Usefulness of monitoring lung function in asthma

Impact of air quality on the health of present-day workers in an Asbestos roof manufacturing industry, Sri Lanka

The study's objective was to determine the air quality in an asbestos-related industry and its impact on current workers' respiratory health. Seventy-seven air and 65 dust samples were collected at 5-day intervals in an asbestos roofing sheets production factory in Sri Lanka having two production facilities. Sampling was performed in ten sites: Defective sheets-storage, Production-plant, Pulverizer, Cement-silo, and Loading-area. A detailed questionnaire and medical screening were conducted on 264 workers, including Lung Function Tests (LFT) and chest X-rays. Asbestos fibres were observed in deposited dust samples collected from seven sites. Free chrysotile fibres were absent in the breathing air samples. Scanning Electron Microscopy confirmed the presence of asbestos fibres, and the Energy Dispersive X-ray analysis revealed Mg, O, and Si in depositions. The average concentrations of trace metals were Cd-2.74, Pb-17.18, Ni-46.68, Cr-81.01, As-7.12, Co-6.77, and Cu-43.04 mg/kg. The average Zn, Al, Mg, and Fe concentrations were within 0.2-163 g/kg. The highest concentrations of PM2.52.5 and PM1010, 258 and 387 µg/m3, respectively, were observed in the Pulverizer site. Forty-four workers had respiratory symptoms, 64 presented LFT abnormalities, 5 indicated chest irregularities, 35.98% were smokers, and 37.5% of workers with abnormal LFT results were smokers. The correlation coefficients between LFT results and work duration with respiratory symptoms and work duration and chest X-ray results were 0.022 and 0.011, respectively. In conclusion, most pulmonary disorders observed cannot directly correlate to Asbestos exposure due to negligible fibres in breathing air, but fibres in the depositions and dust can influence the pulmonary health of the employees.

Knowledge, practice pattern and attitude toward asthma management amongst physicians from Nepal, Malaysia, Lebanon, Myanmar and Morocco

OBJECTIVE

This survey aimed to understand the physicians' practice pattern and challenges faced while treating their patients with asthma in five countries-Malaysia, Nepal, Myanmar, Morocco and Lebanon.

METHODS

Questionnaire-based data was gathered from internal medicine doctors (209), general practitioners (206), chest physicians (152) and pediatricians (58) from 232 locations from across the five countries.

RESULTS

Of the 816 physicians, 374 physicians encountered at least 5 asthma patients daily. Approximately, 38% physicians always used spirometry for diagnosis and only 12% physicians always recommended Peak flow meter (PFM) for home-monitoring. Salmeterol/fluticasone (71%) followed by formoterol/budesonide (38%) were the most preferred ICS/long-acting beta₂-agonists (LABA); Salbutamol (78%) was the most preferred reliever medication. 60% physicians said >40% of their patients were apprehensive to use inhalers. 72% physicians preferred a pressurized metered-dose inhaler (pMDI) to a dry powder inhaler (DPI) with only a third of them using a spacer with the pMDI. 71% physicians believed that using similar device for controller and reliever can be beneficial to patients. Skipping medicines in absence of symptoms (64%), incorrect inhaler technique (48%) and high cost of medication (49%) were considered as major reasons for non-adherence by most physicians. Incorrect inhaler technique (66%) and nonadherence (59%) were considered the most common causes of poor asthma control.

CONCLUSIONS

There are opportunities to improve the use of diagnostic and monitoring tools for asthma. Non-adherence, incorrect inhaler technique and cost remain a challenge to achieve good asthma control. Asthma education, including correct demonstration of inhaler, can potentially help to improve inhaler adherence.

Effect of omalizumab on lung function and eosinophil levels in adolescents with moderate-to-severe allergic asthma

BACKGROUND

Omalizumab improves clinical outcomes in patients with asthma. Several studies have shown lung function improvements with omalizumab; however, this has not been examined exclusively in adolescents.

OBJECTIVE

To assess the effect of omalizumab on lung function and eosinophil counts in adolescents with uncontrolled moderate-to-severe allergic asthma.

METHODS

In this post hoc analysis, data from adolescents aged 12 to 17 years from 8 randomized trials of omalizumab were pooled (studies 008, 009, and 011, and SOLAR, INNOVATE, ALTO, ETOPA, and EXTRA). Changes from baseline to end of study in forced expiratory volume in 1 second (FEV₁), percent predicted FEV₁ (ppFEV₁), forced vital capacity (FVC), and blood eosinophil counts were assessed by fitting an analysis of covariance model and calculating least squares mean (LSM) difference for omalizumab vs placebo.

