Asthma control assessment in a pediatric population: comparison between GINA/NAEPP guidelines, Childhood Asthma Control Test (C-ACT), and physician's rating

Recommendations for asthma monitoring in children: A PeARL document endorsed by APAPARI, EAACI, INTERASMA, REG, and WAO

Monitoring is a major component of asthma management in children. Regular monitoring allows for diagnosis confirmation, treatment optimization, and natural history review. Numerous factors that may affect disease activity and patient well-being need to be monitored: response and adherence to treatment, disease control, disease progression, comorbidities, quality of life, medication side-effects, allergen and irritant exposures, diet and more. However, the prioritization of such factors and the selection of relevant assessment tools is an unmet need. Furthermore, rapidly developing technologies promise new opportunities for closer, or even "real-time," monitoring between visits. Following an approach that included needs assessment, evidence appraisal, and Delphi consensus, the PeARL Think Tank, in collaboration with major international professional and patient organizations, has developed a set of 24 recommendations on pediatric asthma monitoring, to support healthcare professionals in decision-making and care pathway design.

Correlation between impulse oscillometry parameters and test for respiratory and asthma control in kids (TRACK) in asthma control of preschoolers with asthma

BACKGROUND

Little research has been conducted to evaluate the correlation between impulse oscillometry (IOS), Childhood Asthma Control Test (C-ACT), and Test for Respiratory and Asthma Control in Kids (TRACK).

METHODS

This study was conducted at China Medical University Hospital between September 1, 2019, and March 31, 2021. Children aged 2-6 years who had been diagnosed with asthma with acute exacerbation were enrolled and followed-up until the end of the study. Correlations between the parameters of IOS, C-ACT and TRACK were assessed. The validity and reliability of TRACK were verified.

RESULTS

A total of 114 children with asthma and acute exacerbations were recruited. Their mean age was 4.1 ± 1.1 years, and 60.5% were males. After a year of treatment, the change of R5-R20 from baseline 0.64 ± 0.38 kPa/L/s to 12th month 0.48 ± 0.2 kPa/L/s (p = 0.022). TRACK and C-ACT scores were significantly correlated during the observation period. R5-R20 in IOS at baseline and at the 12th month of follow-up as well as the change in IOS parameters were significantly associated with C-ACT (p = 0.003, 0.015, and 0.001, respectively). R5% and R5-R20 changes in IOS were associated with TRACK (p = 0.04 and 0.025, respectively). Sensitivity and specificity of TRACK were 80.8% (67.5-90.4) and 100% (94.1-100), respectively, with cut-off points >95 and AUC 93.8%.

CONCLUSION

TRACK score appears to have a stronger association with the IOS parameter than C-ACT score. Our findings indicate that TRACK is a valid tool for assessing asthma control in preschool children.

Trend of Bronchial Hyperresponsiveness to Methacholine as a Cost Predictor of Mild-to-Moderate Asthma: A Twelve-Month Survey in Teenagers

Bronchial asthma is characterized by variable airflow obstruction, airway inflammation, and bronchial hyperresponsiveness (BHR) to non-specific stimuli. The role of underlying airway inflammation and of related long-lasting BHR has been suboptimally investigated in teenagers with mild-to-moderate asthma, as has the corresponding economic impact over time. The aim of the present study was to calculate the cost of mild-to-moderate atopic asthma in teenagers arising from their degree of persisting BHR over a twelve-month period.

METHODS

Patients aged 12-18 years with mild-to-moderate symptoms treated with fluticasone fumarate/vilanterol 92/22 mcg daily were retrospectively followed for 12 months. Usual spirometric parameters, BHR to methacholine (MCh), and resource consumption (visits, hospitalizations, systemic steroids and/or antibiotics courses, school days off) were assessed at recruitment (the index date) and after 6 and 12 months. Adherence to treatment was also calculated. The cost of asthma was calculated based on Italian tariffs and published papers. The trend over time in BHR and the association between response to MCh and total cost were investigated by using regression models adjusted for repeated measures.

RESULTS

106 teenagers (53 males, age 15.9 ± 1.6 years) were investigated. The annual cost of asthma proved significantly related to the BHR trend: every increment of a factor 10 in the response to MCh was associated with a saving of EUR 184.90 (95% CI -305.89 to -63.90). BHR was progressively optimized after 6 and 12 months in relation to the patients' compliance to treatment (≥70% of prescribed inhalation doses).

CONCLUSIONS

the usual spirometric parameters are largely insufficient to reflect the effects of underlying persistent inflammation in milder forms of asthma in teenagers. In terms of clinical governance, the periodic assessment of non-specific BHR is the appropriate procedure from this point of view. Non-specific BHR proves a reliable procedure for predicting and monitoring the economic impact of mild-to-moderate asthma in teenagers over time.

Fetal growth rather than prematurity determines lung function in children with asthma

BACKGROUND AND OBJECTIVE

Preterm birth or fetal growth has been associated with reduced lung function and asthma during childhood in the general population. We aimed to elucidate whether prematurity or fetal growth has a significant influence on lung function or symptoms in children with stable asthma.

METHODS

We included children with stable asthma who participated in the Korean childhood Asthma Study cohort. Asthma symptoms were determined by asthma control test (ACT). Percent predicted values of pre- and post-bronchodilator (BD) lung function including forced expiratory volume in 1 second (FEV1 ), forced vital capacity (FVC), and forced expiratory flow at 25%-75% of FVC (FEF25%-75% ) were measured. Lung function and symptoms were compared according to the history of preterm birth and birth weight (BW) for gestational age (GA).

