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Approach to Infants and Children with Asthma
... Morbidity of paediatric asthma is substantial worldwide. The prevalence of childhood asthma differs among countries, 1 and up to 20-25% of children have prescriptions for antiasthma medications in some industrialised countries. 2 3 Data from the USA represent an example of the asthma-related burden in children. ...
Introduction:
Use of inhaled corticosteroid (ICS) is the mainstream maintenance therapy for paediatric asthma. Several forms of ICS are available, but the relative effectiveness among ICS has not been well investigated in published, randomised, controlled trials. The paucity of direct comparisons between ICS may have resulted in insufficient estimation in former systematic reviews/meta-analyses. To supplement the information on the comparative effectiveness of ICS for paediatric asthma, we plan to conduct a network meta-analysis that will enable summary of direct and indirect evidence.
Methods and analysis:
We will retrieve randomised, controlled trials that examined the effectiveness of ICS for paediatric asthma from the PubMed and Cochrane Central Register of Controlled Trials. After one author scans the title and abstract for eligible studies, two authors will independently review study data and assess the quality of the study. Studies of children (≤18 years old) with chronic asthma or recurrent wheezing episodes will be included if they used ICS for ≥4 weeks. We will define a priori core outcomes and supplemental outcomes of paediatric asthma, including exacerbation, healthcare use and pulmonary function. Studies reporting a minimum of one core outcome will be entered into the systematic review. After the systematic review is performed, extracted data of relevant studies will be synthesised in the Bayesian framework using a random-effects model.
Ethics and dissemination:
The results will be disseminated through peer-reviewed publications and conference presentations.
Protocol registration number:
UMIN (000016724) and PROSPERO (CRD42015025889).
While foreign body aspirations are mostly seen in children, they are also observed in adulthood, but in a rare frequency. As it can be asymptomatic for a long time, it can also be confused with many clinical conditions, such as asthma, which can cause chronic cough. Various complications, such as bronchiectasis and pneumonia, can develop in the presence of long-standing aspirated foreign body. In this study, we present two cases one of whom diagnosed with asthma and treated for 30 years, and the other diagnosed with asthma and treated for 10 years. Although no pulmonary complications developed in our first case, bronchiectasis in the right middle lobe developed in our second case.
Alternaria is the most important fungal species belonging to the class Deuteromycetes which causes allergic respiratory diseases. The fungus pattern often shows a pronounced seasonal periodicity and with fluctuations related to meteorological conditions. In this study, we aimed to investigate the effect of outdoor Alternaria spore concentrations on monthly lung function tests, symptoms, and medication scores in children sensitised only to Alternaria. Additionally, we planned to determine the Alternaria spores of the outdoor environment in Adana, with special respect to their relationships with meteorological conditions and their seasonal changes.
Twenty-five patients with a clinical diagnosis of asthma and/or rhinitis sensitised only to Alternaria were enrolled in the prospective study. Meteorological data and outdoor samples of airborne fungi were obtained between November 2006 and October 2007.
The outdoor Alternaria spore concentrations were significantly correlated with the monthly average temperature (r=0.626, p=0.03) and monthly average barometric pressure (r=-0.613, p=0.03). Similarly, the outdoor Alternaria spore concentrations were significantly correlated with mean monthly asthma medication score (r=0.599, p=0.04), value monthly PEF (r=-0.737, p=0.006), value monthly FEF25-75% (r=-0.914, p=0.0001) and, variation in PEF (r=0.901, p=0.0001).
The atmospheric concentration of Alternaria spores are markedly affected by meteorological factors such as air temperatures and barometric pressures. In hypersensitive patients, Alternaria spores can induce decreases in respiratory functions and development of allergic symptoms between May and September, being especially more influential in August.
Background: There is a paucity of detailed longitudinal data on wheeze in early childhood. Not all children who wheeze in early infancy will continue to wheeze into childhood and beyond. This study aims to investigate possible risk factors for different patterns of wheeze in the pre-school years.
Subjects and Methods: Study participants were part of the Avon Longitudinal Study of Parents and Children (ALSPAC). Maternal reports of child wheeze between birth and 6 months and again between 30 and 42 months were gathered prospectively. Children were categorized into early wheeze, persistent wheeze or late onset wheeze. A large number of risk factors were assessed for each wheezing phenotype using multivariable logistic regression models.
Results: Over 70% of children who wheezed in the first 6 months did not wheeze 3 years later. Wheezing between 0–6 months was independently associated with the presence of older siblings, male sex, delivery between April and December, bottle feeding, young maternal age, prenatal tobacco smoke exposure, atopy and parental history of asthma. From within this group of early wheezers, risk factors for wheeze that persisted beyond 6 months included pre-term delivery, young maternal age, living in rented local authority housing, atopy and a maternal (not paternal) history of asthma. Atopy and a family history of asthma emerged as the main predictors of wheeze that developed after 6 months of age.
Conclusion: It is clear that a number of wheezing syndromes exist by 3½ years, albeit with some degree of overlap. Detailed follow-up of this cohort is underway to determine whether risk factor associations determined in the first 3½ years have long-term significance for the clinical entity termed ‘asthma’.
Context
Inhaled long-acting β2-agonists improve asthma control
when added to inhaled corticosteroid (ICS) therapy.Objective
To determine whether ICS therapy can be reduced or eliminated in patients
with persistent asthma after adding a long-acting β2-agonist
to their treatment regimen.Design and Setting
A 24-week randomized, controlled, blinded, double-dummy, parallel-group
trial conducted at 6 National Institutes of Health–sponsored, university-based
ambulatory care centers from February 1997 through January 1999.Participants
One hundred seventy-five patients aged 12 through 65 years with persistent
asthma that was suboptimally controlled during a 6-week run-in period of treatment
with inhaled triamcinolone acetonide (400 µg twice per day).Intervention
Patients continued triamcinolone therapy and were randomly assigned
to receive add-on therapy with either placebo (placebo-minus group, n = 21)
or salmeterol xinafoate, 42 µg twice per day (n = 154) for 2 weeks.
The entire placebo-minus group was assigned and half of the salmeterol group
(salmeterol-minus group) was randomly assigned to reduce by 50% (for 8 weeks)
then eliminate (for 8 weeks) triamcinolone treatment. The other half of the
salmeterol group (salmeterol-plus group) was randomly assigned to continue
both salmeterol and triamcinolone for the remaining 16 weeks (active control
group).Main Outcome Measure
Time to asthma treatment failure in patients receiving salmeterol.Results
Treatment failure occurred in 8.3% (95% confidence interval [CI], 2%-15%)
of the salmeterol-minus group 8 weeks after triamcinolone treatment was reduced
compared with 2.8% (95% CI, 0%-7%) of the salmeterol-plus group during the
same period. Treatment failure occurred in 46.3% (95% CI, 34%-59%) of the
salmeterol-minus group 8 weeks after triamcinolone therapy was eliminated
compared with 13.7% (95% CI, 5%-22%) of the salmeterol-plus group. The relative
risk (95% CI) of treatment failure at the end of the triamcinolone elimination
phase in the salmeterol-minus group was 4.3 (2.0-9.2) compared with the salmeterol-plus
group (P<.001).Conclusions
Our results indicate that in patients with persistent asthma suboptimally
controlled by triamcinolone therapy alone but whose asthma symptoms improve
after addition of salmeterol, a substantial reduction (50%) in triamcinolone
dose can occur without a significant loss of asthma control. However, total
elimination of triamcinolone therapy results in a significant deterioration
in asthma control and, therefore, cannot be recommended.
