogenic aspects of severe asthma in childhood, as well as remaining knowledge gaps. RECENT FINDINGS As a group, children with severe asthma have a number of distinct phenotypic features compared with children with mild-to-moderate asthma. Clinically, children with severe asthma are differentiated by greater allergic sensitization, increased exhaled nitric oxide, and significant airflow limitation and air trapping that worsens as a function of age. These findings are accompanied by structural airway changes and increased and dysregulated airway inflammation and oxidant stress which may explain the differential nature of corticosteroid responsiveness in this population. Because children with severe asthma themselves are a heterogeneous group, current efforts are focused on improved definition and sub-phenotyping of the disorder. Whereas the clinical relevance of phenotyping approaches in severe asthma is not yet clear, they may provide important insight into the mechanisms underlying the disorder. SUMMARY Improved classification of severe asthma through unified definitions, careful phenotypic analyses, and mechanism-focused endotyping approaches may ultimately advance knowledge and personalized treatment.
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Abstract
PURPOSE OF REVIEW There is currently limited ability to identify which infants and young children with recurrent wheezing will ultimately develop persistent asthma. In addition, it is not clear how risk factors influence the development of asthma in later childhood and adulthood. This review will discuss efforts to categorize these children with recurrent wheezing and develop asthma-predictive tools. RECENT FINDINGS Transient and persistent wheezing phenotypes have been identified with atopy, reduced lung function, and viral and bacterial respiratory infection as major risk factors for persistence of asthma. Children with severe asthma tend to have greater magnitude of atopy and lower lung function than those with mild-moderate asthma. These phenotypes and risk factors have been described in previous studies and are supported by the recent literature. SUMMARY Heterogeneity of wheezing phenotypes may account for different responses to treatment and varied outcomes. Overlap in phenotypes and instability over time also add additional challenges to defining discrete groups of children with specific outcomes. Further studies are needed to determine combinations of variables that may improve phenotype designation with the goal of improving asthma prevention and treatment as well as predicting outcomes and understanding the pathogenesis of asthma.
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Brown SD, Baxter KM, Stephenson ST, Esper AM, Brown LAS, Fitzpatrick AM. Airway TGF-β1 and oxidant stress in children with severe asthma: association with airflow limitation. J Allergy Clin Immunol 2011; 129:388-96, 396.e1-8. [PMID: 22206775 DOI: 10.1016/j.jaci.2011.11.037] [Citation(s) in RCA: 54] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2011] [Revised: 11/27/2011] [Accepted: 11/29/2011] [Indexed: 01/14/2023]
Abstract
BACKGROUND TGF-β1 is thought to play a role in airway remodeling in asthmatic subjects. TGF-β1 expression might be mediated by an excessive burden of reactive oxygen species and oxidant stress. OBJECTIVE Given the profound airway oxidant stress we have previously observed in children with severe asthma, we sought to (1) quantify TGF-β1 protein and mRNA gene expression in the airways of children with mild-to-moderate and severe atopic asthma and (2) determine the relationship of airway TGF-β1 concentrations to oxidant burden (ie, lipid peroxidation), T(H)2-mediated eosinophilic inflammation, and airflow limitation. METHODS Bronchoalveolar lavage fluid was collected from 68 atopic children with asthma (severe asthma, n = 28) and 12 atopic adult control subjects. Airway TGF-β1 expression and activation were assessed in relation to airway IL-13, 8-isoprostane, and malondialdehyde concentrations. The relationship of airway TGF-β1 expression to airflow limitation in children with asthma was also assessed. RESULTS Children with severe asthma had higher total airway concentrations of TGF-β1 that were associated with increased protein and mRNA expression of TGF-β1 in airway macrophages and an increase in concentrations of the lipid peroxidation biomarkers 8-isoprostanes and malondialdehyde. TGF-β1 activation was also greater in children with severe asthma and was associated with higher airway 8-isoprostane, malondialdehyde, and IL-13 concentrations. Total airway TGF-β1 concentrations were further associated with airflow limitation. CONCLUSIONS Children with severe asthma have increased airway TGF-β1 expression and activation associated with an increased airway oxidant burden. Oxidant stress might mediate the effects of TGF-β1 and promote airway remodeling in children with severe asthma.
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Affiliation(s)
- Sheena D Brown
- Department of Pediatrics, Emory University, Atlanta, GA, USA
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Spanier AJ, Kahn RS, Hornung R, Lierl M, Lanphear BP. Associations of Fraction of Exhaled Nitric Oxide with Beta Agonist Use in Children with Asthma. PEDIATRIC ALLERGY, IMMUNOLOGY, AND PULMONOLOGY 2011; 24:45-50. [PMID: 22276224 PMCID: PMC3255503 DOI: 10.1089/ped.2010.0047] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 02/10/2011] [Indexed: 12/16/2022]
Abstract
The fraction of exhaled nitric oxide (FeNO), a measure of airway inflammation, is a potential noninvasive tool to guide asthma management in children. It remains unclear, however, if FeNO adds any information beyond clinical assessment of asthma control. We evaluated the associations of FeNO level with short acting beta agonist use and compared it with other clinical asthma assessments. We examined a prospective cohort study of 225 tobacco-smoke-exposed children aged 6-12 years with doctor-diagnosed asthma, including measures of FeNO, reported days of short acting beta agonist use, and unscheduled asthma visits. FeNO was analyzed in relation to current and future (3 months later) short acting beta agonist use. Mean FeNO at baseline, 6, and 12 months was 15.5, 15.7, and 16.8 ppb. In multivariable analyses, higher FeNO level was associated with increased short acting beta agonist use but only among children who were not on inhaled corticosteroids. Among those not on an inhaled steroid, there was a 12% increase in current and 15% increase in future days of short acting beta agonist use for every 10 ppb increase in FeNO level. FeNO levels remained associated with current short acting beta agonist use even after adjusting for unscheduled asthma visits. FeNO levels remained associated with future short acting beta agonist use even after adjusting for current short acting beta agonist use or unscheduled asthma visits. We conclude that FeNO levels are associated with short acting beta agonist use but only among children who are not on an inhaled corticosteroid.
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Szefler SJ. Advances in pediatric asthma in 2010: addressing the major issues. J Allergy Clin Immunol 2011; 127:102-15. [PMID: 21211645 PMCID: PMC3032272 DOI: 10.1016/j.jaci.2010.11.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2010] [Accepted: 11/15/2010] [Indexed: 01/05/2023]
Abstract
Last year's "Advances in pediatric asthma" concluded with the following statement: "If we can close these [remaining] gaps through better communication, improvements in the health care system and new insights into treatment, we will move closer to better methods to intervene early in the course of the disease and induce clinical remission as quickly as possible in most children." This year's summary will focus on recent advances in pediatric asthma that take steps moving forward as reported in Journal of Allergy and Clinical Immunology publications in 2010. Some of these recent reports show us how to improve asthma management through steps to better understand the natural history of asthma, individualize asthma care, reduce asthma exacerbations, and manage inner-city asthma and some potential new ways to use available medications to improve asthma control. It is clear that we have made many significant gains in managing asthma in children, but we have a ways to go to prevent asthma exacerbations, alter the natural history of the disease, and reduce health disparities in asthma care. Perhaps new directions in personalized medicine and improved health care access and communication will help maintain steady progress in alleviating the burden of this disease in children, especially young children.
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Affiliation(s)
- Stanley J Szefler
- Division of Pediatric Clinical Pharmacology, Department of Pediatrics, National Jewish Health, Denver, Colo. 80206, USA.
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