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

Progress in Research into the Effectiveness of Pulmonary Rehabilitation in Children with Asthma - A Narrative Review

Asthma is the most common chronic respiratory disease in children. It has a serious impact on children's physical and mental health. Pulmonary rehabilitation is a multidisciplinary and comprehensive intervention for patients with chronic respiratory disease, whose major components include breathing training, inspiratory muscle training and exercise training. Pulmonary rehabilitation is a multidisciplinary and comprehensive intervention for patients with chronic respiratory diseases, the main components of which are breathing training, inspiratory muscle training and exercise training. Pulmonary rehabilitation can improve the physical and mental condition of patients with chronic respiratory diseases and promote healthy behaviors. However, there is little research on pulmonary rehabilitation in children with asthma. This review comprehensively evaluated the effect of pulmonary rehabilitation in children with asthma at home and abroad, aiming to provide reference for clinical research on pulmonary rehabilitation in children with asthma.

A study on viruses and bacteria with particular interest on Mycoplasma pneumoniae in children with exacerbation of asthma from a tertiary care hospital in Sri Lanka

Asthma is a significant public health concern, particularly in children with severe symptoms. Exacerbation of asthma (EOA) is life-threatening, and respiratory infections (RIs) play a crucial role. Though viruses play a significant role in EOA, patients are empirically treated with antibiotics, contributing to antibiotic resistance development. Although there are widely reported associations of EOA with viral or Mycoplasma pneumoniae infections, there are no published data for Sri Lanka. The present study aimed to identify the association of common respiratory viruses, typical respiratory bacterial pathogens and M. pneumoniae in children with EOA and relate them with the compatibility of antimicrobial use. A case-control study was conducted in the paediatric unit of North Colombo Teaching Hospital, Sri Lanka, involving two groups of children between 5 and 15 years of age. Group 1 is children with EOA and Group 2 is children with stable asthma (SA). Each group consisted of 100 children. Sputum/throat swabs were tested for common respiratory viruses using virus-specific fluorescein isothiocyanate-labelled monoclonal antibodies (MAbs), bacteria by routine culture, and M. pneumoniae by real-time polymerase chain reaction. Macrolide resistance in M. pneumoniae was detected using conventional PCR and sequencing specific genetic mutations in the 23S rRNA gene. M. pneumoniae was genotyped using nested multilocus sequence typing, which targeted eight housekeeping genes (ppa, pgm, gyrB, gmk, glyA, atpA, arcC and adk). There was no significant difference in age, gender, demographic or geographical location between the two groups. In children with EOA, antibiotics were used in 66 % (66/100) and macrolides in 42 % (42/100). Samples comprised 78 % (78/100) sputum and 22 % (22/100) throat swabs. Adenovirus was the most common virus identified, and it was significantly higher in children with EOA compared to those with SA. Still, the two groups had no significant difference in typical bacteria findings. M. pneumoniae was detected in one patient with EOA, but none was detected in the SA group. The M. pneumoniae was macrolide-sensitive and ST14 by multilocus sequence typing. This study showed that the empiric use of antibiotics in children with asthma might be better targeted with prior pathogen screening to inform appropriate treatment to minimize antibiotic resistance.

Unhealthy habits and comorbidities associated with uncontrolled asthma in young people

INTRODUCTION

Asthma is a chronic inflammatory disease of the lower airways that affects more than 260 million people worldwide and has been related to more than 460,000 deaths a year. It is estimated that in 60% of asthma cases, the symptoms are not adequately controlled. The objective of this study was to determine the association between some comorbidities, habits, and health risk behaviors with uncontrolled asthma in a sample of young people with asthma.

METHODS

Through a cross-sectional study, data from 1,078 young people aged 17 to 19 years were analyzed. Information was collected through physical examination, direct questioning, and the application of a self-administered questionnaire.

RESULTS

In the group of young people with asthma, the prevalence of uncontrolled asthma was 20.6%, of which 53.8% were women, 76.9% suffered from rhinitis, 46.2% were overweight and 23.1% were obese. In the group of young with uncontrolled asthma, gingivitis was detected in 53.8% and alcohol consumption in 84.6%. Logistic regression analysis showed a significant association between allergic rhinitis, gingivitis, carbohydrate intake, alcohol consumption, overweight, and obesity with uncontrolled asthma.

CONCLUSIONS

Parents and members of the health team need to identify on time the risk factors associated with uncontrolled asthma in young people with asthma to limit its development and the negative effects it generates. The results of this study should be used to strengthen programs that promote the comprehensive health of adolescents.

Rhinitis Control and Medication Use in a Real-World Sample of Patients With Persistent Rhinitis or Rhinosinusitis: A Community Pharmacy Study

BACKGROUND

Little is known about rhinitis control in real-life, nor about the contribution of treatment-related and patient-related factors.

OBJECTIVE

This study aimed to examine the level of rhinitis control and rhinitis medication utilization in patients with persistent rhinitis and to identify predictors of rhinitis control.

METHODS

A cross-sectional observational study was conducted in patients with persistent rhinitis recruited in community pharmacies. Participants completed the Rhinitis Control Assessment Test, a questionnaire on patient/rhinitis characteristics, and rhinitis medication use. A visual analog scale for nasal symptoms was also completed. Pharmacy dispensing data were used to calculate adherence to intranasal glucocorticoids. Nasal spray technique was evaluated using a standardized checklist. Predictors of rhinitis control were explored using a linear regression model.

RESULTS

A total of 1,514 patients, recruited in 215 pharmacies, participated in the study (mean age 48.7 y, 62% female). Almost 60% exhibited suboptimal rhinitis control (Rhinitis Control Assessment Test ≤ 21 of 30). A 50-mm cut-off on the visual analog scale yielded 78.1% sensitivity to identify suboptimal rhinitis control. Participants most frequently used intranasal glucocorticoids (55.6%) and intranasal decongestants (47.4%). Only 10.3% of current nasal spray users demonstrated perfect technique. More than half (54.8%) of glucocorticoid users were identified as underadherent. Female sex, self-reported nasal hyperreactivity, active asthma, and use of oral/intranasal decongestants or nasal saline were identified as predictors of worse rhinitis control.

CONCLUSIONS

Suboptimal rhinitis control was common in this real-life sample of persistent rhinitis patients. Improving use of rhinitis medication may be key to increase disease control.

Pediatric Asthma Therapy Assessment Questionnaire for the Brazilian population: Cross-cultural adaptation and measurement properties

OBJECTIVE

To cross-culturally adapt the Pediatric Asthma Therapy Assessment Questionnaire (ATAQ) into Brazilian Portuguese and analyze its measurement properties.

METHODS

This exploratory methodological study included eight experts and 30 caregivers in the translation and cross-cultural adaptation steps. Thereafter, 118 caregivers of pediatric patients with asthma aged between 5 and 17 years were involved in the analysis of measurement properties. We analyzed the content, structural (exploratory and confirmatory factorial), construct (convergent and discriminant), and known-groups validities; floor and ceiling effects; and determined the cut-off point (receiver operator characteristic curve) to identify pediatric patients with uncontrolled asthma. Intraclass correlation coefficient (ICC) analyzed test-retest reliability with 54 caregivers, whereas Cronbach's α and composite reliability verified the internal consistency of the items.

RESULTS

The committee of experts and caregivers found the instructions and response options relevant, understandable, and clear (K > 0.75). During the cross-cultural adaptation, three items (2, 4, and 12) were slightly modified by including terms to facilitate understanding. A two-factor structure (asthma control and patient-provider communication) was identified. Internal consistency (α > .67; composite reliability > 0.73) and test-retest reliability (ICC > 0.80) were acceptable. For construct and know-groups validities, 85.71% of the hypothesis were confirmed. A cut-off point of >3 for the control domain was considered adequate to identify pediatric patients with uncontrolled asthma (sensitivity: 86.21%; specificity: 80.90%).