Figures in this Article
In patients with persistent asthma inadequately controlled by treatment
with a low dose of inhaled corticosteroids (ICSs), the addition of a long-acting β2-agonist1- 4
provides an incremental improvement in asthma control exceeding that achieved
by increasing dosages of ICS. We anticipated that once this improvement occurred,
many patients would question whether their dosage of ICS could be reduced
or even eliminated. Evidence both supporting5- 6
and refuting7- 9
the concept that continual long-acting β2-agonist therapy
treats symptoms but not the underlying disease6
has generated controversy. Although some studies5,10
have evaluated ICS reduction in patients treated with salmeterol xinafoate,
the disparate and complex nature of the reduction and elimination strategies,
the outcome measures used, and the small numbers of patients evaluated have
not provided sufficient information for clinical decision making. To address
these issues, the National Heart, Lung, and Blood Institute (NHLBI) Asthma
Clinical Research Network (ACRN) conducted the clinical trial Salmeterol ±
Inhaled Corticosteroids (SLIC). The trial tested the hypothesis that in patients
with persistent asthma whose symptoms are suboptimally controlled with a regularly
scheduled ICS (triamcinolone acetonide) but subsequently controlled following
the addition of a scheduled long-acting β2-agonist (salmeterol),
the dosage of ICS can be reduced or eliminated without increasing the risk
of treatment failure. The trial, which used clinically relevant ICS reduction
and elimination strategies that are readily adaptable to patient care, allowed
us to show that while being treated with salmeterol, triamcinolone dosages
could be safely reduced but not eliminated.
We examined the value of maintenance theophylline at serum concentrations of 10 to 20 micrograms per milliliter in a placebo-controlled, randomized, double-blind trial of 33 children with steroid-dependent chronic asthma. Patients were free of all symptoms 63 +/- 6 per cent of the days (mean +/- S.E.M.) when taking theophylline as compared with 42 +/- 6 per cent when taking placebo (P < 0.01). Inhaled metaproterenol was required twice as often with placebo (P < 0.01), and additional daily corticosteroids were needed more than three times as often with placebo (P = 0.02). Daily peak flow measurements improved with theophylline (P < 0.01) as did monthly spirometric measurements and residual volume measured by plethysmography. Theophylline was associated with a 50 per cent increase in the number of patients able to complete an exercise test (P = 0.01) and with a smaller decrease in forced expiratory volume in one second among patients completing the exercise (P < 0.02). We conclude that maintenance bronchodilator therapy with theophylline can provide clinically important benefit for patients with chronic steroid-dependent asthma.
A prospective 28 year follow up of 7 year old children with wheezing and asthma began in 1963 in Melbourne, Australia.1 2 We aimed to describe the outcome of childhood asthma at 35 and the changes since the last review, at 28.3
The children who were selected at 7, on the basis of parents’ responses to a questionnaire, had been classified in terms of wheeze as those who had never wheezed (controls) (n = 106); those with fewer than five episodes associated with apparent respiratory infection (mild wheezy bronchitis) (n = 75); those with five or more episodes associated with an apparent respiratory infection (wheezy bronchitis) (n = 107); and those with wheezing not associated with respiratory infection (asthma) (n = 113). A fifth group of children, with severe asthma (n = 79), was selected at age …
Many studies show asthma to be more common in Black than in White children. This study assessed how much of this difference remains after adjustment for other potentially race-associated predictors of asthma.
We assessed the predictors of active diagnosed asthma and persistent wheeze in 1416 Black and White Philadelphia children aged 9 to 11 years, as reported by parents.
Black race remained a significant predictor of active diagnosed asthma (odds ratio [OR] = 2.3; 95% confidence interval [CI] = 1.3, 4.1) but not of persistent wheeze (OR = 1.0; 95% CI = 0.6, 1.8). The excess risk of asthma in Black children was not appreciably altered by adjustment for other demographic and environmental factors.
Black race is an important risk factor for active diagnosed asthma in these urban children, a relationship not explained by social factors. This finding and the lack of an association of race with persistent wheeze after adjustment for social factors suggest that race may be more important to the acquisition of an asthma diagnosis than to the prevalence of the symptoms.
It has been hypothesized that asthma-related health problems are most severe among children in inner-city areas who are allergic to a specific allergen and also exposed to high levels of that allergen in bedroom dust.
From November 1992 through October 1993, we recruited 476 children with asthma (age, four to nine years) from eight inner-city areas in the United States. Immediate hypersensitivity to cockroach, house-dust-mite, and cat allergens was measured by skin testing. We then measured major allergens of cockroach (Bla g 1), dust mites (Der p 1 and Der f 1), and cat dander (Fel d 1) in household dust using monoclonal-antibody-based enzyme-linked immunosorbent assays. High levels of exposure were defined according to proposed thresholds for causing disease. Data on morbidity due to asthma were collected at base line and over a one-year period.
Of the children, 36.8 percent were allergic to cockroach allergen, 34.9 percent to dust-mite allergen, and 22.7 percent to cat allergen. Among the children's bedrooms, 50.2 percent had high levels of cockroach allergen in dust, 9.7 percent had high levels of dust-mite allergen, and 12.6 percent had high levels of cat allergen. After we adjusted for sex, score on the Child Behavior Checklist, and family history of asthma, we found that children who were both allergic to cockroach allergen and exposed to high levels of this allergen had 0.37 hospitalization a year, as compared with 0.11 for the other children (P=0.001), and 2.56 unscheduled medical visits for asthma per year, as compared with 1.43 (P<0.001). They also had significantly more days of wheezing, missed school days, and nights with lost sleep, and their parents or other care givers were awakened during the night and changed their daytime plans because of the child's asthma significantly more frequently. Similar patterns were not found for the combination of allergy to dust mites or cat dander and high levels of the allergen.
The combination of cockroach allergy and exposure to high levels of this allergen may help explain the frequency of asthma-related health problems in inner-city children.
There is increasing evidence that wheezing during childhood may be a heterogeneous condition, and that different forms of wheezing may be associated with different risk factors and prognosis. The aim of this study was to determine if measures of airway lability and of atopy could identify distinct wheezing phenotypes during childhood.
In a cohort of children followed from birth peak flow variability (n = 600) was evaluated and methacholine challenge responsiveness (n = 397) was measured at age 11 in relation to wheezing before the age of three, and at age six and 11 years total serum IgE and skin test reactivity to allergens were determined.
