RAD: Reactive Airways Disease or Really Asthma Disease?

Clinical Outcomes for Young Children Diagnosed With Asthma Versus Reactive Airway Disease

OBJECTIVE

Clinical diagnoses of asthma and reactive airway disease (RAD) in young children are subjective. We examined how often children were diagnosed with asthma versus RAD, and whether preventive care and 2-year clinical outcomes differed based on initial diagnosis.

METHODS

We conducted a retrospective cohort analysis of children (2-7 years) from a university-based general pediatrics practice who had been diagnosed with RAD or asthma. We performed adjusted comparisons between groups for time until subsequent asthma-related care. We also compared delivery of asthma-related healthcare services, corticosteroid and controller prescriptions, and action plans within 2 years of index diagnosis, using bivariate and regression analyses.

RESULTS

Four hundred three children were included (64% male, 67% Black, 25% Hispanic). RAD was diagnosed in 62% of index visits, and was more likely than asthma to be diagnosed in emergency settings. In the full sample, the time between index visit and subsequent asthma care did not differ between groups, after adjustment for index location. For subjects with complete 24-month follow-up (N = 300), no between-group differences were found in adjusted analyses. Most children with RAD received action plans and controller medications only after a subsequent asthma diagnosis, on average, 9 months after their index visit.

CONCLUSIONS

RAD diagnoses were linked to delayed delivery of preventive care measures, but within 2 years of initial diagnosis, clinical outcomes for those diagnosed with RAD and asthma did not differ. To facilitate clear communication and timely treatment, a prompt diagnosis of asthma, rather than RAD, should be considered for children with asthma symptoms.

Time to Say Goodbye to Bronchiolitis, Viral Wheeze, Reactive Airways Disease, Wheeze Bronchitis and All That

The diagnosis and management of infants and children with a significant viral lower respiratory tract illness remains the subject of much debate and little progress. Over the decades various terms for such illnesses have been in and fallen out of fashion or have evolved to mean different things to different clinicians. Terms such as "bronchiolitis," "reactive airways disease," "viral wheeze," and many more are used to describe the same condition and the same term is frequently used to describe illnesses caused by completely different dominant pathologies. This lack of clarity is due, in large part, to a failure to understand the basic underlying inflammatory and associated processes and, in part, due to the lack of a simple test to identify a condition such as asthma. Moreover, there is a lack of insight into the fact that the same pathology can produce different clinical signs at different ages. The consequence is that terminology and fashions in treatment have tended to go around in circles. As was noted almost 60 years ago, amongst pre-school children with a viral LRTI and airways obstruction there are those with a "viral bronchitis" and those with asthma. In the former group, a neutrophil dominated inflammation response is responsible for the airways' obstruction whilst amongst asthmatics much of the obstruction is attributable to bronchoconstriction. The airways obstruction in the former group is predominantly caused by airways secretions and to some extent mucosal oedema (a "snotty lung"). These patients benefit from good supportive care including supplemental oxygen if required (though those with a pre-existing bacterial bronchitis will also benefit from antibiotics). For those with a viral exacerbation of asthma, characterized by bronchoconstriction combined with impaired b-agonist responsiveness, standard management of an exacerbation of asthma (including the use of steroids to re-establish bronchodilator responsiveness) represents optimal treatment. The difficulty is identifying which group a particular patient falls into. A proposed simplified approach to the nomenclature used to categorize virus associated LRTIs is presented based on an understanding of the underlying pathological processes and how these contribute to the physical signs.

The Problematic 2014 American Academy of Pediatrics Bronchiolitis Guidelines

The 2014 American Academy of Pediatrics bronchiolitis guidelines do not adequately serve the needs and clinical realities of front-line clinicians caring for undifferentiated wheezing infants and children. This article describes the clinical challenges of evaluating and managing a heterogeneous disease syndrome presenting as undifferentiated patients to the emergency department. Although the 2014 American Academy of Pediatrics bronchiolitis guidelines and the multiple international guidelines that they closely mirror have made a good faith attempt to provide clinicians with the best evidence-based recommendations possible, they have all failed to address practical, front-line clinical challenges. The therapeutic nihilism of the guidelines and the dissonance between many of the recommendations and frontline realities have had wide-ranging consequences. Nevertheless, newer evidence of therapeutic options is emerging and forecasts hope for more therapeutically optimistic recommendations with the next revision of the guidelines.

Association between early-childhood antibiotic exposure and subsequent asthma in the US Medicaid population

BACKGROUND

Although socioeconomically disadvantaged children have an increased risk of asthma, the association between early-childhood antibiotics and the incidence of asthma among such children has had limited study.

OBJECTIVE

To examine the association between antibiotic fills in the first 2 years of life and risk of developing asthma among children enrolled in Medicaid plans.

METHODS

This retrospective cohort study of children with continuous medical and pharmacy coverage from birth to 2.5 years of age was performed from July 1, 2012, to November 31, 2018. We excluded children with a diagnosis of asthma before 2.5 years of age. Hazard ratios (HRs) and 95% CIs were estimated from Cox proportional hazards regression models. Covariates included sex, preterm birth, cesarean delivery, and mother's asthma status.

RESULTS

There were 79,582 children in the study cohort of whom 29,931 (37.6%) had 0 antibiotic prescriptions filled, 27,403 (34.4%) had 1 or 2 prescriptions filled, and 22,248 (28.0%) had 3 or more prescriptions filled. A total of 2381 new cases of asthma were observed in 89,545 person-years of follow-up. After adjustment, receipt of 1 or 2 antibiotics was associated with an increased risk of developing asthma, relative to 0 antibiotics (HR, 1.34; 95% CI, 1.21-1.49), and receipt of 3 or more antibiotics was associated with greater increased risk relative to 0 antibiotics (HR, 1.71; 95% CI, 1.54-1.90). After adjustment, the absolute risk of developing asthma by age 4.0 years increased from 2.7% (0 antibiotics) to 3.6% (1-2 antibiotics) and 4.5% (≥3 antibiotics).

CONCLUSION

Antibiotic prescriptions filled in the first 2 years of life were associated with an increased risk of asthma diagnosis from 2.5 to 5 years of age in a Medicaid population.

Asthma diagnosis in infants and preschool children: a systematic review of clinical guidelines

BACKGROUND AND AIM

The definition and diagnosis of asthma are the subject of controversy that is particularly intense in the case of individuals in the first years of life, due to reasons such as the difficulty of performing objective pulmonary function tests or the high frequency with which the symptoms subside in the course of childhood. Since there is no consensus regarding the diagnosis of asthma in preschool children, a systematic review has been carried out.

MATERIALS AND METHODS

A systematic search was made of the clinical guidelines published in the last 10 years and containing information referred to the concept or diagnosis of asthma in childhood - including the first years of life (infants and preschool children). A series of key questions were established, and each selected guide was analyzed in search of answers to those questions. The review protocol was registered in the international prospective register of systematic reviews (PROSPERO), with registration number CRD42017074872.

RESULTS

Twenty-one clinical guidelines were selected: 10 general guides (children and adults), eight pediatric guides and three guides focusing on preschool children. The immense majority accepted that asthma can be diagnosed from the first years of life, without requiring pulmonary function tests or other complementary techniques. The response to treatment and the exclusion of other alternative diagnoses are key elements for establishing the diagnosis. Only one of the guides denied the possibility of diagnosing asthma in preschool children.

CONCLUSIONS

There is generalized although not unanimous agreement that asthma can be diagnosed in preschool children.