RESULTS

The study population consisted of 566 children (age range: 5-18 years). There were no significant differences in lung function and ACT between preterm and term subjects. We observed no significant difference in ACT but significant differences were observed in pre- and post-BD FEV1 , pre- and post-BD FVC, and post-BD FEF25%-75% according to BW for GA in total subjects. Two-way ANOVA revealed that BW for GA rather than prematurity was a significant determining factor for pre- and post-BD lung function. After regression analysis, BW for GA was still a significant determining factor of pre- and post-BD FEV1 and pre- and post-BD FEF25%-75% .

CONCLUSION

Fetal growth rather than prematurity appears to have a significant effect on lung function in children with stable asthma.

Evaluating inhaler education interventions for hospitalized children with asthma: A randomized controlled trial

BACKGROUND

Most children with asthma have poor inhaler technique, with detrimental morbidity effects. Guidelines recommend clinicians provide inhaler education at every opportunity, yet resources are limited. A low-cost, technology-based intervention-Virtual Teach-to-Goal (V-TTG)-was developed to deliver tailored inhaler technique education with high fidelity.

OBJECTIVE

To evaluate whether V-TTG leads to less inhaler misuse among children with asthma who are hospitalized vs brief intervention (BI, reading steps aloud).

METHODS

A single-center randomized controlled trial of V-TTG vs BI was conducted with 5-to-10-year-old children with asthma hospitalized between January 2019 and February 2020. Inhaler technique was assessed pre- and post-education using 12-step validated checklists (misuse: < 10 steps correct).

RESULTS

Among 70 children enrolled, mean age was 7.8 years (SD = 1.6). Most (86%) were Black. Most had an emergency department visit (94%) or hospitalization (90%) in the previous year. At baseline, nearly all children misused inhalers (96%). The proportion of children with inhaler misuse decreased significantly in V-TTG (100%→74%, P = .002) and BI (92%→69%, P = .04) groups, with no difference between groups at both time points (P = .2 and .9). On average, children performed 1.5 more steps correctly (SD = 2.0), with greater improvement with V-TTG (mean [SD] = 1.7 [1.6]) vs BI (mean [SD] = 1.4 [2.3]), though not significant (P = .6). Concerning pre and post technique, older children were significantly more likely than younger children to show more correct steps (mean change = 1.9 vs 1.1, P = .002).

CONCLUSION

A technology-based intervention for tailored inhaler education led to improved technique among children, similarly to reading steps aloud. Older children saw greater benefits. Future studies should evaluate the V-TTG intervention across diverse populations and disease severities to identify the greatest impact.

CLINICAL TRIAL REGISTRATION

NCT04373499.

Validity of the Childhood Asthma Control Test in diverse populations: A systematic review

PURPOSE

We examined the validity of the Childhood Asthma Control Test (C-ACT) and identified recommended thresholds for uncontrolled asthma in children from varying backgrounds.

METHODS

A systematic literature review was performed utilizing PubMed, Ovid Medline, SCOPUS, CINAHL, and conference proceedings. Studies were included if they enrolled children, had a primary outcome of asthma control, examined test validity or psychometrics, and utilized the C-ACT. Along with study design and demographic data, we extracted all outcomes and comparisons used to validate the C-ACT. We evaluated risk of bias using the COSMIN Risk of Bias tool. Our protocol was registered with PROSPERO (CRD42020211119).

RESULTS

Of 4924 records screened, 28 studies were included. Studies were conducted internationally and published between 2007 and 2018. Average number of enrolled participants was 193 (SD = 155, range = 22-671). Ten studies calculated Cronbach's α (mean [SD] = 0.78(0.05), range = 0.677-0.83). Thirteen studies recommended cut-offs for uncontrolled asthma (≤18-≤24). Nine studies found significant agreement or correlation between C-ACT and Global Initiative for Asthma guidelines/physician assessment of asthma control (correlation coefficients range = 0.219-0.65). Correlation coefficients between C-ACT and spirometry were <0.6 in five of six studies that included spirometry. Kappa values for C-ACT and various spirometry measurements ranged 0.00-0.34.

CONCLUSIONS

The C-ACT showed good internal consistency and mixed levels of agreement and correlation with various clinical asthma measures. Recommended cut-offs for asthma control varied and had no consistent relationship with nationality, race, ethnicity, or language. Few studies examined cross-cultural validity and multiple populations remain under-studied.

Update on Long-Acting Anticholinergics in Children and Adolescents With Difficult and Severe Asthma

Tiotropium bromide is the only long-acting muscarinic antagonist (LAMA) approved for treatment of patients aged ≥6 years old who have symptoms of uncontrolled asthma. Results from several clinical trials have found that once-daily inhaled tiotropium bromide is safe and efficacious in 6- to 17-year-olds with symptomatic asthma despite treatment with inhaled corticosteroids, with or without other medications. There are still few available studies investigating the impact of tiotropium bromide treatment in preschool children with suboptimal control. In this narrative review, we summarize the pharmacological effects of the LAMA tiotropium bromide, provide an overview about current asthma studies at different pediatric ages, and describe future research needs.

Association of Urinary Bisphenols Concentration with Asthma in Korean Adolescents: Data from the Third Korean National Environmental Health Survey

The effects of bisphenol A (BPA) on asthma have been reported in various in vitro, animal, and human epidemiologic studies. However, epidemiological studies on the effects of bisphenol S (BPS) and bisphenol F (BPF), which are substitutes of BPA, on asthma are lacking. The purpose of this study was to identify the association between BPA, BPS, and BPF and asthma. An asthma-related questionnaire; urinary BPA, BPS, BPF; and the possible confounders were analyzed among 922 adolescents aged 12–17 years who participated in the Korean National Environmental Health Survey 2016. In males, urinary BPA, BPS, and BPF did not show a significant relationship with the lifetime prevalence of asthma. In females, urinary BPS was higher in the asthma group (p < 0.01). High urinary BPS showed a significant relationship with a high odds ratio (OR) of lifetime asthma prevalence in the model adjusted for possible confounders (p < 0.05). High urinary BPS was particularly associated with an increase in the OR of asthma diagnosed after the age of 60 months (p < 0.01). Urinary BPS was significantly associated with asthma diagnosis, especially after the age of 60 months, among Korean adolescent females.