CONCLUSION

The Pediatric ATAQ was adequately adapted for Brazilian pediatric patients with asthma and produced valid and reliable measures for assessing asthma control. Therefore, it may be considered an adequate instrument for monitoring asthma control in the Brazilian pediatric population.

Critical reappraisal of short-acting bronchodilators for pediatric respiratory diseases

Short-acting bronchodilators are a class of medications commonly used to treat asthma, chronic obstructive pulmonary disease, and other respiratory conditions. The use of these medications has evolved over time as we have gained a better understanding of their effectiveness and safety in the pediatric population. This comprehensive review synthesizes the current understanding of short-acting β2-agonists and short-acting anticholinergics in children. It addresses indications, contraindications, safety considerations, and highlights areas where further research is needed to guide the most effective use of short-acting bronchodilators.

Factors Involved in Decision-Making Dilemmas Faced by Parents of Children with Severe Asthma in PICU During the Development of Discharge Care Plans: A Phenomenological Study

Purpose

This study aims to explore the complicated decision-making dilemma and challenges confronted by parents of children suffering from severe asthma within the Pediatric Intensive Care Unit (PICU) when participating in the development of their children's discharge care plans.

Patients and Methods

Employing a phenomenological methodology, a purposive sampling was performed to engage with 17 parents who participated in in-depth and semi-structured interviews between October 2022 and February 2023. The transcripts of these interviews were transcribed into textual data, which was then subjected to Colaizzi's seven-step analysis for meticulous coding and comprehensive thematic elucidation.

Results

The comprehensive analysis of the factors involved in the intricate decision-making dilemmas faced by parents of children with severe asthma during the process of crafting discharge care plans in the PICU revealed five themes and eight sub-themes: 1) Complexity of asthma-related information; 2) Insufficient provision of comprehensive decision-making support; 3) Encountering negative emotions and wavering confidence; 4) Navigating realistic constraints impacting both parents and HCPs; 5) Balancing the advantages and disadvantages of various plans.

Conclusion

Parents of children with severe asthma in the PICU encounter intricate and multifaceted decision-making dilemmas while engaging in the formulation of discharge care plans. These complexities significantly dampen their decision-making enthusiasm and introduce potential risks to the children's prognosis and recovery. In the future, it is imperative to leverage the guidance provided by healthcare professionals (HCPs) in the decision-making process, develop tailored decision support tools specifically designed for the formulation of discharge care plans for children with severe asthma in the PICU.

The oral bacteriomes of patients with allergic rhinitis and asthma differ from that of healthy controls

Allergic rhinitis and asthma are two of the most common chronic respiratory diseases in developed countries and have become a major public health concern. Substantial evidence has suggested a strong link between respiratory allergy and upper airway dysbacteriosis, but the role of the oral bacteriota is still poorly understood. Here we used 16S rRNA massive parallel sequencing to characterize the oral bacteriome of 344 individuals with allergic rhinitis (AR), allergic rhinitis with asthma (ARAS), asthma (AS) and healthy controls (CT). Four of the most abundant (>2%) phyla (Actinobacteriota, Firmicutes, Fusobacteriota, and Proteobacteria) and 10 of the dominant genera (Actinomyces, Fusobacterium, Gemella, Haemophilus, Leptotrichia, Neisseria, Porphyromonas, Prevotella, Streptococcus, and Veillonella) in the oral cavity differed significantly (p ≤ 0.03) between AR, ARAS or AS and CT groups. The oral bacteriome of ARAS patients showed the highest intra-group diversity, while CT showed the lowest. All alpha-diversity indices of microbial richness and evenness varied significantly (p ≤ 0.022) in ARAS vs. CT and ARAS vs. AR, but they were not significantly different in AR vs. CT. All beta-diversity indices of microbial structure (Unifrac, Bray-Curtis, and Jaccard distances) differed significantly (p ≤ 0.049) between each respiratory disease group and controls. Bacteriomes of AR and ARAS patients showed 15 and 28 upregulated metabolic pathways (PICRUSt2) mainly related to degradation and biosynthesis (p < 0.05). A network analysis (SPIEC-EASI) of AR and ARAS bacteriomes depicted simpler webs of interactions among their members than those observed in the bacteriome of CT, suggesting chronic respiratory allergic diseases may disrupt bacterial connectivity in the oral cavity. This study, therefore, expands our understanding of the relationships between the oral bacteriome and allergy-related conditions. It demonstrates for the first time that the mouth harbors distinct bacteriotas during health and allergic rhinitis (with and without comorbid asthma) and identifies potential taxonomic and functional microbial biomarkers of chronic airway disease.

Multiple manifestations of uncontrolled asthma increase the risk of severe COVID-19

OBJECTIVE

Asthma control is of importance when assessing the risk of severe outcomes of COVID-19. The aim of this study was to explore associations of clinical characteristics and the effect of multiple manifestations of uncontrolled asthma with severe COVID-19.

METHODS

In 2014-2020, adult patients with uncontrolled asthma, defined as Asthma Control Test (ACT) ≤19 were identified in the Swedish National Airway Register (SNAR) (n = 24533). The SNAR database, including clinical data, was linked with national registers to identify patients with severe COVID-19 (n = 221). The effect of multiple manifestations of uncontrolled asthma was based on: 1) ACT ≤15, 2) frequent exacerbations and 3) previous asthma inpatient/secondary care and evaluated stepwise. Poisson regression analyses were conducted with severe COVID-19 as the dependent variable.

RESULTS

In this cohort with uncontrolled asthma, obesity was the strongest independent risk factor for severe COVID-19 in both sexes, but even greater in men. Multiple manifestations of uncontrolled asthma were more common among those with severe COVID-19 vs. without: one, 45.7 vs. 42.3%, two, 18.1 vs. 9.1% and three, 5.0 vs. 2.1%. The risk ratio (RR) of severe COVID-19 increased with an increasing number of manifestations of uncontrolled asthma: one, RR 1.49 (95% CI 1.09-2.02), two, RR 2.42 (95% CI 1.64-3.57) and three, RR 2.96 (95% CI 1.57-5.60), when adjusted for sex, age, and BMI.

CONCLUSIONS

It is important to consider the effect of multiple manifestations of uncontrolled asthma and obesity when assessing patients with COVID-19, as this increases the risk of severe outcomes substantially.

Nasal Bacteriomes of Patients with Asthma and Allergic Rhinitis Show Unique Composition, Structure, Function and Interactions

Allergic rhinitis and asthma are major public health concerns and economic burdens worldwide. However, little is known about nasal bacteriome dysbiosis during allergic rhinitis, alone or associated with asthma comorbidity. To address this knowledge gap we applied 16S rRNA high-throughput sequencing to 347 nasal samples from participants with asthma (AS = 12), allergic rhinitis (AR = 53), allergic rhinitis with asthma (ARAS = 183) and healthy controls (CT = 99). One to three of the most abundant phyla, and five to seven of the dominant genera differed significantly (p < 0.021) between AS, AR or ARAS and CT groups. All alpha-diversity indices of microbial richness and evenness changed significantly (p < 0.01) between AR or ARAS and CT, while all beta-diversity indices of microbial structure differed significantly (p < 0.011) between each of the respiratory disease groups and controls. Bacteriomes of rhinitic and healthy participants showed 72 differentially expressed (p < 0.05) metabolic pathways each related mainly to degradation and biosynthesis processes. A network analysis of the AR and ARAS bacteriomes depicted more complex webs of interactions among their members than among those of healthy controls. This study demonstrates that the nose harbors distinct bacteriotas during health and respiratory disease and identifies potential taxonomic and functional biomarkers for diagnostics and therapeutics in asthma and rhinitis.

