Childhood Asthma Control Test and airway inflammation evaluation in asthmatic children

Application of exhaled nitric oxide (FeNO) in pediatric asthma

PURPOSE OF REVIEW

Fractional concentration of Nitric Oxide in the exhaled air (FeNO) is a moderately good biomarker of type-2 airway inflammation, and its measurement is feasible also in children. The available evidence is still not enough to support the routine use of FeNO to diagnose or manage asthma in every patient in clinical practice. However, its role in identifying asthma with eosinophilic inflammation is of particular interest in the management of severe asthma.

RECENT FINDINGS

In healthy subjects, FeNO levels increase with age and height, particularly in males, and are also influenced by ethnicity. FeNO measurement can support asthma diagnosis and help in predicting asthma development later in life in young children with recurrent wheezing. FeNO-guided asthma management is effective in reducing asthma exacerbations but may result in a higher daily dose of inhaled corticosteroids. FeNO can also be used as a marker to evaluate adherence to asthma treatment and predict response to different biologicals, especially Omalizumab and Dupilumab.

SUMMARY

This review outlines recent data on the application of FeNO in childhood-onset asthma diagnosis and management, as well as in phenotyping subjects with severe asthma who may benefit from monoclonal antibodies administration.

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.

Fractional Exhaled Nitric Oxide (FENO) in the management of asthma: a position paper of the Italian Respiratory Society (SIP/IRS) and Italian Society of Allergy, Asthma and Clinical Immunology (SIAAIC)

Asthma prevalence in Italy is on the rise and is estimated to be over 6% of the general population. The diagnosis of asthma can be challenging and elusive, especially in children and the last two decades has brought evidences that asthma is not a single disease but consists of various phenotypes. Symptoms can be underestimated by the patient or underreported to the clinician and physical signs can be scanty. Usual objective measures, like spirometry, are necessary but sometimes not significant. Despite proper treatment, asthma can be a very severe condition (even leading to death), however new drugs have recently become available which can be very effective in its control. Since asthma is currently thought to be caused by inflammation, a direct measure of the latter can be of paramount importance. For this purpose, the measurement of Fractional Exhaled Nitric Oxide (FE_NO) has been used since the early years of the current century as a non-invasive, easy-to-assess tool useful for diagnosing and managing asthma. This SIP-IRS/SIAAIC Position Paper is a narrative review which summarizes the evidence behind the usefulness of FE_NO in the diagnosis, management and phenotypization of asthma.

Reducing Asthma Attacks in Children using Exhaled Nitric Oxide as a biomarker to inform treatment strategy: a randomised trial (RAACENO)

Background

Childhood asthma is a common condition. Currently there is no validated objective test which can be used to guide asthma treatment in children. This study tests the hypothesis that the addition of fractional exhaled nitric oxide (F_ENO) monitoring in addition to standard care reduces the number of exacerbations (or attacks) in children with asthma.

Methods

This is a multi-centre, randomised controlled study. Children will be included of age 6–16 years who have a diagnosis of asthma, currently use inhaled corticosteroids (ICSs) and have had an exacerbation in the previous 12 months. Exclusion criteria include being unable to provide F_ENO measurement at baseline assessment, having another chronic respiratory condition and being currently treated with maintenance oral steroids. Participants will be recruited in both primary and secondary care settings and will be randomised to either receive asthma treatment guided by F_ENO plus symptoms (F_ENO group) or asthma treatment guided by symptoms only (standard care group). Within the F_ENO group, different treatment decisions will be made dependent on changes in F_ENO. Participants will attend assessments 3, 6, 9 and 12 months post randomisation. The primary outcome is asthma exacerbation requiring prescription and/or use of an oral corticosteroid over 12 months as recorded by the participant/parent or in general practitioner records. Secondary outcomes include time to first attack, number of attacks, asthma control score and quality of life. Adherence to ICS treatment is objectively measured by an electronic logging device. Participants are invited to participate in a “phenotyping” assessment where skin prick reactivity and bronchodilator response are determined and a saliva sample is collected for DNA extraction. Qualitative interviews will be held with participants and research nurses. A health economic evaluation will take place.

Discussion

This study will evaluate whether F_ENO can provide an objective index to guide and stratify asthma treatment in children.

Trial registration

ISRCTN, ISRCTN67875351. Registered on 12 April 2017. Prospectively registered.

Phenotypes favoring fractional exhaled nitric oxide discordance vs guideline-based uncontrolled asthma

BACKGROUND

Despite potential value of identification of allergic inflammation with fractional exhaled nitric oxide (FeNO) in managing asthma, randomized clinical trials have not consistently shown better outcomes compared with guideline management alone.

OBJECTIVE

To assess the effectiveness of FeNO vs non-FeNO-based therapeutic algorithms in managing asthma, and the phenotypic profile associated with FeNO >35 ppb yet well controlled by guidelines, as a potential model to predict better FeNO-based algorithm outcomes.

METHODS

This is a randomized controlled study (RCT) in 88 high-risk children with asthma 7 to 18 years of age across 352 visits over a 1-year period. Generalized estimating equations analysis assessed algorithm group differences in outcomes and characteristics associated with higher odds uncontrolled by FeNO alone in the treatment decision algorithm.

RESULTS

The FeNO treatment algorithm did not show superiority in reducing exacerbations and morbidity (P > .05). Phenotypes that more than doubled the odds FeNO alone identified uncontrolled asthma included adolescence, non-adherence, high atopy (>6+), and baseline FeNO >35 ppb, whereas obesity, FEF_25-75% < 65% predicted, and bronchodilator response >10% decreased the odds. Uncontrolled asthma by FeNO alone (F) vs guidelines alone (G) showed overall F/G > 1.0 in adolescents, but <1.0 in younger patients unless the FeNO threshold was reduced to >20 ppb.

