1
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Hengeveld VS, Lammers N, van der Kamp MR, van der Palen J, Thio BJ. Can the response to a single dose of beclomethasone dipropionate predict the outcome of long-term treatment in childhood exercise-induced bronchoconstriction? Pediatr Allergy Immunol 2022; 33:e13808. [PMID: 35754119 DOI: 10.1111/pai.13808] [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: 02/02/2022] [Revised: 05/09/2022] [Accepted: 05/13/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND Exercise-induced bronchoconstriction (EIB) is a frequent and highly specific symptom of childhood asthma. Inhaled corticosteroids (ICS) are the mainstay of controller therapy for EIB and asthma; however, a proportion of asthmatic children and adolescents is less responsive to ICS. We hypothesized that a single dose response to ICS could function as a predictor for individual long-term efficacy of ICS. OBJECTIVE To assess the predictive value of the bronchoprotective effect of a single-dose beclomethasone dipropionate (BDP) against EIB for the bronchoprotective effect of 4 weeks of treatment, using an exercise challenge test (ECT). METHODS Thirty-two steroid-naïve children and adolescents aged 6 to 18 years with EIB were included in this prospective cohort study. They performed an ECT at baseline, after a single-dose BDP (200µg) and after 4 weeks of BDP treatment (100 µg twice daily) to assess EIB severity. RESULTS The response to a single-dose BDP on exercise-induced fall in FEV1 showed a significant correlation with the response on exercise-induced fall in FEV1 after 4 weeks of BDP treatment (r = .38, p = .004). A reduction in post-exercise fall in FEV1 of more than 8% after a single-dose BDP could predict BDP efficacy against EIB after 4 weeks of treatment with a positive predictive value of 100% (CI: 86.1-100%) and a negative predictive value of 29.4% (CI: 11.7%-53.7%). CONCLUSION We found that the individual response to a single-dose BDP against EIB has a predictive value for the efficacy of long-term treatment with BDP. This could support clinicians in providing personalized management of EIB in childhood asthma.
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Affiliation(s)
- Vera S Hengeveld
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Natasja Lammers
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
| | - Mattienne R van der Kamp
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, The Netherlands.,Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands
| | - Job van der Palen
- Clinical Epidemiology, Medisch Spectrum Twente, Enschede, The Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands
| | - Bernard J Thio
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, The Netherlands
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2
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Hengeveld VS, van der Kamp MR, Thio BJ, Brannan JD. The Need for Testing-The Exercise Challenge Test to Disentangle Causes of Childhood Exertional Dyspnea. Front Pediatr 2021; 9:773794. [PMID: 35071131 PMCID: PMC8770982 DOI: 10.3389/fped.2021.773794] [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: 09/10/2021] [Accepted: 12/13/2021] [Indexed: 11/13/2022] Open
Abstract
Exertional dyspnea is a common symptom in childhood which can induce avoidance of physical activity, aggravating the original symptom. Common causes of exertional dyspnea are exercise induced bronchoconstriction (EIB), dysfunctional breathing, physical deconditioning and the sensation of dyspnea when reaching the physiological limit. These causes frequently coexist, trigger one another and have overlapping symptoms, which can impede diagnoses and treatment. In the majority of children with exertional dyspnea, EIB is not the cause of symptoms, and in asthmatic children it is often not the only cause. An exercise challenge test (ECT) is a highly specific tool to diagnose EIB and asthma in children. Sensitivity can be increased by simulating real-life environmental circumstances where symptoms occur, such as environmental factors and exercise modality. An ECT reflects daily life symptoms and impairment, and can in an enjoyable way disentangle common causes of exertional dyspnea.
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Affiliation(s)
- Vera S Hengeveld
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Mattiènne R van der Kamp
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - Boony J Thio
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - John D Brannan
- Ludwig Engel Centre for Respiratory Research, Westmead Institute for Medical Research, Westmead, NSW, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, New Lambton Heights, NSW, Australia
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3
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van der Kamp MR, Thio BJ, Tabak M, Hermens HJ, Driessen J, van der Palen J. Does exercise-induced bronchoconstriction affect physical activity patterns in asthmatic children? J Child Health Care 2020; 24:577-588. [PMID: 31607144 DOI: 10.1177/1367493519881257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Exercise-induced bronchoconstriction (EIB) is a sign of uncontrolled childhood asthma and classically occurs after exercise. Recent research shows that EIB frequently starts during exercise, called breakthrough-EIB (BT-EIB). It is unknown whether this more severe type of EIB forces children to adapt their physical activity (PA) pattern in daily life. Therefore, this pilot study aims to investigate daily life PA (amount, intensity, duration, and distribution) in children with BT-EIB, 'classic' EIB, and without EIB. A Fitbit Zip activity tracker was used for one week to objectively measure daily life PA at one-minute intervals. Thirty asthmatic children participated. Children with BT-EIB were less physically active compared to children without EIB (respectively 7994 and 11,444 steps/day, p = .02). Children with BT-EIB showed less moderate-to-vigorous PA compared to the children without (respectively 117 and 170 minutes/day, p = .02). Children with EIB (both BT and classic) had significant shorter bouts of activity and a less stretched distribution of bout lengths compared to the non-EIB group (all p < .05). These results emphasize a marked association between EIB severity and PA patterns in daily life, stressing the need for a thorough clinical evaluation of exercise-induced symptoms in childhood asthma.
