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Will Symptom-Based Therapy Be Effective for Treating Asthma in Children?

  • ASTHMA (WJ CALHOUN AND SP PETERS, SECTION EDITORS)
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Abstract

Traditionally, symptoms are important patient-oriented outcomes in asthma treatment, and assessment of symptoms is an essential component of assessing asthma control. However, variable airways obstruction, airways hyperresponsiveness and chronic inflammation are key components of the asthma syndrome, and correlations among these hallmarks and symptoms are weak or even absent. Therefore, it might be questioned if symptom-based therapy is effective for treating asthma in (all) children. To date, there is no firm indication that monitoring asthma based on repetitive lung function measurement or markers of airway inflammation is superior to monitoring based on symptoms only. In the majority of patients, symptom-based asthma management may well be sufficient, and in preschool children, symptoms are presently the only feasible outcome. Nevertheless, there is some evidence that selected groups might benefit from an approach that takes into account individual phenotypic characteristics. In patients with poor perception, those with a discordant phenotype and those with persistent severe asthma, considering lung function, airways hyperresponsiveness and inflammatory markers in treatment decisions might improve outcomes.

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References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. GINA report, Global Strategy for Asthma Management and Prevention. From the Global Strategy for Asthma Management and Prevention, Global Initiative for Asthma (GINA). available from: http://wwwginasthmaorg. 2011.

  2. British Thoracic Society Scottish Intercollegiate Guidelines N. British Guideline on the Management of Asthma. Thorax. 2008;63 Suppl 4:iv1-121.

    Google Scholar 

  3. National Asthma E, Prevention P. Expert Panel Report 3 (EPR-3): Guidelines for the Diagnosis and Management of Asthma-Summary Report 2007. J Allergy Clin Immunol. 2007;120(5 Suppl):S94–S138.

    Google Scholar 

  4. Reddel HK, Taylor DR, Bateman ED, et al. An official American Thoracic Society/European Respiratory Society statement: asthma control and exacerbations: standardizing endpoints for clinical asthma trials and clinical practice. Am J Respir Crit Care Med. 2009;180:59–99.

    Article  PubMed  Google Scholar 

  5. Bacharier LB, Boner A, Carlsen KH, et al. Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy. 2008;63:5–34.

    Article  PubMed  CAS  Google Scholar 

  6. Fuhlbrigge AL, Guilbert T, Spahn J, Peden D, Davis K. The influence of variation in type and pattern of symptoms on assessment in pediatric asthma. Pediatrics. 2006;118:619–25.

    Article  PubMed  Google Scholar 

  7. Gustafsson PM, Watson L, Davis KJ, Rabe KF. Poor asthma control in children: evidence from epidemiological surveys and implications for clinical practice. Int J Clin Pract. 2006;60:321–34.

    Article  PubMed  CAS  Google Scholar 

  8. •• Krishnan JA, Lemanske Jr RF, Canino GJ, et al. Asthma outcomes: symptoms. J Allergy Clin Immunol. 2012;129(3 Suppl):S124–35. This paper, one in a series on asthma outcomes, summarizes available instruments on measuring asthma symptoms in clinical research.

    Article  PubMed  Google Scholar 

  9. Bacharier LB, Strunk RC, Mauger D, et al. Classifying asthma severity in children: mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med. 2004;170:426–32.

    Article  PubMed  Google Scholar 

  10. Yoos HL, Kitzman H, McMullen A, Sidora-Arcoleo K, Anson E. The language of breathlessness: do families and health care providers speak the same language when describing asthma symptoms? J Pediatr Health Care. 2005;19:197–205.

    Article  PubMed  Google Scholar 

  11. del Giudice MM, Brunese FP, Piacentini GL, et al. Fractional exhaled nitric oxide (FENO), lung function and airway hyperresponsiveness in naive atopic asthmatic children. J Asthma. 2004;41:759–65.

    Article  PubMed  Google Scholar 

  12. Lex C, Ferreira F, Zacharasiewicz A, et al. Airway eosinophilia in children with severe asthma: predictive values of noninvasive tests. Am J Respir Crit Care Med. 2006;174:1286–91.

    Article  PubMed  Google Scholar 

  13. Piacentini GL, Bodini A, Costella S, et al. Exhaled nitric oxide, serum ECP and airway responsiveness in mild asthmatic children. Eur Respir J. 2000;15:839–43.

