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Lee B, Turner S, Borland M, Csonka P, Grigg J, Guilbert TW, Jartti T, Oommen A, Twynam-Perkins J, Lewis S, Cunningham S. Efficacy of oral corticosteroids for acute preschool wheeze: a systematic review and individual participant data meta-analysis of randomised clinical trials. THE LANCET. RESPIRATORY MEDICINE 2024; 12:444-456. [PMID: 38527486 DOI: 10.1016/s2213-2600(24)00041-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/18/2023] [Revised: 02/12/2024] [Accepted: 02/14/2024] [Indexed: 03/27/2024]
Abstract
BACKGROUND Oral corticosteroids are commonly used for acute preschool wheeze, although there is conflicting evidence of their benefit. We assessed the clinical efficacy of oral corticosteroids by means of a systematic review and individual participant data (IPD) meta-analysis. METHODS In this systematic review with IPD meta-analysis, we systematically searched eight databases (PubMed, Ovid Embase, CINAHLplus, CENTRAL, ClinicalTrials.gov, EudraCT, EU Clinical Trials Register, WHO Clinical Trials Registry) for randomised clinical trials published from Jan 1, 1994, to June 30, 2020, comparing oral corticosteroids with placebo in children aged 12 to 71 months with acute preschool wheeze in any setting based on the Population, Intervention, Comparison, Outcomes framework. We contacted principal investigators of eligible studies to obtain deidentified individual patient data. The primary outcome was change in wheezing severity score (WSS). A key secondary outcome length of hospital stay. We also calculated a pooled estimate of six commonly reported adverse events in the follow-up period of IPD datasets. One-stage and two-stage meta-analyses employing a random-effects model were used. This study is registered with PROSPERO, CRD42020193958. FINDINGS We identified 16 102 studies published between Jan 1, 1994, and June 30, 2020, from which there were 12 eligible trials after deduplication and screening. We obtained individual data from seven trials comprising 2172 children, with 1728 children in the eligible IPD age range; 853 (49·4%) received oral corticosteroids (544 [63·8%] male and 309 [36·2%] female) and 875 (50·6%) received placebo (583 [66·6%] male and 292 [33·4%] female). Compared with placebo, a greater change in WSS at 4 h was seen in the oral corticosteroids group (mean difference -0·31 [95% CI -0·38 to -0·24]; p=0·011) but not 12 h (-0·02 [-0·17 to 0·14]; p=0·68), with low heterogeneity between studies (I2=0%; τ2<0·001). Length of hospital stay was significantly reduced in the oral corticosteroids group (-3·18 h [-4·43 to -1·93]; p=0·0021; I2=0%; τ2<0·001). Subgroup analyses showed that this reduction was greatest in those with a history of wheezing or asthma (-4·54 h [-5·57 to -3·52]; pinteraction=0·0007). Adverse events were infrequently reported (four of seven datasets), but oral corticosteroids were associated with an increased risk of vomiting (odds ratio 2·27 [95% CI 0·87 to 5·88]; τ2<0·001). Most datasets (six of seven) had a low risk of bias. INTERPRETATION Oral corticosteroids reduce WSS at 4 h and length of hospital stay in children with acute preschool wheeze. In those with a history of previous wheeze or asthma, oral corticosteroids provide a potentially clinically relevant effect on length of hospital stay. FUNDING Asthma UK Centre for Applied Research.
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Affiliation(s)
- Bohee Lee
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK.
| | - Steve Turner
- Royal Aberdeen Children's Hospital, NHS Grampian, Aberdeen, UK
| | - Meredith Borland
- Perth Children's Hospital Emergency Department and Divisions of Paediatrics and Emergency Medicine, School of Medicine, University of Western Australia, WA, Australia
| | - Péter Csonka
- Tampere Center for Child, Adolescent and Maternal Health Research, Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland; Terveystalo Healthcare, Tampere, Finland
| | - Jonathan Grigg
- Centre for Genomics and Child Health, Queen Mary University of London, London, UK
| | - Theresa W Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Department of Pediatrics, University of Cincinnati, Cincinnati, OH, USA
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku, Finland; PEDEGO Research Unit, University of Oulu, Oulu, Finland; Department of Pediatrics, Oulu University Hospital, Oulu, Finland
| | - Abraham Oommen
- Department of Paediatrics, Milton Keynes University Hospital NHS Trust, Milton Keynes, UK
| | - Jonathan Twynam-Perkins
- Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK; Department of Paediatric Respiratory and Sleep Medicine, Royal Hospital for Children and Young People, Edinburgh, UK
| | - Steff Lewis
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Usher Institute, and Edinburgh Clinical Trials Unit, University of Edinburgh, Edinburgh, UK
| | - Steve Cunningham
- Asthma UK Centre for Applied Research, Centre for Population Health Sciences, University of Edinburgh, Edinburgh, UK; Department of Child Life and Health, Centre for Inflammation Research, University of Edinburgh, Edinburgh, UK
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Neeland MR, Gubbels L, Wong ATC, Walker H, Ranganathan SC, Shanthikumar S. Pulmonary immune profiling reveals common inflammatory endotypes of childhood wheeze and suppurative lung disease. Mucosal Immunol 2024; 17:359-370. [PMID: 38492745 DOI: 10.1016/j.mucimm.2024.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/01/2024] [Accepted: 03/05/2024] [Indexed: 03/18/2024]
Abstract
Suppurative lung disease and wheezing are common respiratory diseases of childhood, however, due to poor understanding of underlying pathobiology, there are limited treatment options and disease recurrence is common. We aimed to profile the pulmonary and systemic immune response in children with wheeze and chronic suppurative lung disease for identification of endotypes that can inform improved clinical management. We used clinical microbiology data, highly multiplexed flow cytometry and immunoassays to compare pulmonary [bronchoalveolar lavage (BAL)] and systemic immunity in children with lung disease and controls. Unsupervised analytical approaches were applied to BAL immune data to explore biological endotypes. We identified two endotypes that were analogous in both frequency and immune signature across both respiratory diseases. The hyper-inflammatory endotype had a 12-fold increase in neutrophil infiltration and upregulation of 14 soluble signatures associated with type 2 inflammation and cell recruitment to tissue. The non-inflammatory endotype was not significantly different from controls. We showed these endotypes are measurable in a clinical setting and can be defined by measuring only three immune factors in BAL. We identified hyper-inflammatory and non-inflammatory endotypes common across pediatric wheeze and chronic suppurative lung disease that, if validated in future studies, have the potential to inform clinical management.
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Affiliation(s)
- Melanie R Neeland
- Infection, Immunity and Global Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia.
| | - Liam Gubbels
- Infection, Immunity and Global Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia
| | - Anson Tsz Chun Wong
- Infection, Immunity and Global Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia
| | - Hannah Walker
- Infection, Immunity and Global Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia; Children's Cancer Centre, Royal Children's Hospital, Parkville, Australia
| | - Sarath C Ranganathan
- Infection, Immunity and Global Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia; Respiratory and Sleep Medicine, Royal Children's Hospital, Parkville, Australia
| | - Shivanthan Shanthikumar
- Infection, Immunity and Global Health Theme, Murdoch Children's Research Institute, Royal Children's Hospital, Parkville, Australia; Department of Paediatrics, University of Melbourne, Parkville, Australia; Respiratory and Sleep Medicine, Royal Children's Hospital, Parkville, Australia
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3
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Saglani S. Preventing progression of preschool wheezing to asthma: Opportunities for intervention. Pediatr Allergy Immunol 2024; 35:e14180. [PMID: 38899625 DOI: 10.1111/pai.14180] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2024] [Revised: 06/04/2024] [Indexed: 06/21/2024]
Abstract
Recurrent wheezing in preschool children is heterogeneous and results from numerous genetic and environmental risk factors, which result in the same final clinical manifestation of acute episodes of wheezing but have distinct underlying mechanisms. Effective disease-modifying approaches, therefore, need to target the pathways driving the symptoms. We have good evidence to show that targeting airway eosinophilia alone in early-life preschool wheezing and using inhaled corticosteroids is not disease-modifying. Although airway remodelling develops early in preschool wheezing, the challenge is identifying suitable treatments for structural airway changes. There is increasing evidence for the role of lower airway bacterial infection contributing to wheeze episodes, but clinical trials investigating the impact of targeted antibiotic treatment on disease modification are needed. There is also increasing data supporting an association between lower airway neutrophilia and wheezing in a subgroup of preschool children, but direct causation and the role of neutrophil function remain unknown. Finally, there is encouraging preliminary data for the role of inactivated mixed bacterial lysates in children with non-allergic, infection-associated wheeze episodes, but the impact on longer-term outcomes and their mechanism of action is unknown. This review outlines a range of potential novel targets and approaches that may enable secondary prevention of asthma from preschool wheezing. In parallel, the potential for harm when interventions are introduced indiscriminately is highlighted. Some of the challenges that need to be addressed, including trial designs allowing tailored interventions, the need for non-invasive biomarkers for targeted interventions, and ensuring extended and long-term follow-up after intervention, are highlighted.
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Affiliation(s)
- Sejal Saglani
- National Heart & Lung Institute, Imperial Biomedical Research Centre and Imperial Centre for Paediatrics & Child Health, Imperial College London, London, UK
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4
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O' Hagan S, Norman-Bruce H, Shields M, Groves HE. Role of oral corticosteroids in the treatment of acute preschool wheeze. Arch Dis Child 2024:archdischild-2023-326786. [PMID: 38649255 DOI: 10.1136/archdischild-2023-326786] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 04/10/2024] [Indexed: 04/25/2024]
Affiliation(s)
- Shaun O' Hagan
- Paediatric Infectious Diseases, Royal Belfast Hospital for Sick Children, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Hannah Norman-Bruce
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
| | - Michael Shields
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
- Paediatric Respiratory Medicine, Royal Belfast Hospital for Sick Children, Belfast, Belfast, UK
| | - Helen Elizabeth Groves
- Paediatric Infectious Diseases, Royal Belfast Hospital for Sick Children, Belfast, UK
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast School of Medicine, Belfast, UK
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5
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Makrinioti H, Zhu Z, Saglani S, Camargo CA, Hasegawa K. Infant Bronchiolitis Endotypes and the Risk of Developing Childhood Asthma: Lessons From Cohort Studies. Arch Bronconeumol 2024; 60:215-225. [PMID: 38569771 DOI: 10.1016/j.arbres.2024.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2023] [Revised: 02/08/2024] [Accepted: 02/14/2024] [Indexed: 04/05/2024]
Abstract
Severe bronchiolitis (i.e., bronchiolitis requiring hospitalization) during infancy is a heterogeneous condition associated with a high risk of developing childhood asthma. Yet, the exact mechanisms underlying the bronchiolitis-asthma link remain uncertain. Birth cohort studies have reported this association at the population level, including only small groups of patients with a history of bronchiolitis, and have attempted to identify the underlying biological mechanisms. Although this evidence has provided valuable insights, there are still unanswered questions regarding severe bronchiolitis-asthma pathogenesis. Recently, a few bronchiolitis cohort studies have attempted to answer these questions by applying unbiased analytical approaches to biological data. These cohort studies have identified novel bronchiolitis subtypes (i.e., endotypes) at high risk for asthma development, representing essential and enlightening evidence. For example, one distinct severe respiratory syncytial virus (RSV) bronchiolitis endotype is characterized by the presence of Moraxella catarrhalis and Streptococcus pneumoniae, higher levels of type I/II IFN expression, and changes in carbohydrate metabolism in nasal airway samples, and is associated with a high risk for childhood asthma development. Although these findings hold significance for the design of future studies that focus on childhood asthma prevention, they require validation. However, this scoping review puts the above findings into clinical context and emphasizes the significance of future research in this area aiming to offer new bronchiolitis treatments and contribute to asthma prevention.