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Affiliation(s)
- M R van der Kamp
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands
| | - B J Thio
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands.,Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - M Tabak
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.,Roessingh Research and Development, Enschede, Netherlands
| | - H J Hermens
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.,Roessingh Research and Development, Enschede, Netherlands
| | - Jmm Driessen
- OCON Sport, Ziekenhuisgroep Twente, Hengelo, Netherlands.,Department of Sports Medicine, Ziekenhuis Tjongerschans, Heerenveen, Netherlands
| | - Jam van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, Netherlands
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4
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van der Kamp MR, Klaver EC, Thio BJ, Driessen JMM, de Jongh FHC, Tabak M, van der Palen J, Hermens HJ. WEARCON: wearable home monitoring in children with asthma reveals a strong association with hospital based assessment of asthma control. BMC Med Inform Decis Mak 2020; 20:192. [PMID: 32795352 PMCID: PMC7427745 DOI: 10.1186/s12911-020-01210-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 08/03/2020] [Indexed: 12/19/2022] Open
Abstract
Background Asthma is one of the most common chronic diseases in childhood. Regular follow-up of physiological parameters in the home setting, in relation to asthma symptoms, can provide complementary quantitative insights into the dynamics of the asthma status. Despite considerable interest in asthma home-monitoring in children, there is a paucity of scientific evidence, especially on multi-parameter monitoring approaches. Therefore, the aim of this study is to investigate whether asthma control can be accurately assessed in the home situation by combining parameters from respiratory physiology sensors. Methods Sixty asthmatic and thirty non-asthmatic children were enrolled in the observational WEARCON-study. Asthma control was assessed according to GINA guidelines by the paediatrician. All children were also evaluated during a 2-week home-monitoring period with wearable devices; a physical activity tracker, a handheld spirometer, smart inhalers, and an ambulatory electrocardiography device to monitor heart and respiratory rate. Multiple logistic regression analysis was used to determine which diagnostic measures were associated with asthma control. Results 24 of the 27 uncontrolled asthmatic children and 29 of the 32 controlled asthmatic children could be accurately identified with this model. The final model showed that a larger variation in pre-exercise lung function (OR = 1.34 95%-CI 1.07–1.68), an earlier wake-up-time (OR = 1.05 95%-CI 1.01–1.10), more reliever use (OR = 1.11 95%-CI 1.03–1.19) and a longer respiratory rate recovery time (OR = 1.12 95%-CI 1.05–1.20) were significant contributors to the probability of having uncontrolled asthma. Conclusions Home-monitoring of physiological parameters correlates with paediatrician assessed asthma control. The constructed multivariate model identifies 88.9% of all uncontrolled asthmatic children, indicating a high potential for monitoring of asthma control. This may allow healthcare professionals to assess asthma control at home. Trial registration Netherlands Trail Register, NL6087. Registered 14 February 2017.
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Affiliation(s)
- M R van der Kamp
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, Netherlands. .,Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands. .,Roessingh Research and Development, Enschede, the Netherlands.
| | - E C Klaver
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - B J Thio
- Department of Paediatrics, Medisch Spectrum Twente, Enschede, Netherlands.,Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands
| | - J M M Driessen
- OCON sport, Hengelo, Netherlands.,Department of Sports Medicine, Ziekenhuis Tjongerschans, Heerenveen, Netherlands
| | - F H C de Jongh
- Department of Pulmonology, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Engineering Fluid Dynamics, University of Twente, Enschede, Netherlands
| | - M Tabak
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.,Roessingh Research and Development, Enschede, the Netherlands
| | - J van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, Netherlands
| | - H J Hermens
- Department of Biomedical Signals and Systems, University of Twente, Enschede, Netherlands.,Roessingh Research and Development, Enschede, the Netherlands
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5
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Lammers N, van Hoesel MHT, Kamphuis M, Brusse-Keizer M, van der Palen J, Visser R, Thio BJ, Driessen JMM. Assessing Exercise-Induced Bronchoconstriction in Children; The Need for Testing. Front Pediatr 2019; 7:157. [PMID: 31106184 PMCID: PMC6498950 DOI: 10.3389/fped.2019.00157] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2019] [Accepted: 04/03/2019] [Indexed: 11/13/2022] Open
Abstract
Objective: Exercise-induced bronchoconstriction (EIB) is a specific morbidity of childhood asthma and a sign of insufficient disease control. EIB is diagnosed and monitored based on lung function changes after a standardized exercise challenge test (ECT). In daily practice however, EIB is often evaluated with self-reported respiratory symptoms and spirometry. We aimed to study the capacity of pediatricians to predict EIB based on information routinely available during an outpatient clinic visit. Methods: A clinical assessment was performed in 20 asthmatic children (mean age 11.6 years) from the outpatient clinic of the MST hospital from May 2015 to July 2015. During this assessment, video images were made. EIB was measured with a standardized ECT performed in cold, dry air. Twenty pediatricians (mean years of experience 14.4 years) each evaluated five children, providing 100 evaluations, and predicted EIB severity based on their medical history, physical examination, and video images. EIB severity was predicted again after additionally providing baseline spirometry results. Results: Nine children showed no EIB, four showed mild EIB, two showed moderate, and five showed severe EIB. Based on clinical information and spirometry results, pediatricians detected EIB with a sensitivity of 84% (95% CI 72-91%) and a specificity of 24% (95% CI 14-39%).The agreement between predicted EIB severity classifications and the validated classifications after the ECT was slight [Kappa = 0.05 (95% CI 0.00-0.17)]. This agreement still remained slight when baseline spirometry results were provided [Kappa = 0.19 (95% CI 0.06-0.32)]. Conclusion: Pediatricians' prediction of EIB occurrence was sensitive, but poorly specific. The prediction of EIB severity was poor. Pediatricians should be aware of this in order to prevent misjudgement of EIB severity and disease control.