RESULTS

A total of 340 adolescents were identified (omalizumab, n = 203 [59.7%]; placebo, n = 137 [40.3%]). Omalizumab increased all baseline lung function variables more than placebo by end of study: LSM treatment differences (95% confidence interval) were 3.0% (0.2%-5.7%; P = .035), 120.9 mL (30.6-211.2 mL; P = .009), and 101.5 mL (8.3-194.6 mL; P = .033) for ppFEV₁, absolute FEV₁, and FVC, respectively. The LSM difference demonstrated a greater reduction in eosinophil counts for omalizumab vs placebo: -85.9 cells/μL (-137.1 to -34.6 cells/μL; P = .001).

CONCLUSION

Omalizumab was associated with lung function improvements and circulating eosinophil counts reductions in adolescents with moderate-to-severe uncontrolled asthma. Findings emphasize the effect of omalizumab in young patients and the need to optimize treatment early in the disease course. https://clinicaltrials.gov/: NCT00314574, NCT00046748, NCT00401596.

A virtual asthma clinic for children: fewer routine outpatient visits, same asthma control

eHealth is an appealing medium to improve healthcare and its value (in addition to standard care) has been assessed in previous studies. We aimed to assess whether an eHealth intervention could improve asthma control while reducing 50% of routine outpatient visits.In a multicentre, randomised controlled trial with a 16-month follow-up, asthmatic children (6-16 years) treated in eight Dutch hospitals were randomised to usual care (4-monthly outpatient visits) and online care using a virtual asthma clinic (VAC) (8-monthly outpatient visits with monthly web-based monitoring). Outcome measures were the number of symptom-free days in the last 4 weeks of the study, asthma control, forced expiratory volume in 1 s, exhaled nitric oxide fraction, asthma exacerbations, unscheduled outpatient visits, hospital admissions, daily dose of inhaled corticosteroids and courses of systemic corticosteroids.We included 210 children. After follow-up, symptom-free days differed statistically between the usual care and VAC groups (difference of 1.23 days, 95% CI 0.42-2.04; p=0.003) in favour of the VAC. In terms of asthma control, the Childhood Asthma Control Test improved more in the VAC group (difference of 1.17 points, 95% CI 0.09-2.25; p=0.03). No differences were found for other outcome measures.Routine outpatient visits can partly be replaced by monitoring asthmatic children via eHealth.

Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation

This review focuses on the methods available for measuring reversible airways obstruction, bronchial hyperresponsiveness (BHR) and inflammation as hallmarks of asthma, and their role in monitoring children with asthma. Persistent bronchial obstruction may occur in asymptomatic children and is considered a risk factor for severe asthma episodes and is associated with poor asthma outcome. Annual measurement of forced expiratory volume in 1 s using office based spirometry is considered useful. Other lung function measurements including the assessment of BHR may be reserved for children with possible exercise limitations, poor symptom perception and those not responding to their current treatment or with atypical asthma symptoms, and performed on a higher specialty level. To date, for most methods of measuring lung function there are no proper randomised controlled or large longitudinal studies available to establish their role in asthma management in children. Noninvasive biomarkers for monitoring inflammation in children are available, for example the measurement of exhaled nitric oxide fraction, and the assessment of induced sputum cytology or inflammatory mediators in the exhaled breath condensate. However, their role and usefulness in routine clinical practice to monitor and guide therapy remains unclear, and therefore, their use should be reserved for selected cases.

Respiratory disease and respiratory physiology: putting lung function into perspective: paediatric asthma

Dealing with paediatric asthma in daily practice, we are mostly interested in the airway function: the hallmark of asthma is the variability of airway patency. Various pulmonary function tests (PFT) can be used to quantify airway caliber in asthmatic children. The choice of the test is based on the developmental age of the child, knowledge of the diagnosis/underlying pathophysiology, clinical questions and reasoning, and treatment. PFT is performed to monitor the severity of asthma and the response to therapy, but can also be used as a diagnostic tool, and to study growth and development of the lungs and airways. This review aims to provide clinicians an overview of the differences in assessing PFT in infants and preschool children compared with older cooperative children, which tests are feasible in infants and young children, the limitations of and usefulness of these tests, and of their interpretation in these age groups.