Asthma control is not associated with physical activity level in children with asthma during regular follow-up

OBJECTIVE

Engagement in physical activity (PA) is one of the important aims of long-term asthma treatment. The objective of this study is to evaluate whether improvement of asthma control is associated with enhanced PA during regular follow-up in children with asthma.

METHODS

Children, 6-18 years, with asthma were eligible for inclusion when their asthma was uncontrolled at a regular follow-up visit. Participants completed a seven-day recall questionnaire to assess engagement in different physical activities (Physical Activity Questionnaires for Children) at baseline and at the time asthma control was achieved according to predefined criteria. They were also instructed to wear an accelerometer (Actigraph^TM GT1M) for seven consecutive days at these timepoints.

RESULTS

Thirty children (21 boys), aged 10.5 (2.9) years, with uncontrolled asthma were included. After a median (IQR) follow up time of 163 (94-253) days PA was assessed again. Accelerometer obtained moderate vigorous PA (median (IQR) 56 (43-66) versus 53 (35-63) minutes) as well as self-reported PA (median (IQR) PAQ score 7.4 (5.9-10.1) versus 7.2 (6.5-11.0)) were not significantly different at the time of uncontrolled and controlled asthma. Moderate vigorous PA increased in 46.2%, was comparable in 23.1%, and decreased in 30.7% of patients, respectively. Self-reported PA increased in 19.0%, was comparable in 52.4%, and decreased in 28.6% of patients, respectively.

CONCLUSIONS

Based on the results of this study we conclude that asthma control is not associated with self-reported and accelerometer obtained level of physical activity during regular follow-up in children with asthma.

Risk, Mechanisms and Implications of Asthma-Associated Infectious and Inflammatory Multimorbidities (AIMs) among Individuals With Asthma: a Systematic Review and a Case Study

Our prior work and the work of others have demonstrated that asthma increases the risk of a broad range of both respiratory (e.g., pneumonia and pertussis) and non-respiratory (e.g., zoster and appendicitis) infectious diseases as well as inflammatory diseases (e.g., celiac disease and myocardial infarction [MI]), suggesting the systemic disease nature of asthma and its impact beyond the airways. We call these conditions asthma-associated infectious and inflammatory multimorbidities (AIMs). At present, little is known about why some people with asthma are at high-risk of AIMs, and others are not, to the extent to which controlling asthma reduces the risk of AIMs and which specific therapies mitigate the risk of AIMs. These questions represent a significant knowledge gap in asthma research and unmet needs in asthma care, because there are no guidelines addressing the identification and management of AIMs. This is a systematic review on the association of asthma with the risk of AIMs and a case study to highlight that 1) AIMs are relatively under-recognized conditions, but pose major health threats to people with asthma; 2) AIMs provide insights into immunological and clinical features of asthma as a systemic inflammatory disease beyond a solely chronic airway disease; and 3) it is time to recognize AIMs as a distinctive asthma phenotype in order to advance asthma research and improve asthma care. An improved understanding of AIMs and their underlying mechanisms will bring valuable and new perspectives improving the practice, research, and public health related to asthma.

Determining the Best Tool Comparable with Global Initiative for Asthma Criteria for Assessing Pediatric Asthma Control

Background: Guidelines such as Global Initiative for Asthma (GINA) recommend disease control as the mainstay of asthma management. Objective: To investigate which measure of asthma control best correlates with the GINA criteria for determining asthma control in children. Methods: Child asthma-patients at a tertiary hospital were enrolled in the study after evaluation of response to treatment. Asthma control test (ACT)/pediatric asthma control test (PACT), Pediatric Asthma Quality of Life Questionnaire (PAQLQ), fractional exhaled nitric oxide (FeNO), and lung function parameters were evaluated. Patients were examined by asthma specialists and control status was evaluated based on GINA. Results: The median age (interquartile range) of patients was 10.7 (8.4-12.9) years, 57.9% of patients were boys. Of 228 children, 84.2%, 9.6%, and 6.1% displayed "well-controlled", "partially controlled", and "uncontrolled" asthma, respectively, according to GINA. The patients with "partially controlled" and "uncontrolled" asthma were grouped as "not well-controlled." The cutoff levels were 22, 21, and 5.9 for PACT, ACT, and PAQLQ, respectively, for determining "well-controlled" asthma (P < 0.001). With these cutoff values, ACT exhibited higher comparability with GINA than PACT and PAQLQ (κ = 0.473, 0.221, and 0.150, respectively, P < 0.001). PAQLQ had higher agreement with GINA criteria in children ≥12 years old (κ = 0.326, P < 0.001 and κ = 0.151, P = 0.014, respectively). Correctly classified patients with PACT, ACT, and PALQLQ based on GINA with these cutoff levels were 93 (64.1%), 63 (75.9%), and 139 (62.9%), respectively. FeNO and lung function parameters were unsuccessful at revealing control status according to GINA. Conclusion: ACT is better than PACT for comparability with GINA. Better correlation of PAQLQ and ACT and better comparability of PAQLQ and GINA were evident in older children.

Efficacy of vitamin D supplementation in asthmatic children with vitamin D deficiency: A randomized controlled trial (ESDAC trial)

BACKGROUND

Vitamin D supplementations for asthma control had shown inconsistent results. We aimed to study efficacy and safety of vitamin D supplementation in asthmatic children who were vitamin D deficient.