CONCLUSION

Our study suggests that age and phenotypes play a key role in FeNO discordance compared with the conventional guideline-based uncontrolled asthma. The FeNO-based therapeutic algorithm, if confirmed further, could provide the clinician with an effective asthma management tool. The clinical implication could improve future FeNO-based RCTs and treatment decision algorithms in managing asthma by considering phenotypes and age-dependent FeNO thresholds.

Difficult vs. Severe Asthma: Definition and Limits of Asthma Control in the Pediatric Population

Evaluating the degree of disease control is pivotal when assessing a patient with asthma. Asthma control is defined as the degree to which manifestations of the disease are reduced or removed by therapy. Two domains of asthma control are identified in the guidelines: symptom control and future risk of poor asthma outcomes, including asthma attacks, accelerated decline in lung function, or treatment-related side effects. Over the past decade, the definition and the tools of asthma control have been substantially implemented so that the majority of children with asthma have their disease well controlled with standard therapies. However, a small subset of asthmatic children still requires maximal therapy to achieve or maintain symptom control and experience considerable morbidity. Childhood uncontrolled asthma is a heterogeneous group and represents a clinical and therapeutic challenge requiring a multidisciplinary systematic assessment. The identification of the factors that may contribute to the gain or loss of control in asthma is essential in differentiating children with difficult-to-treat asthma from those with severe asthma that is resistant to traditional therapies. The aim of this review is to focus on current concept of asthma control, describing monitoring tools currently used to assess asthma control in clinical practice and research, and evaluating comorbidities and modifiable and non-modifiable factors associated with uncontrolled asthma in children, with particular reference to severe asthma.

Demographic and medical factors affecting short-term changes in subjective evaluation of asthma control in adolescents

INTRODUCTION

Asthma control is an important measure of disease stabilization, which is linked to the treatment and lifestyle recommendations.

AIM

To assess the impact of selected factors on asthma control in adolescents, as assessed using the Asthma Control Test (ACT™).

MATERIAL AND METHODS

The prospective study included 100 asthma patients aged between 12 and 19. Asthma was assessed in three consecutive follow-up visits spaced 3 months apart, using the standardized ACT™ questionnaire.

RESULTS

Asthma was fully controlled (ACT score = 25 points) in more than half of the patients in all follow-up visits (53.0%, 54.0%, and 56.0%, respectively). More than one third of the participants scored between 20 and 24 points (37.0% vs. 39.0% vs. 40.0%). A minority of patients had uncontrolled asthma (scores below 20), and the group consistently diminished in subsequent visits (10% vs. 7% vs. 4%). Uncontrolled asthma was found significantly more often in female patients (33.33%; p < 0.001) and those living in rural areas (20.59%; p < 0.01). Treatment with a combination of inhaled corticosteroids (ICS) and LABAs was associated with worse asthma control (14.81%; p < 0.05). Better asthma control was found in patients with a family history of allergies (73.85% vs. 75.38% vs. 78.46%; p < 0.001) and in those with concurrent allergies (66.67% vs. 68.00% vs. 70.67%; p < 0.001).

CONCLUSIONS

Asthma control in adolescents differs by sex and residence. Concurrent allergies and family history of allergies improve asthma self-control in adolescents.

Clinical Tools to Assess Asthma Control in Children

Asthma affects an estimated 7 million children and causes significant health care and disease burden. The most recent iteration of the National Heart, Lung and Blood Institute asthma guidelines, the Expert Panel Report 3, emphasizes the assessment and monitoring of asthma control in the management of asthma. Asthma control refers to the degree to which the manifestations of asthma are minimized by therapeutic interventions and the goals of therapy are met. Although assessment of asthma severity is used to guide initiation of therapy, monitoring of asthma control helps determine whether therapy should be maintained or adjusted. The nuances of estimation of asthma control include understanding concepts of current impairment and future risk and incorporating their measurement into clinical practice. Impairment is assessed on the basis of frequency and intensity of symptoms, variations in lung function, and limitations of daily activities. "Risk" refers to the likelihood of exacerbations, progressive loss of lung function, or adverse effects from medications. Currently available ambulatory tools to measure asthma control range are subjective measures, such as patient-reported composite asthma control score instruments or objective measures of lung function, airway hyperreactivity, and biomarkers. Because asthma control exhibits short- and long-term variability, health care providers need to be vigilant regarding the fluctuations in the factors that can create discordance between subjective and objective assessment of asthma control. Familiarity with the properties, application, and relative value of these measures will enable health care providers to choose the optimal set of measures that will adhere to national standards of care and ensure delivery of high-quality care customized to their patients.

Monitoring asthma in childhood: symptoms, exacerbations and quality of life

Monitoring asthma in children in clinical practice is primarily performed by reviewing disease activity (daytime and night-time symptoms, use of reliever medication, exacerbations requiring frequent use of reliever medication and urgent visits to the healthcare professional) and the impact of the disease on children's daily activities, including sports and play, in a clinical interview. In such an interview, most task force members also discuss adherence to maintenance therapy and the patients' (and parents') views and beliefs on the goals of treatment and the amount of treatment required to achieve those goals. Composite asthma control and quality of life measures, although potentially useful in research, have limited value in clinical practice because they have a short recall window and do not cover the entire spectrum of asthma control. Telemonitoring of children with asthma cannot replace face-to-face follow-up and monitoring because there is no evidence that it is associated with improved health outcomes.

Bronchial hyperresponsiveness to mannitol, airway inflammation and Asthma Control Test in atopic asthmatic children

INTRODUCTION

The aim of this study was to evaluate the relationship between airway hyperresponsiveness (AHR) to mannitol and bronchial inflammation measured as exhaled nitric oxide (FeNO) and to assess whether asthma control correlates with AHR to mannitol and FeNO in atopic asthmatic children.

MATERIAL AND METHODS

Allergy evaluation, the mannitol challenge test, FeNO levels and the Asthma Control Test (ACT) questionnaire were assessed in 40 children with intermittent and mild persistent allergic asthma.