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Affiliation(s)
- Natasja Lammers
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | | | - Marije Kamphuis
- Faculty of Science and Technology, University of Twente, Enschede, Netherlands
| | | | - Job van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, Netherlands
| | - Reina Visser
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Boony J Thio
- Department of Pediatrics, Medisch Spectrum Twente, Enschede, Netherlands
| | - Jean M M Driessen
- OCON Sport, Ziekenhuisgroep Twente, Hengelo, Netherlands.,Department of Sportsmedicine, Tjongerschans Hospital, Heerenveen, Netherlands
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6
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de Aguiar KB, Anzolin M, Zhang L. Global prevalence of exercise-induced bronchoconstriction in childhood: A meta-analysis. Pediatr Pulmonol 2018; 53:412-425. [PMID: 29364581 DOI: 10.1002/ppul.23951] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Accepted: 01/03/2018] [Indexed: 11/10/2022]
Abstract
AIM This systematic review and meta-analysis aimed to estimate the global prevalence of exercise-induced bronchoconstriction (EIB) in children and adolescents. METHOD We searched PubMed, Google Scholar, and the Virtual Health Library-BIREME from inception to December 23, 2017. We selected observational studies that reported the prevalence of EIB (diagnosed by exercise challenge test) in children and adolescents aged 5-18 years. We conducted random-effects meta-analyses to estimate the pooled prevalence of EIB and 95% CI. RESULTS We included 66 studies (55 696 participants, 5670 cases of EIB) in the review, of which 33 in general population of children and adolescents, 10 in child and adolescent athletes and 23 in children and adolescents with asthma. The global mean prevalence of EIB in the general population of children and adolescents was 9% (IC95%: 8-10%), with a higher rate (12%) in Asia-Pacific and America. The mean prevalence of EIB was 15% (95% CI: 9-21%) in child and adolescent athletes, and 46% (95% CI: 39-53%) in children and adolescents with asthma. We estimated that, globally, around 16.5 million (95% CI: 15-18 million) children and adolescents up to 18 years of age may have EIB. CONCLUSION EIB in childhood should be considered as a global public health problem that needs more attention. The substantial heterogeneity between studies highlights the need for evidence-based guidelines for diagnosis of EIB in this age group.
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Affiliation(s)
- Karine B de Aguiar
- Postgraduate Program in Health Sciences, Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | - Marina Anzolin
- Faculty of Medicine, Federal University of Rio Grande, Rio Grande, Brazil
| | - Linjie Zhang
- Postgraduate Program in Health Sciences and Postgraduate Program in Public Health, Faculty of Medicine, Federal University of Rio Grande, Rio Grande-RS, Brazil
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7
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Inci D, Guggenheim R, Altintas DU, Wildhaber JH, Moeller A. Reported Exercise-Related Respiratory Symptoms and Exercise-Induced Bronchoconstriction in Asthmatic Children. J Clin Med Res 2017; 9:410-415. [PMID: 28392861 PMCID: PMC5380174 DOI: 10.14740/jocmr2935w] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/30/2017] [Indexed: 11/20/2022] Open
Abstract
Background Unlimited physical activity is one of the key issues of asthma control and management. We investigated how reliable reported exercise-related respiratory symptoms (ERRS) are in predicting exercise-induced bronchoconstriction (EIB) in asthmatic children. Methods In this prospective study, 179 asthmatic children aged 7 - 15 years were asked for specific questions on respiratory symptoms related to exercise and allocated into two groups according to whether they complained about symptoms. Group I (n = 134) consisted of children answering “yes” to one or more of the questions and group II (n = 45) consisted of children answering “no” to all of the questions. Results Sixty-four of 179 children showed a positive exercise challenge test (ECT). There was no difference in the frequency of a positive test between children in group I (n = 48) and group II (n = 12) (P = 0.47). The sensitivity of a positive report for ERRS to predict a positive ECT was only 37%, with a specificity of 0.72. Conclusion According to current guidelines, the report or lack of ERRS has direct consequences on treatment decisions. However, the history of ERRS did not predict EIB and one-third of asthmatic children without complaints of ERRS developed EIB during the ECT. This raises the question of the need for objective measures of bronchial hyperresponsiveness (BHR) in pediatric asthma management.
