Current Allergy and Asthma Reports

, Volume 13, Issue 5, pp 421–426

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

  • Marianne Nuijsink
  • Johan C. De Jongste
  • Mariëlle W. Pijnenburg
ASTHMA (WJ CALHOUN AND SP PETERS, SECTION EDITORS)

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.

Keywords

Asthma Children Symptoms Asthma control Asthma control questionnaire Asthma control test Childhood asthma control test Lung function Airways Symptom-based therapy Hyperresponsiveness Exacerbations Sputum eosinophils Exhaled nitric oxide Monitoring Exhaled breath 

References

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

  1. 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. 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. 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. 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.PubMedCrossRefGoogle Scholar
  5. 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.PubMedCrossRefGoogle Scholar
  6. 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.PubMedCrossRefGoogle Scholar
  7. 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.PubMedCrossRefGoogle Scholar
  8. 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. PubMedCrossRefGoogle Scholar
  9. 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.PubMedCrossRefGoogle Scholar
  10. 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.PubMedCrossRefGoogle Scholar
  11. 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.PubMedCrossRefGoogle Scholar
  12. 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.PubMedCrossRefGoogle Scholar
  13. 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.PubMedCrossRefGoogle Scholar
  14. 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.PubMedCrossRefGoogle Scholar
  15. 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.PubMedCrossRefGoogle Scholar
  16. 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.PubMedCrossRefGoogle Scholar
  17. 17.
    Brouwer AF, Roorda RJ, Brand PL. Home spirometry and asthma severity in children. Eur Respir J. 2006;28:1131–7.PubMedCrossRefGoogle Scholar
  18. 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.PubMedCrossRefGoogle Scholar
  19. 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.PubMedCrossRefGoogle Scholar
  20. 20.
    Roberts EM. Does your child have asthma? Parent reports and medication use for pediatric asthma. Arch Pediatr Adolesc Med. 2003;157:449–55.PubMedCrossRefGoogle Scholar
  21. 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.PubMedCrossRefGoogle Scholar
  22. 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.PubMedCrossRefGoogle Scholar
  23. 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.PubMedCrossRefGoogle Scholar
  24. 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.PubMedCrossRefGoogle Scholar
  25. 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.PubMedCrossRefGoogle Scholar
  26. 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.PubMedCrossRefGoogle Scholar
  27. 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.PubMedCrossRefGoogle Scholar
  28. 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. PubMedGoogle Scholar
  29. 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.PubMedCrossRefGoogle Scholar
  30. 30.
    Brand PL, Roorda RJ. Usefulness of monitoring lung function in asthma. Arch Dis Child. 2003;88:1021–5.PubMedCrossRefGoogle Scholar
  31. 31.
    Kamps AW, Roorda RJ, Brand PL. Peak flow diaries in childhood asthma are unreliable. Thorax. 2001;56:180–2.PubMedCrossRefGoogle Scholar
  32. 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.PubMedCrossRefGoogle Scholar
  33. 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.PubMedCrossRefGoogle Scholar
  34. 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.PubMedCrossRefGoogle Scholar
  35. 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.PubMedCrossRefGoogle Scholar
  36. 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.PubMedCrossRefGoogle Scholar
  37. 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.PubMedCrossRefGoogle Scholar
  38. 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.PubMedCrossRefGoogle Scholar
  39. 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.PubMedCrossRefGoogle Scholar
  40. 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.PubMedCrossRefGoogle Scholar
  41. 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.PubMedCrossRefGoogle Scholar
  42. 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.PubMedCrossRefGoogle Scholar
  43. 43.
    Green RH, Brightling CE, McKenna S, et al. Asthma exacerbations and sputum eosinophil counts: a randomised controlled trial. Lancet. 2002;360:1715–21.PubMedCrossRefGoogle Scholar
  44. 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. PubMedCrossRefGoogle Scholar
  45. 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. PubMedCrossRefGoogle Scholar
  46. 46.
    Taylor DR, Pijnenburg MW, Smith AD, De Jongste JC. Exhaled nitric oxide measurements: clinical application and interpretation. Thorax. 2006;61:817–27.PubMedCrossRefGoogle Scholar
  47. 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.PubMedCrossRefGoogle Scholar
  48. 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.PubMedCrossRefGoogle Scholar
  49. 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.PubMedCrossRefGoogle Scholar
  50. 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.PubMedCrossRefGoogle Scholar
  51. 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.PubMedCrossRefGoogle Scholar
  52. 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.PubMedCrossRefGoogle Scholar
  53. 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.PubMedCrossRefGoogle Scholar
  54. 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. PubMedCrossRefGoogle Scholar
  55. 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. PubMedCrossRefGoogle Scholar
  56. 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.PubMedCrossRefGoogle Scholar
  57. 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.PubMedCrossRefGoogle Scholar
  58. 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.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media New York 2013

Authors and Affiliations

  • Marianne Nuijsink
    • 1
  • Johan C. De Jongste
    • 2
  • Mariëlle W. Pijnenburg
    • 2
  1. 1.Department of PaediatricsJuliana Children’s HospitalThe HagueThe Netherlands
  2. 2.Department of Paediatrics/Paediatric Respiratory MedicineErasmus University Medical Centre RotterdamRotterdamThe Netherlands

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