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.

The Respiratory System

This chapter addresses upper airway physiology for the pediatric intensivist, focusing on functions that affect ventilation, with an emphasis on laryngeal physiology and control in breathing. Effective control of breathing ensures that the airway is protected, maintains volume homeostasis, and provides ventilation. Upper airway structures are effectors for all of these functions that affect the entire airway. Nasal functions include air conditioning and protective reflexes that can be exaggerated and involve circulatory changes. Oral cavity and pharyngeal patency enable airflow and feeding, but during sleep pharyngeal closure can result in apnea. Coordination of breathing with sucking and nutritive swallowing alters during development, while nonnutritive swallowing at all ages limits aspiration. Laryngeal functions in breathing include protection of the subglottic airway, active maintenance of its absolute volume, and control of tidal flow patterns. These are vital functions for normal lung growth in fetal life and during rapid adaptations to breathing challenges from birth through adulthood. Active central control of breathing focuses on the coordination of laryngeal and diaphragmatic activities, which adapts according to the integration of central and peripheral inputs. For the intensivist, knowledge of upper airway physiology can be applied to improve respiratory support. In a second part the mechanical properties of the respiratory system as a critical component of the chain of events that result in translation of the output of the respiratory rhythm generator to ventilation are described. A comprehensive understanding of respiratory mechanics is essential to the delivery of optimized and individualized mechanical ventilation. The basic elements of respiratory mechanics will be described and developmental changes in the airways, lungs, and chest wall that impact on measurement of respiratory mechanics with advancing postnatal age are reviewed. This will be follwowed by two sections, the first on respiratory mechanics in various neonatal pathologies and the second in pediatric pathologies. The latter can be classified in three categories. First, restrictive diseases may be of pulmonary origin, such as chronic interstitial lung diseases or acute lung injury/acute respiratory distress syndrome, which are usually associated with reduced lung compliance. Restrictive diseases may also be due to chest wall abnormalities such as obesity or scoliosis (idiopathic or secondary to neuromuscular diseases), which are associated with a reduction in chest wall compliance. Second, obstructive diseases are represented by asthma and wheezing disorders, cystic fibrosis, long term sequelae of neonatal lung disease and bronchiolitis obliterans following hematopoietic stem cell transplantation. Obstructive diseases are defined by a reduced FEV1/VC ratio. Third, neuromuscular diseases, mainly represented by DMD and SMA, are associated with a decrease in vital capacity linked to respiratory muscle weakness that is better detected by PImax, PEmax and SNIP measurements.

Will symptom-based therapy be effective for treating asthma in children?

Traditionally, symptoms are important patient-oriented outcomes in asthma treatment, and assessment of symptoms is an essential component of assessing asthma control. However, variable airways obstruction, airways hyperresponsiveness and chronic inflammation are key components of the asthma syndrome, and correlations among these hallmarks and symptoms are weak or even absent. Therefore, it might be questioned if symptom-based therapy is effective for treating asthma in (all) children. To date, there is no firm indication that monitoring asthma based on repetitive lung function measurement or markers of airway inflammation is superior to monitoring based on symptoms only. In the majority of patients, symptom-based asthma management may well be sufficient, and in preschool children, symptoms are presently the only feasible outcome. Nevertheless, there is some evidence that selected groups might benefit from an approach that takes into account individual phenotypic characteristics. In patients with poor perception, those with a discordant phenotype and those with persistent severe asthma, considering lung function, airways hyperresponsiveness and inflammatory markers in treatment decisions might improve outcomes.

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.

Quantification of shape of flow-volume loop of healthy preschool children and preschool children with wheezing disorders

BACKGROUND

The earliest change associated with airflow obstruction in small airways is reflected in a concave shape on the maximum expiratory flow-volume loop (MEFVL). The shape of the MEFL changes with age but reference values for curvilinearity indices (CI) for preschool children have not been published. We aimed to describe the normal curvilinearity of healthy preschool MEFVL by CI (the β angle and the ratio of maximum expiratory flow when 50% of forced vital capacity remains to be expired/peak expiratory flow (MEF(50%) /PEF)) and to test their capacity in detecting concavity in preschool children with wheezing disorders.

METHODS

Spirometric data were obtained from 132 healthy preschool children and 171 3-to-5-year-old preschool children with wheezing disorders and reference values for CI calculated.