RESULTS

All the subjects showed positive AHR to mannitol. Pearson's correlation test revealed a significant inverse correlation between AHR (mannitol PD15) and FeNO (p = 0.020). There was also a significant positive correlation between ACT and PD15 (p = 0.020) and a significant negative correlation between ACT and FeNO levels (p = 0.003). The study population was divided into two groups according to FeNO levels (group A ≥ 16 ppb vs. group B < 16 ppb). In group A mannitol PD15 was significantly lower (p = 0.040) and ACT score values were significantly lower (p = 0.001) compared to group B. In group A, the ACT showed that 13.3% of subjects had well-controlled asthma, 80% had partially controlled asthma and 6.7% had uncontrolled asthma. In group B, the ACT showed that 72% of subjects had well-controlled asthma and 28% had partially controlled asthma.

CONCLUSIONS

Our findings indicate that the degree of AHR to mannitol correlates with the degree of airway inflammation in asthmatic atopic children; moreover, better control of asthma correlates with a lower degree of AHR to both mannitol and FeNO.

Respiratory allergies in childhood: Recent advances and future challenges

The burden of allergic airway diseases still represents a major health problem in childhood. Despite many different options are currently available for the diagnostic work-up and management, the overall disease control in terms of impact on quality of life, morbidity and mortality, is not yet satisfactory. The extreme variability of individual risk factors and severity determinants may account for it. On the other side, the knowledge of the multifaceted allergy background could pave the way to primary prevention, early intervention and disease course modification. In fact, most of current research is focusing on the identification of biological and clinical predictive markers of allergy and asthma onset. This review aims at summarizing the latest achievements concerning the complex inter-relation between genetic predisposition and environmental factors, and their impact on prevention strategies and early identification of at risk subjects. An update on the diagnostic and monitoring tools as well as an insight into the newest treatments options is also provided.

Monitoring asthma in children

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. To reach this goal in children with asthma, ongoing monitoring is essential. While all components of asthma, such as symptoms, lung function, bronchial hyperresponsiveness and inflammation, may exist in various combinations in different individuals, to date there is limited evidence on how to integrate these for optimal monitoring of children with asthma. The aims of this ERS Task Force were to describe the current practise and give an overview of the best available evidence on how to monitor children with asthma. 22 clinical and research experts reviewed the literature. A modified Delphi method and four Task Force meetings were used to reach a consensus. This statement summarises the literature on monitoring children with asthma. Available tools for monitoring children with asthma, such as clinical tools, lung function, bronchial responsiveness and inflammatory markers, are described as are the ways in which they may be used in children with asthma. Management-related issues, comorbidities and environmental factors are summarised. Despite considerable interest in monitoring asthma in children, for many aspects of monitoring asthma in children there is a substantial lack of evidence.

Exhaled nitric oxide and the management of childhood asthma--yet another promising biomarker "has been" or a misunderstood gem

Childhood asthma is a common chronic condition. Approximately five percent of all children in western countries are prescribed treatment with inhaled corticosteroids (ICS) to prevent asthma symptoms. Current guidelines advocate titrating ICS dose to symptoms but this approach is not without problem, e.g. how to discern asthmatic from non-asthmatic symptoms? And when to reduce ICS dose? This review describes the strengths and weaknesses of fractional exhaled nitric oxide (FENO) as an objective index for individualising asthma control in children. Epidemiological and mechanistic evidence suggest that FENO should be a promising biomarker for eosinophilic airway inflammation (a hall mark for asthma) but somewhat surprisingly, clinical trials in children have not consistently found benefit from adding FENO to a symptom-based approach to ICS treatment in children. There are a number of reasons why FENO has apparently failed to translate from promising biomarker to clinically useful tool, and one reason may be a lack of understanding of what merits a significant intrasubject change in FENO. This review describes the rise and apparent fall of FENO as biomarker for asthma and then focuses on more recent evidence which suggest that FENO may prove to have a role in the management of childhood asthma, and in particular preventing exacerbations.

Asthma control questionnaires in the management of asthma in children: A review

Several self-administered questionnaires have been developed to assess childhood asthma control in a simple and standardized way. This review discusses the most commonly used questionnaires and explores their usefulness in asthma management in children. We conclude that the use of asthma control questionnaires in daily practice and in research contributes to the standardized evaluation of children with asthma and helps to track asthma symptoms, but validation studies in a wider range of settings are needed.

YKL-40 is correlated with FEV1 and the asthma control test (ACT) in asthmatic patients: influence of treatment

Background

YKL-40 is also called chitinase-3-like-1 (CHI3L1) protein and may be a marker for asthma. The aims of the present study were to investigate whether serum YKL-40 levels are stable or decreased in patients with asthma after appropriate treatment and to evaluate the correlation of YKL-40 levels with lung function and asthma control test (ACT) results.

Methods

A total of 103 asthmatic patients (mean age 33.1 ± 0.9 years) with diagnosed asthma were enrolled in our study. All patients underwent a detailed clinical examination and completed the ACT questionnaire, serum YKL-40 measurement, and spirometry before (visit 1) and 8 weeks after initiation of treatment (visit 2).

Results

At the follow-up, the median serum YKL-40 level was significantly decreased compared to the levels at visit 1 (75.2 [55.8-86.8] ng/ml versus 54.5 [46.4-58.4] ng/ml, p < 0.001). The serum YKL-40 level was negatively correlated with %FEV₁ (r = -0.37, p < 0.001) and ACT score (r = -0.26, p = 0.007) at visit 1. The change in serum YKL-40 levels between the visits was significantly correlated with changes in FEV₁ (r = -0.28, p = 0.006) and ACT score (r = -0.22, p = 0.037). Patients with elevated YKL-40 levels had significantly greater corticosteroid use than patients with lower levels.

Conclusions

YKL-40 was reduced in the serum of asthmatic patients after appropriate treatment, and the levels correlated with improvements in %FEV₁ and ACT. High levels of serum YKL-40 may be refractory to current asthma treatments.

Trial registration

ChiCTR-OCC-13003316

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2466-15-1) contains supplementary material, which is available to authorized users.