Neither positive peak flow variability nor methacholine hyperresponsiveness measured at age 11 were associated with wheezing occurring only during the first three years of life. Both methacholine hyperresponsiveness and positive peak flow variability were associated with wheezing at both ages six and 11 (OR 5.1 (95% CI 2.4 to 10.6) and 2.3 (1.2 to 4.5), respectively). In addition, positive peak flow variability was associated with wheezing up to the age of six but not at age 11 in non-atopic children (OR 2.9 (95% CI 1.0 to 8.8)). Methacholine hyperresponsiveness measured at age 11 was more frequently observed in boys (OR 2.1 (95% CI 1.2 to 3.5)) and was strongly associated with serum IgE levels measured at ages six and 11 (p < 0.001) and with positive skin test reactivity (OR 4.5 (95% CI 2.0 to 10.1)). Peak flow variability was unrelated to sex or markers of atopy (IgE and skin test reactivity).
Methacholine responsiveness and peak flow variability assessed at age 11, together with markers of atopy (IgE and skin test reactivity to allergens) identify three different wheezing phenotypes in childhood: "transient early wheezing" limited to the first three years of life and unrelated to increased airway lability; "non-atopic wheezing" of the toddler and early school years associated with positive peak flow variability but not with methacholine hyperresponsiveness; and "IgE-associated wheeze/asthma" associated with persistent wheezing at any age and with methacholine hyperresponsiveness, peak flow variability, and markers of atopy.
Compelling evidence suggests a causal relation between exposure to parental cigarette smoking and respiratory symptoms during childhood. Still, the roles of prenatal versus postnatal parental smoking need clarification. In this study, the authors assessed the effects of passive smoking on respiratory symptoms in a cohort of over 1,000 children born during 1980-1984. The children were enrolled in the Tucson Children's Respiratory Study in Tucson, Arizona, and were followed from birth to age 11 years. The population was generally middle class and consisted of two main ethnic groups, non-Hispanic Whites (75%) and Hispanics (20%), reflecting Tucson's population. Information on parental smoking and on wheeze and cough in their children was elicited from parents by using questionnaires at five different surveys. Data were analyzed both cross-sectionally and by using the generalized estimation equation approach, a longitudinal mixed-effects model. The best-fitting model indicated that maternal prenatal but not postnatal smoking was associated with current wheeze (odds ratio = 2.3, 95% confidence interval 1.4-3.8) independently of a family history of asthma, socioeconomic factors, and birth weight. This effect was time dependent and significant only below age 3 years; although independent of gender, the association was stronger for girls (odds ratio = 3.6, 95% confidence interval 1.6-8.0). Cough was not associated with parental smoking during the first decade of life. This transitory effect of maternal prenatal smoking on wheezing could be due to changes that affect the early stages of lung development.
While more than 80% of childhood asthmatics are allergic to one or more inhaled allergens, the role of inhaled allergens in the induction of wheeze in the first year of life is unknown. In a prospective birth-cohort study of 499 children of asthmatic/allergic parents from metropolitan Boston, we examined home allergen concentrations measured within the first 3 mo of life as predictors of repeated wheeze episodes in the first year of life. In multivariate analyses adjusting for maternal asthma and dog in the home, predictors of two or more wheeze episodes in the first year of life included maternal smoking during pregnancy (relative risk [RR] = 1.83; 95% confidence limit [CL]: 1.12, 3.00), lower respiratory illness in the first year of life (croup, bronchitis, bronchiolitis, or pneumonia) (RR = 2.25; 95% CL:1.58, 3.19), low birthweight (RR = 1.28, 95% confidence interval [CI]: 1.04, 1.58 for an interquartile difference), and Bla g 1 or 2 (cockroach) allergen level in the family room > 0.05 U/g dust (RR = 1.76; 95% CL: 1.20, 2.57). Cockroach allergen in the family room and repeated wheeze remained significant after adjustment for socioeconomic factors including race and income (RR = 1.63; 95% CL: 1.05, 2.55). It is unknown whether the association between cockroach and repeated wheeze in infancy represents a cockroach-related increased risk of bronchial inflammation through nonallergenic or allergenic mechanisms.
The term “sinusitis” should be replaced by “rhinosinusitis,” which is more accurate and descriptive of this condition because 1) sinusitis typically follows rhinitis, 2) it is unusual to have sinusitis without rhinitis, 3) the mucosa of the nose and sinuses are contiguous, and 4) nasal symptoms such as congestion and discharge are prominent features in sinusitis [1•].
Objective
To evaluate, by systematic review, the efficacy of heliox on respiratory mechanics and outcomes in patients with acute asthma.
Methods
The search strategy included searching electronic databases (MEDLINE, EMBASE, and The Cochrane Library) and the references of relevant articles. Study quality was assessed based on allocation concealment. Randomized controlled trials (RCTs) comparing heliox to an air-oxygen mixture (airO2) as an adjunct treatment in patients with acute asthmatic attacks were analyzed. For the qualitative portion of the analysis, all reports of the use of heliox in patients with acute asthma were included.
Results
Four RCTs (n = 278) were found to have a common respiratory parameter (peak expiratory flow rate as a percentage of predicted) suitable for meta-analysis. Within the 92% confidence interval (CI), there was a small benefit with the use of heliox compared to airO2 (weighted mean difference, + 3%; 95% CI, − 2 to + 8%). There was also a slight improvement in the dyspnea index (weighted mean difference, 0.60; 95% CI, 0.04 to 1.16) with the use of heliox over airO2. Overall, five RCTs, one nonrandomized unblinded parallel trial, one retrospective case-matched control trial, three case series, and one case report had results in favor of heliox; one RCT and one case series showed no improvement with heliox; one RCT showed a possible detrimental effect with heliox; and 1 small RCT was inconclusive. Most investigators did not prevent entrainment of room air during heliox use or compensate for the lower nebulizing efficiency of heliox.
Conclusion
Based on surrogate markers, heliox may offer mild-to-moderate benefits in patients with acute asthma within the first hour of use, but its advantages become less apparent beyond 1 h, as most conventionally treated patients improve to similar levels, with or without it. The effect of heliox may be more pronounced in more severe cases. There are insufficient data on whether heliox can avert tracheal intubation, or change intensive care and hospital admission rates and duration, or mortality.
Upper respiratory tract infection and allergic inflammation are recognized as the important risk factors for acute sinusitis, with upper respiratory tract infection being most common. In children with acute or chronic sinusitis, the respiratory symptoms of nasal discharge, nasal congestion and cough are usually prominent. Radiography has traditionally been used to determine the presence or absence of sinus disease. The radiographic findings most diagnostic of bacterial sinusitis are diffuse opacification, mucous membrane thickening or an air-fluid level. The predominant organisms include Streptococcus pneumoniae, Branhamella catarrhalis and nontypable Haemophilus influenzae. Several viruses including adenovirus and parainfluenzae have also been recovered. Clinical improvement is prompt in nearly all children treated with an appropriate antimicrobial agent.
An imbalance of production of T-helper lymphocyte cytokines, favoring overproduction of IL-4, is believed to be important in the pathogenesis of allergic asthma. However, less is known about the cytokine response in virus-induced wheezing, which is a major cause of morbidity in asthma.
We undertook this study to determine the magnitude of IFN-gamma, IL-4 and IL-10, and leukotriene (LT) responses in infants and children with virus-induced wheezing.