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Affiliation(s)
- Demet Inci
- Division of Respiratory Medicine, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Refoel Guggenheim
- Division of Respiratory Medicine, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
| | - Derya Ufuk Altintas
- Division of Paediatric Allergy and Immunology, Faculty of Medicine, University of Cukurova, 01330 Balcali, Saricam/Adana, Turkey
| | - Johannes H Wildhaber
- Department of Paediatrics, Cantonal Hospital Fribourg, HFR 1708 Freiburg, Switzerland
| | - Alexander Moeller
- Division of Respiratory Medicine, University Children's Hospital Zurich, Steinwiesstrasse 75, 8032 Zurich, Switzerland
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8
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Weiler JM, Brannan JD, Randolph CC, Hallstrand TS, Parsons J, Silvers W, Storms W, Zeiger J, Bernstein DI, Blessing-Moore J, Greenhawt M, Khan D, Lang D, Nicklas RA, Oppenheimer J, Portnoy JM, Schuller DE, Tilles SA, Wallace D. Exercise-induced bronchoconstriction update-2016. J Allergy Clin Immunol 2016; 138:1292-1295.e36. [PMID: 27665489 DOI: 10.1016/j.jaci.2016.05.029] [Citation(s) in RCA: 101] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2016] [Revised: 05/13/2016] [Accepted: 05/25/2016] [Indexed: 12/26/2022]
Abstract
The first practice parameter on exercise-induced bronchoconstriction (EIB) was published in 2010. This updated practice parameter was prepared 5 years later. In the ensuing years, there has been increased understanding of the pathogenesis of EIB and improved diagnosis of this disorder by using objective testing. At the time of this publication, observations included the following: dry powder mannitol for inhalation as a bronchial provocation test is FDA approved however not currently available in the United States; if baseline pulmonary function test results are normal to near normal (before and after bronchodilator) in a person with suspected EIB, then further testing should be performed by using standardized exercise challenge or eucapnic voluntary hyperpnea (EVH); and the efficacy of nonpharmaceutical interventions (omega-3 fatty acids) has been challenged. The workgroup preparing this practice parameter updated contemporary practice guidelines based on a current systematic literature review. The group obtained supplementary literature and consensus expert opinions when the published literature was insufficient. A search of the medical literature on PubMed was conducted, and search terms included pathogenesis, diagnosis, differential diagnosis, and therapy (both pharmaceutical and nonpharmaceutical) of exercise-induced bronchoconstriction or exercise-induced asthma (which is no longer a preferred term); asthma; and exercise and asthma. References assessed as relevant to the topic were evaluated to search for additional relevant references. Published clinical studies were appraised by category of evidence and used to document the strength of the recommendation. The parameter was then evaluated by Joint Task Force reviewers and then by reviewers assigned by the parent organizations, as well as the general membership. Based on this process, the parameter can be characterized as an evidence- and consensus-based document.
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9
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Galera R, Casitas R, Martínez-Cerón E, Romero D, García-Río F. Does airway hyperresponsiveness monitoring lead to improved asthma control? Clin Exp Allergy 2016; 45:1396-405. [PMID: 25817630 DOI: 10.1111/cea.12539] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
The current guidelines recommend an approach to asthma management based on asthma control, rather than asthma severity. Although several specific questionnaires have been developed and control criteria have been established based on clinical guidelines, the evaluation of asthma control is still not optimal. In general, these indicators provide adequate assessment of current control, but they are more limited when estimating future risk. There is much evidence demonstrating the persistence of airway inflammation and airway hyperresponsiveness (AHR) in patients with total control. Therefore, the objective of this review was to analyse the possible role of AHR monitoring as an instrument for assessing asthma control. We will evaluate its capacity as an indicator for future risk, both for estimating the possibility of clinical deterioration and loss of lung function or exacerbations. Furthermore, its relationship with inhaled corticosteroid treatment will be analysed, while emphasizing its capacity for predicting response and adjusting dosage, as well as information about the capability of AHR for monitoring treatment. Last of all, we will discuss the main limitations and emerging opportunities of AHR as an assessment instrument for asthma control.