Disparities in assessments of asthma control between children, parents, and physicians

OBJECTIVE

Assessment of asthma control in children by physicians, patients and their parents was compared, assuming parents may underestimate symptoms in asthmatic children and exploring whether physicians tend to agree with them.

DESIGN

Asthma control perception was assessed in 4- to 11-year-old asthmatic children and their parents, using C-ACT, during 2011-2012. Pediatric pulmonologists used GINA guidelines for their assessment; pediatricians, not having spirometry, used the information given in addition to physical examination. The C-ACT scores given by the children and their parents were further analyzed separately, and compared with their physicians' assessment. Statistical methods, which also measured possible influence of different variables, included kappa, Chi-square, linear-by-linear association, McNemar test and logistic regression.

PATIENT SELECTION

The study comprised 354 parents and children aged 4-11 years with moderate-severe asthma; 129 (36.4%) were treated by 23 pediatricians; 225 (63.6%) by 11 pediatric pulmonologists.

RESULTS

The C-ACT was generally found valid in assessing asthma control (P < 0.001; κ 0.529; CI 0.441, 0.617) and showed that in 229/354 (53%) of children the asthma was uncontrolled. Nevertheless, of the 229 children who indicated their asthma was uncontrolled, 124 (54.1%) of their parents (κ 0.245; CI 0.15, 0.34) and 96 (41.9%) of their physicians believed it to be controlled (κ 0.331; 0.24, 0.43). Comparing the physician-child discordance vis-à-vis the parents, the significant difference was when 96/229 children (41.9%) and 34/126 parents (27.0%) indicated the asthma was uncontrolled while the physician determined it controlled (OR 1.95; 1.19, 3.24). There were no significant differences between pediatric pulmonologists and pediatricians.

CONCLUSIONS

In addition to increasing awareness of parents to symptoms in their asthmatic children, physicians should question the child appropriately, as well as using the children's responses to C-ACT as an information source for properly assessing asthma control.

Relationship between exhaled leukotriene and 8-isoprostane levels and asthma severity, asthma control level, and asthma control test score

OBJECTIVE

Exhaled breath condensate (EBC) is a completely non-invasive method for the collection of airway secretions to measure intense inflammation in the airways of asthmatics. It has been shown that the childhood asthma control test (c-ACT) is a good tool for use in the evaluation of asthmatics. Whether the c-ACT score and asthma control level correlate with the airway inflammation is not well known. We aimed to evaluate the relationship between exhaled cysteinyl leukotrienes (Cys-LTs) and 8-isoprostane levels and asthma severity, asthma control level and c-ACT score in asthmatic children.

METHODS

Thirty asthmatic children were evaluated with c-ACT score and pulmonary function tests. Asthma severity and asthma control level were assessed according to GINA. EBC was collected and Cys-LTs and 8-isoprostane concentrations were determined using a specific immunoassay kit.

RESULTS

Exhaled 8-isoprostane level in patients with moderate persistent asthma [114 (55-146)pg/ml] was higher than in the mild persistent group [52 (21-91)pg/ml] (p=0.05, Mann-Whitney U [MWU]). EBC 8-isoprostane in children with 1-4 asthma exacerbations/year [52 (16-80)pg/ml] was significantly lower than in children with >4 asthma exacerbations/year [114 (57-129)pg/ml] (p<0.05, MWU). No significant relation was determined between exhaled 8-isoprostane and Cys-LTs levels and c-ACT score and asthma control level. Exhaled 8-isoprostane correlated negatively with bronchodilator response (p=0.015, r=-0.45).

CONCLUSIONS

Exhaled 8-isoprostane, as an oxidative stress specifier, was found to be increased in relation with asthma exacerbation frequency and oxidative stress increases with the severity of asthma. In contrast to asthma severity level, c-ACT score and asthma control level may not reflect airway inflammation.

Correlation between nitrites in induced sputum and asthma symptoms in asthmatic schoolchildren

OBJECTIVE

To determine if nitrites (nitric oxide metabolites) measured in induced sputum decrease and correlate with improvement of clinical asthma symptoms after treatment, we performed a prospective longitudinal study in a tertiary care hospital in Arequipa, Peru.

METHODS

In 95 schoolchildren with mild and moderate persistent asthma we determined nitrites in induced sputum samples (measured using the Griess assay). Clinical parameters and exercise bronchial challenge (EBC) test were performed twice, at baseline and after 3 months of beclomethasone-dipropionate treatment (median doses: 300 mcg/day, IQR: 300-450).

RESULTS

Sixty out of 95 children completed the study (median age of 9-year [IQR: 7-13]). A significant change in sputum nitrites levels between admission and the end of the study was observed (34.4 nmol/ml [IQR:18.2-58.4] and 11.2 nmol/ml [6-20.1], respectively, P = < 0.0001). Also a significant correlation between decrease of sputum nitrites levels and improvement of clinical parameters (acute exacerbations [r = 0.361, P = 0.005]; use of salbutamol [r = 0.322, P = 0.013]; emergency visits [r = 0.275, P = 0.033]; and school absence [r = 0.41, P = 0.001]) from admission to the end of the study was found. However, sputum nitrites levels did not correlated with peripherical blood eosinophils or serum IgE levels or with EBC test at any point of the study. The decrease of sputum nitrites levels after the treatment was significant in each asthma group (mild and moderate), but not between groups.

CONCLUSION

This study showed that measured nitrite in induced sputum (a simple and cheap non-invasive method) is a good alternative for monitoring asthmatic treatment in schoolchildren.

