Monitoring asthma in childhood: management-related issues

Home Monitoring of Asthma Exacerbations in Children and Adults With Use of an AI-Aided Stethoscope

PURPOSE

The advent of new medical devices allows patients with asthma to self-monitor at home, providing a more complete picture of their disease than occasional in-person clinic visits. This raises a pertinent question: which devices and parameters perform best in exacerbation detection?

METHODS

A total of 149 patients with asthma (90 children, 59 adults) participated in a 6-month observational study. Participants (or parents) regularly (daily for the first 2 weeks and weekly for the next 5.5 months, with increased frequency during exacerbations) performed self-examinations using 3 devices: an artificial intelligence (AI)-aided home stethoscope (providing wheezes, rhonchi, and coarse and fine crackles intensity; respiratory and heart rate; and inspiration-to-expiration ratio), a peripheral capillary oxygen saturation (SpO2) meter, and a peak expiratory flow (PEF) meter and filled out a health state survey. The resulting 6,029 examinations were evaluated by physicians for the presence of exacerbations. For each registered parameter, a machine learning model was trained, and the area under the receiver operating characteristic curve (AUC) was calculated to assess its utility in exacerbation detection.

RESULTS

The best single-parameter discriminators of exacerbations were wheezes intensity for young children (AUC 84% [95% CI, 82%-85%]), rhonchi intensity for older children (AUC 81% [95% CI, 79%-84%]), and survey answers for adults (AUC 92% [95% CI, 89%-95%]). The greatest efficacy (in terms of AUC) was observed for a combination of several parameters.

CONCLUSIONS

The AI-aided home stethoscope provides reliable information on asthma exacerbations. The parameters provided are effective for children, especially those younger than 5 years of age. The introduction of this tool to the health care system might enhance asthma exacerbation detection substantially and make remote monitoring of patients easier.

Obesity and childhood asthma

PURPOSE OF REVIEW

Asthma is a common chronic disease of the airways characterized by recurrent respiratory symptoms, bronchoreactivity, and airway inflammation. The high toll on quality of life has led to sustained efforts to understand the factors leading to asthma inception and poor disease control. Obesity is another increasingly common pediatric disease, which appears to increase the risk for incident asthma and worsened disease severity. Currently, our understanding of how obesity affects asthma risk and affects its phenotypic characteristics remains incomplete. The current review describes our current understanding of the epidemiology, clinical characteristics, and management considerations of obesity-related asthma in children.

RECENT FINDINGS

The epidemiologic relationship between obesity in children and incident asthma remains confusing despite numerous longitudinal cohort studies, and appears to be influenced by early life exposures, patterns of somatic growth and underlying familial risks of allergic disease. Children with comorbid obesity and asthma demonstrate diverse phenotypic characteristics which are still becoming clear.

SUMMARY

Like any child with asthma, a child with comorbid obesity requires an individualized approach adhering to current best-practice guidelines and an understanding of how obesity and asthma may interact.

The effect of a coaching program on asthma control and health care utilization in children with asthma

ABSRACTObjective: Poor adherence to asthma therapy is a major problem in the management of asthma. We aimed to assess if a designed coaching program in children with asthma, coming from low socioeconomic background, will reduce respiratory morbidity and health care utilization.Methods: A prospective interventional pilot study enrolling children aged 3-18 years, admitted to Soroka University Medical Center (SUMC) between October 2015 and May 2016 due to asthma exacerbation. The intervention group was part of a coaching program, which was conducted by medical and paramedical personnel and included a diagnostic and personal educational office visit and a house visit by a nurse educator for asthma. The control group comprised of demographically matched children with asthma, who were admitted to the SUMC, but did not go through any intervention. Medications purchase and health care utilization were extracted from the participants' HMO databases, during 1-year of follow-up.Results: 41 children were enrolled to the intervention group, with 63 children as a control group. No differences were found in asthma-related drugs purchase, number of clinic visits, ER admissions and hospitalizations during the follow-up year, although the intervention group showed a trend towards having a shorter length of stay (2.3 vs. 4.5 days, Cohen's D = 0.44, p = 0.06). The intervention group demonstrated subjective improvement in asthma control, as reflected in Asthma Control Test questionnaires.Conclusions: In this pilot study of coaching program for children with asthma coming from low income families, no decrease in health care utilization was shown. Larger and longer intervention programs are needed.

MicroRNA 27b-3p Modulates SYK in Pediatric Asthma Induced by Dust Mites

The PI3K-AKT pathway is known to regulate cytokines in dust mite-induced pediatric asthma. However, the underlying molecular steps involved are not clear. In order to clarify further the molecular steps, this study investigated the expression of certain genes and the involvement of miRNAs in the PI3K-AKT pathway, which might affect the resultant cytokine-secretion. in-vivo and in-vitro ELISA, qRT-PCR and microarrays analyses were used in this study. A down-expression of miRNA-27b-3p in dust mite induced asthma group (group D) was found by microarray analysis. This was confirmed by qRT-PCR that found the miRNA-27b-3p transcripts that regulated the expression of SYK and EGFR were also significantly decreased (p < 0.01) in group D. The transcript levels of the SYK and PI3K genes were higher, while those of EGFR were lower in the former group. Meanwhile, we found significant differences in plasma concentrations of some cytokines between the dust mite-induced asthma subjects and the healthy controls. On the other hand, this correlated with the finding that the transcripts of SYK and its downstream PI3K were decreased in HBE transfected with miRNA-27b-3p, but were increased in HBE transfected with the inhibitor in vitro. Our results indicate that the differential expression of the miRNAs in dust mite-induced pediatric asthma may regulate their target gene SYK and may have an impact on the PI3K-AKT pathway associated with the production of cytokines. These findings should add new insight into the pathogenesis of pediatric asthma.