Epigenome-Wide Association Studies of the Fractional Exhaled Nitric Oxide and Bronchodilator Drug Response in Moderate-to-Severe Pediatric Asthma

Asthma is the most prevalent pediatric chronic disease. Bronchodilator drug response (BDR) and fractional exhaled nitric oxide (FeNO) are clinical biomarkers of asthma. Although DNA methylation (DNAm) contributes to asthma pathogenesis, the influence of DNAm on BDR and FeNO is scarcely investigated. This study aims to identify DNAm markers in whole blood associated either with BDR or FeNO in pediatric asthma. We analyzed 121 samples from children with moderate-to-severe asthma. The association of genome-wide DNAm with BDR and FeNO has been assessed using regression models, adjusting for age, sex, ancestry, and tissue heterogeneity. Cross-tissue validation was assessed in 50 nasal samples. Differentially methylated regions (DMRs) and enrichment in traits and biological pathways were assessed. A false discovery rate (FDR) < 0.1 and a genome-wide significance threshold of p < 9 × 10−8 were used to control for false-positive results. The CpG cg12835256 (PLA2G12A) was genome-wide associated with FeNO in blood samples (coefficient= −0.015, p = 2.53 × 10−9) and nominally associated in nasal samples (coefficient = −0.015, p = 0.045). Additionally, three CpGs were suggestively associated with BDR (FDR < 0.1). We identified 12 and four DMRs associated with FeNO and BDR (FDR < 0.05), respectively. An enrichment in allergic and inflammatory processes, smoking, and aging was observed. We reported novel associations of DNAm markers associated with BDR and FeNO enriched in asthma-related processes.

Medication use in uncontrolled pediatric asthma: Results from the SysPharmPediA study

BACKGROUND

Uncontrolled pediatric asthma has a large impact on patients and their caregivers. More insight into determinants of uncontrolled asthma is needed. We aim to compare treatment regimens, inhaler techniques, medication adherence and other characteristics of children with controlled and uncontrolled asthma in the: Systems Pharmacology approach to uncontrolled Paediatric Asthma (SysPharmPediA) study.

MATERIAL AND METHODS

145 children with moderate to severe doctor-diagnosed asthma (91 uncontrolled and 54 controlled) aged 6-17 years were enrolled in this multicountry, (Germany, Slovenia, Spain, and the Netherlands) observational, case-control study. The definition of uncontrolled asthma was based on asthma symptoms and/or exacerbations in the past year. Patient-reported adherence and clinician-reported medication use were assessed, as well as lung function and inhalation technique. A logistic regression model was fitted to assess determinants of uncontrolled pediatric asthma.

RESULTS

Children in higher asthma treatment steps had a higher risk of uncontrolled asthma (OR (95%CI): 3.30 (1.56-7.19)). The risk of uncontrolled asthma was associated with a larger change in FEV₁% predicted post and pre-salbutamol (OR (95%CI): 1.08 (1.02-1.15)). Adherence and inhaler techniques were not associated with risk of uncontrolled asthma in this population.

CONCLUSION

This study showed that children with uncontrolled moderate-to-severe asthma were treated in higher treatment steps compared to their controlled peers, but still showed a higher reversibility response to salbutamol. Self-reported adherence and inhaler technique scores did not differ between controlled and uncontrolled asthmatic children. Other determinants, such as environmental factors and differences in biological profiles, may influence the risk of uncontrolled asthma in this moderate to severe asthmatic population.

Association of Asthma Control With Caregivers' Knowledge and Practices for Children With Asthma in the Tabuk Region of Saudi Arabia: A Cross-Sectional Study

Introduction Asthma is a chronic heterogeneous inflammatory disease that affects millions of individuals around the globe. Standardized asthma management is crucial to maintain and control the disease. Caregivers are the leading players in managing asthma during childhood. Studies are lacking in the Tabuk region. The aim of this study was to elucidate knowledge levels and common practices of caregivers of pediatric patients with asthma in the Tabuk region of Saudi Arabia and its impact on asthma control. Methodology A validated cross-sectional survey of the population of the Tabuk region was conducted from July 1, 2022, to September 30, 2022. Convenience sampling via an internet-based questionnaire within the study area was deployed, followed by phone interviews. Results  A total of 393 caregivers completed the questionnaire, and the data were analyzed. The median age of asthmatic children was nine years, and most of them were males (60.8%). Most caregivers had a higher education (62.1%). The symptoms of allergic rhinitis were found in almost 80% of children. Pulmonary function tests were performed in 42.5% of children, and only one-third underwent radioallergosorbent (RAST) skin testing. About half the children had an asthmatic attack and an emergency department visit once during the previous 12 months, and most were hospitalized during that period. Most caregivers showed good knowledge (score=7) about symptoms of asthma and factors that could worsen the child's asthma, as well as good asthma control practices (score ≥7). Children with poorly controlled asthma were younger, had significant allergic rhinitis symptoms (30%), and underwent pulmonary function tests (60%). Conclusion  In the Tabuk region, the extent of asthma control was significantly associated with caregivers' knowledge and practices for children with asthma. Future public education campaigns should focus on closing the observed knowledge and practice gaps to reduce the impact of childhood asthma.

Progress in diagnosis and treatment of difficult-to-treat asthma in children

At present, medications containing inhaled corticosteroids (ICS-containing) are the keystones of asthma treatment. The majority of asthmatic children can significantly improve clinical outcomes with little worsening by standardized inhaled glucocorticoid treatment, but there is still a small proportion of children who are unable to achieve good symptom control even after the maximum standardized treatment, known as 'children with difficult-to-treat asthma (DA)'. The high heterogeneity of DA makes therapy challenging and expensive, which poses a serious risk to children's health and makes it extremely difficult for clinical physicians to accurately identify and treat children with DA. This article reviews the definition, evaluation, and treatment of this asthma in order to provide a reference for optimal clinical decision-making.

Respiratory comorbidities in severe asthma: focus on the pediatric age

INTRODUCTION

Asthma comorbidities are a frequent cause of adverse outcomes, such as poor asthma control, frequent asthma attacks, reduced quality of life, and higher healthcare costs. Comorbidities are well-known treatable traits whose proper management can help achieve optimal asthma control. Although multimorbidity is frequent among asthmatics, comorbidities are still a potential cause of misdiagnosis and under or over treatments, and little is known about their impact on severe pediatric asthma.

AREAS COVERED

We provided a comprehensive, 5-year updated review focusing on the main respiratory comorbidities in severe asthma, particularly in epidemiology, pathogenesis, and current and future therapies.

EXPERT OPINION

Respiratory comorbidities have unique characteristics in childhood. Their management must be multidisciplinary, age-specific, and integrated. Further longitudinal studies are needed to understand better the mutual interrelation and synergistic effect between asthma and its respiratory comorbidities, the identification of common, treatable risk factors leading to potential asthma prevention, the effectiveness of actual and future target-therapies, and the correlation between long-lasting respiratory comorbidities and poor lung function trajectories.