METHODS

This double-blind, randomized controlled trial enrolled asthmatic children of 4-12 years of age who had 25-hydroxyvitamin D [25(OH)D] levels <20 ng/mL. The participants were randomized to receive either vitamin D orally 1000 IU/d for 9 months or similar-looking placebo. The primary outcomes were the proportion of children having the Childhood Asthma Control Test (CACT) score of ≥20 at the end of the treatment and adverse effects.

RESULTS

The trial included 250 children (125 in each group) with a mean age of 8.1 ± 2.3 years and 180 boys. The baseline parameters were similar between the groups, including CACT score (21.7 ± 4.2 vs 21.9 ± 3.6, vitamin D vs placebo). At the end of the study, the proportion of asthmatic children who had CACT score ≥ 20 was similar between vitamin D and placebo group (93.6% vs 92.0%, P = .625). The number of exacerbations of asthma and side effect profile was also identical between the groups. 25(OH)D levels increased significantly in the vitamin D group (18.06 ± 7.11 vs 12.03 ± 5.98 ng/mL, P < .001). The results did not change when we did subgroup analysis for children with baseline CACT score < 20 and 25(OH)D levels at the end of the study ≥20 ng/mL.

CONCLUSION

Vitamin D supplementation in asthmatic children with vitamin D deficiency did not improve control of asthma.

[Correlation between bronchial dilation test and asthma control level in children with asthma]

OBJECTIVE

To study the correlation between the bronchial dilation test (BDT) and asthma control level in children with asthma.

METHODS

A total of 153 children with asthma, aged 5-14 years, who attended the outpatient service from March 2016 to March 2018 were enrolled. According to the presence or absence of atopic constitution, they were divided into an allergic group with 79 children and a non-allergic group with 74 children. The correlation between BDT and Childhood Asthma Control Test (C-ACT) scores was analyzed for both groups.

RESULTS

All basic pulmonary function parameters were positively correlated with C-ACT scores in the non-allergic group (P < 0.05). Except the forced vital capacity, peak expiratory flow and maximal expiratory flow at 25% vital capacity in percent predicted values, the other pulmonary function parameters were positively correlated with C-ACT scores in the allergic group (P < 0.05). The improvement rates of all BDT parameters (except maximal expiratory flow at 25% vital capacity in the allergic group and maximal expiratory flow at 50% vital capacity in the non-allergic group) were negatively correlated with C-ACT scores in the two groups (P < 0.05).

CONCLUSIONS

The improvement rate of BDT is well correlated with C-ACT scores in children with asthma, suggesting that BDT can be used as an index for predicting asthma control level.

Heterogeneity of Childhood Asthma in Korea: Cluster Analysis of the Korean Childhood Asthma Study Cohort

PURPOSE

Asthma is a heterogeneous airway disease occurring in children, and it has various clinical phenotypes. A clear differentiation of the clinical phenotypes can provide better asthma management and prediction of asthma prognosis. Little is currently known about asthma phenotypes in Korean children. This study was designed to identify asthma phenotypes in school-aged Korean children.

METHODS

This study enrolled 674 children with physician-diagnosed asthma from the Korean childhood Asthma Study (KAS) cohort. The physicians verified the relevant histories of asthma and comorbid diseases, as well as airway lability and hyper-responsiveness from the results of pulmonary function tests and bronchial provocation tests. Questionnaires regarding the participants' baseline characteristics, their environment and self-rating of asthma control were collected at the time of enrollment. Laboratory tests were performed to assess allergy and airway inflammation. Children with asthma were classified by hierarchical cluster analysis.

RESULTS

Of the 674 patients enrolled from the KAS cohort, 447 were included in the cluster analysis. Cluster analysis of these 447 children revealed 4 asthma phenotypes: cluster 1 (n = 216, 48.3%) which was characterized by male-dominant atopic asthma; cluster 2 (n = 79, 17.7%) which was characterized by early-onset atopic asthma with atopic dermatitis; cluster 3 (n = 47, 10.5%) which was characterized by puberty-onset, female-dominant atopic asthma with the low lung function; and cluster 4 (n = 105, 23.5%) which was characterized by early-onset, non-atopic dominant asthma.

CONCLUSIONS

The asthma phenotypes among Korean children can be classified into 4 distinct clusters. Long-term follow-up with these phenotypes will be needed to define their prognosis and response to treatment.

Pragmatic Markers in the Management of Asthma: A Real-World-Based Approach

Bronchial hyperreactivity, reversible airflow limitation and chronic airway inflammation characterize asthma pathophysiology. Personalized medicine, i.e., a tailored management approach, is appropriate for asthma management and is based on the identification of peculiar phenotypes and endotypes. Biomarkers are necessary for defining phenotypes and endotypes. Several biomarkers have been described in asthma, but most of them are experimental and/or not commonly available. The current paper will, therefore, present pragmatic biomarkers useful for asthma management that are available in daily clinical practice. In this regard, eosinophil assessment and serum allergen-specific IgE assay are the most reliable biomarkers. Lung function, mainly concerning forced expiratory flow at 25-755 of vital capacity (FEF_25-75), and nasal cytology may be envisaged as ancillary biomarkers in asthma management. In conclusion, biomarkers have clinical relevance in asthma concerning both the endotype definition and the personalization of the therapy.

Comparability of asthma control test scores between self and physician-administered test

BACKGROUND

The Asthma Control Test (ACT) is a tool that allows physicians to estimate the control of asthma symptoms on each patient in a quick way.