We measured the concentrations of IFN-gamma, IL-4 and IL-10, and cysteinyl LTs in respiratory secretions of 82 infants and young children during acute episodes of virus-induced wheezing. Control subjects were 47 infants and children with uncomplicated upper respiratory infections and 18 normal healthy infants.
Ratios of IFN-gamma to IL-4 were higher (due to increased quantities of IFN-gamma) in subjects with wheezing than in those with upper respiratory infection alone (P =. 003). Quantities of LTs were also increased in wheezing subjects in comparison with those with upper respiratory infections (P =.009). There was a significant correlation between measured concentrations of IFN-gamma and LTs (correlation coefficient =.451, P =.007). Quantities of IL-4 were slightly suppressed in the wheezing groups.
An imbalance favoring overproduction of IFN-gamma appears to be associated temporarily with virus-induced wheezing. A possible mechanism is the enhanced release of LTs from eosinophils or mast cells after sensitization by IFN-gamma.
We report that individuals carrying the CCR5▵32 mutation, a naturally occurring variant of the C-C chemokine receptor 5 (CCR5), are at reduced risk of developing asthma. These data suggest a possible explanation for the high prevalence of this mutation in the general population.
Background
Systematic international comparisons of the prevalences of asthma and other allergic disorders in children are needed for better understanding of their global epidemiology, to generate new hypotheses, and to assess existing hypotheses of possible causes. We investigated worldwide prevalence of asthma, allergic rhinoconjunctivitis, and atopic.
Methods
We studied 463 801 children aged 13–14 years in 155 collaborating centres in 56 countries. Children self-reported, through one-page questionnaires, symptoms of these three atopic disorders. In 99 centres in 42 countries, a video asthma questionnaire was also used for 304 796 children.
Findings
We found differences of between 20-fold and 60-fold between centres in the prevalence of symptoms of asthma, allergic rhinoconjunctivitis, and atopic eczema, with four-fold to 12-fold variations between the 10th and 90th percentiles for the different disorders. For asthma symptoms, the highest 12-month prevalences were from centres in the UK, Australia, New Zealand, and Republic of Ireland, followed by most centres in North, Central, and South America; the lowest prevalences were from centres in several Eastern European countries, Indonesia, Greece, China, Taiwan, Uzbekistan, India, and Ethiopia. For allergic rhinoconjunctivitis, the centres with the highest prevalences were scattered across the world. The centres with the lowest prevalences were similar to those for asthma symptoms. For atopic eczema, the highest prevalences came from scattered centres, including some from Scandinavia and Africa that were not among centres with the highest asthma prevalences; the lowest prevalence rates of atopic eczema were similar in centres, as for asthma symptoms.
Interpretation
The variation in the prevalences of asthma, allergic rhinoconjunctivitis, and atopic-eczema symptoms is striking between different centres throughout the world. These findings will form the basis of further studies to investigate factors that potentially lead to these international patterns.
Objectives
This study was designed to compare the effects of a 6-month treatment with budesonide 100 μg bid (low dose) and 400 μg bid (standard reference dose) in controlling symptoms and lung function in a group of asthmatics with moderate asthma (baseline FEV1 ≥ 50% and ≤ 90% of predicted values) previously treated with inhaled beclomethasone dipropionate (500 to 1,000 μg/d). Moreover, we investigated whether or not asthma exacerbations could be treated by a short-term increase in the daily dose of budesonide.
Methods
After a 2-week run-in period and 1-month treatment with a high dose of budesonide (800μ g bid), 213 patients with moderate asthma were assigned to randomized treatments. Daily treatment included budesonide (bid) plus an additional treatment in case of exacerbation (qid for 7 days). Treatments were as follows: budesonide 400 μg plus placebo (group 1); budesonide 100 μg plus budesonide 200 μg (group 2); and budesonide 100 μg plus placebo (group 3). Symptoms and a peak expiratory flow (PEF) diary were recorded and lung function was measured each month. An exacerbation was defined as a decrease in PEF > 30% below baseline values on 2 consecutive days.
Results
We found that that 1-month treatment with a high budesonide dose remarkably reduced all asthma symptoms. Moreover, symptoms were under control in all treatment groups throughout the study period. Similarly, lung function improved and remained stable, and no relevant differences between groups were observed. In each treatment group, the majority of patients had no exacerbations. In patients treated with the standard budesonide dose (group 1), the number of exacerbations and days with exacerbations were significantly lower than in group 3 (intention-to-treat analysis). Additionally, patients treated with low budesonide dose plus budesonide (group 2) experienced a significantly lower number of exacerbations and days with exacerbations compared to group 3 (per-protocol analysis).
Conclusions
This study demonstrates that when patients with moderate asthma had reached a stable clinical condition with a high dose of budesonide, a low dose of budesonide (200 μg/d) is as effective as the standard dose (800 μg/d) in the control of symptoms and lung function over a period of several months. Furthermore, results showed that the addition of inhaled budesonide (800 μg/d) at onset of an asthmatic exacerbation has a beneficial clinical effect.
Objective.
—To examine changes in the prevalence and distribution of childhood asthma and its relationship with various measures of children's health and functioning between 1981 and 1988. It was hypothesized that there would be an increase in the prevalence of asthma, especially among black children, and that available measures would suggest a deterioration in the health and functioning of children with asthma over this period.
The longitudinal lung function data in 286 subjects from a 28 year follow-up of childhood asthma is reported. Airway obstruction in mid-adult life was present mainly in those with moderately severe asthma. Subjects who had been wheeze free for at least 3 years, even if asthma had been persistent in childhood, had normal lung function and no increased bronchial reactivity. Only two subjects, both with persistent asthma from childhood, failed to show an improvement in FEV1 of greater than 10% following inhalation of a beta-adrenergic agonist. Subjects with relatively mild asthma who had not taken inhaled steroids did not appear to be disadvantaged with respect to lung function. Pediatr Pulmonol. 1997; 23:14–20. © 1997 Wiley-Liss, Inc.
Background:
Preliminary evidence suggests that inadequately controlled allergic rhinitis in asthmatic patients can contribute towards increased asthma exacerbations and poorer symptom control, which may increase medical resource use. The objective of this study was therefore to assess the effect of concomitant allergic rhinitis on asthma-related hospital resource utilization among children below 15 years of age with asthma in Norway.
Methods:
A population-based retrospective cohort study of children (aged 0-14 years) with asthma was conducted using data from a patient-specific public national database of hospital admissions during a 2-year period, 1998-1999. Multivariate linear regression, adjusting for risk factors including age, gender, year of admission, urban/rural residence and severity of asthma episode, estimated the association between allergic rhinitis and total hospital days. A multivariate Cox proportional-hazards model estimated relative hazard of readmission according to concomitant allergic rhinitis status.
Results:
Among 2961 asthmatic children under 15 years of age with at least one asthma-related hospital admission over a 2-year period, 795 (26.8%) had a recorded history of allergic rhinitis. Asthmatic children with allergic rhinitis had a 1.72-times greater hazard of asthma-related readmissions than asthmatic children without allergic rhinitis. Multivariate analysis revealed that history of concomitant allergic rhinitis was a significant predictor of increased number of hospital days per year (least-squares mean difference 0.23 days, P < 0.05).