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Affiliation(s)
- R Galera
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - R Casitas
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - E Martínez-Cerón
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - D Romero
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain
| | - F García-Río
- Servicio de Neumología, Hospital Universitario La Paz, IdiPAZ, Madrid, Spain.,Universidad Autónoma de Madrid, Madrid, Spain.,CIBER de Enfermedades Respiratorias, Madrid, Spain
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10
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Tripodi S, Barreto M, Di Rienzo-Businco A, Grossi O, Sfika I, Ragusa G, Campisano M, Miceli-Sopo S. Asthma Control Test and Bronchial Challenge with Exercise in Pediatric Asthma. Front Pediatr 2016; 4:16. [PMID: 27014666 PMCID: PMC4782564 DOI: 10.3389/fped.2016.00016] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 02/22/2016] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND Poor asthma control can lead to exercise-induced bronchoconstriction (EIB), but the relationship between subjective disease control and EIB is unclear. No studies have compared asthma control test (ACT) scores of children with those of their parents regarding EIB. We assessed whether ACT scores predict the occurrence of EIB in two age groups. We also evaluated ACT scores and objective measures as explanatory variables for airway response to exercise. METHODS Patients (71, aged <12 years; 93, aged ≥12 years) and their parents completed an ACT questionnaire separately. Current therapy, skin prick testing, and spirometry at baseline and after exercise were assessed. EIB was defined as a fall in forced expiratory volume in 1 s (FEV1) of at least 12% from baseline. Sensitivity and specificity for cut-off values of ACT scores predictive of EIB were plotted, and the area under curve (AUC) was described. RESULTS Atopy and current therapy were similarly frequent. EIB was observed in 23.9% of children aged <12 years and in 33.3% of children aged ≥12 years. EIB occurrence in subjects previously scored as having full control (25), partial control (20-24), and no control (<20) varied according to the age group and responders. Percentages of EIB cases increased as ACT scores decreased in children aged ≥12 years alone (child ACT scores, 25: 21.9%, 20-24: 31.1%, <20: 62.5%, p = 0.017). Plots for ACT scores as predictors of EIB yielded low non-significant AUC values in children aged <12 years; in contrast, moderate AUC values emerged in children aged ≥12 years (child: 0.67, p = 0.007; parent: 0.69, p = 0.002). Sensitivity of ACT scores below 20 as a predictor of EIB was low in older children (child: 32.3%, parent: 22.6%), whereas specificity was high (child: 90.3%, parent: 93.5%). Multiple regression analysis with percent fall in FEV1 as dependent variable included FEV1/FVC%, ACT child score, and gender in the prediction model (r = 0.42, p = 0.000). CONCLUSION ACT scores are a more effective means of excluding than confirming EIB in asthmatic patients aged ≥12 years; their predictive value decreases in younger patients. ACT scores together with lung function may help to predict airway response to exercise. New tools for pediatric asthma assessment may optimize this association.
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Affiliation(s)
- Salvatore Tripodi
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Mario Barreto
- NESMOS Department, Faculty of Medicine and Psychology, Pediatric Unit Sant'Andrea Hospital, "Sapienza" University , Rome , Italy
| | | | - Oriano Grossi
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Ifigenia Sfika
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Giovanni Ragusa
- Allergy Pediatric Unit, Pediatrics Department, Sandro Pertini Hospital , Rome , Italy
| | - Martina Campisano
- NESMOS Department, Faculty of Medicine and Psychology, Pediatric Unit Sant'Andrea Hospital, "Sapienza" University , Rome , Italy
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11
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Visser R, Wind M, de Graaf B, de Jongh FHC, van der Palen J, Thio BJ. Protective effect of a low single dose inhaled steroid against exercise induced bronchoconstriction. Pediatr Pulmonol 2015; 50:1178-83. [PMID: 25418114 DOI: 10.1002/ppul.23144] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2014] [Revised: 10/02/2014] [Accepted: 10/19/2014] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Daily use of inhaled corticosteroids (ICS) reduces exercise induced bronchoconstriction (EIB) in asthmatic children. A high single dose of ICS also provided acute protection against EIB. Objective of this study is to investigate whether a low single dose of ICS offers protection against EIB in asthmatic children. METHODS 31 Mild asthmatic children not currently treated with inhaled corticosteroids, 5-16 years, with EIB (fall in FEV0.5/1 ≥ 13%) were included in a prospective intervention study. They performed two ECT's within 2 weeks. Four hours before the second test children inhaled 200 μg beclomethasone-dipropionate (BDP) with a breath-actuated inhaler (BAI). RESULTS The median fall in FEV0.5/1 after 200 μg BDP was significantly reduced from 30.9% at baseline to 16.0% (P < 0.001). Twenty children (64.5%) showed a good response to 200 μg BDP (≥ 50% decrease in fall of FEV0.5/1), while 8 children showed a moderate response (25-50%), and three children showed no response at all (< 25%). CONCLUSION A low single dose ICS offers acute protection against EIB in the majority of asthmatic children not currently treated with inhaled corticosteroids.