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Affiliation(s)
- Heidi Makrinioti
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
| | - Zhaozhong Zhu
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Kohei Hasegawa
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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6
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Custovic A, Custovic D, Fontanella S. Understanding the heterogeneity of childhood allergic sensitization and its relationship with asthma. Curr Opin Allergy Clin Immunol 2024; 24:79-87. [PMID: 38359101 PMCID: PMC10906203 DOI: 10.1097/aci.0000000000000967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW To review the current state of knowledge on the relationship between allergic sensitization and asthma; to lay out a roadmap for the development of IgE biomarkers that differentiate, in individual sensitized patients, whether their sensitization is important for current or future asthma symptoms, or has little or no relevance to the disease. RECENT FINDINGS The evidence on the relationship between sensitization and asthma suggests that some subtypes of allergic sensitization are not associated with asthma symptoms, whilst others are pathologic. Interaction patterns between IgE antibodies to individual allergenic molecules on component-resolved diagnostics (CRD) multiplex arrays might be hallmarks by which different sensitization subtypes relevant to asthma can be distinguished. These different subtypes of sensitization are associated amongst sensitized individuals at all ages, with different clinical presentations (no disease, asthma as a single disease, and allergic multimorbidity); amongst sensitized preschool children with and without lower airway symptoms, with different risk of subsequent asthma development; and amongst sensitized patients with asthma, with differing levels of asthma severity. SUMMARY The use of machine learning-based methodologies on complex CRD data can help us to design better diagnostic tools to help practising physicians differentiate between benign and clinically important sensitization.
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Affiliation(s)
- Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
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Mishra PE, Melén E, Koppelman GH, Celedón JC. T2-low asthma in school-aged children: unacknowledged and understudied. THE LANCET. RESPIRATORY MEDICINE 2023; 11:1044-1045. [PMID: 38030372 DOI: 10.1016/s2213-2600(23)00369-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 09/15/2023] [Accepted: 09/21/2023] [Indexed: 12/01/2023]
Affiliation(s)
- Pooja E Mishra
- Division of Pediatric Pulmonary Medicine, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA
| | - Erik Melén
- Department of Clinical Science and Education, Karolinska Institute, Stockholm, Sweden; Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Gerard H Koppelman
- University of Groningen, University Medical Center Groningen, Beatrix Children's Hospital, Department of Pediatric Pulmonology and Pediatric Allergology and GRIAC Research Institute, Groningen, The Netherlands
| | - Juan C Celedón
- Division of Pediatric Pulmonary Medicine, University of Pittsburgh, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA 15224, USA.
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Fitzpatrick AM, Mohammad AF, Huang M, Stephenson ST, Patrignani J, Kamaleswaran R, Grunwell JR. Functional immunophenotyping of blood neutrophils identifies novel endotypes of viral response in preschool children with recurrent wheezing. J Allergy Clin Immunol 2023; 152:1433-1443. [PMID: 37604313 PMCID: PMC10841272 DOI: 10.1016/j.jaci.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/07/2023] [Accepted: 08/15/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND Preschool children with recurrent wheezing are heterogeneous, with differing responses to respiratory viral infections. Although neutrophils are crucial for host defense, their function has not been studied in this population. OBJECTIVE We performed functional immunophenotyping on isolated blood neutrophils from 52 preschool children with recurrent wheezing (aeroallergen sensitization, n = 16; no sensitization, n = 36). METHODS Blood neutrophils were purified and cultured overnight with polyinosinic:polycytidylic acid [poly(I:C)] as a viral analog stimulus. Neutrophils underwent next-generation sequencing with Reactome pathway analysis and were analyzed for cytokine secretion, apoptosis, myeloperoxidase, and extracellular DNA release. CD14+ monocytes were also exposed to neutrophil culture supernatant and analyzed for markers of M1 and M2 activation. RESULTS A total of 495 genes, related largely to the innate immune system and neutrophil degranulation, were differently expressed in children with versus without aeroallergen sensitization. Functional experiments identified more neutrophil degranulation and extracellular trap formation (ie, more myeloperoxidase and extracellular DNA) and less neutrophil proinflammatory cytokine secretion in children with aeroallergen sensitization. Neutrophils also shifted CD14+ monocytes to a more anti-inflammatory (ie, M2) phenotype in sensitized children and a more proinflammatory (ie, M1) phenotype in nonsensitized children. Although both groups experienced viral exacerbations, annualized exacerbation rates prompting unscheduled health care were also higher in children without aeroallergen sensitization after enrollment. CONCLUSIONS Systemic neutrophil responses to viral infection differ by allergic phenotype and may be less effective in preschool children without allergic inflammation. Further studies of neutrophil function are needed in this population, which often has less favorable therapeutic responses to inhaled corticosteroids and other therapies directed at type 2-high inflammation.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | | | - Min Huang
- Department of Biomedical Informatics, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
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Donath H, Klenner H, Hutter M, Meoli A, Trischler J, Schulze J, Blumchen K, Zielen S. Severe bronchial hyperresponsiveness along with house dust mite allergy indicates persistence of asthma in young children. Pediatr Allergy Immunol 2023; 34:e14047. [PMID: 38146109 DOI: 10.1111/pai.14047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Revised: 10/26/2023] [Accepted: 11/01/2023] [Indexed: 12/27/2023]
Abstract
BACKGROUND Significant risk factors for persistence of asthma later in life are family history of allergies, early allergic sensitization and bronchial hyperresponsiveness (BHR). The evolution of BHR in young children without allergic sensitization and with house dust mite allergy (HDM) was investigated. METHODS In this retrospective analysis, electronic charts of 4850 young children with asthma and wheezy bronchitis between 2005 and 2018 were reviewed in order to study all patients ≤6 years with BHR assessed by methacholine provocation tests (MCT) at least once (n = 1175). Patients with more than two follow-up measurements were divided in group 1 (no allergic sensitization; n = 110) and group 2 (HDM allergy; n = 88). Additionally, skin prick test, exhaled nitrite oxide (eNO), and asthma treatment were analyzed. RESULTS Forty-seven patients of group 1 aged median 4.3 years and 48 patients of group 2 aged median 4.7 years showed initially severe BHR <0.1 mg. At follow-up, patients with HDM were more likely to show persistence of severe BHR than non-sensitized patients (severe BHR group 1: n = 5 (10.6%) vs. group 2: n = 21 (43.8%), p < .001). In addition, 89.4% of group 1 had mild to moderate or no BHR, compared to only 56.2% of group 2. There was a significant difference in eN0 (median group 1: 9 ppb vs. group 2: 26 ppb, p < .001), at last follow-up. Age, sex, and asthma therapy had no effect on BHR. CONCLUSION In young children without sensitization BHR normalizes, whereas HDM allergy indicates a persistence of asthma beyond infancy.
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Affiliation(s)
- Helena Donath
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Hans Klenner
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Martin Hutter
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Aniello Meoli
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Jordis Trischler
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Johannes Schulze
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Katharina Blumchen
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
| | - Stefan Zielen
- Department of Pediatrics, Division of Pneumology, Allergology, Infectious Diseases and Gastroenterology, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt, Germany
- Institute for Respiratory Diseases, Medaimun GmbH, Frankfurt, Germany
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Custovic D, Fontanella S, Custovic A. Understanding progression from pre-school wheezing to school-age asthma: Can modern data approaches help? Pediatr Allergy Immunol 2023; 34:e14062. [PMID: 38146116 DOI: 10.1111/pai.14062] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 12/27/2023]
Abstract
Preschool wheezing and childhood asthma create a heavy disease burden which is only exacerbated by the complexity of the conditions. Preschool wheezing exhibits both "curricular" and "aetiological" heterogeneity: that is, heterogeneity across patients both in the time-course of its development and in its underpinning pathological mechanisms. Since these are not fully understood, but clinical presentations across patients may nonetheless be similar, current diagnostic labels are imprecise-not mapping cleanly onto underlying disease mechanisms-and prognoses uncertain. These uncertainties also make a identifying new targets for therapeutic intervention difficult. In the past few decades, carefully designed birth cohort studies have collected "big data" on a large scale, incorporating not only a wealth of longitudinal clinical data, but also detailed information from modalities as varied as imaging, multiomics, and blood biomarkers. The profusion of big data has seen the proliferation of what we term "modern data approaches" (MDAs)-grouping together machine learning, artificial intelligence, and data science-to make sense and make use of this data. In this review, we survey applications of MDAs (with an emphasis on machine learning) in childhood wheeze and asthma, highlighting the extent of their successes in providing tools for prognosis, unpicking the curricular heterogeneity of these conditions, clarifying the limitations of current diagnostic criteria, and indicating directions of research for uncovering the etiology of the diseases underlying these conditions. Specifically, we focus on the trajectories of childhood wheeze phenotypes. Further, we provide an explainer of the nature and potential use of MDAs and emphasize the scope of what we can hope to achieve with them.
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Affiliation(s)
- Darije Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
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van Beveren GJ, Said H, van Houten MA, Bogaert D. The respiratory microbiome in childhood asthma. J Allergy Clin Immunol 2023; 152:1352-1367. [PMID: 37838221 DOI: 10.1016/j.jaci.2023.10.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/27/2023] [Accepted: 10/04/2023] [Indexed: 10/16/2023]
Abstract
Asthma is the most prevalent noncommunicable disease in childhood, characterized by reversible airway constriction and inflammation of the lower airways. The respiratory tract consists of the upper and lower airways, which are lined with a diverse community of microbes. The composition and density of the respiratory microbiome differs across the respiratory tract, with microbes adapting to the gradually changing physiology of the environment. Over the past decade, both the upper and lower respiratory microbiomes have been implicated in the etiology and disease course of asthma, as well as in its severity and phenotype. We have reviewed the literature on the role of the respiratory microbiome in asthma, making a careful distinction between the relationship of the microbiome with development of childhood asthma and its relationship with the disease course, while accounting for age and the microbial niches studied. Furthermore, we have assessed the literature regarding the underlying asthma endotypes and the impact of the microbiome on the host immune response. We have identified distinct microbial signatures across the respiratory tract associated with asthma development, stability, and severity. These data suggest that the respiratory microbiome may be important for asthma development and severity and may therefore be a potential target for future microbiome-based preventive and treatment strategies.
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Affiliation(s)
- Gina J van Beveren
- Spaarne Gasthuis Academy, Hoofddorp and Haarlem, Hoofddorp, The Netherlands; Department of Paediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands
| | - Hager Said
- Department of Pediatrics, Spaarne Gasthuis Haarlem
| | - Marlies A van Houten
- Spaarne Gasthuis Academy, Hoofddorp and Haarlem, Hoofddorp, The Netherlands; Department of Pediatrics, Spaarne Gasthuis Haarlem
| | - Debby Bogaert
- Department of Paediatric Immunology and Infectious Diseases, Wilhelmina Children's Hospital/University Medical Center Utrecht, Utrecht, The Netherlands; Centre for Inflammation Research, Queen's Medical Research Institute, University of Edinburgh, Edinburgh, United Kingdom.