RESULTS

Mean (SD) β angle of healthy children was 203° (16°) and mean MEF(50%) /PEF of healthy children was 0.71 (0.12) indicating convexity of MEFVL, both decreased with increasing age (P = 10(-4) ). Children with wheezing disorders had lower z-score values of CI (P ≤ 10(-6) ) indicating more concave MEFVL. Among the two CI, MEF(50%) /PEF allowed for the best discrimination between healthy children and children with wheezing disorders (Wilks' lambda = 0.898, P = 10(-7) ).

CONCLUSION

These CI can detect and quantify the concavity of the descending limb of the MEFVL in preschool children with wheezing disorders, MEF(50%) /PEF having the highest sensitivity in detecting the concavity.

Correlation between peak flow and body mass index in obese and non-obese children in Kocaeli, Turkey

AIMS

To investigate the relationship between body mass index (BMI) and peak expiratory flow (PEF) values in children between the ages of 6 and 14 years.

METHODS

Data were collected from 1,439 children during public health screening. Each child was classified on the basis of age- and sex-specific BMI percentile as non-obese or obese (BMI >95th percentile). PEF and BMI were compared among age-sex-BMI percentile groups.

RESULTS

PEF values were lower in obese children than in non-obese children. There were also significant differences between girls and boys.

CONCLUSIONS

The association of higher BMI with lower PEF may indicate that obesity is an important risk factor for reduced airflow or lung function in children. These findings emphasise the importance of the prevention of obesity in children and adolescents in order to avoid possible future respiratory problems.

Knowledge and attitudes of adolescents towards asthma: questionnaire results before and after a school-based education program

BACKGROUND

Previous studies on school-based education programs have reported that asthmatic and nonasthmatic adolescents, teachers and school personnel do not have enough information on asthma. However, the number of education programs including adolescents without asthma is not sufficient. The aim of the present study was to determine the knowledge of school children about asthma and to investigate whether their knowledge of asthma can be increased by an education program through a booklet distributed as a handout.

METHODS

This cross-sectional prospective questionnaire survey was carried out in a private school in Ankara, Turkey, between February and April 2006. 720 adolescents in grades 6, 7 and 8 were included. Knowledge about asthma was evaluated by a scoring system before and after the education offered by means of a booklet.

RESULTS

The final analysis was conducted on 642 students in total. The number of right answers in 5 categories, percentage of right answers and total questionnaire score improved significantly after the education received (p < 0.001). The total questionnaire scores of the girls (p = 0.002), those students with a university graduate mother (p = 0.006) and those with a physician parent (p = 0.041) were higher than those of the other pupils.

CONCLUSION

Theoretical material in the form of a booklet can be used in a school-based asthma education program in order to improve the knowledge of adolescents about asthma.

Asthma: are we monitoring the correct measures?

The prevalence of asthma, a common chronic inflammatory disease of the airways, has risen sharply over the past 25-30 years, with the biggest increase found in children. Currently, more than 22 million Americans have asthma. Asthma also is associated with significant morbidity and mortality worldwide. Each year, asthma is responsible for $16 billion in direct and indirect costs due to health care utilization and loss of productivity, with over 14 million missed workdays. Asthma also accounts for almost 1.8 million emergency room visits and almost 500,000 hospitalizations annually. Therefore, assessment and monitoring of disease activity is critical to improve clinical and economic outcomes for patients with asthma. To help in this endeavor, practitioners and payers rely on evidence-based guidelines to classify disease severity, to guide treatment decisions, and to assess the degree of asthma control. In August 2007, the National Asthma Education and Prevention Program (NAEPP) updated its guidelines based on greater knowledge of disease pathophysiology and the development of newer therapeutic agents. This includes an increased emphasis on the need to establish disease severity, including the components of impairment and risk, as well as on the level of asthma control. Despite the availability of the NAEPP and other guidelines, asthma control often remains suboptimal. While numerous clinical and patient-reported measures are available, it is clear that the optimal monitoring schema for patients with asthma remains undefined. To clearly establish whether asthma control is attained, multiple measures are required and should include clinical and patient-reported assessments.

Management of severe asthma in children

Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.