METHODS

We conducted a prospective single-center observational study enrolling 97 patients with asthma, selected from the Outpatient Respiratory Service of "Policlinico-Vittorio Emanuele" in Catania. Patients answered the ACT in full autonomy. Subsequently, the physician, blinded to the previous ACT evaluation, administered a new ACT and then assessed patients' medical condition during his/her visit. A second physician evaluated patients' level of symptom control according to GINA guidelines. Agreement in ACT score was analyzed using the Kendall coefficient of concordance (W) for ACT individual items and overall score. The impact of different education levels on the ACT was analyzed with the Mann-Whitney test.

MAIN FINDINGS

There was no significant difference in ACT total score obtained by either administration mode (p > 0.05). Responses to ACT single items showed a statistically significant difference between patients with lower and higher education levels in ACT items n°3 and 5, (p < 0.05), with lower education levels influencing patients symptom perception and disease control. Moreover, a significant difference in the evaluation of asthma control was found between ACT and GINA assessment of symptom control (p < 0.05).

[The management of asthma as a chronic inflammatory disease and global health problem: A position paper from the scientific societies]

Asthma is the most prevalent respiratory disease worldwide and it can affect people of all ages and is potentially fatal. Today, maintenance treatments are available that are effective in most patients, yet a significant proportion have poorly controlled disease, despite the resources on offer. This document, endorsed by members of the Spanish medical societies involved in the treatment of asthma, is intended to draw the attention of society and professionals to this problem in Spain. It focuses on the clinical, diagnostic and therapeutic aspects of asthma, and proposes some actions for improvement as regards patients and healthcare professionals which, in view of the current results arising from inadequate asthma control, might be beneficial to improve outcomes for both patients and public health.

The sensitivity and specificity of the forced oscillation technique in the diagnosis of bronchoconstriction in children

OBJECTIVE

The forced oscillation technique (FOT) is a useful diagnostic respiratory system for children. However, the final value of the FOT in the diagnosis of bronchoconstriction is still open. The aim of the study was to evaluate the sensitivity and specificity of the FOT vs. body plethysmography tests in the measure of bronchoconstriction in asthmatic children.

MATERIALS AND METHODS

A total of 102 children aged 2 to 6 years diagnosed with early-onset asthma and 52 healthy controls were included in this prospective, randomized study. All asthmatic patients and healthy controls underwent a basic FOT as one measurement, according to the recommendation of the Resmon Pro FOT. Then, the reversibility test was performed 20 min after the administration of 200 mg salbutamol using the FOT and body plethysmography in all patients.

RESULTS

The mean basic Rrs, Xrs and sRaw in asthmatic patients were, respectively, 11.13 ± 1.28 kPa sL^-1, -4.6 ± 1.18 kPa sL^-1 and 1.72 ± 0.58 kPa s. Similar parameters were significantly better in the control group (p < 0.05). A total of 73 (71.6%) asthmatic patients had a positive test using the FOT according to Calogero. In 4 (7.7%) patients in the control group, a positive test was obtained. In body plethysmography, similar results were reached, with a positive test in 76 (74.5%) study patients and 5 (9.6%) control patients.

CONCLUSIONS

A bronchial reversibility test with the use of the FOT is useful for the diagnosis of bronchial asthma, especially with the use of an Rrs parameter, such as the body plethysmography test.

[The Childhood Asthma Control Test improves the therapeutic adaptations recommended for asthmatics aged 6 to 11 years in primary practice. A Randomized comparative prospective study]

OBJECTIVES

Asthma is the leading chronic disease of the child; control and treatment remain inadequate. Our objective was to assess whether the use of the Childhood Asthma Control Test (C -ACT) in primary care had an impact on adapting therapy.

METHODS

The study was quantitative prospective and compared 2 groups of general practioners. All had the same reminders about childhood asthma management. The C-ACT was detailed to one group only. Doctors in the control group had to work as usual without C-ACT. Doctors included asthmatic children aged 6 to 11 years who were consulting for their asthma or any other reason. The primary endpoint was the adaptation of asthma treatment according to the Global Initative for Asthma (GINA). Evaluations of the control group were compared with the after consultation self-administered online C-ACT.

RESULTS

From April to October 2014, 61 physicians included 179 patients in two comparable groups. Although not significant statistically, doctors using C-ACT found 45% of uncontrolled asthma (vs. 31%). When the reason for consultation was not related to asthma, the figure was 25% (vs. 15%). Doctors using the C-ACT made twice less therapeutic adaptations not recommended by the GINA: 8% vs. 16%. 25% of evaluations of doctors in the control group were discordant with the internet C-ACT. After correction with the internet C-ACT of these imprecise initial assessments, the figure was 25%: 3 times more than in the C-ACT group (P=0.014).

CONCLUSION

The use in primary care of C-ACT should allow a better assessment of asthma control and adaptation of treatment in children.

Asthma control in children: Body plethysmography in addition to spirometry

BACKGROUND

There is a lack of agreement among measures of asthma control in children. In Central Europe, body plethysmography is additionally used for asthma monitoring. However, its value is still unclear.

OBJECTIVES

We investigated the possible additional value of body plethysmographic measures (specific resistance, residual volume-total lung capacity ratio [RV/TLC]) compared with spirometric measures forced expiratory volume in 1 second (FEV ₁ ), forced vital capacity (FVC), FEV ₁ /FVC, forced expiratory flow at 25% to 75% of forced vital capacity (FEF _25-75 ), and fraction of exhaled nitric oxide (FeNO) for assessment of asthma control.

METHODS

One hundred and forty-five asthmatic children aged 5 to 17 were included. All children performed measurements of FeNO, spirometry, and body plethymography. Asthma control was assessed by the asthma control test (c-ACT/ACT) and a doctor's assessment of asthma control.