Anti-inflammatory activities of Qingfei oral liquid and its influence on respiratory microbiota in mice with ovalbumin-induced asthma

Dysbiosis of respiratory microbiota is closely related to the pathophysiological processes of asthma, including airway inflammation. Previous studies have shown that Qingfei oral liquid (QF) can alleviate airway inflammation and airway hyper-responsiveness in respiratory syncytial virus-infected asthmatic mice, but its effect on the respiratory microbiota is unknown. We therefore aimed to observe the effects of QF on airway inflammation and respiratory microbiota in ovalbumin (OVA)-induced asthmatic mice. We also explored the potential mechanism of QF in reducing airway inflammation by regulating respiratory microbiota. Hematoxylin and eosin as well as periodic acid-Schiff staining were performed to observe the effects of QF on lung pathology in asthmatic mice. Cytokine levels in bronchoalveolar lavage fluid (BALF) specimens were also measured. Changes in respiratory microbiota were analyzed using 16S rRNA gene sequencing, followed by taxonomical analysis. In order to verify the metagenomic function prediction results, the expression of key proteins related to the MAPK and NOD-like receptor signaling pathways in the lung tissues were detected by immunohistochemistry. The current study found that QF had a significant anti-inflammatory effect in the airways of asthmatic mice. This is mainly attributed to a reduction in lung pathology changes and regulating cytokine levels in BALF. Analysis of the respiratory microbiota in asthmatic mice showed that the abundance of Proteobacteria at the phylum level and Pseudomonas at the genus level increased significantly and QF could significantly regulate the dysbiosis of respiratory microbiota in asthmatic mice. Metagenomic functional prediction showed that QF can downregulate the MAPK and Nod-like receptor signaling pathways. Immunohistochemical results showed that QF could downregulate the expression of p-JNK, p-P38, NLRP3, Caspase-1, and IL-1β, which are all key proteins in the signaling pathway of lung tissue. Our study therefore concluded that QF may reduce airway inflammation in asthmatic mice by regulating respiratory microbiota, and to the possibly downregulate MAPK and Nod-like receptor signaling pathways as its underlying mechanism.

Omalizumab for the treatment of severe allergic asthma in children: A tale of two

Omalizumab is a monoclonal antibody which targets immunoglobulin E. It is approved as an add‐on therapy for children with severe allergic asthma. Assessment of endotype and phenotype is necessary in order to correctly identify those patients who are most likely to respond to omalizumab. Children with severe asthma represent a complex heterogeneous group. This report outlines the background, management, and outcomes for two children initiated on omalizumab for severe allergic asthma in Children's Health Ireland at Tallaght. It demonstrates the difficulties faced by this cohort and the positive impact targeted biological therapy can have. Given the substantial cohort of children with asthma attending our tertiary center, it also indicates that comprehensive stepwise care can achieve adequate control in the vast majority of cases without the requirement for additional therapies.

Challenges in uncontrolled asthma in pediatrics: important considerations for the clinician

INTRODUCTION

Despite symptoms control being the primary focus of asthma management according to guidelines, uncontrolled asthma is still an issue worldwide, leading to huge costs and asthma deaths at all ages. In childhood, poor asthma control can be even more harmful, as it can irreversibly compromise the children's lung function and the whole family's well-being.

AREAS COVERED

Given the problem extent, this review aims to discuss the leading modifiable causes of uncontrolled asthma in Pediatrics, giving some practical insights regarding the critical role of families and the main tools for monitoring control and drug adherence, even at a distance. The most recent GINA documents were used as the primary reference, along with the latest evidence regarding the management of asthma control and the impact of the COVID-19 pandemic on asthma.

EXPERT OPINION

In managing pediatric asthma, a multidisciplinary, multi-determinant, personalized approach is needed, actively involving families, schools, and other specialists. In addition to current strategies for implementing control, electronic health strategies, new validated asthma control tools, and the identification of novel inflammatory biomarkers could lead to increasingly tailored therapies with greater effectiveness in reaching asthma control.

Comprehensive In-Patient Education Consult for Asthma Exacerbations

BACKGROUND

Asthma is the most common chronic disease leading to hospital admissions and readmissions in childhood. Bedside nurses and respiratory therapists are the primary asthma educators, but they may lack time or knowledge to provide comprehensive asthma education and identify barriers to care. Patients and their parent(s) may benefit from comprehensive education and assessment of barriers from a certified asthma educator.

METHODS

A team of certified asthma educators used a quality improvement method to create an in-patient asthma education consulting service. The in-patient pulmonary consult and medical teams referred subjects ≥ 1 y in age with a new or existing diagnosis of asthma who had been admitted to the ICU or identified as having concerns for poor medication adherence to the asthma consult. The asthma consult provided face-to-face education with the subject and parent(s), addressed barriers to the plan of care, and helped facilitate appointments to an asthma specialist after discharge.

RESULTS

There were 126 subjects eligible for the asthma consult pilot implemented October 1, 2018-April 30, 2020. The asthma consult saw 52 subjects. Subjects who received consults had a higher rate of previous health care utilization and existing specialist for asthma. After the in-patient stay, the odds of returning to the emergency department/urgent care (UC) or hospital within the following 12 months did not differ between asthma consult and control group. However, after adjusting for covariates of age, race, ethnicity, previous health care utilization, and existing specialist, there was a significant difference in the odds of readmission and revisits (adjusted odds ratio 0.39 [95% CI 0.16-0.98], P = .04) for the asthma consult group compared to the control group.

CONCLUSIONS

Providing comprehensive, face-to-face asthma education and working with subjects and their parent(s) to address barriers to medication adherence and facilitate specialty follow-up post discharge decreased health care utilization.

Association of mold levels in urban children's homes with difficult-to-control asthma

BACKGROUND

Mold sensitization and exposure are associated with asthma severity, but the specific species that contribute to difficult-to-control (DTC) asthma are unknown.

OBJECTIVE

We sought to determine the association between overall and specific mold levels in the homes of urban children and DTC asthma.

METHODS

The Asthma Phenotypes in the Inner-City study recruited participants, aged 6 to 17 years, from 8 US cities and classified each participant as having either DTC asthma or easy-to-control (ETC) asthma on the basis of treatment step level. Dust samples had been collected in each participant's home (n = 485), and any dust remaining (n = 265 samples), after other analyses, was frozen at -20^oC. The dust samples (n = 265) were analyzed using quantitative PCR to determine the concentrations of the 36 molds in the Environmental Relative Moldiness Index. Logistic regression was performed to discriminate specific mold content of dust from homes of children with DTC versus ETC asthma.

RESULTS

Frozen-dust samples were available from 54% of homes of children with DTC (139 of 253) and ETC asthma (126 of 232). Only the average concentration of the mold Mucor was significantly (P < .001) greater in homes of children with DTC asthma. In homes with window air-conditioning units, the Mucor concentration contributed about a 22% increase (1.6 odds ratio; 95% CI, 1.2-2.2) in the ability to discriminate between cases of DTC and ETC asthma.

CONCLUSIONS

Mucor levels in the homes of urban youth were a predictor of DTC asthma, and these higher Mucor levels were more likely in homes with a window air-conditioner.

Pharmacogenomics: A Step forward Precision Medicine in Childhood Asthma

Personalized medicine, an approach to care in which individual characteristics are used for targeting interventions and maximizing health outcomes, is rapidly becoming a reality for many diseases. Childhood asthma is a heterogeneous disease and many children have uncontrolled symptoms. Therefore, an individualized approach is needed for improving asthma outcomes in children. The rapidly evolving fields of genomics and pharmacogenomics may provide a way to achieve asthma control and reduce future risks in children with asthma. In particular, pharmacogenomics can provide tools for identifying novel molecular mechanisms and biomarkers to guide treatment. Emergent high-throughput technologies, along with patient pheno-endotypization, will increase our knowledge of several molecular mechanisms involved in asthma pathophysiology and contribute to selecting and stratifying appropriate treatment for each patient.