Current evidence and future research needs for FeNO measurement in respiratory diseases

Although not yet widely implemented, fraction of exhaled nitric oxide (FeNO) has emerged in recent years as a potentially useful biomarker for the assessment of airway inflammation both in undiagnosed patients with non-specific respiratory symptoms and in those with established airway disease. Research to date essentially suggests that FeNO measurement facilitates the identification of patients exhibiting T-helper cell type 2 (Th2)-mediated airway inflammation, and effectively those in whom anti-inflammatory therapy, particularly inhaled corticosteroids (ICS), is beneficial. In some studies, FeNO-guided management of patients with established airway disease is associated with lower exacerbation rates, improvements in adherence to anti-inflammatory therapy, and the ability to predict risk of future exacerbations or decline in lung function. Despite these data, concerns regarding the applicability and utility of FeNO in clinical practice still remain. This article reviews the current evidence, both supportive and critical of FeNO measurement, in the diagnosis and management of asthma and other inflammatory airway diseases. It additionally provides suggestions regarding the practical application of FeNO measurement: how it could be integrated into routine clinical practice, how its utility could be assessed and its true value to both clinicians and patients could be established. Although some unanswered questions remain, current evidence suggests that FeNO is potentially a valuable tool for improving the personalised management of inflammatory airway diseases.

Wheezing in preschool children

Wheezing is a common condition in pediatric practice, it can be defined as a musical sound, high-pitched and continuous, emitting from the chest during breath exhalation. Although almost 50% of children experiences wheeze in the first 6 years of life, only 40% of them will report continued wheezing symptoms after childhood. The classification of wheeze in preschool children is more difficult compared to school aged children. It is based on the onset and duration of symptoms and divided children in three categories: transient early wheezing, non-atopic wheezing and atopic wheezing/asthma. History and physical examination, skin prick test, exhaled nitric oxide, lung function test are the parameter to evaluate children with wheezing. The aim of management of wheezing is to finalize the control of symptoms, reduce exacerbations and improve the quality of life. All guidelines underline the complexity in making a diagnosis of asthma under five years and the need to identify phenotypes that may help paediatricians in the therapeutic choices.

Longitudinal measurements of exhaled nitric oxide in children-what is a significant change in FE(NO) ?

BACKGROUND

The principle aim of this study was to describe the variability of exhaled nitric oxide (FE(NO)) concentrations over 10 months in children with and without asthma.

METHODS

FE(NO) was measured on six occasions at 2-month intervals in a community-based cohort of children with and without asthma.

RESULTS

There were 178 children recruited, 47 had asthma, mean age 9.6 yr. A total of 851 FE(NO) measurements were made. The change in FE(NO) values was positively associated with the initial FE(NO) concentration (p < 0.001) and duration between paired measurements (p = 0.016) but not asthma diagnosis; there was an interaction between initial FE(NO) and duration between measurements. As an approximate rule-of-thumb, a child's FE(NO) may rise by up to 100% of their current FE(NO) over 2 and 4 months, independent of asthma.

CONCLUSIONS

Both the baseline FE(NO) and interval between repeated FE(NO) measurements are relevant to FE(NO) values, independent of asthma. These findings may be useful to clinical interpretation of FE(NO) results in children.

The clinician's guide on monitoring children with asthma

Based on a review of the evidence on the usefulness of monitoring disease outcome parameters in childhood asthma and the author's 20-yr clinical experience in managing childhood asthma, this article provides the clinician with up-to-date recommendations on how to monitor childhood asthma in everyday clinical practice. Monitoring should be focused on patient-centered outcomes, such as exacerbations and impact on sports and play. Composite asthma control measures, although reasonably validated, do not take exacerbations into account and have a short recall window, limiting their usefulness as a routine monitoring tool in clinical practice. Lung function, airways hyperresponsiveness, exhaled nitric oxide, and inflammatory markers in sputum are surrogate end points, of little if any interest to patients. There is no evidence to support their use as a monitoring tool in clinical practice; office spirometry may be used as additional information. Rather than monitoring surrogate end points, clinicians should focus on showing a genuine interest in the impact of asthma on children's daily lives, and building and maintaining a partnership by monitoring those characteristics of asthma which have the biggest impact on children (exacerbations and limitations in sports and play), and adjusting treatment accordingly.

Nasal nitric oxide is a marker of poor asthma control

Asthma control, evaluated by symptoms, exacerbations rate and lung function may be greatly influenced by comorbidities, particularly chronic rhinosinusitis (CRS). Measurement of nasal nitric oxide (nNO) is a simple way to assess the severity of CRS. We aimed to analyze the relationship between asthma control and nasal NO. All patients with moderate-to-severe asthma on regular follow-up at our Outpatients' Clinic between November 2009 and April 2010 were included into the study. All patients were evaluated for asthma control by asthma control questionnaire (ACQ) and comorbidities (rhinitis, chronic rhinosinusitis with (CRSwNP) or without nasal polyps, obesity). Exhaled nitric oxide and nNO were obtained in all patients. Eighty-two patients were enrolled (mean age: 48 years, range: 21-80; 42 females). According to ACQ, 53 patients (64.6%) reported controlled asthma. Patients with uncontrolled asthma had lower nNO and higher prevalence of CRSwNP, with a significant correlation between nNO and ACQ. nNO is a biomarker negatively related to asthma control. As low nNO values were associated to CRSwNP, our results indicate that asthma control is highly influenced by this comorbidity.

Four of a kind: asthma control, FEV1, FeNO, and psychosocial problems in adolescents

BACKGROUND

Many adolescents have poor asthma control and are at high risk for psychosocial problems. However, structured assessment of asthma control or psychosocial problems is still not implemented in routine asthma care. Pediatricians typically rely on their clinical view and physiological measurements. To date, it is unknown whether clinical and patient reported outcomes are interrelated. Furthermore, there is no consensus on who should be the informant; the adolescent or his caregiver. STUDY AIM(S): This study aimed to assess the relationship between patient and caregiver reported outcomes [Asthma Control Questionnaire and Strengths and Difficulties Questionnaire (SDQ)] and physiological parameters (FEV1 and Fractional exhaled Nitric Oxide) in adolescents (aged 11-16) with asthma.

METHODS

A multicenter observational study was performed in four Dutch pediatric outpatient departments. Association between asthma control, physiological parameters, and results of psychosocial questionnaires completed by both adolescent and caregiver was analyzed.