Conclusions:
Concomitant allergic rhinitis in asthmatic children was associated with increased likelihood of asthma-related hospital readmissions and greater total hospital days.
To determine whether the incidence of asthma had increased in Rochester, Minnesota, from January 1, 1964 through December 31, 1983, we used a population-based computer-linked medical diagnosis system to identify individual medical records with diagnosis of asthma or other conditions mimicking asthma. All records were reviewed using explicit predetermined diagnostic criteria; we identified 3,622 incident cases of asthma, including definite asthma (n = 1,547), probable asthma (n = 952), and single wheezing episodes (n = 1,123). The annual age- and sex-adjusted incidence of definite + probable asthma rose from 183 per 100,000 in 1964 to 284 per 100,000 in 1983. This rise was entirely accounted for by increased incidence rates in children and adolescents (age range, 1 to 14 yr); incidence rates for infants younger than 1 yr of age and for adults remained constant. For definite + probable asthma cases, the incidence rates for males were higher than for females from infancy through 9 yr of age and for persons older than 50; incidence rates for females were higher than for males from 15 through 49 yr of age. The median age at onset was 3 yr for males and 8 yr for females. We conclude that asthma begins in early childhood, with a higher incidence and earlier onset in males, and that the increase in incidence rates seen from 1964 to 1983 occurred only in children and in adolescents.
Wheezing lower respiratory tract illness in infancy and asthma share the clinical findings of wheezing and respiratory distress. Although the link between wheezing lower respiratory tract illness in infancy and the subsequent development of asthma is a limited one, both conditions do share some common risk factors, including exposure to environmental tobacco smoke, difficult living conditions (low socioeconomic class, crowding, allergen exposure), and increased risk in males. The impact of baseline lung function on wheezing lower respiratory tract illness risk is substantial and may be independent of airway reactivity. In contrast, the development of chronic airway inflammation mediated by allergic sensitization plays a central role in the development of persistent asthma. Although the endogenous risks for these two outcomes may be fixed, it is clear that caregivers may help to reduce or eliminate the exogenous risks listed earlier by parental education and improvement of the living conditions of young children.
Recent reports have identified New York City as having asthma mortality rates that are substantially higher than expected based on US rates. This study investigates the problems of asthma morbidity and mortality in New York City.
Data on asthma hospitalizations (1982 to 1986) and deaths (1982 to 1987) among persons aged 0 to 34 years were studied. Descriptive and multivariate techniques were used to examine differences in rates among subgroups and across geographic areas.
The average annual hospitalization rate was 39.2 per 10,000; the mortality rate was 1.2 per 100,000. Hospitalization and death rates among Blacks and Hispanics were 3 to 5.5 times those of Whites. Large geographic variations in hospitalizations and mortality occurred. Asthma hospitalization and mortality rates were highly correlated (r = .67), with the highest rates concentrated in the city's poorest neighborhoods. Household income, percentage of population Black, and percentage of population Hispanic were significant predictors of area hospitalization rates (adjusted R2 = .75).
These findings provide a basis for focusing investigations of the causes of variations in asthma outcomes and targeting interventions to reduce the disproportionate morbidity and mortality borne by poor and minority populations.
• Unlike a number of childhood problems, it is not clear that there are racial or socioeconomic disparities in the prevalence of childhood asthma. We analyzed data from the Child Health Supplement to the 1981 National Health Interview Survey, a population-based survey with information concerning 15 416 children, to address the following questions: are there racial or socioeconomic differences in rates of childhood asthma; if yes, what is the contribution of social and environmental characteristics to the observed differences? In this sample, black children were more likely to have asthma than were white children (4.4% vs 2.5%). Racial disparities in prevalence emerged early and at all childhood ages were due to higher black rates of onset between the ages of 1 and 3 years. Poverty status, maternal cigarette smoking, large family size, smaller size of home, low birth weight, and maternal age younger than 20 years at the child's birth were all associated with increased rates of childhood asthma. When available social and environmental characteristics were controlled for using multivariate analyses, the increased risk for asthma among black and poor children was reduced to statistical insignificance. We conclude that black and poor children in the United States do have higher rates of asthma, that social and environmental factors exert substantial influences on rates of asthma, and that much of the racial and economic disparity in prevalence can be accounted for by a variety of social and environmental characteristics.
(AJDC. 1990;144:1189-1194)
In 16 healthy and 16 asymptomatic asthmatic children (age range 5-8 yr; 8 girls, 24 boys) we studied the influence of breathing frequency on the results and the diagnostic value of body plethysmographic measurements. Airway resistance (Raw), specific airway resistance (SRaw), and thoracic gas volume (TGV) were measured during breathing (or breathing efforts against a closed shutter) at 0.4, 1, and 2 Hz. SRaw was computed by a simplified procedure directly from flow at the mouth vs. box volume-curves. The diagnostic value of each parameter was assessed as the percentage of correctly classified healthy and asthmatic subjects by means of discriminant analysis. When frequency was increased from 0.4 to 1 and 2 Hz mean TGV rose by 5 and 14% in healthy children and by 11 and 21% in asthmatic children, respectively. From 0.4 to 1 Hz mean Raw decreased by 16% (P = 0.002) in healthy children and by 25% (P = 0.0004) in asthmatic children. The differences in Raw between both groups decreased with frequency (3.5, 1.8, and 1.5 cm H2O.L-1.s at 0.4, 1, and 2 Hz, respectively) and those of TGV increased (0.13, 0.21, and 0.23 L). SRaw showed similar frequency characteristics as Raw. As intra-group variability changed in parallel with the differences the diagnostic value of the parameters remained constant with frequency. Simplified SRaw alone and TGV combined with Raw exhibited no differences in their diagnostic values (81-84% correctly classified).(ABSTRACT TRUNCATED AT 250 WORDS)
Studies have suggested increases in hospitalization for asthma and in asthma mortality during the early 1980s. Using US Vital Records, we examined asthma mortality from 1968 through 1987 to describe the rates of change among children and young adults (aged 5 to 34 years) with time and in small geographic areas. During the 1970s, US asthma mortality declined by 7.8% per annum (+/- 1.0%), declining faster among women and nonwhites. During the 1980s, mortality increased by 6.2% per annum (+/- 1.2%), increasing faster among those aged 5 to 14 years than among those aged 15 to 34 years. Small-area geographic analysis revealed four areas with persistently high asthma mortality. Neither changes in International Classification of Diseases coding nor improved recognition of asthma, as demonstrated by trends in autopsy rates or rates of in-hospital deaths, seems to explain the increasing mortality of the 1980s.
Although three effective topical treatments for allergic rhinitis are available, little information to assist the clinician in choosing among them has been reported. Therefore, we conducted a randomized clinical trial to compare beclomethasone nasal solution, flunisolide, and cromolyn with placebo in 120 patients with hay fever during the ragweed season of 1984. We found that all three agents were superior to placebo (P less than 0.001) and that the glucocorticoids were more effective than cromolyn (P less than 0.001). Surprisingly, we also found that these intranasal treatments considerably reduced the symptoms of seasonal asthma. Further study of this therapeutic advantage is needed.