Asthma-Related Knowledge and Practices among Mothers of Asthmatic Children: A Latent Class Analysis

Mothers’ knowledge about childhood asthma influences management practices and disease control, but validating knowledge/practice questionnaires is difficult due to the lack of a gold standard. We hypothesized that Latent Class Analysis (LCA) could help identify underlying mother profiles with similar knowledge/practices. A total of 438 mothers of asthmatic children answered a knowledge/practice questionnaire. Using answers to the knowledge/practice questionnaire as manifest variables, LCA identified two classes: Class 1, “poor knowledge” (33%); Class 2, “good knowledge” (67%). Classification accuracy was 0.96. Mothers in Class 2 were more likely to be aware of asthma-worsening factors and indicators of attacks. Mothers in Class 1 were more likely to prevent exposure to tobacco smoke (91.1% vs. 78.8%, p = 0.005). For attacks, mothers in Class 2 were more likely to go to the emergency department and follow the asthma action plan. Mothers in Class 2 more frequently had a high education level (79.5% vs. 65.2%, p = 0.004). Children in Class 2 more frequently had fully controlled asthma (36.7% vs. 25.9%, p = 0.015) and hospitalizations for attacks in the previous 12 months (24.2% vs. 10.7%, p = 0.003). LCA can help discover underlying mother profiles and plan targeted educational interventions.

Severe Pediatric Asthma Therapy: Mepolizumab

There is a growing need for advanced treatment in children with persistent and severe asthma symptoms. As a matter of fact, between 2 and 5% of asthmatic children experience repeated hospitalizations and poor quality of life despite optimized treatment with inhaled glucocorticoid plus a second controller. In this scenario, mepolizumab, a humanized monoclonal antibody, has proven to be effective in controlling eosinophil proliferation by targeting interleukin-5 (IL-5), a key mediator of eosinophil activation pathways. Mepolizumab is approved since 2015 for adults at a monthly dose of 100 mg subcutaneously and it has been approved for patients ≥ 6 years of age in 2019. Especially in children aged 6 to 11 years, mepolizumab showed a greater bioavailability, with comparable pharmacodynamics parameters as in the adult population. The recommended dose of 40 mg every 4 weeks for children aged 6 through 11 years, and 100 mg for patients ≥ 12 years provides appropriate concentration and proved similar therapeutic effects as in the adult study group. A marked reduction in eosinophil counts clinically reflects a significant improvement in asthma control as demonstrated by validated questionnaires, reduction of exacerbation rates, and the number of hospitalizations. Finally, mepolizumab provides a safety and tolerability profile similar to that observed in adults with adverse events mostly of mild or moderate severity. The most common adverse events were headache and injection-site reaction. In conclusion, mepolizumab can be considered a safe and targeted step-up therapy for severe asthma with an eosinophilic phenotype in children and adolescents.

Novel therapeutic approaches targeting endotypes of severe airway disease

Introduction: Severe asthma and chronic rhinosinusitis (CRS), with nasal polyps (CRSwNP) and without nasal polyps (CRSsNP), are heterogeneous diseases characterized by different mechanistic pathways (endotypes) and variable clinical presentations (phenotypes).Areas covered: This review provides the clinician with an overview of the prevalence and clinical impact of severe chronic upper and lower airways disease and suggests a novel therapeutic approach with biological agents with possible biomarkers. To select relevant literature for inclusion in this review, we conducted a literature search using the PubMed database, using terms 'severe airways disease' AND 'endotype' AND 'treatment.' The literature review was performed for publication years 2010-2020, restricting the articles to humans and English language publications.Expert opinion: The coronavirus disease (COVID-19) pandemic has brought forth many challenges for patients with severe airway disease and healthcare practitioners involved in care. These patients could have an increased risk of developing severe SARS-CoV-2 disease, although treatment with biologics is not associated with a worse prognosis. Eosinopenia on hospital admission plays a key role as a diagnostic and prognostic biomarker.

Biological Therapies in Children and Adolescents with Severe Uncontrolled Asthma: A Practical Review

Severe uncontrolled asthma is a complex and heterogeneous disease. A multidisciplinary assessment is required to correctly identify and manage children and adolescents with severe asthma because they may require strict monitoring and additional treatment with advanced targeted therapies. Recent research efforts have focused on identifying epidemiologic, clinical, and molecular mechanisms that underlie severe asthma, leading to the recognition of different phenotypes and endotypes and identifying biomarkers able to predict the response to biologic therapies. Additional progress has occurred by introducing biological therapies that have revolutionized the care of chronic allergic diseases in the adult and pediatric population. In this review, we briefly summarized the current literature on biological therapies to treat severe asthma in children and adolescents.

Inter-society consensus for the use of inhaled corticosteroids in infants, children and adolescents with airway diseases

Background

In 2019, a multidisciplinary panel of experts from eight Italian scientific paediatric societies developed a consensus document for the use of inhaled corticosteroids in the management and prevention of the most common paediatric airways disorders. The aim is to provide healthcare providers with a multidisciplinary document including indications useful in the clinical practice. The consensus document was intended to be addressed to paediatricians who work in the Paediatric Divisions, the Primary Care Services and the Emergency Departments, as well as to Residents or PhD students, paediatric nurses and specialists or consultants in paediatric pulmonology, allergy, infectious diseases, and ear, nose, and throat medicine.

Methods

Clinical questions identifying Population, Intervention(s), Comparison and Outcome(s) were addressed by methodologists and a general agreement on the topics and the strength of the recommendations (according to the GRADE system) was obtained following the Delphi method. The literature selection included secondary sources such as evidence-based guidelines and systematic reviews and was integrated with primary studies subsequently published.

Results

The expert panel provided a number of recommendations on the use of inhaled corticosteroids in preschool wheezing, bronchial asthma, allergic and non-allergic rhinitis, acute and chronic rhinosinusitis, adenoid hypertrophy, laryngitis and laryngospasm.

Conclusions

We provided a multidisciplinary update on the current recommendations for the management and prevention of the most common paediatric airways disorders requiring inhaled corticosteroids, in order to share useful indications, identify gaps in knowledge and drive future research.

Difficult and Severe Asthma in Children

Asthma is the most frequent chronic inflammatory disease of the lower airways affecting children, and it can still be considered a challenge for pediatricians. Although most asthmatic patients are symptom-free with standard treatments, a small percentage of them suffer from uncontrolled persistent asthma. In these children, a multidisciplinary systematic assessment, including comorbidities, treatment-related issues, environmental exposures, and psychosocial factors is needed. The identification of modifiable factors is important to differentiate children with difficult asthma from those with true severe therapy-resistant asthma. Early intervention on modifiable factors for children with difficult asthma allows for better control of asthma without the need for invasive investigation and further escalation of treatment. Otherwise, addressing a correct diagnosis of true severe therapy-resistant asthma avoids diagnostic and therapeutic delays, allowing patients to benefit from using new and advanced biological therapies.