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12
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van Breugel M, Fehrmann RSN, Bügel M, Rezwan FI, Holloway JW, Nawijn MC, Fontanella S, Custovic A, Koppelman GH. Current state and prospects of artificial intelligence in allergy. Allergy 2023; 78:2623-2643. [PMID: 37584170 DOI: 10.1111/all.15849] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/08/2023] [Accepted: 07/31/2023] [Indexed: 08/17/2023]
Abstract
The field of medicine is witnessing an exponential growth of interest in artificial intelligence (AI), which enables new research questions and the analysis of larger and new types of data. Nevertheless, applications that go beyond proof of concepts and deliver clinical value remain rare, especially in the field of allergy. This narrative review provides a fundamental understanding of the core concepts of AI and critically discusses its limitations and open challenges, such as data availability and bias, along with potential directions to surmount them. We provide a conceptual framework to structure AI applications within this field and discuss forefront case examples. Most of these applications of AI and machine learning in allergy concern supervised learning and unsupervised clustering, with a strong emphasis on diagnosis and subtyping. A perspective is shared on guidelines for good AI practice to guide readers in applying it effectively and safely, along with prospects of field advancement and initiatives to increase clinical impact. We anticipate that AI can further deepen our knowledge of disease mechanisms and contribute to precision medicine in allergy.
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Affiliation(s)
- Merlijn van Breugel
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- MIcompany, Amsterdam, the Netherlands
| | - Rudolf S N Fehrmann
- Department of Medical Oncology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Faisal I Rezwan
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- Department of Computer Science, Aberystwyth University, Aberystwyth, UK
| | - John W Holloway
- Human Development and Health, Faculty of Medicine, University of Southampton, Southampton, UK
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, UK
| | - Martijn C Nawijn
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Department of Pathology and Medical Biology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, UK
- National Institute for Health and Care Research Imperial Biomedical Research Centre (BRC), London, UK
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
- National Institute for Health and Care Research Imperial Biomedical Research Centre (BRC), London, UK
| | - Gerard H Koppelman
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children's Hospital, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
- Groningen Research Institute for Asthma and COPD (GRIAC), University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
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13
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Chatziparasidis G, Bush A, Chatziparasidi MR, Kantar A. Airway epithelial development and function: A key player in asthma pathogenesis? Paediatr Respir Rev 2023; 47:51-61. [PMID: 37330410 DOI: 10.1016/j.prrv.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/07/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
Though asthma is a common and relatively easy to diagnose disease, attempts at primary or secondary prevention, and cure, have been disappointing. The widespread use of inhaled steroids has dramatically improved asthma control but has offered nothing in terms of altering long-term outcomes or reversing airway remodeling and impairment in lung function. The inability to cure asthma is unsurprising given our limited understanding of the factors that contribute to disease initiation and persistence. New data have focused on the airway epithelium as a potentially key factor orchestrating the different stages of asthma. In this review we summarize for the clinician the current evidence on the central role of the airway epithelium in asthma pathogenesis and the factors that may alter epithelial integrity and functionality.
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Affiliation(s)
- Grigorios Chatziparasidis
- Paediatric Respiratory Unit, IASO Hospital, Larissa, Thessaly, Greece; Faculty of Nursing, Thessaly University, Greece.
| | - Andrew Bush
- National Heart and Lung Institute, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | | | - Ahmad Kantar
- Pediatric Asthma and Cough Centre, Instituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
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14
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Foppiano F, Schaub B. Childhood asthma phenotypes and endotypes: a glance into the mosaic. Mol Cell Pediatr 2023; 10:9. [PMID: 37646843 PMCID: PMC10469115 DOI: 10.1186/s40348-023-00159-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2023] [Accepted: 07/10/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND Asthma is an inflammatory lung disease that constitutes the most common noncommunicable chronic disease in childhood. Childhood asthma shows large heterogeneity regarding onset of disease, symptoms, severity, prognosis, and response to therapy. MAIN BODY Evidence suggests that this variability is due to distinct pathophysiological mechanisms, which has led to an exhaustive research effort to understand and characterize these distinct entities currently designated as "endotypes." Initially, studies focused on identifying specific groups using clinical variables yielding different "clinical phenotypes." In addition, the identification of specific patterns based on inflammatory cell counts and cytokine data has resulted in "inflammatory endotypes." More recently, an increasing number of molecular data from high-throughput technology ("omics" data) have allowed to investigate more complex "molecular endotypes." CONCLUSION A better definition and comprehension of childhood asthma heterogeneity is key for improving diagnosis and treatment. This review aims at summarizing the current knowledge on this topic and discusses some limitations in their application as well as recommendations for future studies.
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Affiliation(s)
- Francesco Foppiano
- Department of Pulmonary and Allergy, Dr. Von Hauner Children's Hospital, LMU Munich, 80337, Munich, Germany
| | - Bianca Schaub
- Department of Pulmonary and Allergy, Dr. Von Hauner Children's Hospital, LMU Munich, 80337, Munich, Germany.
- German Lung Centre (DZL), CPC-Munich, 80337, Munich, Germany.
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15
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Lloyd CM, Saglani S. Early-life respiratory infections and developmental immunity determine lifelong lung health. Nat Immunol 2023; 24:1234-1243. [PMID: 37414905 DOI: 10.1038/s41590-023-01550-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Accepted: 06/06/2023] [Indexed: 07/08/2023]
Abstract
Respiratory infections are common in infants and young children. However, the immune system develops and matures as the child grows, thus the effects of infection during this time of dynamic change may have long-term consequences. The infant immune system develops in conjunction with the seeding of the microbiome at the respiratory mucosal surface, at a time that the lungs themselves are maturing. We are now recognizing that any disturbance of this developmental trajectory can have implications for lifelong lung health. Here, we outline our current understanding of the molecular mechanisms underlying relationships between immune and structural cells in the lung with the local microorganisms. We highlight the importance of gaining greater clarity as to what constitutes a healthy respiratory ecosystem and how environmental exposures influencing this network will aid efforts to mitigate harmful effects and restore lung immune health.
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Affiliation(s)
- Clare M Lloyd
- National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK.
| | - Sejal Saglani
- National Heart and Lung Institute, Faculty of Medicine, Imperial College, London, UK.
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16
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Salehian S, Fleming L, Saglani S, Custovic A. Phenotype and endotype based treatment of preschool wheeze. Expert Rev Respir Med 2023; 17:853-864. [PMID: 37873657 DOI: 10.1080/17476348.2023.2271832] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 10/13/2023] [Indexed: 10/25/2023]
Abstract
INTRODUCTION Preschool wheeze (PSW) is a significant public health issue, with a high presentation rate to emergency departments, recurrent symptoms, and severe exacerbations. A heterogenous condition, PSW comprises several phenotypes that may relate to a range of pathobiological mechanisms. However, treating PSW remains largely generalized to inhaled corticosteroids and a short acting beta agonist, guided by symptom-based labels that often do not reflect underlying pathways of disease. AREAS COVERED We review the observable features and characteristics used to ascribe phenotypes in children with PSW and available pathobiological evidence to identify possible endotypes. These are considered in the context of treatment options and future research directions. The role of machine learning (ML) and modern analytical techniques to identify patterns of disease that distinguish phenotypes is also explored. EXPERT OPINION Distinct clusters (phenotypes) of severe PSW are characterized by different underlying mechanisms, some shared and some unique. ML-based methodologies applied to clinical, biomarker, and environmental data can help design tools to differentiate children with PSW that continues into adulthood, from those in whom wheezing resolves, identifying mechanisms underpinning persistence and resolution. This may help identify novel therapeutic targets, inform mechanistic studies, and serve as a foundation for stratification in future interventional therapeutic trials.
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Affiliation(s)
- Sormeh Salehian
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Adnan Custovic
- NIHR Imperial Biomedical Research Centre (BRC), London, UK
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17
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Bush A. Basic clinical management of preschool wheeze. Pediatr Allergy Immunol 2023; 34:e13988. [PMID: 37492909 DOI: 10.1111/pai.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
Preschool wheeze is very common and often difficult to treat. Most children do not require any investigations; only a detailed history and physical examination to ensure an alternative diagnosis is not being missed; and the differential diagnosis, and hence investigation protocols for the child in whom a major illness is suspected, shows geographical variation. The pattern of symptoms may be divided into episodic viral and multiple trigger to guide treatment, but the pattern of symptoms must be re-assessed regularly. However, symptom patterns are a poor guide to underlying pathology. Attention to the proper use of spacers, and adverse environmental exposures such as tobacco smoke exposure, is essential. There are no disease-modifying therapies, so therapy is symptomatic. This paper reviews recent advances in treatment, including new data on the place of leukotriene receptor antagonists, prednisolone for acute attacks of wheeze, and antibiotics, based on new attempts to understand the underlying pathology in a way that is clinically practical.
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Affiliation(s)
- Andrew Bush
- Imperial College, London, UK
- National Heart and Lung Institute, London, UK
- Royal Brompton Harefield NHS Foundation Trust, London, UK
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18
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Smith FM, Saglani S. Demystifying controversies in preschool wheeze. Expert Rev Respir Med 2023; 17:1023-1031. [PMID: 37979137 DOI: 10.1080/17476348.2023.2283128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 11/09/2023] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Wheezing disorders in preschool children are common. Current treatment approaches assume all preschool wheezers are the same and will respond to a short course of oral corticosteroids (OCS) during acute attacks and subsequent maintenance inhaled corticosteroids (ICS) to prevent future attacks. But we have increasing evidence showing preschool wheezing disorders are markedly heterogeneous and the response to corticosteroids either during acute attacks or as maintenance therapy can be variable between patients and is determined by disease severity and underlying pathological phenotype. AREAS COVERED The aim of this review is to discuss recent evidence which will help to explain a few critical pathophysiological concepts that are often misunderstood, thus helping to demystify the controversies that often surround preschool wheezing disorders and can contribute to ineffective management. EXPERT OPINION Preschool wheezing disorders are distinct from school-age allergic asthma. There is little evidence to support the use of oral corticosteroids for acute attacks. A staged approach to confirm the diagnosis, and objective tests to determine the pathological phenotype of preschool wheeze is essential prior to initiating maintenance therapy to control symptoms and prevent attacks in children with recurrent preschool wheeze.
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Affiliation(s)
- Frank M Smith
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
- National Heart & Lung Institute, Imperial College London, London, UK
- Imperial Centre for Paediatrics and Child Health, Imperial College London, London, UK
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19
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Scotney E, Fleming L, Saglani S, Sonnappa S, Bush A. Advances in the pathogenesis and personalised treatment of paediatric asthma. BMJ MEDICINE 2023; 2:e000367. [PMID: 37841968 PMCID: PMC10568124 DOI: 10.1136/bmjmed-2022-000367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Accepted: 05/05/2023] [Indexed: 10/17/2023]
Abstract
The diversity of pathology of severe paediatric asthma demonstrates that the one-size-fits-all approach characterising many guidelines is inappropriate. The term "asthma" is best used to describe a clinical syndrome of wheeze, chest tightness, breathlessness, and sometimes cough, making no assumptions about underlying pathology. Before personalising treatment, it is essential to make the diagnosis correctly and optimise basic management. Clinicians must determine exactly what type of asthma each child has. We are moving from describing symptom patterns in preschool wheeze to describing multiple underlying phenotypes with implications for targeting treatment. Many new treatment options are available for school age asthma, including biological medicines targeting type 2 inflammation, but a paucity of options are available for non-type 2 disease. The traditional reliever treatment, shortacting β2 agonists, is being replaced by combination inhalers containing inhaled corticosteroids and fast, longacting β2 agonists to treat the underlying inflammation in even mild asthma and reduce the risk of asthma attacks. However, much decision making is still based on adult data extrapolated to children. Better inclusion of children in future research studies is essential, if children are to benefit from these new advances in asthma treatment.
