Development of lung function in relation to increased degree of bronchial responsiveness

Development of bronchial hyperresponsiveness during childhood

Bronchial hyperresponsiveness (BHR) produces the characteristic pathological abnormalities seen in asthma and clearly plays a central role in the pathophysiology of asthma. The presence of BHR has been demonstrated in infants with asthma, as has the possibility of BHR persisting through the childhood period. The level of BHR may not only reflect the state of the airways, as a marker of airway dysfunction, but may also predict the persistent prognosis of the disease. Thus, measurement of BHR may provide important information about the symptoms and lung function in children with asthma. In view of multiple pathophysiological mechanisms, BHR does not seem to have a single cause. Many potential confounding variables, such as age, gender and genetic status, and some environmental factors, such as allergens, infections, and pollutants, could be responsible for the establishment of childhood BHR. There may be differences between the mechanisms that induce transient BHR and the mechanisms that induce persistent BHR. Also, there may be differences between the causes that induce BHR in the infantile period and the causes that maintain persistent BHR during childhood asthma. There is also disagreement as to the most suitable method to measure BHR in children, especially in infants. The assessment of BHR in young children has not been uniformly successful, and measurements of BHR changes over the childhood period (are associated with a number of problems. To resolve these problems, there may be two ways to study childhood BHR. One is to use age-matched specific techniques to clarify the precise BHR in each age group; the other is to use simple techniques that can be performed over the childhood period on a large number of subjects. In studies of infantile respirator, dysfunction the ultimate goal is to establish a simple, noninvasive method by which measurements of respiratory function may be obtained in infants. Further investigations and acceptable methods will be needed to clarify, the mechanisms involved in the establishment of asthma throughout the childhood period.

Consequences of long-term inflammation. The natural history of asthma

Although asthma is classically defined as reversible airflow obstruction, and often remits in younger subjects with milder disease, the natural history of asthma is that various degrees of airflow obstruction may persist and, in the long-term, asthma may become moderately to fully irreversible. Severe, irreversible airflow obstruction may develop despite apparently appropriate therapy and in the absence of other risk factors, such as smoking and environmental insults. All studies of subjects with persisting asthma show increased decline in lung function compared with normal subjects. Persistent abnormal physiology is reflected both in reduced airflow rates and in increased airway responsiveness. The cellular and molecular mechanisms of airway remodeling are described elsewhere in this issue. Questions not yet clearly answered are the reasons for these persistent abnormalities in some asthmatics, and which subjects are most at risk. Factors that adversely impact the outcome as adults identified relatively consistently among many longitudinal studies of the natural history of asthma include: Female gender. Environmental tobacco smoke exposure in childhood. Personal tobacco smoking in adolescence and adulthood. Age of onset of symptoms. Severity of childhood asthma. Duration of asthma. Severity of lung function abnormality in childhood. Bronchodilator reversibility. Degree of airway hyperresponsiveness. Delay in initiating anti-inflammatory therapy. Remission among adult asthmatics is uncommon, but is associated with better initial lung function, young age, male gender, and lesser degrees of airway responsiveness. The role of atopy remains controversial. Conversely, risk factors for death from asthma include older age, smoking, atopy, impaired lung function, and moderate to high reversibility. Treatment can improve lung function, reduce airway responsiveness, and improve quality of life. The overall effect of treatment on the natural history of the disease is not yet clear, despite significant short-term improvements from effective anti-inflammatory therapy.

Cotinine excretion as a predictor of peak flow variability

Environmental tobacco smoke (ETS) is suspected to be an important risk factor for bronchial hyperresponsiveness. In order to test the effect of ETS, we measured expiratory flow rates and urine cotinine excretion (UCE) within a narrow time window in two consecutive years. Maternal smoking habits and medical history were ascertained by standardized questionnaires. The percentage ratio of the amplitude over the mean (AVAM) of the diurnal peak flow rates of children (complete values from at least five consecutive days) was calculated as an indicator of bronchial responsiveness. The association of UCE and log10AVAM was analyzed by multiple linear regression. Complete data were available for a sample of 417 children. The median of UCE in children of parents who smoked (3.2 ng/mg and 2.9 ng/mg creatinine, Surveys 1 and 2, respectively) was higher than the median in children of nonsmoking parents (0 ng/mg in both surveys). With increasing UCE the log10AVAM rose in the first and second surveys, as well as in the longitudinal analysis (p = 0.003). This association, however, showed up only in boys (p = 0.0001) and not in girls (p = 0.31). Our data suggest that there is a need both for further analysis of the gender difference and for more support of strategies against passive smoking as far as children are concerned, since airway hyperresponsiveness is a risk factor for chronic airway impairment.

Age-related changes in bronchial hyperreactivity during the adolescent period

To evaluate the influence of bronchial hyperreactivity on the improvement of asthma seen during adolescence, age-related changes of bronchial reactivity to methacholine (BRm) in adolescence were evaluated in two studies. Study 1 included 261 asthmatic children and 89 controls, aged 6-26 years, and in Study 2, yearly BRm variations from age 11 to 16 years of 23 asthmatic children of study 1 were studied. Methacholine inhalation challenge was performed by using an oscillation method; that is, respiratory resistance (Rrs) was directly measured by an oscillation technique, and subsequent doses were then doubled, until a twofold increase in Rrs from the baseline was reached. The cumulative dose of methacholine at the inflection point of the Rrs was considered to represent the BRm. From ages 6 to 9, Dmin in the asthmatic children were low (from 2.07 units to 1.38 units), but after age 12, the value gradually increased, and finally became sustained after age 16 (from 2.27 units to 4.80 units). These same age-related changes were seen in the age-matched controls. From ages 6 to 11, Dmin in the control children were also low (from 8.07 units to 12.9 units), but after age 12, Dmin gradually increased, and finally became sustained after age 16 (from 18.5 units to 43.2 units). However, for each year, the Dmin of the asthmatic children were significantly lower than those of the controls. Further, the mean of yearly Dmin variation from age 13 was less than that of younger subjects (from 0.65 unit/year to 0.92 unit/year, from 1.16 units/year younger subjects (from 0.65 unit/year to 0.92 unit/year, from 1.16 units/year to 4.16 units/year, respectively). We, therefore, concluded that the natural age-related BRm changes and the increased stability of yearly BRm variation that occur in adolescence may play a role in the improvement of childhood asthma seen during this period.