Allowing for the opposite: the parents of asthmatic children cooperate by making use of each other's differences

This article focuses on one of the interactive processes that parents use to cope with their child's asthma. The concept allowing for the opposite was developed in the course of a clinical project designed to improve consultation methods in pediatric allergy care. We examined material from 67 conversations carried out with 22 heterosexual couples held with two family therapists: one male pediatrician and one female social worker. We found that parents made use of each other's differences in personality and parenting style, allowing each other to take opposing positions on how to cope with their child's asthma. Disagreement should be added to the list of coping mechanisms used by parents in their cooperative efforts to handle their child's asthma.

Asthma education and monitoring: what has been shown to work

Cochrane systematic reviews and meta-analyses on education and monitoring of asthmatic children have come to divergent conclusions, mainly because of the heterogeneity of education programmes and patients. There is little doubt that education is useful. However, the useful components of the education programmes remain to be elucidated, not only by randomized controlled trials but also by observational studies performed within distinct asthma phenotypes. Any education and monitoring package needs to contain basic explanation about the disease and its influencing factors, as well as inhalation instructions. There is no good evidence to justify home monitoring of lung function; symptom monitoring suffices. Probably, the crucial part of asthma education programmes is a high level of agreement between patient and doctor regarding the goals of the treatment (patient-doctor partnership). Therefore, further exploration of the patient's needs should be worthwhile.

[Variability in peak expiratory flow does not classify asthma according to severity]

OBJECTIVE

The aim of this study was to determine whether variability in peak expiratory flow (PEF) could be used to classify the level of severity of asthma in children.

PATIENTS AND METHODS

We studied 387 boys and girls diagnosed with asthma and classified severity according to clinical criteria (Spanish Society of Pediatric Pneumology). PEF variability was determined using a portable mini-Wright peak flow meter (Clement Clarke International, London, UK; range, 50 L/min-800 L/min) over a 14-day period, with no changes in normal treatment. The following indices were used to calculate PEF variability: 1) difference between morning PEF and nighttime PEF, expressed as a percentage of the mean value of the PEF measurements taken on that day; 2) minimum PEF rate during a week, expressed as a percentage of the highest value recorded during that week; 3) difference between the highest and the lowest PEF values, expressed as a percentage of the highest value; and 4) the 10th percentile of PEF values recorded during a week, expressed as a percentage of the highest value recorded during that week. We assessed agreement between clinical classification and PEF variability using the weighted kappa coefficient. We also analyzed the sensitivity and specificity of PEF variability indices for episodic and persistent asthma.

RESULTS

The analysis of levels of agreement between clinical classification of asthma and formulas 1, 2, 3, and 4 gave quadratic weighted kappa coefficients of 0.494, 0, 0.488, and 0.346, respectively. The results were similar when patients were grouped and analyzed by type of asthma (episodic or persistent asthma).

CONCLUSIONS

The monitoring of PEF variability, a recommendation common in national and international guidelines on the management of asthma in children, is not valid for classifying severity of asthma in children.

Monitoring of asthma control in children

PURPOSE OF REVIEW

The focus in managing asthma has undergone a paradigm shift from the concept of assessing severity to assessing control. The recent Practice Parameter on attaining optimal asthma control highlights the need to titrate the step-care management of asthma to the level of control assessed at each clinic encounter.

RECENT FINDINGS

Recent advances in the monitoring of asthma control in children include the use of questionnaires such as the Childhood Asthma Control Test, use of biomarkers such as fractional concentration of exhaled nitric oxide, sophisticated hand-held electronic monitoring of lung function such as peak flow and forced expiratory volume, indicators of lung growth and bronchial hyper-responsiveness such as post-bronchodilator forced expiratory volume, outcomes-utilization data, markers of atopy, and electronic measures of adherence.

SUMMARY

Three recent proof-of-concept studies in adults have demonstrated the relevance of criteria other than guidelines-recommended asthma symptoms and pulmonary function tests. These studies used airway hyper-responsiveness, sputum eosinophilia, and fraction of exhaled nitric oxide as indices to facilitate fine-tuning of asthma control and use of controller-inhaled steroids. The next logical step would be to determine the applicability of these and other measures to children in both research and clinical settings.