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Affiliation(s)
- Elizabeth Scotney
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Samatha Sonnappa
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton Hospital, London, UK
- Centre for Paediatrics and Child Health, Imperial College London, London, UK
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20
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Fitzpatrick AM, Diani B, Kavalieratos D, Corace EA, Mason C, Van Dresser M, Grunwell JR. Poorer Caregiver Mental and Social Health Is Associated With Worse Respiratory Outcomes in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1814-1822. [PMID: 36868472 PMCID: PMC10258161 DOI: 10.1016/j.jaip.2023.02.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 02/17/2023] [Accepted: 02/21/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND Mental and social health in caregivers of preschool children has been inadequately studied, but it may influence respiratory symptom recognition and management. OBJECTIVE To identify preschool caregivers at highest risk for poor mental and social health outcomes on the basis of patient-reported outcome measures. METHODS Female caregivers 18 to 50 years old (N = 129) with a preschool child aged 12 to 59 months with recurrent wheezing and at least 1 exacerbation in the previous year completed 8 validated patient-reported outcome measures of mental and social health. k-means cluster analysis was performed using the T score for each instrument. Caregiver/child dyads were followed for 6 months. Primary outcomes included caregiver quality of life and wheezing episodes in their preschool children. RESULTS Three clusters of caregivers were identified: low risk (n = 38), moderate risk (n = 56), and high risk (n = 35). The high-risk cluster had the lowest life satisfaction, meaning and purpose, and emotional support and the highest social isolation, depression, anger, perceived stress, and anxiety that persisted for more than 6 months. This cluster had the poorest quality of life and marked disparities in social determinants of health. Preschool children from caregivers in the high-risk cluster had more frequent respiratory symptoms and a higher occurrence of any wheezing episode, but a lower outpatient physician utilization for wheezing management. CONCLUSIONS Caregiver mental and social health is associated with respiratory outcomes in preschool children. Routine assessment of mental and social health in caregivers is warranted to promote health equity and improve wheezing outcomes in preschool children.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Badiallo Diani
- Department of Biomedical Engineering, Emory University, Atlanta, Ga; Department of Biomedical Engineering, Georgia Institute of Technology, Atlanta, Ga
| | - Dio Kavalieratos
- Department of Family and Preventative Medicine, Emory University, Atlanta, Ga
| | | | | | | | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Children's Healthcare of Atlanta, Atlanta, Ga
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21
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Granell R, Curtin JA, Haider S, Kitaba NT, Mathie SA, Gregory LG, Yates LL, Tutino M, Hankinson J, Perretti M, Vonk JM, Arshad HS, Cullinan P, Fontanella S, Roberts GC, Koppelman GH, Simpson A, Turner SW, Murray CS, Lloyd CM, Holloway JW, Custovic A. A meta-analysis of genome-wide association studies of childhood wheezing phenotypes identifies ANXA1 as a susceptibility locus for persistent wheezing. eLife 2023; 12:e84315. [PMID: 37227431 PMCID: PMC10292845 DOI: 10.7554/elife.84315] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2022] [Accepted: 05/22/2023] [Indexed: 05/26/2023] Open
Abstract
Background Many genes associated with asthma explain only a fraction of its heritability. Most genome-wide association studies (GWASs) used a broad definition of 'doctor-diagnosed asthma', thereby diluting genetic signals by not considering asthma heterogeneity. The objective of our study was to identify genetic associates of childhood wheezing phenotypes. Methods We conducted a novel multivariate GWAS meta-analysis of wheezing phenotypes jointly derived using unbiased analysis of data collected from birth to 18 years in 9568 individuals from five UK birth cohorts. Results Forty-four independent SNPs were associated with early-onset persistent, 25 with pre-school remitting, 33 with mid-childhood remitting, and 32 with late-onset wheeze. We identified a novel locus on chr9q21.13 (close to annexin 1 [ANXA1], p<6.7 × 10-9), associated exclusively with early-onset persistent wheeze. We identified rs75260654 as the most likely causative single nucleotide polymorphism (SNP) using Promoter Capture Hi-C loops, and then showed that the risk allele (T) confers a reduction in ANXA1 expression. Finally, in a murine model of house dust mite (HDM)-induced allergic airway disease, we demonstrated that anxa1 protein expression increased and anxa1 mRNA was significantly induced in lung tissue following HDM exposure. Using anxa1-/- deficient mice, we showed that loss of anxa1 results in heightened airway hyperreactivity and Th2 inflammation upon allergen challenge. Conclusions Targeting this pathway in persistent disease may represent an exciting therapeutic prospect. Funding UK Medical Research Council Programme Grant MR/S025340/1 and the Wellcome Trust Strategic Award (108818/15/Z) provided most of the funding for this study.
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Affiliation(s)
- Raquel Granell
- MRC Integrative Epidemiology Unit, Department of Population Health Sciences, Bristol Medical School, University of BristolBristolUnited Kingdom
| | - John A Curtin
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Sadia Haider
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Negusse Tadesse Kitaba
- Human Development and Health, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
| | - Sara A Mathie
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Lisa G Gregory
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Laura L Yates
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Mauro Tutino
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Jenny Hankinson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Mauro Perretti
- William Harvey Research Institute, Barts and The London School of Medicine Queen Mary University of LondonLondonUnited Kingdom
| | - Judith M Vonk
- Department of Epidemiology, University of Groningen, University Medical Center Groningen\GroningenNetherlands
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC)GroningenNetherlands
| | - Hasan S Arshad
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation TrustSouthamptonUnited Kingdom
- David Hide Asthma and Allergy Research CentreIsle of WightUnited Kingdom
- Clinical and Experimental Sciences, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - Graham C Roberts
- Human Development and Health, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation TrustSouthamptonUnited Kingdom
- David Hide Asthma and Allergy Research CentreIsle of WightUnited Kingdom
| | - Gerard H Koppelman
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC)GroningenNetherlands
- Department of Pediatric Pulmonology and Pediatric Allergology, University of Groningen, University Medical Center Groningen, Beatrix Children’s HospitalGroningenNetherlands
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Steve W Turner
- Child Health, University of AberdeenAberdeenUnited Kingdom
| | - Clare S Murray
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University NHS Foundation TrustManchesterUnited Kingdom
| | - Clare M Lloyd
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
| | - John W Holloway
- Human Development and Health, Faculty of Medicine, University of SouthamptonSouthamptonUnited Kingdom
- NIHR Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation TrustSouthamptonUnited Kingdom
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College LondonLondonUnited Kingdom
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22
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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23
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Abstract
Asthma is one of the most common chronic non-communicable diseases worldwide and is characterised by variable airflow obstruction, causing dyspnoea and wheezing. Highly effective therapies are available; asthma morbidity and mortality have vastly improved in the past 15 years, and most patients can attain good asthma control. However, undertreatment is still common, and improving patient and health-care provider understanding of when and how to adjust treatment is crucial. Asthma management consists of a cycle of assessment of asthma control and risk factors and adjustment of medications accordingly. With the introduction of biological therapies, management of severe asthma has entered the precision medicine era-a shift that is driving clinical ambitions towards disease remission. Patients with severe asthma often have co-existing conditions contributing to their symptoms, mandating a multidimensional management approach. In this Seminar, we provide a clinically focused overview of asthma; epidemiology, pathophysiology, diagnosis, and management in children and adults.
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Affiliation(s)
- Celeste Porsbjerg
- Department of Respiratory and Infectious Diseases, Bispebjerg Hospital, Copenhagen, Denmark; Institute of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.
| | - Erik Melén
- Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet and Sachs' Children and Youth Hospital, Stockholm, Sweden
| | - Lauri Lehtimäki
- Allergy Centre, Tampere University Hospital, Tampere, Finland; Faculty of Medicine and Health Technology, Tampere University, Tampere, Finland
| | - Dominick Shaw
- National Institute for Health and Care Research Nottingham Biomedical Research Centre, Division of Respiratory Medicine, School of Medicine, University of Nottingham, Nottingham, UK
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24
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Dijoux E, Klein M, Misme-Aucouturier B, Cheminant MA, de Carvalho M, Collin L, Hassoun D, Delage E, Gourdel M, Loirand G, Sauzeau V, Magnan A, Bouchaud G. Allergic Sensitization Driving Immune Phenotyping and Disease Severity in a Mouse Model of Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:246-261. [PMID: 37021509 PMCID: PMC10079520 DOI: 10.4168/aair.2023.15.2.246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 09/30/2022] [Accepted: 10/17/2022] [Indexed: 04/07/2023]
Abstract
PURPOSE Asthma is a frequent chronic inflammatory bronchial disease affecting more than 300 million patients worldwide, 70% of whom are secondary to allergy. The diversity of asthmatic endotypes contributes to their complexity. The inter-relationship between allergen and other exposure and the airway microbiome adds to the phenotypic diversity and defines the natural course of asthma. Here, we compared the mouse models of house dust mite (HDM)-induced allergic asthma. Allergic sensitization was performed via various routes and associated with outcomes. METHODS Mice were sensitized with HDM via the oral, nasal or percutaneous routes. Lung function, barrier integrity, immune response and microbiota composition were analyzed. RESULTS Severe impairment of respiratory function was observed in the mice sensitized by the nasal and cutaneous paths. It was associated with epithelial dysfunction characterized by an increased permeability secondary to junction protein disruption. Such sensitization paths induced a mixed eosinophilic and neutrophilic inflammatory response with high interleukin (IL)-17 airway secretion. In contrast, orally sensitized mice showed a mild impairment of respiratory function. Epithelial dysfunction was mild with increased mucus production, but preserved epithelial junctions. Regarding lung microbiota, sensitization provoked a significant loss of diversity. At the genus level, Cutibacterium, Acinetobacter, Streptococcus and Lactobacillus were found to be modulated according to the sensitization pathway. An increase in theanti-inflammatory microbiota metabolites was observed in the oral-sensitization group. CONCLUSIONS Our study highlights the strong impact of the sensitization route on the pathophysiology and the critical phenotypic diversity of allergic asthma in a mouse model.
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Affiliation(s)
- Eléonore Dijoux
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Martin Klein
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | | | | | | | - Louise Collin
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Dorian Hassoun
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Erwan Delage
- Université de Nantes, CNRS UMR 6004, LS2N, Nantes, France
| | - Mathilde Gourdel
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
- CRNH-Ouest Mass Spectrometry Core Facility, Nantes, France
| | - Gervaise Loirand
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Vincent Sauzeau
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
| | - Antoine Magnan
- Hôpital Foch, Suresnes, France
- UMR 0892 Virologie et Immunologie Moléculaire, Université de Versailles Saint-Quentin-en-Yvelines (UVSQ), Université Paris-Saclay INRAE, Paris, France
| | - Grégory Bouchaud
- Nantes Université, CNRS, INSERM, L'institut du Thorax, Nantes, France
- INRAe, Biopolymères Interactions Assemblages (BIA), Nantes, France.