Asthma and Medicines - Long-Term Side-Effects, Monitoring and Dose Titration

Asthma is a major pediatric respiratory morbidity requiring long-term management. A thorough knowledge of long-term medication side-effects in children is, thus, essential for every physician dealing with childhood asthma. Establishing diagnosis and initiating treatment is just a beginning of the journey. Ongoing monitoring is an essential component of comprehensive asthma management programme. Monitoring includes not only assessment of asthma control but also checking for adherence to treatment, technique of inhaler device use, associated co-morbities, if any, and potential environmental exposure. Various tools - both subjective and objective - are available for assessment of asthma control. However, evidence for their optimum use in different settings and patient groups is lacking and monitoring has to be customized depending on available resources and individual patient characteristics. Patient education is an important component of long-term asthma therapy. The ultimate aim is to achieve optimum asthma control i.e., achieve and maintain control of clinical symptoms, decrease future risk to patients (risk of exacerbations, progressive loss of lung function and development of fixed airflow obstruction, adverse effects of medications) and enabling the child to lead a life without restrictions, at lowest possible dose of drugs. This article reviews the side-effects of medications used for long-term management of asthma and discusses current literature on asthma monitoring and dose titration in pediatric population to help the asthma therapist not only prescribe the drugs rationally but also help the family make right choices for treatment.

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

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

Key paediatric messages from the 2017 European Respiratory Society International Congress

In this article, the group chairs of the Paediatric Assembly of the European Respiratory Society (ERS) highlight some of the most interesting findings presented at the 2017 ERS International Congress, which was held in Milan, Italy.

Is impaired glucose metabolism the missing piece in the obesity-asthma puzzle?

Obesity is a major risk factor for several conditions including atherosclerotic disease, metabolic syndrome, and upper airway dysfunction. However, the purported link between obesity and asthma has remained more difficult to define, in part due to limitations in past epidemiologic studies and the inherent challenge in accurately defining asthma in children. It is possible that obesity leads to asthma only in the presence of a mediating variable such as an obesity-related conditions such as esophageal reflux or insulin resistance. The article by Karampatakis and colleagues in this week's edition of the journal is important because it addresses the hypothesis that altered glucose metabolism/insulin resistance associates with bronchial hyperresponsiveness (BHR), a central and objectively measured marker of asthma. They studied pre-pubertal children with and without asthma with a range of body mass indices and found for the first time in pre-pubertal asthmatic children that both insulin resistance and impaired glucose tolerance were more closely related to BHR than was obesity. Their work opens the way for directed mechanistic study of the effects of impaired glucose metabolism on airway development during childhood and airway responsiveness, and for the study of insulin sensitizing therapies in children to prevent lower airway disease. Pediatr Pulmonol. 2017;52:147-150. © 2016 Wiley Periodicals, Inc.

Evaluation of monitoring strategies for childhood asthma

INTRODUCTION

The goal of monitoring pediatric asthma is to obtain and maintain asthma control, which is defined as minimizing asthma symptoms, restrictions to daily activities and the use of rescue medication. Long term goals include reducing the risk of fixed airflow limitation, and preventing asthma exacerbations and side effects of treatment. Several monitoring tools are available but no consensus exists on how to monitor patients in the most optimal way. Areas covered: In this review, we provide an overview of different tools and address general considerations on monitoring childhood asthma. Asthma care should be tailored to the individual patient. The health care professional should decide which monitoring strategy and frequency is optimal for the individual patient. Expert commentary: Personalized medicine should be the key issue in monitoring asthma in children. It is crucial to monitor disease activity and deterioration but there is no monitoring strategy that is clearly superior compared to others: The optimal strategy and frequency will vary between patients. Actually, both treatment and monitoring of pediatric asthma probably benefit from a personalized approach.

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

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

Monitoring asthma in childhood

The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. However, to date there is limited evidence on how to monitor patients with asthma. Childhood asthma introduces specific challenges in terms of deciding what, when, how often, by whom and in whom different assessments of asthma should be performed. The age of the child, the fluctuating course of asthma severity, variability in clinical presentation, exacerbations, comorbidities, socioeconomic and psychosocial factors, and environmental exposures may all influence disease activity and, hence, monitoring strategies. These factors will be addressed in herein.

We identified large knowledge gaps in the effects of different monitoring strategies in children with asthma. Studies into monitoring strategies are urgently needed, preferably in collaborative paediatric studies across countries and healthcare systems.

Monitoring asthma in children is essential for disease control and should reflect age, triggers and disease activityhttp://ow.ly/J0k7f

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

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

The European Respiratory Review: farewell from the editor with confidence for the future

As my third year as Chief Editor of the European Respiratory Review comes to an end, it is time for me to pass this responsibility onto a new team. It is also time to look back at what has been accomplished and what challenges are faced by the Review.

The European Respiratory Review will continue to develop and to accompany respiratory physicians intheir practicehttp://ow.ly/TcDKh

Monitoring asthma in children

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