RESULTS

Investigating single lung function parameters, FEV₁ , FEV ₁ /FVC, FEF _25-75 and RV/TLC differed between controlled and partly controlled asthma. However, we found no differences between controlled and uncontrolled asthma with regard to single lung function parameters or for any parameter if investigated in a multivariable approach. This was also true if we combined obtained parameters from spirometry (comparing pathologic vs normal spirometry). Investigating the combination of body plethysmography and doctor's assessment of asthma control a significant association was found ( P = 0.02). Furthermore, combined spirometry and body plethysmography showed a significant association with both doctor's assessed asthma control ( P = 0.009) and the c-ACT/ACT ( P = 0.04). The addition of FeNO did not improve the results.

CONCLUSIONS

The combination of body plethysmography and spirometry shows best agreement with asthma control in children compared with spirometry or body plethysmography alone. Further studies are needed to find out whether additional measurements of body plethysmography improve the outcome of children in asthma monitoring.

Socioeconomic and Environmental Risk Factors for Pediatric Asthma in an American Indian Community

BACKGROUND

American Indian (AI)/Alaska Native children have increased asthma prevalence, morbidity, and mortality compared to non-Hispanic white children. Our study sought to examine environmental and socioeconomic factors of asthma among children in an AI community.

METHODS

This case-control study included children with physician-diagnosed asthma and age-matched controls, ages 6 through 17 years, in an AI community. Diagnosis and clinical characteristics were obtained from medical record review. Home visits included interviews regarding sociodemographic and household environmental exposures, physical exams, spirometry, and asthma control questionnaires (cases only).

RESULTS

Among the 108 asthma cases and 215 controls, 64% had an annual household income of <$25,000. Children with asthma had significantly higher odds of living in a multi-unit dwelling (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.2-4.4) or in residences with rodent or insect infestation (OR, 2.1; 95% CI, 1.1-3.8) and were less likely to live in homes with more than 8 occupants (OR, 0.5; 95% CI, 0.3-0.9). Also, there was a trend for lower caregiver education level, unmarried caregiver marital status, and annual household income level of <$25,000 in univariate analysis. However, after adjustment for socioeconomic status and household environmental factors, these estimates were not significant. Nearly half of cases had poorly controlled asthma and reported persistent cough, wheeze, and dyspnea, yet only 24% reported using a controller medication.

CONCLUSIONS

In this low-income AI community, we identified several social and environmental determinants of asthma, which were mediated by socioeconomic status and other household environmental factors, suggesting a complex interplay between socioeconomic status and environmental exposures. Furthermore, many children with asthma reported poor asthma control.

Health-related quality of life in infants and children with interstitial lung disease

INTRODUCTION

Interstitial lung disease in children (chILD) is a highly heterogeneous group of rare and severe respiratory disorders. The disease by itself, the burden of the treatments (oxygen therapy, corticosteroid pulses, nutritional support) and recurrent hospitalizations may impair the quality of life (QoL) of these children. The aim of the study was to compare the health-related QoL (HR-QoL) in chILD compared to a healthy population and to find out the predictive factors of an altered QoL.

METHODS

Patients aged 1 month to 18 years with ILD of known or unknown etiology were prospectively included. Parents and children over 8 years old were asked to fill the PedsQL 4.0 Generic Core Scale ranging from 0 to 100 points.

RESULTS

A total of 78 children were recruited in 13 French pediatric centers. Total scores were 11.94 points (P = 0.0003) less for child self-report and 14.08 points ( P < 0.0001) less for parent proxy-report with respect to the healthy population. The clinical factors associated with a lower total score were: extrapulmonary expression of the disease, higher Fan severity score, long-term oxygen therapy, nutritional support, and a number of oral treatments.

CONCLUSION

Using a validated quality of life (QoL) scale, we showed that health-related-QoL is significantly impaired in chILD compared with a healthy population. Factors altering QoL score are easy to recognize and could help identify children at a heightened risk of low QoL.

Adolescent ownership of asthma health: A concept analysis

AIM

This concept analysis was developed to produce a working definition regarding ownership of health in advanced practice nursing.

BACKGROUND

Ownership of health is a new concept developed in nursing. Adolescence is a time of learning identity and needed life skills for a chronic illness. Nurses can utilize this concept for improvement of outcomes for their adolescent patients.

DESIGN/METHOD

This concept analysis is based on Walker and Avant.

DATA SOURCE AND REVIEW OF LITERATURE

As ownership of health is new in nursing, a literature search was based on elements of Donnelley's Functional Mastery of Health Ownership nursing model.

RESULTS

Attributes (responsibility, self-efficacy, mastery/control, and self-image), model/contrary case, antecedents (awareness, willingness, desire, and acceptance), consequences, and empirical referents are discussed.

CONCLUSIONS

The definition of ownership is critical to both nursing and the advanced practice nurse. Adolescents are a special population of patients; learning how to both be independent and to care for their health. By employing a framework of ownership, adolescents can be more likely to thrive versus merely survive with asthma and the impact will go beyond the patients to their families and impact health outcomes as well.

Pediatric asthma: An unmet need for more effective, focused treatments

BACKGROUND

Despite remarkable advances in our understanding of asthma, there are still several unmet needs associated with the management of pediatric asthma.

METHODS

A two-day, face-to-face meeting was held in London, United Kingdom, on October 28 and 29, 2017, involving a group of international expert clinicians and scientists in asthma management to discuss the challenges and unmet needs that remain to be addressed in pediatric asthma.

RESULTS

These unmet needs include a lack of clinical efficacy and safety evidence, and limited availability of non-steroid-based alternative therapies in patients <6 years of age. An increased focus on children is needed in the context of clinical practice guidelines for asthma; current pediatric practice relies mostly on extrapolations from adult recommendations. Furthermore, no uniform definition of pediatric asthma exists, which hampers timely and robust diagnosis of the condition in affected patients.