Inhaled corticosteroids have become an important therapeutic option in the treatment of childhood asthma. The preparations currently available for pediatric use (beclomethasone dipropionate and triamcinolone acetonide) do not, in general, cause significant hypothalamic-pituitary-adrenal axis suppression and physical signs of glucocorticoid excess have not been described with their use. We report an 8-year-old girl with asthma in whom obesity, hirsutism, and growth retardation developed during treatment with inhaled triamcinolone acetonide alone. Laboratory studies showed suppression of endogenous cortisol production but did not demonstrate suppression of the hypothalamic-pituitary-adrenal axis. Cessation of inhaled triamcinolone acetonide therapy resulted in resolution of obesity and hirsutism, resumption of normal growth, and a return to normal of serum cortisol levels and urinary 17-hydroxycorticosteroid excretion. Careful monitoring of growth velocity and (if clinically indicated) morning serum cortisol levels in asthmatic children using inhaled corticosteroids will detect the rare instance of glucocorticoid excess resulting from systemic absorption of these drugs.
This study uses Maryland hospital discharge data for the period 1979-82 to determine whether Black children are more likely to be hospitalized for asthma and whether this difference persists after adjustment for poverty. The average annual asthma discharge rate was 1.95/1000 children aged 1-19; 3.75/1000 for Black children, and 1.25/1000 for White. Medicaid-enrolled children of both races had increased discharge rates for asthma compared to those whose care was paid for by other sources: 5.68/1000 vs 2.99/1000 for Blacks, and 3.10/1000 vs 1.11/1000 for Whites. When ecologic analyses were performed, populations of Black and White children had nearly equal asthma discharge rates after adjustment for poverty. The statewide adjusted rate was 2.70/1000 (95% CL = 1.93, 3.78) for Black children and 2.10/1000 (1.66, 2.66) for White children. Among Maryland counties and health planning districts, variation in asthma discharge rates was not associated with the supply of hospital beds or the population to primary-care physician ratio. We conclude that Black children are at increased risk of hospitalization for asthma, but that some or all of this increase is related to poverty rather than to race.
To determine the prevalence and severity of childhood asthma in New Zealand we studied 815 children from a birth cohort by questionnaire, clinical examination and pulmonary physiological measurements at age 9 years. More than 19% of the sample had experienced wheezing in the previous year, and 11% had wheezed in the month before assessment. In all, 220 of 815 children (27.1%) had had wheezing episodes by age 9; in 34 (4.2%) episodes had been of sufficient frequency to warrant regular anti-asthma treatment. Only 32% of all wheezing children were reported by their parents to suffer from asthma, and, in groups matched for frequency of symptoms, treatment given for wheezing was influenced strongly by whether or not the label of 'asthma' had been given. The detailed history provided most information useful in diagnosing asthma; clinical examination, peak flow records, spirometry and bronchial provocation testing provided only limited additional information. A wide spectrum of frequency and severity of recurrent wheezing disorders was evident in New Zealand children. Throughout all degrees of severity, prevalence rates appeared higher than those reported in studies from the United Kingdom.
The effect of intranasally administered corticosteroid (budesonide) on nasal symptoms, mode of respiration (nasal versus mouth breathing), and asthma was investigated in 37 asthmatic children who were mouth breathers because of chronic nasal obstruction. After a 2-wk run-in period, the children were allocated randomly to 4 wk of intranasal therapy with either budesonide (400 micrograms/day) or placebo spray. A double-blind, parallel design was used. Diaries for peak expiratory flow, asthma, and rhinitis symptom scores and degree of mouth breathing were recorded at home. Nasal eosinophilia, nasal airway resistance at a flow of 0.2 L/s (NAR0.2), and lung function at rest and after exercise challenge were assessed at the clinic immediately before and at end of the 4-wk treatment. Budesonide, when compared with placebo, significantly decreased nasal obstruction (p less than 0.05), secretion (p less than 0.01), and eosinophilia (p less than 0.02), as well as NAR0.2 (p less than 0.05) and mouth breathing (p less than 0.01). The improvement in nasal obstruction correlated closely to the changes in mouth breathing (r = 0.80, n = 17, p less than 0.001). Furthermore, intranasally administered budesonide resulted in less exercise-induced asthma (EIA) (p less than 0.02) and decreased cough and asthma severity significantly. Pulmonary mechanics were only marginally improved. The present study showed that intranasally administered budesonide is effective in the treatment of perennial allergic rhinitis. An attenuation of EIA and a tendency to less asthma after budesonide therapy suggest a decrease in bronchial reactivity, but the results gave no clear evidence of an association between nasal airway function and asthma.
We evaluated the effects of a new semisynthetic macrolide antibiotic, roxithromycin, on the bronchial hyperresponsiveness to histamine in children with asthma. Twelve hospitalized asthmatic children, aged 11 to 15 years (mean age, 12.9 years), were enrolled in this study. They were treated with 150 mg of roxithromycin once a day orally for 8 weeks without any side effects. The PC20 value 4 or 8 weeks after the administration of roxithromycin increased significantly over the initial values (p < 0.05, p < 0.01, respectively). No significant change was observed in serum theophylline concentrations during this study. Serum cortisol level in the morning did not change after the administration of roxithromycin for 4 weeks. These results suggest that administration of roxithromycin may act favorably in the treatment of childhood asthma.
Many young children wheeze during viral respiratory infections, but the pathogenesis of these episodes and their relation to the development of asthma later in life are not well understood.
In a prospective study, we investigated the factors affecting wheezing before the age of three years and their relation to wheezing at six years of age. Of 1246 newborns in the Tucson, Arizona, area enrolled between May 1980 and October 1984, follow-up data at both three and six years of age was available for 826. For these children, assessments in infancy included measurement of cord-serum IgE levels (measured in 750 children), pulmonary-function testing before any lower respiratory illness had occurred (125), measurement of serum IgE levels at nine months of age (672), and questionnaires completed by the children's parents when the children were one year old (800). Assessments at six years of age included measurement of serum IgE levels (in 460), pulmonary-function testing (526), and skin allergy testing (629).
At the age of six years, 425 children (51.5 percent) had never wheezed, 164 (19.9 percent) had had at least one lower respiratory illness with wheezing during the first three years of life but had no wheezing at six years of age, 124 (15.0 percent) had no wheezing before the age of three years but had wheezing at the age of six years, and 113 (13.7 percent) had wheezing both before three years of age and at six years of age. The children who had wheezing before three years of age but not at the age of six had diminished airway function (length-adjusted maximal expiratory flow at functional residual capacity [Vmax FRC]) both before the age of one year and at the age of six years, were more likely than the other children to have mothers who smoked but not mothers with asthma, and did not have elevated serum IgE levels or skin-test reactivity. Children who started wheezing in early life and continued to wheeze at the age of six were more likely than the children who never wheezed to have mothers with a history of asthma (P < 0.001), to have elevated serum IgE levels (P < 0.01), to have normal lung function in the first year of life, and to have elevated serum IgE levels (P < 0.001) and diminished values for VmaxFRC (P < 0.01) at six years of age.