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Affiliation(s)
- R Visser
- Department of Pediatrics, Medisch Spectrum Twente, KA Enschede, The Netherlands
| | - M Wind
- Department of Emergency, Röpcke-Zweers Hospital, Hardenberg, The Netherlands
| | - B de Graaf
- Department of Pediatrics, Medisch Spectrum Twente, KA Enschede, The Netherlands
| | - F H C de Jongh
- Department of Pulmonary Function, Medisch Spectrum Twente, Enschede, The Netherlands
| | - J van der Palen
- Medical School Twente, Medisch Spectrum Twente, Enschede, The Netherlands.,Department of Research Methodology, Measurement and Data Analysis, University of Twente, Enschede, The Netherlands
| | - B J Thio
- Department of Pediatrics, Medisch Spectrum Twente, KA Enschede, The Netherlands
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12
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Muñoz X, Bustamante V, Lopez-Campos JL, Cruz MJ, Barreiro E. Usefulness of noninvasive methods for the study of bronchial inflammation in the control of patients with asthma. Int Arch Allergy Immunol 2015; 166:1-12. [PMID: 25765083 DOI: 10.1159/000371849] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Bronchial asthma is one of the most prevalent respiratory conditions. Although it is defined as an inflammatory disease, the current guidelines for both diagnosis and follow-up of patients are based only on clinical and lung function parameters. Current research is focused on finding markers that can accurately predict future risk, and on assessing the ability of these markers to guide medical treatment and thus improve prognosis. The use of noninvasive methods to study airway inflammation is gaining increasing support. The study of eosinophils in induced sputum has proved useful for the diagnosis of asthma; however, its clinical implementation is complex. Some studies have shown that the measurement of exhaled nitric oxide (FeNO) may also be useful to establish disease phenotypes and improve control. Others have found that the measurement of pH and certain markers of oxidative stress, cytokines and prostanoids in exhaled breath condensate (EBC) may also be useful as well as the measurement of the temperature of exhaled breath and the analysis of volatile organic compounds (VOCs). In conclusion, since asthma is an inflammatory disease, it seems appropriate to try to control it through the study of airway inflammation using noninvasive methods. In this regard, the analysis of induced sputum cells has proved very useful, although the clinical implementation of this technique seems difficult. Other techniques such as temperature measurement, the analysis of FeNO, the analysis of the VOCs in exhaled breath, or the study of certain biomarkers in EBC require further study in order to determine their clinical applicability.
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Affiliation(s)
- Xavier Muñoz
- Pulmonology Service, Medicine Department, Hospital Universitari Vall d'Hebron, Barcelona, Spain
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13
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Barnes PJ, Casale TB, Dahl R, Pavord ID, Wechsler ME. The Asthma Control Questionnaire as a clinical trial endpoint: past experience and recommendations for future use. Allergy 2014; 69:1119-40. [PMID: 25039248 DOI: 10.1111/all.12415] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/19/2014] [Indexed: 12/24/2022]
Abstract
The goal of asthma treatment is to control the disease according to guidelines issued by bodies such as the Global Initiative for Asthma. Effective control is dependent upon evaluation of symptoms, initiation of appropriate treatment and minimization of the progressive adverse effects of the disease and its therapies. Although individual outcome measures have been shown to correlate with asthma control, composite endpoints are preferred to enable more accurate and robust monitoring of the health of the individual patient. A number of validated instruments are utilized to capture these component endpoints; however, there is no consensus on the optimal instrument for use in clinical trials. The Asthma Control Questionnaire (ACQ) has been shown to be a valid, reliable instrument that allows accurate and reproducible assessment of asthma control that compares favourably with other commonly used instruments. This analysis provides a summary of the use of ACQ in phase II, III and IV asthma trials. Comparisons between the ACQ and other instruments are also presented. Our analysis suggests that the ACQ is a valid and robust measure for use as a primary or secondary endpoint in future clinical trials.
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Affiliation(s)
- P. J. Barnes
- Airway Disease Section; National Heart & Lung Institute; London UK
| | | | - R. Dahl
- Allergy Centre; Odense University Hospital; Odense Denmark
| | - I. D. Pavord
- Department of Respiratory Medicine; Nuffield Department of Medicine; University of Oxford; Oxford UK
| | - M. E. Wechsler
- Department of Medicine; National Jewish Health; Denver CO USA
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Bikov A, Galffy G, Tamasi L, Bartusek D, Antus B, Losonczy G, Horvath I. Exhaled breath condensate pH decreases during exercise-induced bronchoconstriction. Respirology 2014; 19:563-9. [PMID: 24612285 DOI: 10.1111/resp.12248] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2013] [Revised: 09/17/2013] [Accepted: 12/24/2013] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE Exercise-induced bronchoconstriction (EIB) is the temporary narrowing of the airways caused by physical exercise. Its exact pathophysiology is unclear; however, acute changes in airways pH may play a role. Exhaled breath condensate (EBC) pH was suggested as a surrogate indicator for airway acid-base status, but its value is also affected by volatile molecules and respiratory droplet dilution. The aim of the study was to assess changes in EBC pH during EIB. METHODS Twenty-two asthmatics who reported breathlessness following exercise and 16 healthy individuals participated in the study. Lung function test was performed and exhaled breath samples were collected for pH, dilution factor and volatile compound pattern measurements (Cyranose 320) pre-exercise and at 0, 10, 20 and 30 min after physical exercise challenge. Fractional exhaled nitric oxide was measured before exercise. RESULTS EIB developed in 13 asthmatic subjects. In these participants, but not in the EIB-negative asthmatics (P = 0.51), EBC pH reduced significantly during exercise (P = 0.01). In addition, changes in EBC pH were related to the degree of bronchospasm in the EIB-positive group (P = 0.01, r = 0.68). Exhaled volatile pattern became altered (P < 0.05) during exercise in all subjects (asthmatics and controls). EBC pH changes were not related to EBC dilution or volatile compound pattern alterations (P > 0.05). CONCLUSIONS The development of EIB was related to acute changes of EBC pH, which suggest the role of airway pH decrease in the pathophysiology of EIB. Exercise-induced changes in exhaled biomarkers suggest methodological precautions to avoid physical exercise before performing exhaled breath tests.