RESULTS

Forty-eight adolescents and their caregivers participated in this study. Asthma was uncontrolled in about 30%. Asthma control was not associated with age, gender, FEV1, FeNO, or psychosocial problems. Agreement between adolescents and caregivers about how well asthma was controlled was moderate (κ = 0.577, P < 0.01).

DISCUSSION

Asthma control, physiological parameters, and psychosocial problems are different domains of health status. It could be suggested to use validated patient and caregiver reported outcomes in routine adolescent asthma care.

CONCLUSION

Patient and caregiver reported outcomes on asthma control and the presence of psychosocial problems add valuable, unique information to physiological parameters in adolescent asthma management.

Cut points for Asthma Control Tests in Mexican children in Orange County, California

BACKGROUND

The Childhood Asthma Control Test (C-ACT) and the Asthma Control Test (ACT) are validated measures of asthma control in which a score of 19 is defined as uncontrolled according to published reports. However, different cut points may exist in different ethnic populations.

OBJECTIVE

To determine the cut point for uncontrolled asthma in a Mexican descent population from Orange Country, California, compared with an age- and asthma severity-matched non-Hispanic cohort.

METHODS

The C-ACT (in children 6-11 years old) and ACT (in children 12-17 years old) scores were collected from 151 children of Mexican descent and 48 non-Hispanic controls with mild-to-moderate asthma who lived in Orange County. Physicians were masked to C-ACT and ACT scores while assessing control based on National Asthma Education and Prevention program guidelines. The receiver operating characteristic method was used to examine the screening accuracy of the tests to detect uncontrolled asthma. The optimal cut points were selected by maximizing the total sensitivity and specificity.

RESULTS

Cronbach α values for the C-ACT (0.76) and the ACT (0.80) confirmed that both tests were reliable in our study population. The C-ACT and ACT scores were statistically higher in children of Mexican descent than non-Hispanic children (P = .008). A cut point of 22 was optimal to detect uncontrolled asthma in children of Mexican descent 6 to 11 years old (group 1: sensitivity, 0.74; specificity, 0.86; area under the curve [AUC], 0.83) and children 12 to 17 years old (group 3: sensitivity, 0.78; specificity, 0.68; AUC, 0.79). For non-Hispanic controls, a cut point of 20 were optimal to detect uncontrolled asthma in children 6 to 11 years old (group 2: sensitivity, 0.70; specificity, 0.91; AUC, 0.86) and children 12 to 17 years old (group 4: sensitivity, 0.83; specificity, 0.87; AUC, 0.91).

CONCLUSION

In this cross-ethnic validation study, children of Mexican descent in Orange County seem to underreport asthma symptoms compared with a non-Hispanic population and may require higher C-ACT and ACT cut points to detect uncontrolled asthma.

Exhaled nitric oxide in pediatrics: what is new for practice purposes and clinical research in children?

Fractional exhaled NO (FeNO) is universally considered an indirect marker of eosinophilic airways inflammation, playing an important role in the physiopathology of childhood asthma. Advances in technology and standardization have allowed a wider use of FeNO in clinical practice in children from the age of four years. FeNO measurements add a new dimension to the traditional clinical tools (symptoms scores, lung function tests) in the assessment of asthma. To date a number of studies have suggested a possible use of FeNO in early identification of exacerbation risk and in inhaled corticosteroids titration. The aim of this paper is to address practical issues of interest to paediatric clinicians who are attempting to use FeNO measurements as an adjunctive tool in the diagnosis and management of childhood airway diseases.

Asthma control test (ACT): comparison with clinical, functional, and biological markers of asthma control

BACKGROUND

Asthma Control Test (ACT) is a simple tool for assessing the level of asthma control in clinical practice, and it has been validated in comparison with a general clinical assessment of asthma control, including forced expiratory volume in the first second (FEV(1)).

OBJECTIVE

To evaluate the relationship between ACT score and clinical and functional findings of asthma control and biomarkers of airway inflammation.

METHODS

A total of 68 asthmatic patients observed in our asthma clinic (33 regularly treated with inhaled corticosteroids (ICS) and 35 ICS-naïve) filled ACT questionnaire and underwent the following measurements: (a) FEV(1) before and after salbutamol; (b) exhaled nitric oxide; (c) bronchial hyperresponsiveness to methacholine; (d) sputum eosinophil count; and (e) daytime and nighttime symptoms, rescue salbutamol, and twice-daily peak expiratory flow (PEF) recording on a 4-week diary card.

RESULTS

ACT score significantly correlated with symptom score, rescue medication use, and PEF variability, but not with FEV(1), FEV(1) reversibility, and markers of airway inflammation, which could not distinguish controlled from uncontrolled patients according to ACT, regardless of ICS treatment.

CONCLUSION

ACT score is a valid tool to simply assess the current level of asthma control in terms of symptoms, rescue medication use, and PEF variability. Pulmonary function and biomarkers of airway inflammation are not related to the clinical asthma control as assessed by ACT and may represent additional measurements potentially useful in asthma management.

Evaluation of association between exercise-induced bronchoconstriction and childhood asthma control test questionnaire scores in children

OBJECTIVE

Asthma control represents a major challenge in the management of asthmatic children; however, correct perception of control is poor. The aim of the study was to evaluate the association between subjective answers given to the Childhood Asthma Control Test (C-ACT) and objective evaluation of exercise-induced bronchonstriction (EIB) by standardized treadmill exercise challenge.

METHODS

EIB was evaluated by standardized treadmill exercise challenge and related to C-ACT scores in 92 asthmatic children.

RESULTS

Of the 92 studied children only six children had a concordance between a positive challenge test (ΔFEV1 ≥ 13%) and a positive response to the exercise-related issue of the C-ACT questionnaire (C-ACT total score ≤ 19). There was no significant association between the degree of EIB and the scores relative to the single question on exercise-related problems while a significant association was found when considering the whole questionnaire with C-ACT total score > 19 (r = -0.40, P < 0.001). The two single questions showing a significant association were those focusing on nocturnal asthma. The areas under the ROC curve (AUC) for the sum of the scores of these questions in relationship to a positive response to the exercise test was 0.74. The AUC of the C-ACT total score was 0.76 and 0.55 for the specific question on EIB related problems.