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25
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Custovic A, Fontanella S, Haider S. Reply to Beck et al. and to Owora. Am J Respir Crit Care Med 2023; 207:634-636. [PMID: 36480959 PMCID: PMC10870903 DOI: 10.1164/rccm.202211-2130le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Adnan Custovic
- National Heart and Lung InstituteImperial College London, United Kingdom
| | - Sara Fontanella
- National Heart and Lung InstituteImperial College London, United Kingdom
| | - Sadia Haider
- National Heart and Lung InstituteImperial College London, United Kingdom
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26
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Wang G, Hallberg J, Faner R, Koefoed HJ, Kebede Merid S, Klevebro S, Björkander S, Gruzieva O, Pershagen G, van Hage M, Guerra S, Bottai M, Georgelis A, Gehring U, Bergström A, Vonk JM, Kull I, Koppelman GH, Agusti A, Melén E. Plasticity of Individual Lung Function States from Childhood to Adulthood. Am J Respir Crit Care Med 2023; 207:406-415. [PMID: 36409973 PMCID: PMC9940138 DOI: 10.1164/rccm.202203-0444oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 11/21/2022] [Indexed: 11/23/2022] Open
Abstract
Rationale: Recent evidence highlights the importance of optimal lung development during childhood for health throughout life. Objectives: To explore the plasticity of individual lung function states during childhood. Methods: Prebronchodilator FEV1 z-scores determined at age 8, 16, and 24 years in the Swedish population-based birth cohort BAMSE (Swedish abbreviation for Child [Barn], Allergy, Milieu, Stockholm, Epidemiological study) (N = 3,069) were used. An unbiased, data-driven dependent mixture model was applied to explore lung function states and individual state chains. Lung function catch-up was defined as participants moving from low or very low states to normal or high or very high states, and growth failure as moving from normal or high or very high states to low or very low states. At 24 years, we compared respiratory symptoms, small airway function (multiple-breath washout), and circulating inflammatory protein levels, by using proteomics, across states. Models were replicated in the independent Dutch population-based PIAMA (Prevention and Incidence of Asthma and Mite Allergy) cohort. Measurements and Main Results: Five lung function states were identified in BAMSE. Lung function catch-up and growth failure were observed in 74 (14.5%) BAMSE participants with low or very low states and 36 (2.4%) participants with normal or high or very high states, respectively. The occurrence of catch-up and growth failure was replicated in PIAMA. Early-life risk factors were cumulatively associated with the very low state, as well as with catch-up (inverse association) and growth failure. The very low state as well as growth failure were associated with respiratory symptoms, airflow limitation, and small airway dysfunction at adulthood. Proteomics identified IL-6 and CXCL10 (C-X-C motif chemokine 10) as potential biomarkers of impaired lung function development. Conclusions: Individual lung function states during childhood are plastic, including catch-up and growth failure.
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Affiliation(s)
- Gang Wang
- Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Sichuan, China
- Department of Clinical Science and Education, Södersjukhuset
- Institute of Environmental Medicine, and
- West China Biomedical Big Data Center, West China Hospital, Sichuan University, Chengdu, China
| | - Jenny Hallberg
- Department of Clinical Science and Education, Södersjukhuset
- Sachs’ Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Rosa Faner
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS)
| | | | | | - Susanna Klevebro
- Department of Clinical Science and Education, Södersjukhuset
- Sachs’ Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | | | - Olena Gruzieva
- Institute of Environmental Medicine, and
- Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Göran Pershagen
- Institute of Environmental Medicine, and
- Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Marianne van Hage
- Division of Immunology and Allergy, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Stefano Guerra
- Asthma and Airway Disease Research Center, University of Arizona, Tucson, Arizona
- ISGlobal, Barcelona, Spain
| | - Matteo Bottai
- Division of Biostatistics, Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Antonios Georgelis
- Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Ulrike Gehring
- Institute for Risk Assessment Sciences, Utrecht University, Utrecht, the Netherlands; and
| | - Anna Bergström
- Institute of Environmental Medicine, and
- Centre for Occupational and Environmental Medicine, Region Stockholm, Stockholm, Sweden
| | - Judith M. Vonk
- Groningen Research Institute for Asthma and COPD (GRIAC) and
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Inger Kull
- Department of Clinical Science and Education, Södersjukhuset
- Sachs’ Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
| | - Gerard H. Koppelman
- Groningen Research Institute for Asthma and COPD (GRIAC) and
- Department of Pediatric Pulmonology and Pediatric Allergology, Beatrix Children’s Hospital, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Alvar Agusti
- Centro de Investigación Biomédica en Red Enfermedades Respiratorias (CIBERES), Madrid, Spain
- Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS)
- Cátedra de Salud Respiratoria and
- Respiratory Institute, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Erik Melén
- Department of Clinical Science and Education, Södersjukhuset
- Sachs’ Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
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Fayon M, Beaufils F, Esteves P, Campagnac M, Maurat E, Michelet M, Siao-Him-Fa V, Lavrand F, Simon G, Begueret H, Berger P. Bronchial Remodeling-based Latent Class Analysis Predicts Exacerbations in Severe Preschool Wheezers. Am J Respir Crit Care Med 2023; 207:416-426. [PMID: 36108144 DOI: 10.1164/rccm.202205-0913oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Children with preschool wheezing represent a very heterogeneous population with wide variability regarding their clinical, inflammatory, obstructive, and/or remodeling patterns. We hypothesized that assessing bronchial remodeling would help clinicians to better characterize severe preschool wheezers. Objectives: The main objective was to identify bronchial remodeling-based latent classes of severe preschool wheezers. Secondary objectives were to compare cross-sectional and longitudinal clinical and biological data between classes and to assess the safety of bronchoscopy. Methods: This double-center prospective study (NCT02806466) included severe preschool wheezers (1-5 yr old) requiring fiberoptic bronchoscopy. Bronchial remodeling parameters (i.e., epithelial integrity, reticular basement membrane [RBM] thickness, mucus gland, fibrosis and bronchial smooth muscle [BSM] areas, the density of blood vessels, and RBM-BSM distance) were assessed and evaluated by latent class analysis. An independent cohort of severe preschool wheezers (NCT04558671) was used to validate our results. Measurements and Main Results: Fiberoptic bronchoscopy procedures were well tolerated. A two-class model was identified: Class BR1 was characterized by increased RBM thickness, normalized BSM area, the density of blood vessels, decreased mucus gland area, fibrosis, and RBM-BSM distance compared with Class BR2. No significant differences were found between classes in the year before fiberoptic bronchoscopy. By contrast, Class BR1 was associated with a shorter time to first exacerbation and an increased risk of both frequent (3 or more) and severe exacerbations during the year after bronchoscopy in the two cohorts. Conclusions: Assessing bronchial remodeling identified severe preschool wheezers at risk of frequent and severe subsequent exacerbations with a favorable benefit to risk ratio.
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Affiliation(s)
- Michael Fayon
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Fabien Beaufils
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Pauline Esteves
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Maryline Campagnac
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Elise Maurat
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Marine Michelet
- CHU Toulouse, Hôpital des Enfants, Service de pneumologie-allergologie pédiatrique, Service d'Anatomopathologie; and.,University Toulouse Paul Sabatier, INSERM U1043 (CPTP), F-31059 Toulouse, France
| | - Valerie Siao-Him-Fa
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Frederic Lavrand
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Guillaume Simon
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Hugues Begueret
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Patrick Berger
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
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28
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McCready C, Haider S, Little F, Nicol MP, Workman L, Gray DM, Granell R, Stein DJ, Custovic A, Zar HJ. Early childhood wheezing phenotypes and determinants in a South African birth cohort: longitudinal analysis of the Drakenstein Child Health Study. THE LANCET. CHILD & ADOLESCENT HEALTH 2023; 7:127-135. [PMID: 36435180 PMCID: PMC9870786 DOI: 10.1016/s2352-4642(22)00304-2] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 10/06/2022] [Accepted: 10/10/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND Developmental trajectories of childhood wheezing in low-income and middle-income countries (LMICs) have not been well described. We aimed to derive longitudinal wheeze phenotypes from birth to 5 years in a South African birth cohort and compare those with phenotypes derived from a UK cohort. METHODS We used data from the Drakenstein Child Health Study (DCHS), a longitudinal birth cohort study in a peri-urban area outside Cape Town, South Africa. Pregnant women (aged ≥18 years) were enrolled during their second trimester at two public health clinics. We followed up children from birth to 5 years to derive six multidimensional indicators of wheezing (including duration, temporal sequencing, persistence, and recurrence) and applied Partition Around Medoids clustering to derive wheeze phenotypes. We compared phenotypes with a UK cohort (the Avon Longitudinal Study of Parents and Children [ALSPAC]). We investigated associations of phenotypes with early-life exposures, including all-cause lower respiratory tract infection (LRTI) and virus-specific LRTI (respiratory syncytial virus, rhinovirus, adenovirus, influenza, and parainfluenza virus) up to age 5 years. We investigated the association of phenotypes with lung function at 6 weeks and 5 years. FINDINGS Between March 5, 2012, and March 31, 2015, we enrolled 1137 mothers and there were 1143 livebirths. Four wheeze phenotypes were identified among 950 children with complete data: never (480 children [50%]), early transient (215 children [23%]), late onset (104 children [11%]), and recurrent (151 children [16%]). Multivariate adjusted analysis indicated that LRTI and respiratory syncytial virus-LRTI, but not other respiratory viruses, were associated with increased risk of recurrent wheeze (odds ratio [OR] 2·79 [95% CI 2·05-3·81] for all LTRIs; OR 2·59 [1·30-5·15] for respiratory syncytial virus-LRTIs). Maternal smoking (1·88 [1·12-3·02]), higher socioeconomic status (2·46 [1·23-4·91]), intimate partner violence (2·01 [1·23-3·29]), and male sex (2·47 [1·50-4·04]) were also associated with recurrent wheeze. LRTI and respiratory syncytial virus-LRTI were also associated with early transient and late onset clusters. Wheezing illness architecture differed between DCHS and ALSPAC; children included in ALSPAC in the early transient cluster wheezed for a longer period before remission and late-onset wheezing started at an older age, and no persistent phenotype was identified in DCHS. At 5 years, airway resistance was higher in children with early or recurrent wheeze compared with children who had never wheezed. Airway resistance increased from 6 weeks to 5 years among children with recurrent wheeze. INTERPRETATION Effective strategies to reduce maternal smoking and psychosocial stressors and new preventive interventions for respiratory syncytial virus are urgently needed to optimise child health in LMICs. FUNDING UK Medical Research Council; The Bill & Melinda Gates Foundation; National Institutes of Health Human Heredity and Health in Africa; South African Medical Research Council; Wellcome Trust.
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Affiliation(s)
- Carlyle McCready
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa; Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; SA-Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Sadia Haider
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Francesca Little
- Department of Statistical Sciences, University of Cape Town, Cape Town, South Africa
| | - Mark P Nicol
- Marshall Centre, School of Biomedical Sciences, University of Western Australia, Perth, WA, Australia
| | - Lesley Workman
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; SA-Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Diane M Gray
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; SA-Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Raquel Granell
- Medical Research Council Integrative Epidemiology Unit, Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
| | - Dan J Stein
- Department of Psychiatry and Mental Health, University of Cape Town, Cape Town, South Africa; SA-Medical Research Council Unit on Risk and Resilience, University of Cape Town, Cape Town, South Africa
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Heather J Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa; SA-Medical Research Council Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa.