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Affiliation(s)
- Andras Bikov
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
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15
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Anderson SD, Kippelen P. Assessment of EIB: What you need to know to optimize test results. Immunol Allergy Clin North Am 2013; 33:363-80, viii. [PMID: 23830130 DOI: 10.1016/j.iac.2013.02.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Respiratory symptoms and asthma control questionnaires are poor predictors of the presence or severity of exercise-induced bronchoconstriction (EIB), and objective measurement is recommended. To optimize the chance of a positive test result, there are several factors to consider when exercising patients for EIB, including the ventilation achieved and sustained during exercise, water content of the inspired air, and the natural variability of the response. The high rate of negative exercise test results has led to the development of surrogates to identify EIB in laboratory or office settings, including eucapnic voluntary hyperpnea of dry air and inhalation of hyperosmolar aerosols.
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Affiliation(s)
- Sandra D Anderson
- Department of Respiratory and Sleep Medicine, Royal Prince Alfred Hospital, Camperdown, New South Wales 2050, Missenden road, Australia.
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16
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van Leeuwen JC, Driessen JMM, Kersten ETG, Thio BJ. Assessment of exercise-induced bronchoconstriction in adolescents and young children. Immunol Allergy Clin North Am 2013; 33:381-94, viii-ix. [PMID: 23830131 DOI: 10.1016/j.iac.2013.02.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
Recent research shows important differences in exercise-induced bronchoconstriction (EIB) between children and adults, suggesting a different pathophysiology of EIB in children. Although exercise can trigger classic symptoms of asthma, in children symptoms can be subtle and nonspecific; parents, children, and clinicians often do not recognize EIB. With an age-adjusted protocol, an exercise challenge test can be performed in children as young as 3 years of age. However, an alternative challenge test is sometimes necessary to assess potential for EIB in children. This review summarizes age-related features of EIB and recommendations for assessing EIB in young children and adolescents.
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Affiliation(s)
- Janneke C van Leeuwen
- Department of Pediatrics, Medisch Spectrum Twente, VKC poli 17, Haaksbergerstraat 55, Enschede 7513 ER, The Netherlands.
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Anderson SD. The prevention of exercise-induced bronchoconstriction: what are the options? Expert Rev Respir Med 2013; 6:355-7. [PMID: 22971059 DOI: 10.1586/ers.12.33] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Muñoz X, Sanchez-Vidaurre S, Roca O, Torres F, Morell F, Cruz MJ. Bronchial inflammation and hyperresponsiveness in well controlled asthma. Clin Exp Allergy 2013; 42:1321-8. [PMID: 22925318 DOI: 10.1111/j.1365-2222.2012.04004.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Little research has been devoted to the characteristics of bronchial inflammation in patients with stable, well controlled asthma. OBJECTIVE The aim of this study was to assess the degree and type of airway inflammation and to investigate the relationship between inflammation and bronchial hyperresponsiveness in patients with well controlled asthma. METHODS A cross-sectional study was conducted in 84 adult patients (43 men, mean age 43 years) with documented well controlled asthma. Induced sputum samples were obtained and cell types determined by differential cell count. Spirometry and methacholine challenge testing were performed. Asthma Control Questionnaire (ACQ) was used to assess symptoms. Patients were included if their ACQ score was < 0.75. RESULTS A total of 59 patients had persistent bronchial inflammation: 28 cases were considered eosinophilic, 28 neutrophilic, and 3 mixed. Median (range) percentage of eosinophils was 4% (0-64) in patients testing positive to methacholine challenge (n = 66) and 1% (0-3) in those testing negative (n = 18) (P = 0.003). A positive correlation was found between eosinophil percentage and the methacholine dose/response ratio (r = 0.477, P = 0.0001). The geometric mean (95% CI) of the methacholine PC20 was 1.74 mg/mL (1.04-2.93) in patients with eosinophilic inflammation and 4.14 mg/mL (2.5-6.84) in those with neutrophilic inflammation (P = 0.03). CONCLUSIONS Inflammation and bronchial hyperresponsiveness persist in most patients with well controlled asthma. CLINICAL RELEVANCE The study demonstrates that eosinophilic or neutrophilic inflammation persisted in most well controlled asthma patients despite the fact that their condition was controlled and therefore, measurement of bronchial inflammation seems essential to achieve proper asthma control.