Digital health interventions in children with asthma

Although healthcare providers are actively involved in offering education, information and interventions for asthmatic patients, medication and therapeutic adherence remain low in the paediatric population, with estimates suggesting that adherence rates hover below 50%. A range of available digital health interventions has been explored in paediatric asthma with promising but variable results, limiting their widespread adoption in clinical practice. They include emerging technologies that yield the advantage of tracking asthma symptoms and medications, setting drug reminders, improving inhaler technique and delivering asthma education, such as serious games (video games designed for medical‐ or health‐related purposes), electronic monitoring devices, speech recognition calls, text messaging, mobile apps and interactive websites. Some of the proposed digital interventions have used multiple components, including educational and behavioural strategies and interactions with medical professionals. Overall, the implementation of such interventions may offer the opportunity to improve adherence and asthma control. In a state of emergency as the COVID‐19 pandemic, telemedicine can also play a central role in supporting physicians in managing children with asthma. This review evaluates the published literature examining digital health interventions for paediatric asthma and explores the most relevant issues affecting their implementation in practice and the associated evidence gaps, research limitations and future research perspectives.

Biologics to Treat Severe Asthma in Children and Adolescents: A Practical Update

Background: Severe asthma represents a significant challenge for children and adolescents. At the same time, it often places a burden on patients, caregivers, and society, mainly related to morbidity, mortality, and health care resources. In children and adolescents, severe asthma is mostly characterized by type 2 inflammation, which leads to bronchial eosinophilia that may be suppressed by corticosteroids. However, in this age group, a high dosage of inhaled corticosteroids combined with systemic corticosteroids sometimes results in unacceptable side effects, such as reduced growth velocity and reduced bone mineral density. Therefore, there is increasing and enthusiastic interest in today's biologics, including omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. There is growing evidence that they may be effective and safe add-on options for children and adolescents. In 2009, omalizumab was approved by the European Medicines Agency as the first available therapeutic option for allergic asthma in patients as young as 6 years of age, followed by a similar approval by the U.S. Food and Drug Administration in 2016. Previously, omalizumab was marketed for this indication in patients ≥ age 12. Subsequent biologics, namely mepolizumab, reslizumab, and benralizumab, are IL-5 targeted agents that are presently approved in some countries for severe eosinophilic asthma starting at 6 years of age. Dupilumab is targeted against the IL-4 receptor α-chain, and it has been approved in the United States and the European Union as an add-on maintenance therapy in patients ≥12 years of age. Conclusion: This review presents the most recent evidence on approved biologics for the treatment of severe asthma and discusses the unmet needs and future perspective, focusing on the pediatric and adolescent age groups.

ControL'Asma Project: new insights

The Italian Society of Paediatric Allergy and Immunology has developed the project "ControL'Asma," a nationwide study involved ten third-level pediatric allergy clinics across Italy. The first findings of the "ControL'Asma" project showed that asthma was more frequent in males, had an early onset and allergic phenotype with very frequent rhinitis comorbidity, uncontrolled, and partly controlled asthma affected about the half of subjects, and the assessment of asthma symptom perception by VAS could be a reliable tool in the asthma management.

Asthma in children and adolescents: the ControL'Asma project

The control of asthma is the objective of asthma management. However, it is difficult to obtain in clinical practice. The Italian Society of Allergy and Clinical Immunology promoted the nationwide project "ControL'Asma" to investigate the real situation in a group of children and adolescents with asthma. The preliminary outcomes demonstrated that many asthmatic subjects do not achieve adequate asthma control. Moreover, asthma in Italian children and adolescents was usually more frequent in males, had an early onset and allergic phenotype with very frequent rhinitis comorbidity, uncontrolled and partly controlled asthma affected about the half of subjects. However, this project suggested that the assessment of asthma symptom perception by VAS could be a reliable tool in the asthma management.

An update on the role of chronic rhinosinusitis with nasal polyps as a co-morbidity in severe asthma

INTRODUCTION

Chronic rhinosinusitis and asthma are heterogeneous diseases with complex pathogenesis. The presence of chronic rhinosinusitis with nasal polyps has been associated with increased asthma exacerbation frequency and may represent a predictor of future exacerbations in severe asthma.

AREAS COVERED

This review provides the clinician with an overview of the prevalence and clinical impact of the chronic rhinosinusitis with nasal polyps in severe asthma and summarizes recommended therapeutic approaches, including innovative biologic therapies. To select relevant literature for inclusion in this review, we conducted a literature search using the PubMed and ClinicalTrials.gov databases, using terms 'chronic rhinosinusitis with nasal polyps' AND 'asthma' OR 'severe asthma.' The literature review was performed for publication years 2010-2020, restricting the articles to humans and English language publications.

EXPERT OPINION

Biological therapies have opened new perspectives in the treatment of upper and lower airway allergic diseases. Care pathways in severe asthma are almost consolidated, while they still rely on phenotypic rather than endotypic features in chronic rhinosinusitis with nasal polyps. Unveiling the correlation between clinical phenotypes and molecular endotypes will allow better stratification of patients with chronic rhinosinusitis with nasal polyps to identify candidates who benefit most from biological therapy.

An update on biological therapies for pediatric allergic diseases

Allergic diseases represent a global health burden. Patients with allergic diseases may experience disability, reduced quality of life and productivity, emotional distress, and social restrictions, especially in the most severe cases. Current advances in unveiling the pathogenesis of allergic disorders have paved the way for the development of novel therapeutic strategies. Biological drugs have been widely studied in pediatric allergic asthma, with strong evidence of efficacy and safety. Moreover, promising results derive from studies on other conditions such as atopic dermatitis, chronic spontaneous urticaria, and food allergy. This review analyzes recent evidence on the role of biologic therapies for allergic diseases, focusing on the pediatric age.

Measuring inflammation in paediatric severe asthma: biomarkers in clinical practice

Severe asthma in children is a highly heterogeneous disorder, encompassing different clinical characteristics (phenotypes) and immunopathological pathways (endotypes). Research is focusing on the identification of noninvasive biomarkers able to predict treatment response and assist in designing personalised therapies for severe asthma. Blood and sputum eosinophils, serum IgE and exhaled nitric oxide fraction mostly reflect type 2 airway inflammation in children. However, in the absence of available point-of-care biomarkers, the diagnosis of non-type 2 asthma is still reached by exclusion. In this review, we present the most recent evidence on biomarkers for severe asthma and discuss their implementation in clinical practice. We address the methods for guiding treatment decisions and patient identification, focusing on the paediatric age group.

Noninvasive biomarkers should be integrated with clinical findings to assist in diagnosing and guiding personalised therapies for severe asthma in childrenhttp://bit.ly/2JPvKFV

The presence of Aspergillus fumigatus in asthmatic airways is not clearly related to clinical disease severity

BACKGROUND

It is suggested that airway fungi, in particular Aspergillus may impinge on clinical phenotype in asthma. Indeed, the term severe asthma with fungal sensitization (SAFS) has been coined. We aimed to ascertain whether the presence of fungi, in particular Aspergillus fumigatus, in the airway correlated with asthma severity and control. Furthermore, we aimed to determine whether traditional markers of Aspergillus sensitization related to the presence of Aspergillus within the airway.

METHODS

Sixty-nine patients characterized by asthma severity (GINA) and level of control (ACQ-7) underwent bronchoscopy and bronchoalveolar lavage (BAL). Serum was assessed for A fumigatus-specific IgE and total IgE. Galactomannan and relevant cytokine levels were assessed in serum, plasma and BAL. BAL was analyzed for the presence of A fumigatus.

RESULTS

In BAL, fungi were visible by microscopy in 70% and present by qPCR in 86% of patients, while A fumigatus was detectable by qPCR in 46%. Plasma and BAL IL-4, IL-6, IL-10, IL-13 and TNF-α correlated with BAL fungal presence, while plasma IL-17 correlated with BAL fungal presence. Aspergillus positive BAL correlated with increased plasma and BAL IL-6 and BAL IL-13. There was no relationship between fungal airway presence and steroid dose, asthma severity or control. The presence of Aspergillus within the airway did not relate to serum IgE positivity for Aspergillus.