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Grandinetti R, Fainardi V, Caffarelli C, Capoferri G, Lazzara A, Tornesello M, Meoli A, Bergamini BM, Bertelli L, Biserna L, Bottau P, Corinaldesi E, De Paulis N, Dondi A, Guidi B, Lombardi F, Magistrali MS, Marastoni E, Pastorelli S, Piccorossi A, Poloni M, Tagliati S, Vaienti F, Gregori G, Sacchetti R, Mari S, Musetti M, Antodaro F, Bergomi A, Reggiani L, Caramelli F, De Fanti A, Marchetti F, Ricci G, Esposito S. Risk Factors Affecting Development and Persistence of Preschool Wheezing: Consensus Document of the Emilia-Romagna Asthma (ERA) Study Group. J Clin Med 2022; 11:6558. [PMID: 36362786 PMCID: PMC9655250 DOI: 10.3390/jcm11216558] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 11/01/2022] [Accepted: 11/02/2022] [Indexed: 07/30/2023] Open
Abstract
Wheezing at preschool age (i.e., before the age of six) is common, occurring in about 30% of children before the age of three. In terms of health care burden, preschool children with wheeze show double the rate of access to the emergency department and five times the rate of hospital admissions compared with school-age asthmatics. The consensus document aims to analyse the underlying mechanisms involved in the pathogenesis of preschool wheezing and define the risk factors (i.e., allergy, atopy, infection, bronchiolitis, genetics, indoor and outdoor pollution, tobacco smoke exposure, obesity, prematurity) and the protective factors (i.e., probiotics, breastfeeding, vitamin D, influenza vaccination, non-specific immunomodulators) associated with the development of the disease in the young child. A multidisciplinary panel of experts from the Emilia-Romagna Region, Italy, addressed twelve key questions regarding managing preschool wheezing. Clinical questions have been formulated by the expert panel using the PICO format (Patients, Intervention, Comparison, Outcomes). Systematic reviews have been conducted on PubMed to answer these specific questions and formulate recommendations. The GRADE approach has been used for each selected paper to assess the quality of the evidence and the degree of recommendations. Based on a panel of experts and extensive updated literature, this consensus document provides insight into the pathogenesis, risk and protective factors associated with the development and persistence of preschool wheezing. Undoubtedly, more research is needed to improve our understanding of the disease and confirm the associations between certain factors and the risk of wheezing in early life. In addition, preventive strategies must be promoted to avoid children's exposure to risk factors that may permanently affect respiratory health.
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Affiliation(s)
- Roberto Grandinetti
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Valentina Fainardi
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Carlo Caffarelli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Gaia Capoferri
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Angela Lazzara
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Marco Tornesello
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Aniello Meoli
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
| | - Barbara Maria Bergamini
- Paediatric Unit, Department of Medical and Surgical Sciences of Mothers, Children and Adults, University of Modena and Reggio Emilia, 41125 Modena, Italy
| | - Luca Bertelli
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Loretta Biserna
- Paediatrics and Neonatology Unit, Ravenna Hospital, AUSL Romagna, 48121 Ravenna, Italy
| | - Paolo Bottau
- Paediatrics Unit, Imola Hospital, 40026 Imola, Italy
| | | | - Nicoletta De Paulis
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Arianna Dondi
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Battista Guidi
- Hospital and Territorial Paediatrics Unit, Pavullo, 41026 Pavullo Nel Frignano, Italy
| | | | - Maria Sole Magistrali
- Paediatrics and Neonatology Unit, Guglielmo da Saliceto Hospital, 29121 Piacenza, Italy
| | - Elisabetta Marastoni
- Paediatrics Unit, Santa Maria Nuova Hospital, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | | | - Alessandra Piccorossi
- Paediatrics and Paediatric Intensive Care Unit, Cesena Hospital, AUSL Romagna, 47521 Cesena, Italy
| | - Maurizio Poloni
- Paediatrics Unit, Rimini Hospital, AUSL Romagna, 47921 Rimini, Italy
| | | | - Francesca Vaienti
- Paediatrics Unit, G.B. Morgagni—L. Pierantoni Hospital, AUSL Romagna, 47121 Forlì, Italy
| | - Giuseppe Gregori
- Primary Care Pediatricians, AUSL Piacenza, 29121 Piacenza, Italy
| | | | - Sandra Mari
- Primary Care Pediatricians, AUSL Parma, 43126 Parma, Italy
| | | | | | - Andrea Bergomi
- Primary Care Pediatricians, AUSL Modena, 41125 Modena, Italy
| | | | - Fabio Caramelli
- Pediatric Intensive Care Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Alessandro De Fanti
- Paediatrics Unit, Santa Maria Nuova Hospital, AUSL-IRCCS of Reggio Emilia, 42123 Reggio Emilia, Italy
| | - Federico Marchetti
- Paediatrics and Neonatology Unit, Ravenna Hospital, AUSL Romagna, 48121 Ravenna, Italy
| | - Giampaolo Ricci
- Pediatric Clinic, Scientific Institute for Research and Healthcare (IRCCS) Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Susanna Esposito
- Pediatric Clinic, Department of Medicine and Surgery, University of Parma, 43126 Parma, Italy
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30
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Haider S, Fontanella S, Ullah A, Turner S, Simpson A, Roberts G, Murray CS, Holloway JW, Curtin JA, Cullinan P, Arshad SH, Hurault G, Granell R, Custovic A. Evolution of Eczema, Wheeze, and Rhinitis from Infancy to Early Adulthood: Four Birth Cohort Studies. Am J Respir Crit Care Med 2022; 206:950-960. [PMID: 35679320 PMCID: PMC9802000 DOI: 10.1164/rccm.202110-2418oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 06/09/2022] [Indexed: 01/07/2023] Open
Abstract
Rationale: The relationship between eczema, wheeze or asthma, and rhinitis is complex, and epidemiology and mechanisms of their comorbidities is unclear. Objectives: To investigate within-individual patterns of morbidity of eczema, wheeze, and rhinitis from birth to adolescence/early adulthood. Methods: We investigated onset, progression, and resolution of eczema, wheeze, and rhinitis using descriptive statistics, sequence mining, and latent Markov modeling in four population-based birth cohorts. We used logistic regression to ascertain if early-life eczema or wheeze, or genetic factors (filaggrin [FLG] mutations and 17q21 variants), increase the risk of multimorbidity. Measurements and Main Results: Single conditions, although the most prevalent, were observed significantly less frequently than by chance. There was considerable variation in the timing of onset/remission/persistence/intermittence. Multimorbidity of eczema+wheeze+rhinitis was rare but significantly overrepresented (three to six times more often than by chance). Although infantile eczema was associated with subsequent multimorbidity, most children with eczema (75.4%) did not progress to any multimorbidity pattern. FLG mutations and rs7216389 were not associated with persistence of eczema/wheeze as single conditions, but both increased the risk of multimorbidity (FLG by 2- to 3-fold, rs7216389 risk variant by 1.4- to 1.7-fold). Latent Markov modeling revealed five latent states (no disease/low risk, mainly eczema, mainly wheeze, mainly rhinitis, multimorbidity). The most likely transition to multimorbidity was from eczema state (0.21). However, although this was one of the highest transition probabilities, only one-fifth of those with eczema transitioned to multimorbidity. Conclusions: Atopic diseases fit a multimorbidity framework, with no evidence for sequential atopic march progression. The highest transition to multimorbidity was from eczema, but most children with eczema (more than three-quarters) had no comorbidities.
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Affiliation(s)
| | | | | | - Stephen Turner
- Royal Aberdeen Children’s Hospital National Health Service Grampian Aberdeen, Aberdeen, United Kingdom
- Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Angela Simpson
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - Graham Roberts
- Human Development and Health and
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
- David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Clare S. Murray
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | - John W. Holloway
- Human Development and Health and
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
| | - John A. Curtin
- Division of Immunology, Immunity to Infection and Respiratory Medicine, School of Biological Sciences, The University of Manchester, Manchester Academic Health Science Centre, and Manchester University National Health Service Foundation Trust, Manchester, United Kingdom
| | | | - Syed Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom
- National Institute for Health and Care Research Southampton Biomedical Research Centre, University Hospitals Southampton NHS Foundation Trust, Southampton, United Kingdom
- David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Guillem Hurault
- Faculty of Engineering, Department of Bioengineering, Imperial College London, London, United Kingdom
| | - Raquel Granell
- MRC Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
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Chatziparasidis G, Bush A. Enigma variations: The multi-faceted problems of pre-school wheeze. Pediatr Pulmonol 2022; 57:1990-1997. [PMID: 35652262 DOI: 10.1002/ppul.26027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Revised: 04/27/2022] [Accepted: 05/31/2022] [Indexed: 11/08/2022]
Abstract
Numerous publications on wheezing disorders in children younger than 6 years have appeared in the medical literature over the last decades with the aim of shedding light on the mechanistic pathways (endotypes) and treatment. Nevertheless, there is yet no consensus as to the appropriate way to manage preschool wheeze mainly because of the lack of a clear definition of "preschool asthma" and the paucity of scientific evidence concerning its underlying endotypes. A symptom-based approach is inadequate since the human airway can respond to external stimuli with a limited range of symptoms and signs, including cough and wheeze, and these manifestations represent the final expression of many clinical entities with potentially different pathophysiologies requiring different individualized treatments. Hence, new studies challenge the symptom-based approach and promote the importance of managing the wheezy child based on the "airway phenotype." This will enable the clinician to identify not only the child with a serious underlying pathology (e.g., a structural airway disorder or immunodeficiency) who is in need of prompt and specific treatment but also increase the specificity of treatment for the child with symptoms suggestive of an "asthma" syndrome. In the latter case, focus should be given to the identification of treatable traits. This review summarizes the current understanding in management of preschool wheezing and highlights the unmet need for further research.
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Affiliation(s)
- Grigorios Chatziparasidis
- Department of Paediatrics, Metropolitan Hospital, Athens, and Primary Cilia Dyskinesia Unit, University of Thessaly, Volos, Greece
| | - Andrew Bush
- Departments of Paediatrics and Paediatric Respiratory Medicine, Royal Brompton Harefield NHS Foundation Trust and Imperial College, London, UK
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32
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Zaitsu M, Matsuo M. Transient low IgG4 levels cause recurrent wheezing requiring multiple hospitalizations in infancy. Pediatr Pulmonol 2022; 57:1631-1634. [PMID: 35435330 DOI: 10.1002/ppul.25927] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 02/24/2022] [Accepted: 04/15/2022] [Indexed: 11/10/2022]
Abstract
OBJECTIVES To investigate whether the immunoglobulin G (IgG4) subclass is associated with recurrent wheezing and/or asthma in infants. SUBJECTS AND METHODS From April 2015 to March 2016, 77 infants under 3 years old who attended our hospital were enrolled in four groups (Group 1, controls; Group 2, infants with recurrent wheezing and multiple hospitalizations despite starting inhaled corticosteroids [ICS]; Group 3, infants with recurrent wheezing and without hospitalization after starting ICS; Group 4, allergic infants without wheezing). The relationship between IgG subclasses, especially IgG4, and recurrent wheezing resistant to ICS and requiring multiple hospitalizations in infants was examined. RESULTS The serum IgG, IgM, IgA, IgG1, IgG2, and IgG3 levels did not differ significantly among the four groups. The IgG4 level in Group 2 infants (3.1 ± 0.2 mg/dl) was significantly lower than in Groups 1, 3, and 4 (9.9 ± 8.0, 8.4 ± 6.1, and 23.4 ± 18.0 mg/dl). Of the 16 infants in Group 2, 10 could be followed to age 6 years. Nine of them had no recurrent wheezing at 6 years without medication. In addition, their IgG4 levels at age 6 years (16.1 ± 7.1 mg/dl) were significantly increased from those in infancy (3.0 ± 0.1 mg/dl). CONCLUSION A transient low IgG4 level in infancy might cause recurrent wheezing and/or asthmatic symptoms in infants, and it may be one of the types of early transient wheezing.