CONCLUSIONS

There is a need for a uniform definition of pediatric asthma, clearly distinguishable from adult asthma. Furthermore, guidelines which provide specific treatment recommendations for the management of pediatric asthma are also needed. Clinical trials and real-world evidence studies assessing anti-immunoglobulin E (IgE) therapies and other monoclonal antibodies in children <6 years of age with asthma may provide further information regarding the most appropriate treatment options in these vulnerable patients. Early intervention with anti-IgE and non-steroid-based alternative therapies may delay disease progression, leading to improved clinical outcomes.

Implementation of the Asthma Control Test in Primary Care to Improve Patient Outcomes

BACKGROUND

Asthma is one of the major chronic diseases in the pediatric population, affecting 9.5% of children. The National Heart, Lung, and Blood Institute recommends the use of the Asthma Control Test (ACT) for periodic assessment of asthma control. The purpose of this evidence-based project was to implement the Asthma Control Test screening tool into the primary care practice to improve management of patients with asthma by more accurately addressing asthma control.

METHODS

The project was a pre- and post-implementation study comparing two different groups of patients with asthma seen at the clinic over 5-week periods.

RESULTS

After the implementation of the educational program and project, 82.6% of advanced practice registered nurses and 30.7% of pediatric resident physicians used an Asthma Control Test, resulting in identification of 9 (21%) patients who were considered not well-controlled. All (100%) of those children identified as not well-controlled through the Asthma Control Test received an adjustment in their medication therapy.

CONCLUSIONS

The Childhood ACT and ACT are simple, self-administered, validated questionnaires that can easily be incorporated into a primary care practice to assess the level of asthma control and to identify patients with asthma that is not well controlled.

Cross-sectional study assessing the performance of the Arabic translated childhood asthma control test

The standard Arabic version of the Childhood Asthma Control Test (C-ACT) has never been previously evaluated in Arab countries. We studied its correlation in Arabic speaking children in the United Arab Emirates (UAE), with both the GINA assessment of asthma control and the resulting changes in asthma management. The Arabic C-ACT was completed by the children or by their parents when needed. A GINA based level of asthma control score was assigned by their managing physician. The correlation between the different cut- scores of the C-ACT and GINA were studied. A total of 105 eligible children with asthma (aged between 4 and 11.8 years, 61% boys) were enrolled. The Arabic translated C-ACT had a high reliability (Cronbach alpha 81%) and validity (as it correlated well with the GINA level of control). We found that using it with the traditional cut-score of 19 overestimated the degree of asthma control. Instead, a calculated optimal cut-score of 20 estimated more accurately the level of asthma control as assessed both by the GINA assessment and also by changes in asthma management. The current Arabic version of the C-ACT has a good reliability and validity. By using a single optimal cut-point of 20, it can be used to assess both the level of asthma control and of treatment control. It does not, however, accurately define asthma control when using the originally proposed cut-score of 19. Physicians need to recognise that the C-ACT cut-points may vary in different populations. We suggest that cut-scores of translated versions need to be modified in different geographical settings.

The cut-off score suggestive of poor disease management in the Childhood Asthma Control Test (C-ACT) may need to be changed for different geographical populations. Majid AlTeneiji at Tawam Hospital in Al-Ain, and co-workers across the United Arab Emirates compared the performance of the Arabic version of the C-ACT with the global asthma control test, GINA, in verifying levels of asthma and treatment control. The researchers enrolled 105 children aged 4 to 11 who completed both tests. The Arabic C-ACT performed with high reliability and validity, but the team found that the original English cut-point score of 19, indicating poor disease management, should be raised to 20 in their Arabic population to improve test accuracy. AlTeneiji’s team suggest that the C-ACT test points system may need to be revised for different geographical settings around the world.

Prospective observational cohort study of symptom control prediction in paediatric asthma by using the Royal College of Physicians three questions

The Royal College of Physicians three questions (RCP3Q) is widely used for assessing asthma control within primary care in the UK, despite limited evidence in children. This study compared the RCP3Q as a tool for assessing asthma control in children (5–16 years) against the validated Asthma Control Test (ACT), Childhood Asthma Control Test (C-ACT), and Mini-Paediatric Quality of Life Questionnaire (MiniPAQLQ). We conducted a prospective observational cohort study involving children from eight primary care practices in Leicestershire. Children with doctor diagnosed asthma, or receiving regular asthma medication, were invited to participate. A total of 319 participants completed the MiniPAQLQ and the C-ACT/ACT questionnaires, before RCP3Q responses were collected as part of their routine asthma review conducted immediately afterwards. RCP3Q sensitivity for detecting uncontrolled asthma ranged from 43–60% and specificity from 80–82%. Using an RCP3Q score ≥2 to predict uncontrolled asthma and an RCP3Q score of zero to predict well-controlled asthma resulted in 10% of participants misclassified as uncontrolled and 8% as well-controlled, respectively. Using an RCP3Q threshold score of ≥1 resulted in 25% of participants being misclassified as uncontrolled. Our data suggests limited utility of the RCP3Q to assess asthma control in children. Alternative indicators of asthma control, such as the validated Asthma Control Test and the Children’s Asthma Control Test should be considered instead.

Validated asthma control tests should be used to assess children rather than the ‘three questions’ survey recently developed by the Royal College of Physicians. The UK-based organisation developed the RCP3Q as a practical, rapid way of assessing asthma control in primary care. However, the RCP3Q was never comprehensively trialed for use with children. Erol Gaillard and co-workers at the University of Leicester compared the RCP3Q with three validated tests and questionnaires to determine its efficacy in assessing patients aged 5 to 16. 319 child patients completed the validated tests and their RCP3Q responses were collected immediately afterwards on the same day. In comparison with validated tests, the RCP3Q varied in its accuracy depending on the threshold scores selected. A threshold score of 1 resulted in 25 per cent of participants being misclassified with uncontrolled asthma.