A pilot study on a cognitive-behavioral asthma self-management program for adults

The purpose of our research was to design, implement and evaluate a cognitive-behavioral asthma self-management program for adults. Seventeen adults with asthma completed an eight-week course (two hours, once a week) that consisted of interactive small group discussions and a behavior change procedure. The group discussions were led by a multi-disciplinary faculty (nurse, respiratory therapist, allergist, social worker, psychologist). Following each weekly discussion, participants would attempt to change a behavior related to the discussion. At the following meeting, participants would share their results and get feedback from the group; subsequently a new topic was introduced for discussion and a new behavioral change goal was added at the end of the meeting. Primary outcome measurements included asthma related quality of life, peak flow rate and frequency of key lifestyle behaviors. Outcome analyses indicated statistically significant improvements in frequency of: 1) peak flow monitoring; 2) practicing relaxation; 3) drinking 64 ounces of water a day (P < 0.05). Outcome analyses also indicated statistically significant improvements in quality-of-life (QOL) and asthma knowledge (P < 0.05). These results provide evidence that a cognitive-behavioral asthma education program that incorporates a behavior change procedure with interactive group discussions can lead to both knowledge acquisition and behavioral changes. Such outcomes are essential for reducing asthma morbidity and asthma mortality.

What are the best estimates of pediatric asthma control?

PURPOSE OF REVIEW

To evaluate asthma outcome measures in the face of the variable nature of asthma. The outcome measures are divided into objective and subjective clinical measures, humanistic measures such as quality of life, and costs of asthma control.

RECENT FINDINGS

Objective measures of asthma include those traditionally used such as spirometry, peak expiratory flow rate, and airway hyperresponsiveness. Recently, more attention has been geared towards markers of inflammation including exhaled nitric oxide and sputum eosinophils. Subjective measures of asthma control include patient-derived parameters such as number of wheezing episodes, nocturnal symptoms, exercise-induced symptoms, short-acting beta-agonist use, steroid bursts, emergency-department visits, and hospitalizations. Asthma-related quality of life is related to asthma morbidity, and patients with better baseline quality of life have improved outcomes. Asthma-related costs include direct costs mostly comprised of hospitalizations and emergency-room visits, and indirect costs including school absenteeism.

SUMMARY

There is no ideal outcome measure for evaluating pediatric asthma control, but each of these outcome measures must be used together to evaluate a patient at each outpatient visit. Patient-centered measures of asthma control must also be further incorporated into office visits for improved asthma management.

Disease control in asthmatic children seen in private practice in Switzerland

BACKGROUND

Asthma is the most common chronic childhood disease in Switzerland with a prevalence of 10%. Asthma has a high economic burden accounting for high medical costs. Assessment of disease control is likely to be of help in the implementation of strategies to improve asthma. Therefore, we aimed to evaluate asthma control and therapy regimens among children in private practice.

METHODS

We assessed asthma control as well as therapy regimens in 575 asthmatic children in an experience programme in Switzerland by using an abbreviated questionnaire based on the asthma control questionnaire and the child health questionnaire on Visit 1 and Visit 2.

RESULTS

Good asthma control at Visit 1 was only present in 25.7% of asthmatic children. Occasional asthma symptoms, limitation of physical activity, nocturnal awakening and anxiety of the parent was present in 80.5%, 41.2%, 46.8% and 57% of the children, respectively. After adjustment of therapy regimens at Visit 1, mainly by adding a leukotriene receptor antagonist, asthma control was reported to be much better in 53.4% of the children at Visit 2.

CONCLUSIONS

As asthma control is inadequately achieved within a major portion of asthmatic children, it is imperative to find measures to improve asthma control and hence, to reduce the burden of disease.

The effects of exposure to environmental tobacco smoke on pulmonary function in children undergoing anesthesia for minor surgery

BACKGROUND

The objectives of this study were to assess whether children exposed to environmental tobacco smoke (ETS) present for surgery with poorer pulmonary function, and experience a more pronounced deterioration in pulmonary function following anesthesia and surgery, than non-ETS-exposed children.

METHODS

Fifty-four children aged 5-15 years with a history of ETS exposure from one or both parents and 54 children with no such ETS history were included in the study. All participants were presenting for ambulatory surgery and were judged to conform to American Society of Anesthesiology class I or II. Spirometry was performed preoperatively, postoperatively in the recovery ward when the child met criteria for discharge (Aldrete score 8), and before discharge from the day ward.

RESULTS

The ETS-exposed group had a significantly lower mean preoperative peak expiratory flow rate (PEFR) (9.5 points lower percent predicted, 95% confidence interval -18.1 to -1.0, P = 0.03). Although not statistically significant, they also had lower percent predicted baseline mean values of the other spirometric variables that were measured (forced expiratory volume in 1 s -4.5%, P = 0.07; forced vital capacity -4.1%, P = 0.10; forced expiratory flow between 25% and 75%-3.6%, P = 0.44). Pulmonary function tests (PFTs) performed in recovery were between 8% and 14% worse than preoperative values, but the results were similar in the two groups of children. PFTs performed before hospital discharge demonstrated an near-complete recovery to baseline values. Again the pattern was similar in exposed and nonexposed children.