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Affiliation(s)
- Masafumi Zaitsu
- Department of Pediatrics, National Hospital Organization Ureshino Medical Center, Ureshino, Japan.,Department of Pediatrics, Saga University Hospital, Saga, Japan
| | - Muneaki Matsuo
- Department of Pediatrics, Saga University Hospital, Saga, Japan
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33
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Mocelin HT, da Silva Filho LVRF, Castro-Rodriguez JA, Sarria EE, Fischer GB. The wheezy infant: A viewpoint from low-middle income countries. Paediatr Respir Rev 2022:S1526-0542(22)00045-8. [PMID: 35906146 DOI: 10.1016/j.prrv.2022.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Accepted: 06/20/2022] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To review the recent evidence in the literature of various aspects of recurrent/severe wheezing in children under 3 in low-middle income countries [LMICS]. SOURCES A non-systematic review including articles in English. We mainly selected publications from the last 5 years. Studies on epidemiology, aetiology, diagnosis, treatment, and prevention were included in the search. We reviewed differential diagnoses of wheezing that focused on LMICS. We also reviewed aspects of prevention. SUMMARY OF THE FINDINGS Many epidemiological studies have shown a variable but significant number of wheezy infants [WI] cases in LMICS when compared to other countries. The differential diagnosis of causes of wheezing in this age group is mandatory, taking into account local facilities. Few treatment options have been well studied for this age group. In LMICS, a pragmatic approach could be considered, as described in the article. It is difficult to study primary prevention for WI and secondary prevention (mainly environmental) may have some impact. A schematic approach for recurrent wheezers is presented, which takes into account settings with limited resources. CONCLUSION Severely or recurrently wheezy children under 3 is a common clinical issue in LMICS. Studies on this age group are needed to reduce the significant morbidity. It may be possible to lower the high burden of wheezing in this age group by selecting the phenotype which may respond to inhaled steroids.
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Affiliation(s)
- Helena Teresinha Mocelin
- Department of Paediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil; Paediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.
| | - Luiz Vicente Ribeiro Ferreira da Silva Filho
- Instituto da Criança e do Adolescente, Hospital das Clínicas, University of São Paulo Medical School (USP), São Paulo, SP; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil
| | - Jose A Castro-Rodriguez
- Department of Paediatric Pulmonology, School of Medicine, Pontificia Universidad Católica de Chile (PUC), Santiago, Chile
| | - Edgar E Sarria
- Department of Paediatrics, School of Medicine, Federal University of Rio Grande do Sul (UFRGS), Porto Alegre, Brazil.
| | - Gilberto Bueno Fischer
- Department of Paediatrics, Federal University of Health Sciences of Porto Alegre (UFCSPA), Brazil; Paediatric Pulmonology Section, Hospital da Criança Santo Antônio, Porto Alegre, Brazil.
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Duijts L, Fleming LJ, Bacharier LB, Pitrez PM, Reddel HK. Reply to Baraldi and Piacentini: Global Initiative for Asthma 2021: Asthma in Preschool Children and Short-Acting β 2-Agonist-Only Treatment. Am J Respir Crit Care Med 2022; 205:972-973. [PMID: 35202561 PMCID: PMC9838630 DOI: 10.1164/rccm.202112-2788le] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023] Open
Affiliation(s)
- Liesbeth Duijts
- Erasmus MC, University Medical Center RotterdamRotterdam, the Netherlands
| | - Louise J. Fleming
- National Heart and Lung Institute, Imperial College LondonLondon, United Kingdom
| | | | | | - Helen K. Reddel
- The Woolcock Institute of Medical ResearchSydney, New South Wales, Australia,The University of SydneySydney, New South Wales, Australia,Corresponding author (e-mail: )
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Haider S, Granell R, Curtin J, Fontanella S, Cucco A, Turner S, Simpson A, Roberts G, Murray CS, Holloway JW, Devereux G, Cullinan P, Arshad SH, Custovic A. Modeling Wheezing Spells Identifies Phenotypes with Different Outcomes and Genetic Associates. Am J Respir Crit Care Med 2022; 205:883-893. [PMID: 35050846 PMCID: PMC9838626 DOI: 10.1164/rccm.202108-1821oc] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Rationale: Longitudinal modeling of current wheezing identified similar phenotypes, but their characteristics often differ between studies. Objectives: We propose that a more comprehensive description of wheeze may better describe trajectories than binary information on the presence/absence of wheezing. Methods: We derived six multidimensional variables of wheezing spells from birth to adolescence (including duration, temporal sequencing, and the extent of persistence/recurrence). We applied partition-around-medoids clustering on these variables to derive phenotypes in five birth cohorts. We investigated within- and between-phenotype differences compared with binary latent class analysis models and ascertained associations of these phenotypes with asthma and lung function and with polymorphisms in asthma loci 17q12-21 and CDHR3 (cadherin-related family member 3). Measurements and Main Results: Analysis among 7,719 participants with complete data identified five spell-based wheeze phenotypes with a high degree of certainty: never (54.1%), early-transient (ETW) (23.7%), late-onset (LOW) (6.9%), persistent (PEW) (8.3%), and a novel phenotype, intermittent wheeze (INT) (6.9%). FEV1/FVC was lower in PEW and INT compared with ETW and LOW and declined from age 8 years to adulthood in INT. 17q12-21 and CDHR3 polymorphisms were associated with higher odds of PEW and INT, but not ETW or LOW. Latent class analysis- and spell-based phenotypes appeared similar, but within-phenotype individual trajectories and phenotype allocation differed substantially. The spell-based approach was much more robust in dealing with missing data, and the derived clusters were more stable and internally homogeneous. Conclusions: Modeling of spell variables identified a novel intermittent wheeze phenotype associated with lung function decline to early adulthood. Using multidimensional spell variables may better capture wheeze development and provide a more robust input for phenotype derivation.
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Affiliation(s)
- Sadia Haider
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Raquel Granell
- Medical Research Council Integrative Epidemiology Unit, Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, United Kingdom
| | - John Curtin
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Sara Fontanella
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Alex Cucco
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Stephen Turner
- Royal Aberdeen Children’s Hospital National Health Service Grampian, Aberdeen, United Kingdom;,Child Health, University of Aberdeen, Aberdeen, United Kingdom
| | - Angela Simpson
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - Graham Roberts
- Human Development and Health and,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom;,David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Clare S. Murray
- Division of Infection, Immunity and Respiratory Medicine, School of Biological Sciences, Faculty of Biology, Medicine and Health, University of Manchester, Manchester Academic Health Science Centre, Manchester, United Kingdom
| | - John W. Holloway
- Human Development and Health and,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom
| | - Graham Devereux
- Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, United Kingdom
| | - Paul Cullinan
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Syed Hasan Arshad
- Clinical and Experimental Sciences, Faculty of Medicine, University of Southampton, Southampton, United Kingdom;,National Institute for Health Research Southampton Biomedical Research Centre, University Hospitals Southampton National Health Service Foundation Trust, Southampton, United Kingdom;,David Hide Asthma and Allergy Research Centre, Isle of Wight, United Kingdom; and
| | - Adnan Custovic
- National Heart and Lung Institute, Imperial College London, London, United Kingdom
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36
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Feleszko W, Jartti T, Bacharier LB. Current strategies for phenotyping and managing asthma in preschool children. Curr Opin Allergy Clin Immunol 2022; 22:107-114. [PMID: 35197432 DOI: 10.1097/aci.0000000000000819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Half of all children will experience an episode of wheezing by 6 years. Recurrent preschool wheezing is associated with early lung function loss and has a lifelong impact on airway health, so deciding which children should be treated to prevent exacerbations while also avoiding irreversible health consequences is crucial. The purpose of this review is to provide a practical approach to the pediatric patient under 5 years of age with asthma, with particular attention to the recent enhanced identification of wheeze phenotypes. RECENT FINDINGS Here, we note the difficulty of defining 'asthma' for this age group and advocate that it be determined by the set of respiratory symptoms presented, without assumptions about the underlying mechanisms of the disease. In addition, we propose a forward-looking approach, what treatment to apply to particular phenotypes, which child should be treated, and, if so, which treatment strategy to choose. No clear recommendation exists for the management of nonallergic preschool wheezing, a substantial clinical and research gap. SUMMARY We recommend an empathetic approach to parent anxiety and considering objective markers: timing, severity, and frequency of symptoms, along with an assessment of other biomarkers, including viral etiology, aeroallergen sensitization, and blood eosinophils, that contribute to successful decision-making.
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Affiliation(s)
- Wojciech Feleszko
- Department of Pediatric Pneumonology and Allergy, The Medical University of Warsaw, Warsaw, Poland
| | - Tuomas Jartti
- Department of Pediatrics, Turku University Hospital and University of Turku, Turku
- Department of Pediatrics, Oulu University Hospital and the University of Oulu
- Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Leonard B Bacharier
- Division of Pediatric Allergy, Immunology and Pulmonary Medicine, Monroe Carell Jr Children's Hospital at Vanderbilt, Nashville, Tennessee, USA
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37
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Achten NB, van Rossum AMC, Bacharier LB, Fitzpatrick AM, Hartert TV. Long-Term Respiratory Consequences of Early-Life Respiratory Viral Infections: A Pragmatic Approach to Fundamental Questions. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:664-670. [PMID: 34942383 DOI: 10.1016/j.jaip.2021.12.005] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2021] [Revised: 12/01/2021] [Accepted: 12/08/2021] [Indexed: 06/14/2023]
Abstract
Early-life viral infection can have profound effects on the developing lung and immune systems, both important in asthma development. For decades, research has aimed to establish whether there is a causal link between these viral infections as an exposure and asthma later in childhood. Establishing causality will remain important, but new insights regarding early-life viral infection as an exposure, the recognition of asthma as a heterogeneous outcome, and the shared genetic susceptibility to both suggest a refocus from answering the theoretical question of causality toward additional pragmatic approaches focusing on improving patient outcomes across the spectrum of respiratory disease. This Clinical Commentary reviews the evidence on the consequences of early-life viral infection and aims to look beyond the question of causality, suggesting a research agenda specifically aimed at what matters for human development, and for the quality of life of current and future patients with wheezing disorders.
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Affiliation(s)
- Niek B Achten
- Department of Pediatrics, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands.
| | - Annemarie M C van Rossum
- Department of Pediatrics, Erasmus University Medical Centre-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Leonard B Bacharier
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn
| | - Anne M Fitzpatrick
- Department of Pediatrics, Emory University School of Medicine, Atlanta, Ga
| | - Tina V Hartert
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tenn; Department of Medicine, Vanderbilt University Medical Center, Nashville, Tenn
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38
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Ramakrishnan S, Beaufils F, De Brandt J, Viney K, Bradley C, Cottin V, Hassan M, Cruz J. European Respiratory Society International Congress 2021: highlights from best-abstract awardees. Breathe (Sheff) 2022; 18:210176. [PMID: 36338250 PMCID: PMC9584552 DOI: 10.1183/20734735.0176-2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Accepted: 02/11/2022] [Indexed: 12/26/2022] Open
Abstract
This article provides an overview of some of the highlights of the @EuroRespSoc Congress 2021 from the perspective of the best-abstract awardees of the ERS Assemblies @EarlyCareerERS @OrphaLung https://bit.ly/3JCjHYS.