    Article  PubMed  CAS  Google Scholar 

  14. Wilson NM, Bridge P, Spanevello A, Silverman M. Induced sputum in children: feasibility, repeatability, and relation of findings to asthma severity. Thorax. 2000;55:768–74.

    Article  PubMed  CAS  Google Scholar 

  15. van den Toorn LM, Overbeek SE, de Jongste JC, et al. Airway inflammation is present during clinical remission of atopic asthma. Am J Respir Crit Care Med. 2001;164:2107–13.

    Article  PubMed  Google Scholar 

  16. Rabe KF, Adachi M, Lai CK, et al. Worldwide severity and control of asthma in children and adults: the global asthma insights and reality surveys. J Allergy Clin Immunol. 2004;114:40–7.

    Article  PubMed  Google Scholar 

  17. Brouwer AF, Roorda RJ, Brand PL. Home spirometry and asthma severity in children. Eur Respir J. 2006;28:1131–7.

    Article  PubMed  CAS  Google Scholar 

  18. Motomura C, Odajima H, Tezuka J, et al. Perception of dyspnea during acetylcholine-induced bronchoconstriction in asthmatic children. Ann Allergy Asthma Immunol. 2009;102:121–4.

    Article  PubMed  Google Scholar 

  19. Voorend-van Bergen S, Brackel H, Caudri D, de Jongste J, Pijnenburg M. Assessment of asthma control by children and parents. Eur Respir J. 2013;41:233–4.

    Article  PubMed  Google Scholar 

  20. Roberts EM. Does your child have asthma? Parent reports and medication use for pediatric asthma. Arch Pediatr Adolesc Med. 2003;157:449–55.

    Article  PubMed  Google Scholar 

  21. Cabana MD, Slish KK, Nan B, Lin X, Clark NM. Asking the correct questions to assess asthma symptoms. Clin Pediatr (Phila). 2005;44:319–25.

    Article  PubMed  Google Scholar 

  22. Juniper EF, O'Byrne PM, Guyatt GH, Ferrie PJ, King DR. Development and validation of a questionnaire to measure asthma control. Eur Respir J. 1999;14:902–7.

    Article  PubMed  CAS  Google Scholar 

  23. Juniper EF, Bousquet J, Abetz L, Bateman ED, Committee G. Identifying 'well-controlled' and 'not well-controlled' asthma using the Asthma Control Questionnaire. Respir Med. 2006;100:616–21.

    Article  PubMed  Google Scholar 

  24. Juniper EF, Gruffydd-Jones K, Ward S, Svensson K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010;36:1410–6.

    Article  PubMed  CAS  Google Scholar 

  25. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol. 2007;119:817–25.

    Article  PubMed  Google Scholar 

  26. Nathan RA, Sorkness CA, Kosinski M, et al. Development of the asthma control test: a survey for assessing asthma control. J Allergy Clin Immunol. 2004;113:59–65.

    Article  PubMed  Google Scholar 

  27. Skinner EA, Diette GB, Algatt-Bergstrom PJ, et al. The Asthma Therapy Assessment Questionnaire (ATAQ) for children and adolescents. Dis Manag. 2004;7:305–13.

    Article  PubMed  Google Scholar 

  28. • Okupa AY, Sorkness CA, Mauger DT, Jackson DJ, Lemanske RF. Daily Diaries vs Retrospective Questionnaires to Assess Asthma Control and Therapeutic Responses in Asthma Clinical Trials: Is Participant Burden Worth the Effort? Chest. 2013;143:993–9. In this substudy of the BADGER trial, daily diaries are compared to the Asthma Control Test which asks back for 4 weeks. Th study shows that symptom diaries and ACT cannot be used interchangeably.

    PubMed  Google Scholar 

  29. Ireland AM, Wiklund I, Hsieh R, Dale P, O'Rourke E. An electronic diary is shown to be more reliable than a paper diary: results from a randomized crossover study in patients with persistent asthma. J Asthma. 2012;49:952–60.