CONCLUSIONS

Environmental tobacco smoke exposure is associated with lower preoperative PEFR values, but does not impact on recovery from anesthesia for healthy children undergoing ambulatory anesthesia.

Office spirometry in primary care pediatrics: a pilot study

OBJECTIVE

The aim of this study was to investigate the validity of office spirometry in primary care pediatric practices.

METHODS

Ten primary care pediatricians undertook a spirometry training program that was led by 2 pediatric pulmonologists from the Pediatric Department of the University of Padova. After the pediatricians' training, children with asthma or persistent cough underwent a spirometric test in the pediatrician's office and at a pulmonary function (PF) laboratory, in the same day in random order. Both spirometric tests were performed with a portable turbine flow sensor spirometer. We assessed the quality of the spirometric tests and compared a range of PF parameters obtained in the pediatricians' offices and in the PF laboratory according to the Bland and Altman method.

RESULTS

A total of 109 children (mean age: 10.4 years; range: 6-15) were included in the study. Eighty-five (78%) of the spirometric tests that were performed in the pediatricians' offices met all of the acceptability and reproducibility criteria. The 24 unacceptable test results were attributable largely to a slow start and failure to satisfy end-of-test criteria. Only the 85 acceptable spirometric tests were considered for analysis. The agreement between the spirometric tests that were performed in the pediatrician's office and in the PF laboratory was good for the key parameters (forced vital capacity, forced expiratory volume in 1 second, and forced expiratory flow between 25% and 75%). The repeatability coefficient was 0.26 L for forced expiratory volume in 1 second (83 of 85 values fall within this range), 0.30 L for forced vital capacity (81 values fall within this range), and 0.58 L/s for forced expiratory flow between 25% and 75% (82 values fall within this range). In 79% of cases, the primary care pediatricians interpreted the spirometric tests correctly.

CONCLUSIONS

It seems justifiable to perform spirometry in pediatric primary care, but an integrated approach involving both the primary care pediatrician and certified pediatric respiratory medicine centers is recommended because effective training and quality assurance are vital prerequisites for successful spirometry.

Successful withdrawal of inhaled corticosteroids in childhood asthma

OBJECTIVE

Although inhaled corticosteroids are useful and effective in the prophylaxis of childhood asthma, there is a dearth of information regarding the duration of treatment. The present study was undertaken to assess the possibility of successful withdrawal of inhaled corticosteroids in childhood asthma following good control of the disease.

METHODOLOGY

The study was carried out at the Asiri Hospital, Colombo, Sri Lanka and was a prospective observational clinical study. The participants were consecutive children with documented moderately severe and severe asthma seen over a period of 4 years from January 1990 and followed up to December 2003. Patients were allocated randomly to receive either beclomethasone dipropionate or budesonide. Initial dose of the selected drug was 300, 400 or 600 microg/day, depending on the child's age. After a period of stabilization, the dose was reduced from the starting dose to a maintenance level of 200, 300 or 400 microg/day, respectively. Once sustained control had been maintained for a period ranging from 9 to 18 months, gradual withdrawal was attempted. The dosage was reduced by 50-100 microg each time, at intervals of 3 months. Long-term follow up was maintained following withdrawal of inhaled corticosteroids. Breakthrough wheezing, acute severe attacks, hospitalization for wheezing and absence from school were used to assess the response.

RESULTS

Eighty-six children were recruited into the study. Eighty children responded well. The initial period on a high dose of corticosteroid was 8.4 months (range 4-12 months) and the average period of maintenance dosing was 11.7 months (range 9-18 months). The average time taken for withdrawal was 12.6 months (range 9-18 months). Successful withdrawal was achieved in 73 children. In this group, the mean total duration of treatment was 27.4 months (range 20-44 months). Up to December 2003, the subjects had been observed for an average period of 97.1 months (range 86-121 months) following withdrawal of inhaled corticosteroids. Of the 73 children in whom corticosteroids were withdrawn, 57 (78%) have remained well without any episodes of wheezing, and 14 (19%) have had mild episodes of wheezing that were easily controlled by bronchodilators. No patient needed hospitalization, long-term treatment or systemic corticosteroids. In two (3%) patients, it was necessary to restart inhaled corticosteroids because of troublesome recurrences.