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Affiliation(s)
- Sanjay Ramakrishnan
- Oxford NIHR Biomedical Research Centre, University of Oxford, Oxford, UK,School of Medical and Health Sciences, Edith Cowan University, Perth, Australia,These authors contributed equally
| | - Fabien Beaufils
- Univ. Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, INSERM U1045, Bordeaux Imaging Center, Bordeaux, France,CHU Bordeaux, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France,These authors contributed equally
| | - Jana De Brandt
- Faculty of Rehabilitation Sciences, Rehabilitation Research Center REVAL, Biomedical Research Institute BIOMED, Hasselt University, Hasselt, Belgium,Faculty of Medicine, Dept of Community Medicine and Rehabilitation, Section of Physiotherapy, Umeå University, Umeå, Sweden,These authors contributed equally
| | - Kerri Viney
- Global Tuberculosis Programme, World Health Organization, Geneva, Switzerland,These authors contributed equally
| | - Claire Bradley
- Leeds Teaching Hospitals, Leeds, UK,These authors contributed equally
| | - Vincent Cottin
- National French Reference Coordinating Center for Rare Pulmonary Diseases, Louis Pradel Hospital and Hospices Civils de Lyon, Université de Lyon, Université Claude Bernard Lyon 1, INRAE, member of ERN-LUNG, Lyon, France,These authors contributed equally
| | - Maged Hassan
- Chest Diseases Dept, Alexandria University Faculty of Medicine, Alexandria, Egypt,These authors contributed equally
| | - Joana Cruz
- Center for Innovative Care and Health Technology (ciTechCare), School of Health Sciences (ESSLei), Polytechnic of Leiria, Leiria, Portugal,Corresponding author: Joana Cruz ()
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39
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Bush A. How to Choose the Correct Drug in Severe Pediatric Asthma. Front Pediatr 2022; 10:902168. [PMID: 35722499 PMCID: PMC9201103 DOI: 10.3389/fped.2022.902168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/02/2022] [Indexed: 12/01/2022] Open
Abstract
When a child with severe asthma (asthma defined clinically for the purposes of this review as wheeze, breathlessness, and chest tightness sometimes with cough) does not respond to treatment, it is important to be sure that an alternative or additional diagnosis is not being missed. In school age children, the next step is a detailed protocolized assessment to determine the nature of the problem, whether within the airway or related to co-morbidities or social/environmental factors, in order to personalize the treatment. For example, those with refractory difficult asthma due to persistent non-adherence may benefit from using budesonide and formoterol combined in a single inhaler [single maintenance and reliever treatment (SMART)] as both a reliever and preventer. For those with steroid-resistant Type 2 airway inflammation, the use of biologicals such as omalizumab and mepolizumab should be considered, but for mepolizumab at least, there is a paucity of pediatric data. Protocols are less well developed in preschool asthma, where steroid insensitive disease is much more common, but the use of two simple measurements, aeroallergen sensitization, and peripheral blood eosinophil count, allows the targeted use of inhaled corticosteroids (ICSs). There is also increasing evidence that chronic airway infection may be important in preschool wheeze, increasing the possibility that targeted antibiotics may be beneficial. Asthma in the first year of life is not driven by Type 2 inflammation, so beyond avoiding prescribing ICSs, no evidence based recommendations can be made. In the future, we urgently need to develop objective biomarkers, especially of risk, so that treatment can be targeted effectively; we need to address the scandal of the lack of data in children compared with adults, precluding making evidence-based therapeutic decisions and move from guiding treatment by phenotypes, which will change as the environment changes, to endotype based therapy.
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Affiliation(s)
- Andrew Bush
- National Heart and Lung Institute, Imperial College, London, United Kingdom.,Imperial Centre for Paediatrics and Child Health, London, United Kingdom.,Royal Brompton Hospital, London, United Kingdom
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40
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Santamaria F, Ziello C, Lorello P, Bouchè C, Borrelli M. Update on Long-Acting Anticholinergics in Children and Adolescents With Difficult and Severe Asthma. Front Pediatr 2022; 10:896865. [PMID: 35928684 PMCID: PMC9343620 DOI: 10.3389/fped.2022.896865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 06/22/2022] [Indexed: 11/13/2022] Open
Abstract
Tiotropium bromide is the only long-acting muscarinic antagonist (LAMA) approved for treatment of patients aged ≥6 years old who have symptoms of uncontrolled asthma. Results from several clinical trials have found that once-daily inhaled tiotropium bromide is safe and efficacious in 6- to 17-year-olds with symptomatic asthma despite treatment with inhaled corticosteroids, with or without other medications. There are still few available studies investigating the impact of tiotropium bromide treatment in preschool children with suboptimal control. In this narrative review, we summarize the pharmacological effects of the LAMA tiotropium bromide, provide an overview about current asthma studies at different pediatric ages, and describe future research needs.
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Affiliation(s)
- Francesca Santamaria
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Carla Ziello
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Paola Lorello
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Cristina Bouchè
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
| | - Melissa Borrelli
- Department of Translational Medical Sciences, University of Naples Federico II, Naples, Italy
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41
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Saglani S, Bingham Y, Balfour-Lynn I, Goldring S, Gupta A, Banya W, Moreiras J, Fleming L, Bush A, Rosenthal M. Blood eosinophils in managing preschool wheeze: Lessons learnt from a proof-of-concept trial. Pediatr Allergy Immunol 2022; 33:e13697. [PMID: 34783100 DOI: 10.1111/pai.13697] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND Management of preschool wheeze is based predominantly on symptom patterns. OBJECTIVE To determine whether personalizing therapy using blood eosinophils or airway bacterial infection results in fewer attacks compared with standard care. METHODS A proof-of-concept, randomized trial to investigate whether the prescription of inhaled corticosteroids (ICS) guided by blood eosinophils, or targeted antibiotics for airway bacterial infection, results in fewer unscheduled healthcare visits (UHCVs) compared with standard care. Children aged 1-5 years with ≥2 wheeze attacks in the previous year were categorized as episodic viral wheeze (EVW) or multiple trigger wheeze (MTW). The intervention group was prescribed ICS if blood eosinophils ≥3%, or targeted antibiotics if there is positive culture on induced sputum/cough swab. The control group received standard care. The primary outcome was UHCV at 4 months. RESULTS 60 children, with a median age of 36.5 (range 14-61) months, were randomized. Median blood eosinophils were 5.2 (range 0-21)%, 27 of 60 (45%) children were atopic, and 8 of 60 (13%) had airway bacterial infection. There was no relationship between EVW, MTW and either blood eosinophils, atopic status or infection. 67% in each group were prescribed ICS. 15 of 30 control subjects and 16 of 30 patients in the intervention group had UHCV over 4 months (p = .8). The time to first UHCV was similar. 50% returned adherence monitors; in those, median ICS adherence was 67%. There were no differences in any parameter between those who did and did not have an UHCV. CONCLUSION Clinical phenotype was unrelated to allergen sensitization or blood eosinophils. ICS treatment determined by blood eosinophils did not impact UHCV, but ICS adherence was poor.
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Affiliation(s)
- Sejal Saglani
- National Heart & Lung Institute, Imperial College London, London, UK.,Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Yvonne Bingham
- National Heart & Lung Institute, Imperial College London, London, UK.,Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Ian Balfour-Lynn
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Stephen Goldring
- Department of Paediatrics, The Hillingdon Hospitals NHS Foundation Trust, London, UK
| | - Atul Gupta
- Department of Respiratory Paediatrics, Kings College Hospital NHS Foundation Trust, London, UK
| | - Winston Banya
- Research & Development Department, Royal Brompton Hospital, London, UK
| | - John Moreiras
- Department of Paediatrics, The Whittington Hospital, London, UK
| | - Louise Fleming
- National Heart & Lung Institute, Imperial College London, London, UK.,Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Andrew Bush
- National Heart & Lung Institute, Imperial College London, London, UK.,Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
| | - Mark Rosenthal
- Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
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42
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Custovic A, Siddiqui S, Saglani S. Considering biomarkers in asthma disease severity. J Allergy Clin Immunol 2021; 149:480-487. [PMID: 34942235 DOI: 10.1016/j.jaci.2021.11.021] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 11/25/2021] [Accepted: 11/30/2021] [Indexed: 10/19/2022]
Abstract
Amongst patients with asthma, reliance on the type/dose of prescribed medication and symptom control does not adequately capture those at risk of adverse outcomes, and we need biomarkers for risk and treatment stratification which are consistently accurate, readily quantifiable and reproducible. The majority of patients with severe asthma, regardless of age, have predominant type-2 (T2) inflammation mediated disease, making airway/blood eosinophils, FeNO, periostin and/or allergic sensitization potentially important biomarkers for severe disease. In both adult and pediatric asthma, there is scope to improve prediction of severe attacks by using a composite T2 biomarkers of blood eosinophils and FeNO. Technological advances in component-resolved diagnostics (CRD) microarray technologies coupled with the development of interpretation software offer a possibility to use CRD as biomarkers of asthma severity amongst sensitized asthmatics. Genetic predisposition and polygenic risk scores of relevant traits (e.g., lung function, host immune responses, biomarkers of exposure from the indoor and outdoor environment, infection and microbial dysbiosis) may also contribute to prediction algorithms. We challenge the idea that asthma can be accurately defined in an individual patient by a discrete and static "endotype" (e.g., T2-high asthma). As we traverse the new era of molecular endotyping in asthma, we need to understand how relevant mechanisms impact patient outcomes, and in parallel develop new tools and approaches to stratify therapies and define individual patient trajectories.
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Affiliation(s)
- Adnan Custovic
- National Heart and Lung Institute, Imperial College London, UK.
| | - Salman Siddiqui
- Department of Respiratory Sciences, University of Leicester and NIHR Respiratory Biomedical Research Unit, Glenfield Hospital, Leicester UK
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College London, UK
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Pijnenburg MW, Frey U, De Jongste JC, Saglani S. Childhood asthma- pathogenesis and phenotypes. Eur Respir J 2021; 59:13993003.00731-2021. [PMID: 34711541 DOI: 10.1183/13993003.00731-2021] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2021] [Accepted: 10/15/2021] [Indexed: 11/05/2022]
Abstract
In the pathogenesis of asthma in children there is a pivotal role for a type 2 inflammatory response to early life exposures or events. Interactions between infections, atopy, genetic susceptibility, and environmental exposures (such as farmyard environment, air pollution, tobacco smoke exposure) influence the development of wheezing illness and the risk for progression to asthma. The immune system, lung function and the microbiome in gut and airways develop in parallel and dysbiosis of the microbiome may be a critical factor in asthma development. Increased infant weight gain and preterm birth are other risk factors for development of asthma and reduced lung function. The complex interplay between these factors explains the heterogeneity of asthma in children. Subgroups of patients can be identified as phenotypes based on clinical parameters, or endotypes, based on a specific pathophysiological mechanism. Paediatric asthma phenotypes and endotypes may ultimately help to improve diagnosis of asthma, prediction of asthma development and treatment of individual children, based on clinical, temporal, developmental or inflammatory characteristics. Unbiased, data-driven clustering, using a multidimensional or systems biology approach may be needed to better define phenotypes. The present knowledge on inflammatory phenotypes of childhood asthma has now been successfully applied in the treatment with biologicals of children with severe therapy resistant asthma, and it is to be expected that more personalized treatment options may become available.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Urs Frey
- University Children's Hospital Basel (UKBB), Basel, Switzerland
| | - Johan C De Jongste
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Sejal Saglani
- National Heart and Lung Institute, Imperial College, London, UK
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