    Article  PubMed  Google Scholar 

  30. Brand PL, Roorda RJ. Usefulness of monitoring lung function in asthma. Arch Dis Child. 2003;88:1021–5.

    Article  PubMed  CAS  Google Scholar 

  31. Kamps AW, Roorda RJ, Brand PL. Peak flow diaries in childhood asthma are unreliable. Thorax. 2001;56:180–2.

    Article  PubMed  CAS  Google Scholar 

  32. Zemek RL, Bhogal SK, Ducharme FM. Systematic review of randomized controlled trials examining written action plans in children: what is the plan? Arch Pediatr Adolesc Med. 2008;162:157–63.

    Article  PubMed  Google Scholar 

  33. Wensley D, Silverman M. Peak flow monitoring for guided self-management in childhood asthma: a randomized controlled trial. Am J Respir Crit Care Med. 2004;170:606–12.

    Article  PubMed  Google Scholar 

  34. Nair SJ, Daigle KL, DeCuir P, Lapin CD, Schramm CM. The influence of pulmonary function testing on the management of asthma in children. J Pediatr. 2005;147:797–801.

    Article  PubMed  Google Scholar 

  35. Fuhlbrigge AL, Kitch BT, Paltiel AD, et al. FEV(1) is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001;107:61–7.

    Article  PubMed  CAS  Google Scholar 

  36. Horak E, Lanigan A, Roberts M, et al. Longitudinal study of childhood wheezy bronchitis and asthma: outcome at age 42. BMJ. 2003;326:422–3.

    Article  PubMed  Google Scholar 

  37. Sont JK, Willems LN, Bel EH, et al. Clinical control and histopathologic outcome of asthma when using airway hyperresponsiveness as an additional guide to long-term treatment. The AMPUL Study Group. Am J Respir Crit Care Med. 1999;159:1043–51.

    Article  PubMed  CAS  Google Scholar 

  38. Nuijsink M, Hop WC, Sterk PJ, Duiverman EJ, de Jongste JC. Long-term asthma treatment guided by airway hyperresponsiveness in children: a randomised controlled trial. Eur Respir J. 2007;30:457–66.

    Article  PubMed  CAS  Google Scholar 

  39. Gogate S, Katial R. Pediatric biomarkers in asthma: exhaled nitric oxide, sputum eosinophils and leukotriene E4. Curr Opin Allergy Clin Immunol. 2008;8:154–7.

    Article  PubMed  CAS  Google Scholar 

  40. Duong M, Subbarao P, Adelroth E, et al. Sputum eosinophils and the response of exercise-induced bronchoconstriction to corticosteroid in asthma. Chest. 2008;133:404–11.

    Article  PubMed  CAS  Google Scholar 

  41. Zacharasiewicz A, Wilson N, Lex C, et al. Clinical use of noninvasive measurements of airway inflammation in steroid reduction in children. Am J Respir Crit Care Med. 2005;171:1077–82.

    Article  PubMed  Google Scholar 

  42. Jayaram L, Pizzichini MM, Cook RJ, et al. Determining asthma treatment by monitoring sputum cell counts: effect on exacerbations. Eur Respir J. 2006;27:483–94.

    Article  PubMed  CAS  Google Scholar 

  43. Green RH, Brightling CE, McKenna S, et al. Asthma exacerbations and sputum eosinophil counts: a randomised controlled trial. Lancet. 2002;360:1715–21.

    Article  PubMed  Google Scholar 

  44. •• Fleming L, Wilson N, Regamey N, Bush A. Use of sputum eosinophil counts to guide management in children with severe asthma. Thorax. 2012;67:193–8. This is the first pediatric study using sputum eosinophils to guide asthma treatment in children with severe asthma. Contrary to adults, this strategy was not shown to be superior to usual care.

    Article  PubMed  Google Scholar 

  45. •• Dweik RA, Boggs PB, Erzurum SC, et al. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med. 2011;184:602–15. This practice guideline summarizes all the evidence on exhaled nitric oxide measurements in asthma and gives recommendations on the use of FENO in clinical care.

    Article  PubMed  CAS  Google Scholar 

  46. Taylor DR, Pijnenburg MW, Smith AD, De Jongste JC. Exhaled nitric oxide measurements: clinical application and interpretation. Thorax. 2006;61:817–27.

    Article  PubMed  CAS  Google Scholar 

  47. de Jongste JC, Carraro S, Hop WC, Group CS, Baraldi E. Daily telemonitoring of exhaled nitric oxide and symptoms in the treatment of childhood asthma. Am J Respir Crit Care Med. 2009;179:93–7.