The majority of infants with wheezing have transient conditions associated with diminished airway function at birth and do not have increased risks of asthma or allergies later in life. In a substantial minority of infants, however, wheezing episodes are probably related to a predisposition to asthma.
The rate of mortality from asthma has increased substantially in the United States since 1978. We analyzed the patterns of the rates of death from asthma in Philadelphia between 1969 and 1991.
The rates of death from asthma were analyzed and compared with trends in the concentrations of major air pollutants: ozone, carbon monoxide, nitrogen dioxide, particulate matter (particles < 10 microns in diameter), and sulfur dioxide. Univariate and multivariate analyses were used to study the rates of death from asthma from 1985 to 1991 and their association with race, poverty, sex, and other factors.
The rate of death from asthma decreased from 1.68 per 100,000 people in 1969 to 0.68 per 100,000 in 1977, but then increased to 0.92 per 100,000 in 1978 and 2.41 per 100,000 in 1991. Between 1965 and 1990, the concentrations of major air pollutants declined substantially. From 1985 to 1991, 258 people were identified for whom asthma was the primary cause of death. According to multivariate analysis, the rates of death from asthma from 1985 to 1991 were significantly higher in census tracts with higher percentages of blacks (P = 0.032), Hispanics (P = 0.013), female residents (P < 0.001), and people with incomes in the poverty range (P < 0.001).
The rates of death from asthma have increased in Philadelphia, whereas concentrations of major air pollutants have declined. The rates are highest in census tracts with the highest percentages of poor people and minority residents, particularly blacks. Public health efforts should target urban areas where the risk of death from asthma is highest.
The domestic cockroach has been identified as an important source of indoor aeroallergens worldwide in both temperate and tropical climates. Because cockroach populations are highest in crowded urban areas, some have suggested that the increased asthma morbidity and mortality rates in inner cities could be related in part to cockroach allergen exposure. We have examined cockroach allergen exposure in the homes of children with asthma in both urban and suburban locations and have related the rates of exposure and sensitization to socioeconomic, racial, and demographic factors.
The study was designed to determine the independent contribution of race, socioeconomic status, and place of residence to the risk of cockroach allergen exposure and sensitization in children with asthma.
Eighty-seven children with moderate to severe allergic asthma, aged 5 to 17 years, participating in a prospective trial of immunotherapy, were evaluated. Extracted dust samples from three home locations were analyzed by using two-site monoclonal immunoassays for major cockroach allergens (Bla g 1 and Bla g 2). A puncture skin test with a mixed cockroach allergen extract was performed in 81 of the 87 subjects.
In the 87 homes evaluated, 26% of the bedroom dust samples had detectable levels of cockroach allergen. In homes with detectable bedroom cockroach allergen levels, mean Bla g 1 and Bla g 2 concentrations in urban and suburban homes were similar. Over 80% of children with bedroom Bla g 1 or Bla g 2 of 1 U/gm or greater demonstrated skin sensitivity to cockroach allergen. The rate of cockroach sensitization was directly related to the level of bedroom exposure. African-American race was the only factor that was independently associated with cockroach allergen exposure (p = 0.05). Lower socioeconomic status, age greater than 11 years, cockroach exposure, and African-American race were all independently associated with cockroach allergen sensitization on the basis of stepwise multiple linear regression analysis.
African-American race and low socioeconomic status were both independent, significant risk factors for cockroach allergen sensitization in children with atopic asthma. Cockroach allergen is detectable throughout the house, including the critical bedroom environment.
With the cooperation of 12 Maternity Hospitals we have started a prospective study to evaluate the effect of dietary and environmental measures in the development of atopic disease in "at risk" newborns. The preventive measures included: exclusive breast feeding for the first 6 months of life, soy milk supplement when breast milk is not sufficient, elimination of house dust, no smoking in the house, etc. All infants were seen at the age of 1, 3, 6, 9, 12 months and twice-a-year afterwards. 1213 babies have been enrolled. At the last follow-up of 48 months 531 children are 4 year old. The cumulative prevalence of atopic disease was 20%: 11 (2%) children developed atopic dermatitis, 69 (13%) asthma, 21 (4%) rinithis, 5 (1%) urticaria. The low prevalence of atopic disease and the trivial course of the allergic manifestations in the children who followed the preventive measures (78/444 = 18%) and the higher (28/87 = 32%) in these who did not (p < 0.01) stressed the importance of such manipulations for the prevention of atopy in "at risk" babies.
The relationships of asthma and allergic rhinitis with individual immediate skin test responses were examined for preferential associations and for changes with age in children raised in a semiarid environment. Prevalence of physician-diagnosed asthma was 9.8% at age 6 (n = 948) and 15.5% at age 11 (n = 895). Immediate skin test responses to Bermuda grass were the most prevalent among children with allergic rhinitis and control subjects, whereas responses to the mold, Altenaria alternata, were the most prevalent among asthmatics. Skin test responses for crude house dust, Dermatophagoides farinae, and cat had low prevalences in all groups. By logistic regression, Alternaria was the only allergen independently associated with increased risk for asthma at both ages 6 and 11. Allergic rhinitis showed independent association with sensitization to Bermuda grass and mulberry tree pollen at age 11 but did not show an independent relation to any single allergen at age 6. Logistic regression further revealed that persistent asthma (diagnosed before age 6) was independently associated with Alternaria skin tests at both ages 6 and 11, whereas new asthma (diagnosed after age 6) was associated with Alternaria skin tests at age 6 but not at age 11. We conclude that Alternaria is the major allergen associated with the development of asthma in children raised in a semiarid environment and that skin test responses at age 6 are more closely linked to asthma than those at age 11.
The natural history of allergic sensitization is complex and poorly understood. A prospective nonrandomized study was carried out in a population of asthmatic children younger than 6 years of age whose only allergic sensitivity was to house dust mites (HDMs).
The study was designed to determine whether specific immunotherapy (SIT) with standardized allergen extracts could prevent the development of new sensitizations over a 3-year follow-up survey.
We studied 22 children monosensitized to HDM who were receiving SIT with standardized allergen extracts and 22 other age-matched control subjects who were monosensitized to HDM. The initial investigation included a full clinical history, skin tests with a panel of standardized allergens, and the measurement of allergen-specific IgE, depending on the results of skin tests. Children were followed up on an annual basis for 3 years, and the development of new sensitizations in each group was recorded.
Ten of 22 children monosensitized to HDM who were receiving SIT did not have new sensitivities compared with zero of 22 children in the control group (p = 0.001, chi square test).
This study suggests that SIT in children monosensitized to HDM alters the natural course of allergy in preventing the development of new sensitizations.