CONCLUSIONS

Fungi were present in a large proportion of our asthmatic patients' airways, but their presence was not predicted by traditional markers of sensitization, nor did it appear to be related to measures of disease severity or control.

Telehealth delivery of adherence and medication management system improves outcomes in inner-city children with asthma

Healthcare disparities exist in pediatric asthma in the United States. Children from minority, low-income families in inner-city areas encounter barriers to healthcare, leading to greater rates of poorly controlled asthma and healthcare utilization. Finding an effective way to deliver high-quality healthcare to this underserved population to improve outcomes, reduce morbidity and mortality, and reduce healthcare utilization is of the utmost importance. The purpose of this study was to assess the feasibility and efficacy of a novel school-based care delivery model that incorporates video-based telehealth (VBT) medical and self-management visits with electronic inhaler monitoring to improve asthma outcomes. Over a 6-month period, children from inner-city, low-income schools with uncontrolled asthma completed seven scheduled medical visits with an asthma specialist and five self-management visits with an adherence psychologist at school using VBT. Composite Asthma Severity Index (CASI) scores and electronic inhaler monitor data were recorded and analyzed. A total of 21 patients were enrolled in the study. Study subjects with higher baseline severity (CASI ≥ 4 at visit 1) demonstrated a greater reduction in their score than those with lower baseline severity (CASI < 4 at visit 1). The CASI domains showed improvement in daytime symptoms, nighttime symptoms, and exacerbations. Adherence results demonstrated a significant improvement in adherence from baseline to postintervention. Study retention was 100%. This study demonstrates that a multicomponent medical and behavioral interventional program delivered by VBT to a school-based setting is feasible and can significantly improve asthma outcomes and care in a challenging population.

Pharmacogenetics of Pediatric Asthma: Current Perspectives

Asthma is a chronic respiratory disease that affects 339 million people worldwide and has a considerable impact on the pediatric population. Asthma symptoms can be controlled by pharmacological treatment. However, some patients do not respond to therapy and continue suffering from symptoms, which impair the quality of life of patients and limit their daily activity. Genetic variation has been shown to have a role in treatment response. The aim of this review is to update the main findings described in pharmacogenetic studies of pediatric asthma published from January 1, 2018 to December 31, 2019. During this period, the response to short-acting beta-agonists and inhaled corticosteroids in childhood asthma has been evaluated by eleven candidate-gene studies, one meta-analysis of a candidate gene, and six pharmacogenomic studies. The findings have allowed validating the association of genes previously related to asthma treatment response (ADRB2, GSDMB, FCER2, VEGFA, SPAT2SL, ASB3, and COL2A1), and identifying novel associations (PRKG1, DNAH5, IL1RL1, CRISPLD2, MMP9, APOBEC3B-APOBEC3C, EDDM3B, and BBS9). However, some results are not consistent across studies, highlighting the need to conduct larger studies in diverse populations with more homogeneous definitions of treatment response. Once stronger evidence was established, genetic variants will have the potential to be applied in clinical practice as biomarkers of treatment response enhancing asthma management and improving the quality of life of asthma patients.

Severe uncontrolled asthma in children: practical approach on diagnosis and management

Severe uncontrolled asthma in children is a complex and heterogeneous disease and is considered a challenge for the pediatricians. Although nearly 5% of children with asthma present with a severe uncontrolled disease, these patients and their caregivers face a significant burden, including troublesome persistent symptoms, life-threatening acute attacks, medication side effects, impaired school performance, neuropsychological problems, and lower quality of life (QoL). Moreover, these patients also account for substantially higher healthcare resource use and costs than average patients with asthma. Thus, it is essential to accurately define and diagnose severe asthma in children as they potentially need close monitoring and additional treatment with advanced therapies. This review aims to update knowledge on diagnosis and management of severe uncontrolled asthma in childhood. We describe a practical approach to differentiate children with difficult-to-treat asthma from those with true severe therapy-resistant asthma. Moreover, the recent advances in the understanding of the pathogenetic mechanisms and inflammatory mediators involved in asthma have paved the way for the development of a precision medicine approach. In this context, we analyze approved personalized therapies for severe uncontrolled asthma, focusing on the pediatric indications.

Severe asthma in children: Current goals and unmet needs

Severe asthma in children is considered a complex and heterogeneous disease. A multidisciplinary assessment is required to correctly identify and manage these children because they potentially need close monitoring and additional treatment with advanced targeted therapies. Recent research efforts focused on the identification of epidemiologic, clinical, and functional characteristics of the disease in the pediatric age. Novel findings on the molecular mechanisms underlying severe asthma have led to the recognition of different endotypes and related biomarkers able to predict the response to advanced biologic therapies. Progress in our knowledge of severe asthma has occurred with the introduction of biologic therapies. Future goals in asthma care include the identification of the links between phenotypes and endotypes, as well as the identification of novel predictive biomarkers. They will help to select candidates for innovative biologic therapies and ultimately improve outcomes in children with severe asthma.

The Relationship Between Bronchial Patency and Parameters of ECG Supraventricular Component in Children With Bronchial Asthma

Background: Uncontrolled asthma (BA) can be complicated by cardiac conduction disturbances and arrhythmias. It is typical mainly for adult asthmatics patients. In asthmatics children the effect of bronchoconstriction on cardiac conduction, including the supraventricular component of the ECG, is currently under discussion. The objective of the research is to analyze ECG parameters of the atrial complex and atrioventricular conduction and to assess their relationship with spirometric indicators in children with BA. Methods: Hundred three patients with BA from the age of 6-17 years were examined. The spirometric parameters were evaluated, including the Tiffeneau index (TI): FEV1/FVC (%), according to the level of which the patient groups were distinguished. Group 1 (G1): with TI more than 85%, (n = 15); Group 2 (G2): with TI from 85 to 75%, (n = 40); Group 3 (G3): with TI <75%, (n = 48). The ECG parameters that characterize supraventricular conduction, including the PQ interval (sec) and the sPQ segment (sec), were analyzed. We had calculated relative PQ (rPQ) by the formula rPQ=PQ/PQmed, where PQ is the patient's PQ, PQmed are the median PQ values of healthy children of age selected. Results: The duration of the PQ in groups G1 and G2 was 0.13 (0.11; 0.14) s; and 0.13 (0.12; 0.14) s, respectively, which is statistically significantly less than in patients of groups G3-0.14 (0.13; 0.15] s, p = 0.01. The duration of the sPQ segment in children of groups G1 and G2 was also generally shorter than in patients of groups G3, and amounted, respectively, to 0.05 (0.04; 0.06) s, 0.04 (0.04; 0.05) s, and 0.06 (0.04; 0.07) s, p = 0.02. The rPQ increased progressively as TI decreased and amounted in G1 to 92.9 (85.7; 106.3) %, in G2 100.0 (92.9; 103.0) %, and in G3 104 (100.0; 107.7) %, p = 0.009. A statistically significant negative correlation between IT and PQ-r = -0.23, p = 0.02; with sPQ-r = -0.20, p = 0.045; and with rPQ-r = -0.25, p = 0.01 was revealed. Conclusion: A decrease in TI in asthmatics children is associated with a prolongation of the PQ. This may indicate a slowdown in supraventricular conduction in patients with uncontrolled asthma and, thus, be considered as a risk for the formation of subsequent supraventricular arrhythmias.