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Affiliation(s)
- X Muñoz
- Pulmonology Service, Medicine Department, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain.
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Purokivi M, Koskela H, Kontra K. Determinants of asthma control and quality of life in stable asthma: evaluation of two new cough provocation tests. CLINICAL RESPIRATORY JOURNAL 2012; 7:253-60. [PMID: 22822927 DOI: 10.1111/j.1752-699x.2012.00313.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 02/24/2012] [Revised: 06/27/2012] [Accepted: 07/06/2012] [Indexed: 11/29/2022]
Abstract
INTRODUCTION Asthma control and quality of life are poorly associated with traditional asthma biomarkers. OBJECTIVES In the present study, we evaluated two new cough provocation tests in this respect. METHODS Asthma Control Questionnaire and Leicester Cough Questionnaire were completed by 36 stable asthmatics. Cough provocation tests with hypertonic saline and isocapnic hyperpnoea of dry air were performed, as well as spirometry, ambulatory peak expiratory flow (PEF) monitoring and exhaled nitric oxide (eNO) measurement. RESULTS Leicester Cough Questionnaire score correlated closely with cough responsiveness to hypertonic saline and isocapnic hyperpnoea (R = -0.66, P < 0.001 and R = -0.49, P = 0.002, respectively). Asthma Control Questionnaire score also correlated with the cough responsiveness to these tests (R = 0.52, P = 0.001 and R = 0.43, P = 0.008, respectively). Forced expiratory volume in 1 s (%predicted), diurnal PEF variation and eNO did not correlate with cough-related quality of life but showed some association with asthma control. There was a significant correlation between Leicester Cough Questionnaire and Asthma Control Questionnaire (R = -0.54, P = 0.001). CONCLUSIONS Asthma control and cough-related quality of life are more closely associated with cough responsiveness to the investigated cough provocation tests than to eNO and traditional indices of bronchial obstruction. Cough is a major contributor to poor asthma control.
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Affiliation(s)
- Minna Purokivi
- Center for Medicine and Clinical Research, Division of Respiratory Medicine, Kuopio University Hospital, Kuopio, Finland.
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Driessen JM, van der Palen J, van Aalderen WM, de Jongh FH, Thio BJ. Inspiratory airflow limitation after exercise challenge in cold air in asthmatic children. Respir Med 2012; 106:1362-8. [PMID: 22789953 DOI: 10.1016/j.rmed.2012.06.017] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2012] [Revised: 06/20/2012] [Accepted: 06/25/2012] [Indexed: 10/28/2022]
Abstract
Methacholine and histamine can lead to inspiratory flow limitation in asthmatic children and adults. This has not been analyzed after indirect airway stimuli, such as exercise. The aim of the study was to analyze airflow limitation after exercise in cold, dry air. 72 asthmatic children with mild to moderate asthma (mean age 13.2 ± 2.2 yrs) performed a treadmill exercise challenge. A fall of >10% in FEV(1) was the threshold for expiratory flow limitation and a fall of >25% of MIF(50) was the threshold for inspiratory flow limitation. The occurrence of wheeze, stridor and cough were quantified before and after exercise. After exercise, the mean fall in FEV(1) was 17.7 ± 14.6%, while the mean fall in MIF(50) was 25.4 ± 15.8%; no correlation was found between fall in FEV(1) and MIF(50) (R(2): 0.04; p = 0.717). 53 of the 72 children showed an inspiratory and/or expiratory airflow limitation. 38% (20/53) of these children showed an isolated expiratory flow limitation, 45% (24/53) showed both expiratory and inspiratory flow limitation and 17% (9/53) showed an isolated inspiratory flow limitation. The fall in FEV(1) peaked 9 min after exercise and correlated to expiratory wheeze. The fall in MIF(50) peaked 15 min after exercise and correlated to inspiratory stridor. The time difference in peak fall between FEV(1) and MIF(50) was statistically significant (5.9 min; p < 0.001, 99% CI: 2.3-9.5 min). In conclusion, this study shows that an exercise challenge in asthmatic children can give rise to inspiratory airflow limitation, which may give rise to asthma like symptoms.
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Affiliation(s)
- Jean M Driessen
- Department of Pediatrics Medisch Spectrum Twente, P.O. Box 50 000, 7500 KA Enschede, The Netherlands.
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Current World Literature. Curr Opin Allergy Clin Immunol 2012; 12:91-4. [DOI: 10.1097/aci.0b013e32834fd85c] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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