CONCLUSION

The discrimination power of the C-ACT total score in relationship to EIB was moderately good, and C-ACT questionnaire was capable of correctly predicting the absence of EIB in children reporting a global score > 19. However, direct questions on EIB are associated with a high number of false positive and negative responses; better associations are found questioning on the presence on nocturnal symptoms.

Assessing asthma control: symptom scores, GINA levels of asthma control, lung function, and exhaled nitric oxide

BACKGROUND

The childhood asthma control test (C-ACT) is a validated symptom score for assessing asthma control in children. We used a slightly modified version (C-ACT(M) ) of the German C-ACT and compared our results with the literature, correlated the children's part of C-ACT (C-ACT(children) ) with a visual analogue scale (VAS(children) ), explored the agreement between C-ACT(M) and GINA levels of asthma control, as well as the relationship between C-ACT(M) and lung function and exhaled nitric oxide (FeNO).

METHODS

We investigated 107 children with a diagnosis of asthma. The study protocol consisted of a clinical examination, assessment of asthma control according to GINA guidelines, administration of C-ACT(M) , VAS(children) , lung function, and FeNO.

RESULTS

Of our patients 66% had, according to GINA, partly controlled-/uncontrolled asthma, 18% were uncontrolled according to C-ACT(M) . Children with partly controlled-/uncontrolled asthma according to GINA had lower C-ACT(M) scores than did children with controlled asthma (16.1 ± 3.6 SD vs. 25.4 ± 1.8 SD; P < 0.000), and children with a C-ACT(M) score ≤ 19 had poorer lung function (mean FEV1% predicted 81.5 ± 13.5 SD vs. 94.2 ± 12.1 SD; P = 0.002). Spearman's rank correlation coefficients revealed significant correlations between all symptom scores. Multiple linear regression adjusted for age, gender, FEV1 and FeNO demonstrated a significant relationship between C-ACT(M) , VAS(children) , and FEV1 (P = 0.003, resp. <0.000), but no significant correlation between C-ACT(M) , VAS(children) , and FeNO.

CONCLUSIONS

The German version of C-ACT(M) is valid and useful for monitoring children with asthma along with tests aimed to follow up lung function and airway inflammation. Concordance between C-ACT(M) and GINA is moderate, because asthma control assessed by C-ACT(M) allows more symptoms and lung function is not included in the scoring.

A 26-week, randomized, double-blind, placebo-controlled, multicenter study to evaluate the effect of omalizumab on asthma control in patients with persistent allergic asthma

OBJECTIVE

The 2007 National Heart, Lung, and Blood Institute (NHLBI) asthma guidelines shifted the focus of care from asthma severity to ongoing assessment of asthma control using the components of impairment and risk. We evaluated the effect of omalizumab on asthma control in patients with persistent allergic asthma inadequately controlled with NHLBI Step 4 or above asthma therapy.

METHODS

In this double-blind, placebo-controlled study, patients ≥12 years (n = 271) received omalizumab (n = 136) or placebo (n = 135) every 2 or 4 weeks for 24 weeks. The primary efficacy variable, change from baseline in Asthma Control Test (ACT) total score, and Investigator's Global Evaluation of Treatment Effectiveness (IGETE, secondary efficacy variable) were evaluated at week 24.

RESULTS

ACT score improved more with omalizumab compared with placebo (least squares means [LSMs]: 5.01, 4.36); however, the difference was not significant (p = .1779). Similarly, IGETE was not significantly different (p = .1177), but more patients treated with omalizumab (26/127, 20%) compared with placebo (19/131, 15%) had IGETE rated as "Excellent." Significant benefits were observed for omalizumab compared with placebo for change in ACT score (LSMs: 6.66, 5.27; p = .0334) and IGETE (p = .0321) at week 24 in a subgroup of patients with very poorly controlled asthma (ACT ≤ 15) at baseline. There were no significant differences for the subgroup of patients with forced expiratory volume in 1 second ≤ 80% predicted at baseline. Adverse events (AEs) were similar between groups with no drug-related serious AEs or deaths.

CONCLUSIONS

For allergic asthma patients with NHLBI Step 4 or above asthma therapy, omalizumab consistently improved asthma control; however, compared with placebo, differences were not significant. Placebo-treated patients had substantial improvement in their ACT score, which may have limited the ability to detect differences between treatment groups. Subgroup analyses showed significant improvements with omalizumab versus placebo in patients with very poorly controlled asthma.

Association between the results of the childhood asthma control test and objective parameters in asthmatic children

OBJECTIVE

The Childhood Asthma Control Test (C-ACT), a seven-item, self-administered questionnaire, has been used as a tool to assess the control level in children with asthma. The aim of this study was to determine whether the C-ACT reflects airflow limitation and airway inflammation in addition to clinical manifestations.

METHODS

Asthmatic children aged 5-11 years who were able to perform the lung function test and fractional exhaled nitric oxide (FeNO) evaluation correctly were recruited during their regular visits. Children and their parents were asked to answer the officially developed Japanese version of the C-ACT.

RESULTS

Among 258 children (176 boys, median age 9 years), there was a significant positive correlation between the C-ACT score and the percent predicted forced expiratory volume in 1 s (%FEV(1)) (r = 0.317, p < .001). The accuracy of the C-ACT for identifying asthmatic subjects with normal lung function (%FEV(1) >80%) described as the area under the receiver operating characteristic curve was 71.5% (95% CI = 62.8-80.2%, p < .001), and based on the Youden index the optimal cutoff score was 23 (sensitivity of 78% and specificity of 54%). In contrast, there was no relationship between the C-ACT score and the FeNO value.

CONCLUSIONS

These results suggest that a cutoff score of 23 for the C-ACT could be useful for identifying children with well-controlled asthma and normal lung function. Further studies are warranted to develop an easy-to-use questionnaire to assess the extent of airway inflammation in children.