    Article  PubMed  Google Scholar 

  48. Fritsch M, Uxa S, Horak F, et al. Exhaled nitric oxide in the management of childhood asthma: a prospective 6-months study. Pediatr Pulmonol. 2006;41:855–62.

    Article  PubMed  Google Scholar 

  49. Pijnenburg MW, Bakker EM, Hop WC, De Jongste JC. Titrating steroids on exhaled nitric oxide in children with asthma: a randomized controlled trial. Am J Respir Crit Care Med. 2005;172:831–6.

    Article  PubMed  Google Scholar 

  50. Shaw DE, Berry MA, Thomas M, et al. The use of exhaled nitric oxide to guide asthma management: a randomized controlled trial. Am J Respir Crit Care Med. 2007;176:231–7.

    Article  PubMed  CAS  Google Scholar 

  51. Smith AD, Cowan JO, Brassett KP, Herbison GP, Taylor DR. Use of exhaled nitric oxide measurements to guide treatment in chronic asthma. N Engl J Med. 2005;352:2163–73.

    Article  PubMed  CAS  Google Scholar 

  52. Szefler SJ, Mitchell H, Sorkness CA, et al. Management of asthma based on exhaled nitric oxide in addition to guideline-based treatment for inner-city adolescents and young adults: a randomised controlled trial. Lancet. 2008;372:1065–72.

    Article  PubMed  Google Scholar 

  53. Petsky HL, Cates CJ, Lasserson TJ, et al. A systematic review and meta-analysis: tailoring asthma treatment on eosinophilic markers (exhaled nitric oxide or sputum eosinophils). Thorax. 2012;67:199–208.

    Article  PubMed  CAS  Google Scholar 

  54. • Thomas PS, Lowe AJ, Samarasinghe P, et al. Exhaled breath condensate in pediatric asthma: Promising new advance or pouring cold water on a lot of hot air? A systematic review. Pediatr Pulmonol. 2013;48:419–42. Nice overview of studies on the analysis of exhaled breath condensate in children.

    Article  PubMed  CAS  Google Scholar 

  55. • van de Kant KD, van der Sande LJ, Jobsis Q, van Schayck OC, Dompeling E. Clinical use of exhaled volatile organic compounds in pulmonary diseases: a systematic review. Respir Res. 2012;13:117. Excellent overview on exhaled breath analysis, summarizing all pediatric studies and discussing pitfalls.

    Article  PubMed  Google Scholar 

  56. Haldar P, Pavord ID, Shaw DE, et al. Cluster analysis and clinical asthma phenotypes. Am J Respir Crit Care Med. 2008;178:218–24.

    Article  PubMed  Google Scholar 

  57. Powell H, Murphy VE, Taylor DR, et al. Management of asthma in pregnancy guided by measurement of fraction of exhaled nitric oxide: a double-blind, randomised controlled trial. Lancet. 2011;378:983–90.

    Article  PubMed  CAS  Google Scholar 

  58. Fleming L, Tsartsali L, Wilson N, Regamey N, Bush A. Sputum inflammatory phenotypes are not stable in children with asthma. Thorax. 2012;67:675–81.

    Article  PubMed  Google Scholar 

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Conflict of Interest

Mariëlle W. Pijnenburg has received grant support from ZonMw, the Dutch Asthma Fund, and Fund Nuts Ohra; has received payment for development of educational presentations (including service on speakers bureaus) from GlaxoSmithKline; and has had travel/accommodations expenses covered/reimbursed for participation in ERS meetings as an officer.

Marianne Nuijsink and Johan C. De Jongste declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

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Authors and Affiliations

  1. Department of Paediatrics, Juliana Children’s Hospital, The Hague, The Netherlands

    Marianne Nuijsink

  2. Department of Paediatrics/Paediatric Respiratory Medicine, Erasmus University Medical Centre Rotterdam, Room Sp3456, Dr Molewaterplein 60, 3015 GJ, Rotterdam, The Netherlands

    Johan C. De Jongste & Mariëlle W. Pijnenburg

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  1. Marianne Nuijsink
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  2. Johan C. De Jongste
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Nuijsink, M., De Jongste, J.C. & Pijnenburg, M.W. Will Symptom-Based Therapy Be Effective for Treating Asthma in Children?. Curr Allergy Asthma Rep 13, 421–426 (2013). https://doi.org/10.1007/s11882-013-0364-x

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