CONCLUSION

It is possible to gradually withdraw inhaled corticosteroids in a significant proportion of asthmatic children once good control has been sustained on a maintenance dose for a considerable period.

The need for standardisation of peak flow charts

Peak expiratory flow (PEF) monitoring is recommended in asthma guidelines as a tool for assessing severity, monitoring response to treatment, detecting exacerbations, identifying triggers, and providing objective justification for treatment to the patient, but some clinicians have expressed concerns about its relevance in the management of asthma. We have identified a sevenfold variation in the scale of existing PEF charts, with resulting wide variation in the appearance of the same PEF date on different charts. There is an obvious need for standardisation of PEF charts to avoid confusion for patients and to allow development of pattern recognition skills by clinicians. Evidence is provided from visual perception studies to suggest that preference should be given to a horizontally compressed PEF chart to facilitate identification of exacerbations and of overall trends, but this needs to be formally evaluated by retrospective and prospective studies. It is hoped that clinical expertise in PEF pattern recognition can eventually be incorporated into electronic decision making algorithms, as has occurred in occupational asthma, but, in the meantime, the ideal PEF chart for asthma management will represent a compromise between ease of manual data entry and ease of interpretation.

The use of spirometers and peak flow meters in the diagnosis and management of asthma among Spanish pediatricians. Results from the TRAP study

The objective of this study was to determine the level of adherence of pediatricians in Spain to the Spanish National Guidelines for Asthma Treatment with regard to the use of a peak flow meter (PEFR) or a spirometer in the diagnosis and management of asthma in childhood and to analyze sources of variations in these practices. A prospective survey (consisting of demographic and asthma knowledge sections) was conducted over a 2-wk time interval of 3000 pediatricians throughout the country. At least one part of the questionnaire was completed and returned by 2773 individuals (92.4%), with 2347 (78.2%) answering both sections; results are for this population. Around 62% of the pediatricians reported having a peak flow meter or a spirometer in their office; however, only 33% and 48% of them used the devices for the diagnosis and treatment of asthma, respectively. There was a significant association between being older (36-55 yr old) and using PEFR or spirometry for the diagnosis (OR: 1.35, 95% CI 1.11-1.66) and the management (OR 1.47, 95% CI 1.22-1.77) of asthma. Males used a peak flow meter or a spirometer more often than females for the diagnosis (37.8% vs. 30.9%, p = 0.001) and management of asthma (52.0% vs. 45.6%, p = 0.008). Pediatricians with formal pediatric residence training used these devices more for the diagnosis (OR: 1.39, 95% CI 1.09-1.75) and management (OR: 1.58, 95% CI 1.27-1.96) than those without. Working in a hospital was also related with more peak flow meter or spirometer use than working in health centers (OR: 2.08, 95% CI 1.71-2.54 for diagnosis; OR: 1.83, 95% CI 1.50-2.22 for management). About one-third of the Spanish pediatricians surveyed use spirometers and/or peak flow meters for diagnosing asthma and about half use one of these devices occasionally for managing the disease. Independent factors favoring their use are: age 36-55 yr, male gender, working in a hospital setting, and having been trained in a formal pediatric residence program.

Peak flow monitoring for guided self-management in childhood asthma: a randomized controlled trial

We asked whether the addition of PEF recordings to a symptom-based self-management plan improved outcome in school children with asthma. In an open-randomized, parallel-group, controlled trial, we studied children aged 7-14 years with moderate asthma. After a 4-week run-in, 90 children were randomized to receive either PEF plus symptom-based management or symptom-based management alone for 12 weeks. Thresholds for action based on PEF were 70% of best (for increasing inhaled steroids) and 50% of best (for commencing prednisolone). Children were asked to perform twice-daily spirometry at home (using an electronic recording spirometer that revealed only PEF to the study group alone) and to record a symptom diary. The mean daily symptom score was the main outcome. There were no differences between groups in mean symptom score or in spirometric lung function, PEF, quality of life score, or reported use of health services over 12 weeks. During acute episodes, children responded to changes in symptoms by increasing their inhaled steroids at a mean value of PEF of greater than 70% of best so that overall PEF did not contribute to this important self-management decision. Knowledge of PEF did not enhance self-management even during acute exacerbations.