Biologics in Children with Allergic Diseases

The prevalence of allergic diseases has been remarkably increased in the last decades. The global health burden of these conditions is substantial, since patients may experience disability, anxiety and emotional distress, social restrictions, and reduced quality of life and productivity, in particular, in the most severe cases. Recent advances in understanding the pathophysiology of allergic disorders have allowed identifying novel therapeutic strategies for the treatment of severe and uncontrolled allergic diseases. Although most studies have been performed in allergic asthma, biological drugs targeting other allergic diseases such as chronic spontaneous urticaria, atopic dermatitis, and food allergy are showing promising results. In this review, the most recent evidence on biologic therapies for allergic diseases, focusing on the pediatric age has been presented.

Evaluation of a Diagnostic Therapeutic Educational Pathway for Asthma Management in Children and Adolescents

Background: Limited evidence exists for the effectiveness of educational programs that improve pediatric asthma control in real-world settings. We aimed to assess the impact of a diagnostic, therapeutic, and educational pathway (DTEP) for asthma management in children and adolescents attending an asthma referral center. Methods: This is a retrospective population-based cohort study, including two groups of patients with asthma, aged 6-17 years and residing in the Local Health Authority (LHA) of Brescia, Italy: (a) the children who followed a DTEP (intervention group) and (b) all the children residing in the LHA who did not follow DTEP (control group). The incidence rates (IRs) of hospitalization, emergency room visit, use of outpatient services, and drug prescription for dyspnea, wheezing, or respiratory symptoms were computed for time before and after attending DTEP in the intervention group and for "early" and "late" time since asthma diagnosis in the control group. Results: There were 9,191 patients included in the study, 804 of whom followed DTEP. In the before-DTEP/early time, the intervention and control groups showed similar IRs for all the outcomes apart from emergency room visits (IRs of 138.6 and 60.3 per 1,000 person-years, respectively). The IRs decreased from before to after DTEP and from early to late time in both groups. The IR decrease for emergency room visits was significantly higher in the intervention than in the control group (-51.3 and -28.2%, respectively; IRR = 0.61, P = 0.001). Conclusion: The DTEP can increase patients' capability in managing asthma and preventing asthma attacks.

Omalizumab and mepolizumab in the landscape of biological therapy for severe asthma in children: how to choose?

Severe asthma has a substantial epidemiological impact on children and biological treatments can be an option to take into account, as they target specific molecules and pathways involved in its pathogenesis. Modern medicine is continuously and progressively oriented towards tailored treatments designed specifically for the pathology patterns observed in individual patients and identified as endotypes with associated biomarkers. In this regard, biologic treatments in asthma are one of the best examples. Among the biological drugs currently available, omalizumab is the one with the greatest amount of data on efficacy and safety, and the one we have more real-life clinical experience with. However, mepolizumab will likely be accessible soon globally for clinical use. Moreover, research on biological drugs for the treatment of severe asthma is expanding rapidly, with some molecules currently used in adult patients that could be registered also for pediatric use and new molecules that could be available in the future. On the other hand, due to this potential abundance of therapeutic options, new criteria could become necessary to guide clinicians through an evidence-based choice between omalizumab and these new drugs. For the same reason, more data collected specifically from pediatric clinical trials are necessary. In this review we aim to analyze the factors that could help clinicians make their choice and to highlight the unmet need for a more evidence-based choice.

Could we diagnose childhood asthma by LIBS technique?

Asthma affects children related to trace elements. Our aim was to investigate the levels of trace elements using laser-induced breakdown spectroscopy (LIBS). The study included 120 children aged 4-12 years from both sexes. They were divided into three groups: Group 1 of 40 children was diagnosed as cases of controlled asthma. Group 2 consisted of 40 children diagnosed as cases of uncontrolled asthma. Group 3 consisted of 40 children as normal control. Asthmatic children were classified according to GINA 2015. They were analyzed for serum levels of total IgE, eosinophil count, and trace metals (Zn, Cu, Pb, Mg, and Fe) by using LIBS. There was significant decrease in serum levels of Zn, Mg and Fe in children with asthma than in normal children. There was a significant decrease in uncontrolled asthmatic children than in controlled asthmatic children. But the Cu and Pb concentration in children with asthma was significantly higher than that in normal children, and there was a significant increase in uncontrolled asthmatic children than in controlled asthmatic children. Furthermore, we examined the peak flow meter, eosinophil count, and total IgE and found that the peak flow metric study had shown a significant difference in controlled cases, total eosinophil count, and IgE; the difference was more significant in the uncontrolled group than in the controlled group, and the total levels were higher in the uncontrolled group. Asthma is a common pediatric disease that is related to deficiency of Fe, Zn, and Mg and occurs with increased Pb and Cu. LIBS is a safe and rapid technique that helps in detecting asthma.

What Is the Impact of Innovative Electronic Health Interventions in Improving Treatment Adherence in Asthma? The Pediatric Perspective

Suboptimal adherence to treatment is a significant issue in the management of pediatric asthma and is a major cause of uncontrolled disease, life-threatening attacks, and increased use of health care resources. Electronic health solutions have the potential to positively impact asthma self-management in children and adolescents and their families, thereby improving treatment adherence and asthma outcomes. However, there is a lack of sufficient data to support widespread adoption of electronic health tools in pediatric asthma practice. A critical evaluation of the impact of these new interventions on treatment adherence in childhood asthma must consider unmet needs, heterogeneity of trials, safety and data security issues, long-term effects, and cost-effectiveness. This article explores the most relevant issues facing the role of electronic health and its subcategory-mobile health-in promoting treatment adherence in childhood asthma, focusing on current evidence gaps and limitations, and future research perspectives.

Targeted Therapy for Severe Asthma in Children and Adolescents: Current and Future Perspectives

Severe asthma in children remains a significant issue. It places a heavy burden on affected individuals and society as a whole in terms of high morbidity, mortality, consumption of healthcare resources, and side effects from high-dose corticosteroid therapy. New, targeted biologic therapies for asthma have emerged as effective add-on options, complementing our expanding understanding of asthma phenotypes/endotypes and the underlying immunopathology of the disease spectrum. They include omalizumab, mepolizumab, reslizumab, benralizumab, and dupilumab. Omalizumab represents the first available therapeutic option for allergic asthma in patients as young as 6 years of age. Its efficacy and safety have been established by several randomized controlled trials specifically conducted in pediatric patients, leading to its final registration > 10 years ago. Three new interleukin (IL)-5 targeted agents, mepolizumab, reslizumab, and benralizumab, have been approved for the treatment of severe eosinophilic asthma starting from 6 years of age, and varying by country. More recently, dupilumab, a targeted agent against the IL-4 receptor α-chain, was approved for patients ≥12 years of age in the United States after pivotal trials were completed. The late-stage clinical testing of these targeted agents has mostly involved patients aged 12 years and up, and the application of those data to younger children can be inappropriate and carry risk. The efficacy and safety of these newer biologics in children should be supported by adequate research within this targeted age group. In this review, we will present the most recent evidence on these five biological therapies for severe asthma and will discuss dosage and administration, their efficacy, safety, and future prospects, with a focus on the pediatric age group, defined as age < 18 years.

Novel therapeutic targets for allergic airway disease in children

The aim of precision medicine is setting up targeted therapies for selected patients that would ideally have high effectiveness and few side effects. This is made possible by targeted therapy drugs that selectively act on a specific pathway. Precision medicine is spreading to many medical specialties, and there is increasing interest in the context of allergic airway diseases, such as allergic rhinitis, chronic rhinosinusitis, and asthma. This review is an update of new targets in the treatment of childhood allergic upper airway diseases and asthma, including the most recent biologic drugs that have already been licensed or are in the pipeline to be tested with children.