The reliability and validity of Turkish version of Childhood Asthma Control Test

INTRODUCTION

The reliability and validity of Turkish version of Childhood Asthma Control Test (C-ACT).

PURPOSE

The management of asthma is an important as well as difficult issue of physician's daily practice particularly in busy clinical settings. C-ACT was created to identify asthma control levels in children aged 4-11 years. Our aim was to evaluate the reliability, validity and responsiveness of C-ACT in a Turkish sample of children with asthma.

METHOD

In this multicenter study, 368 children were enrolled. C-ACT was completed every month by parents and patients who were evaluated in 3 visits within 2 month intervals. At each visit, physicians interpret the control level and decided for the treatment step as established in GINA guidelines.

RESULTS

The internal consistency reliability of the Turkish version of C-ACT (C-ACT1 to C-ACT5) was found to be 0.82, 0.83, 0.82, 0.82 and 0.80, respectively (reliability statistics, Cronbach's alpha). Test-retest reliability was 0.71. There was significant correlation between C-ACT and physician's assessment of asthma control at visit 1 (r = 0.65, P < 0.001).

CONCLUSIONS

Turkish version of C-ACT is an accurate and reliable tool to evaluate asthma control in children aged 4-11 years. Its widespread use may facilitate appropriate assessment of asthma control and may lead to decrease the number of uncontrolled patients.

Control maintenance can be predicted by exhaled NO monitoring in asthmatic patients

BACKGROUND

Fractional exhaled nitric oxide (F(E)NO) is a marker of airway inflammation in asthma. Monitoring of such inflammation is currently not included in asthma guidelines and remains controversial. The hypothesis underlying the present study was that, F(E)NO could help assessing asthma control and, therefore, improve its management, by predicting loss of control in asthmatics.

METHODS

A total of 90 adult asthmatics were included in the study. Asthma control was evaluated according to ACQ. All patients underwent F(E)NO by chemiluminescent (EndoNO) and hand-held (MINO) devices, followed by lung function testing.

RESULTS

MINO was accurate as compared to EndoNO. F(E)NO was significantly increased in uncontrolled as compared to controlled asthmatics using both devices. F(E)NO measurement was able to predict control maintenance in controlled asthmatics in the absence of any change in their treatment. Indeed, using cut-off values of 31 and 40 ppb, the negative predictive values were 95 and 97% for EndoNO and MINO, respectively. EndoNO and MINO were also able to assess asthma control, although to a lesser extent.

CONCLUSIONS

These findings suggest that F(E)NO can predict the persistence of asthma control in controlled patients and may now be used in asthma management since it can accurately be measured by means of hand-held devices.

[Comparison of the Asthma Control Test (ACT) with lung function, levels of exhaled nitric oxide and control according to the Global Initiative for Asthma (GINA)]

INTRODUCTION

The current goal of asthma treatment is to achieve and maintain control. This study aimed to explore the relationship between the ACT (Asthma Control Test) questionnaire and the levels of control according to GINA (Global Initiative for Asthma) to establish the cut-off points for the ACT and evaluate its relationship with lung function and fractionated exhaled nitric oxide level (FeNO).

PATIENTS AND METHODS

A multi-centre prospective study including 441 patients followed up in an outpatient Chest Clinic. A clinical protocol was followed, and FeNO, spirometry and ACT performed. Disease was classified according to levels of control using GINA. The study analysed sensitivity, specificity and area under the curve (ROC), and the ACT cut-off points. We studied the differences between the functional parameters and FeNO between levels of control.

RESULTS

For controlled asthma the cut-off obtained was ACT> or =21 (area under the curve 0.791) and for uncontrolled < or =18 (AUC 0.774). We found significant differences in FeNO levels and pulmonary function among ACT> or =21 and ACT< or =18, although only 26.3% of patients with ACT< or =18 had a FEV1 <80% and 40% higher FeNO (> or =35 ppb). We found a correlation between baseline FEV1 and ACT (r=0.19, P<0.01) and between ACT and FeNO (r=-0.16, P<0.01).

CONCLUSIONS

The cut-off points would be, for controlled asthma ACT> or =21, partly controlled asthma ACT=19-20 and uncontrolled asthma ACT< or =18. A more complete assessment would require including monitoring operating parameters and FeNO.

Exhaled nitric oxide fractions are well correlated with clinical control in recurrent infantile wheeze treated with inhaled corticosteroids

Fractional exhaled nitric oxide (FeNO) is a non-invasive marker of bronchial inflammation in asthma. However, the interest of FeNO measurement remained limited in infantile wheeze. The aim of this prospective study was to evaluate the feasibility and reproducibility of FeNO off-line measurement in very young children with recurrent wheeze and to assess whether clinical control of infantile wheeze correlates with FeNO levels. Two exhalation samples were collected in mylar balloon during quite tidal breathing. FeNO measurements were performed off-line by a NO analyzer. The participating patients were aged ≤36 months, wheezes had started before the age of 24 months, and they were receiving maintenance treatment with inhaled corticosteroids for at least 3 months duration. The studied population comprised of 40 uncontrolled infants with persistent wheezy respiratory symptoms, median age 14.5 months, and 40 with optimal controlled infantile wheeze, median age 14 months. The reproducibility was excellent (r = 0.95; p < 0.0001). There was a significant difference in FeNO levels between the groups of persistent wheeze and well-controlled infants: 19.8 (2.5-99.3) ppb vs. 7.7 (0.6-29.5) ppb, p < 0.0001. At a FeNO level >15 ppb, the predictive values for uncontrolled disease were as follows: positive predictive value = 65%, negative predictive value = 90%. FeN0 levels were not increased by atopy or passive tobacco. Off-line assessment of FeNO is feasible, reproducible, and well accepted in wheezy very young children. Optimal clinical control of infantile wheeze appeared to be associated with the control of bronchial inflammation when evaluated by FeNO measurements.