The Usefulness of the Forced Oscillation Technique in the Diagnosis of Bronchial Asthma in Children

The forced oscillation technique (FOT) requires minimal patient cooperation and is useful for children. However, comprehensive values of respiratory impedance at baseline and after the reversibility test have not been definitively confirmed. The aim of this study was to evaluate the basic parameters of FOT reactance (Xrs) and resistance (Rrs) in groups of healthy children and children with controlled and uncontrolled asthma. The second aim was the assessment of the reversibility bronchial test using the forced oscillation method in children with bronchial asthma. Materials and Methods. One hundred and six children aged from 2 to 6 years diagnosed with early-onset controlled or uncontrolled asthma and healthy controls were included in this single-center, prospective, randomized study. All asthmatic patients and healthy controls underwent basic FOT as one measurement according to the recommendation of Resmon Pro FOT. The reversibility test was then performed 15 min after the administration of 200 mcg salbutamol by MDI in all patients. Results. Basic Rrs showed significantly higher mean values in patients with uncontrolled asthma compared to patients with controlled asthma, which were in turn higher than the values for patients in the control group (11.14 ± 1.29 versus 15.71 ± 2.6 versus 9.21 ± 0.98, resp.; p < 0.05). The data analysis showed similar relationships in terms of the Xrs between the studied groups (−4.76 ± 1.19 versus −7.31 ± 2.33 versus −2.11 ± 0.48, resp.; p < 0.05). According to the changes in the Rrs values, 35 (66%) positive bronchial reversibility tests were obtained in 53 subjects with controlled asthma and in 39 (74%) subjects with uncontrolled asthma. Conclusions. Rrs and Xrs obtained by FOT well-discriminate patients with asthma from healthy children. A bronchial reversibility test involving the use of FOT is valuable for the diagnosis of bronchial asthma.

Evaluation of Asthma Control in Children Using Childhood- Asthma Control Test (C-ACT) and Asthma Therapy Assessment Questionnaire (ATAQ)

OBJECTIVE

To evaluate the efficacy of Childhood-asthma control test (C-ACT) and the Asthma therapy assessment questionnaire by (ATAQ) checking its consistency with Global Initiative for Asthma (GINA) criteria.

METHODS

Asthma control of 97 children was assessed using C-ACT, ATAQ and GINA criteria separately, and their results were compared.

RESULTS

C-ACT had better performance for evaluating control as per GINA criteria with sensitivity of 48.3%, specificity of 68.9%, and area under the receiver operative curve (ROC) of 0.647. The above parameters for ATAQ were: 93.1%, 17.2% and 0.552, respectively. A cut-off score of 20 for C-ACT is more suitable as it has maximum ROC area (0.667), and higher kappa score (0.315); P= 0.001.

Conclusion

C-ACT can be validity used to monitor asthma control. However, the cut-off score 20 is more accurate for the Indian population. The performance of ATAQ in evaluating asthma control is not satisfactory.

Introduction of a new paediatric asthma guideline: Effects on asthma control levels

BACKGROUND

In 2008, a new national paediatric asthma management guideline based on the international Global Initiative for Asthma (GINA) guideline was launched in the Netherlands. We studied whether asthma control and treatment regimens improved after introduction of the guideline by comparing survey data before and after the guideline introduction.

METHODS

Two comparable groups of children (6-16 years) with asthma were included before (2004) and after (2013) the introduction of the guideline. Children, parents and paediatricians completed questionnaires about asthma symptoms, medication and healthcare use. Spirometry was performed.

RESULTS

Data of 209 patients were analysed. Level of asthma control did not improve between 2004 and 2013 with a proportion of (partly) controlled asthmatics of 51% in 2004 and 59% in 2013 (p = 0.28). In 2013, paediatricians characterized 76% of children as (partly) controlled, while 59% of children was (partly) controlled according to GINA criteria (p < 0.05). Step-down treatment in controlled patients was more applied by paediatricians in 2013 compared to 2004 (from 8 to 40%, p < 0.05). Step-up treatment in uncontrolled patients did not improve.

CONCLUSIONS

Asthma control did not improve after the introduction of the new guideline. Compared to 2004, an improvement was observed in step-down treatment in patients with controlled disease.

Factors associated with asthma control in children: findings from a national Web-based survey

BACKGROUND

Although achieving and maintaining control of asthma is considered to be the goal of asthma treatment, determinants of asthma control are not fully understood. Our aim was to assess factors associated with asthma control among paediatric patients in the general population.

METHODS

In June 2012, a Web-based survey was conducted to identify Japanese children aged 6 to 11 yr who currently have asthma and evaluate control of their disease using the Childhood Asthma Control Test (C-ACT). Associations were evaluated among uncontrolled asthma (C-ACT score <20) between environmental factors, demographics and comorbid allergic diseases.

RESULTS

Among the 3066 children with current asthma, 447 (14.6%) had uncontrolled asthma. Multivariable analysis identified factors such as low birthweight (adjusted OR 1.65, 95% CI 1.25-2.18), obesity (adjusted OR 1.44, 95% CI 1.05-1.99) and pet ownership before birth (adjusted OR 1.68, 95% CI 1.24-2.29) to be associated with uncontrolled disease. Comorbid allergic diseases, especially rhinitis were a significant risk of uncontrolled asthma (adjusted OR for severe rhinitis: 3.88, 95% CI 2.50-6.00). The severity of rhinitis symptoms was inversely correlated with the C-ACT score (p < 0.001).

CONCLUSIONS

A population-based Web survey showed an association between several factors and the control of paediatric asthma. The assessment of these factors may help identify the children at risk with uncontrolled asthma.