The purpose of this study was to describe patterns of health care use by inner-city patients with asthma and to identify patients at risk for hospitalization. We performed a retrospective cohort study of 1788 patients with asthma aged 5 to 34 years from a large hospital-based multi-specialty practice in inner-city Indianapolis from 1985 to 1992. Compared with 633 white patients, 1155 African-American patients had fewer outpatient encounters including primary care visits, urgent visits to the emergency department and urgent care centers, and prescription refills. Emergency department use was greater for African-American males compared with white males. With patients 30 years of age as the referent, survival analysis revealed three to sixfold greater relative risk of hospitalization for asthma for younger patient age groups, and greatest risk among young African-American males. Adolescent patients had the highest cumulative percentage hospitalization and the longest lengths of stay. We conclude that inadequate routine primary care among African-American patients may increase their risk of asthma exacerbation requiring hospitalization. Age, gender, and race are all important predictors of hospitalization for asthma. Further studies are needed to explore the relation between sources of care and asthma exacerbation.
An inhaled glucocorticoid is currently the medication of choice for long-term control of persistent asthma in children. The role of long-acting beta2-adrenergic-receptor agonists, such as salmeterol, needs to be defined.
We conducted a randomized, double-blind, placebo-controlled, parallel-group, one-year study of 241 children (mean [+/-SD] age, 9.3+/-2.4 years) with clinically stable asthma and less than one month of prior glucocorticoid use. We compared inhaled beclomethasone dipropionate (200 microg twice daily) with salmeterol xinafoate (50 microg twice daily) and placebo (lactose). The primary outcome measure, airway responsiveness (as assessed with a methacholine challenge) was evaluated before treatment; after 3, 6, 9, and 12 months of treatment (12 and 36 hours after study medications had been withheld); and 2 weeks after the end of treatment. Spirometry, symptoms, use of rescue medication (200 microg of albuterol inhaled as needed), and adverse effects were also assessed.
During months 1 through 12 overall, beclomethasone was associated with significantly less airway hyperresponsiveness than salmeterol (P= 0.003) or placebo (P<0.001). This effect was lost two weeks after treatment had been stopped. As compared with placebo, beclomethasone was associated with less variability between morning and evening in the peak expiratory flow (P=0.002), as was salmeterol (P=0.02). Beclomethasone was also associated with a reduced need for albuterol as rescue therapy (P<0.001) and fewer withdrawals because of asthma exacerbations (P=0.03), but salmeterol was not (P=0.09 and 0.55, respectively). During months 1 through 12, linear growth was 3.96 cm in the children receiving beclomethasone, as compared with 5.40 cm in the salmeterol group (P=0.004) and 5.04 cm in the placebo group (P=0.018). Height was not measured after treatment ended.
Beclomethasone was effective in reducing airway hyperresponsiveness and in controlling symptoms of asthma, but it was associated with decreased linear growth. Salmeterol was not as effective as beclomethasone in reducing airway hyperresponsiveness or in controlling symptoms; however, it was an effective bronchodilator and was not associated with rebound airway hyperresponsiveness, masking of symptoms, or adverse effects.
The purpose of the study was to examine medication use reported by families participating in an urban school-based community intervention program and to relate this use to other social and medical variables.
The design of the study was a cross-sectional questionnaire survey.
Patients and their families recruited from elementary schools in a community setting were interviewed between December 1991 and January 1992.
A total of 508 children with asthma were identified by school health records and teacher surveys. Their families confirmed the diagnosis and agreed to enter the study. Questionnaires were completed by 392 families.
The 392 families participated in a controlled trial of asthma education after providing the data that are the basis of this report.
More than half of the children took two or more medications for asthma. Thirty-one percent took theophylline alone or in combination with an adrenergic agent; 11% took some form of daily antiinflammatory medication, either cromolyn (8%) or inhaled steroids (3%). The pattern of medication use related to measures of severity and to regular visits to physicians or nurses. In general, however, children were undermedicated. A total of 78 children (20%) reported no medication or over-the-counter medication use, although 37% reported asthma severe enough to be associated with >/=20 days of school missed per month, and 37% had had an emergency room visit for asthma in the past 6 months. More than half of children >/=9 years old supervised their own medication.
We concluded that undermedication is common in poor children with asthma living in urban areas. Antiinflammatory medications are used less commonly than in the general population, and theophylline is used more often. School children may be likely to supervise their own medication.
The purpose of this study is to examine the co-existence of asthma and allergic rhinitis among former college students who were diagnosed with these diseases either before or after their freshman year. A total of 738 former Brown University students (69% males and 31% females) who were evaluated and underwent skin testing during their freshman year completed a 23-year follow-up questionnaire inquiring of their history of allergies and asthma. The mean age of the participants at the time of the follow-up study was 40 years. In this group, the cumulative incidence of asthma was 11.3% (84/738), hay fever was 41.5% (306/738), and nonseasonal allergic rhinitis was 14.0% (103/738). The cumulative incidence of allergic rhinitis (hay fever) and/or nonseasonal allergic rhinitis (was 45.8% (338/738). Among the 84 individuals with a cumulative incidence of asthma, 63 (75.0%) had a history of hay fever, 27 (32.1%) had a history of nonseasonal allergic rhinitis, and 72 (85.7%) had a history of allergic rhinitis. Among the 306 participants with a cumulative incidence of hay fever, 63 (20.6%) had a history of asthma. Twenty-seven (26.2%) of the 103 individuals with a history of nonseasonal allergic rhinitis had a cumulative incidence of asthma. Among the 338 individuals with a cumulative incidence of allergic rhinitis 72 (21.3%) had a history of asthma. Among the participants with a history of both asthma and hay fever, 44.8% developed hay fever first, 34.5% developed asthma first, and 20.7% developed both diseases at the same time. Among the individuals with a history of asthma and nonseasonal allergic rhinitis, 38.5% developed nonseasonal allergic rhinitis first, 30.8% developed asthma first, and 30.8% developed both diseases at the same time. This study further demonstrates the frequent co-existence of asthma and allergic rhinitis. Among asthmatics, allergic rhinitis occurred in 85.7%. Only 14.3% of asthmatics did not have allergic rhinitis. Among individuals with allergic rhinitis, asthma occurred in 21.3%. Also, allergic rhinitis often precedes or occurs at the same time as asthma.
To investigate the efficacy of an increased dose of inhaled steroid used within the context of an asthma self management plan for treating exacerbations of asthma.
Randomised, double blind, placebo controlled, crossover trial.
Twenty eight children aged 6-14 years with asthma of mild to moderate severity were studied for six months. Eighteen pairs of exacerbations were available for analysis, during which subjects took an increased dose of inhaled steroids or continued on the same dose.
There was no significant difference between increasing inhaled steroids or placebo on morning or evening peak expiratory flow rates (PEFRs), diurnal peak flow variability, or symptom scores in the two weeks following an asthma exacerbation. Difference (95% confidence intervals) in baseline PEFR on days 1-3 were 3.4% (-3.5% to 10.4%) and -0.9% (-4.7% to 2.9%) for inhaled steroid and placebo, respectively. Spirometric function and the parents' opinion of the effectiveness of asthma medications at each exacerbation were also not significantly different between inhaled steroid or placebo.
This study suggests that increasing the dose of inhaled steroids at the onset of an exacerbation of asthma is ineffective and should not be included in asthma self management plans.
Asthma is a common and costly condition. Concomitant asthma and allergic rhinitis (AR) have been shown to increase the medication costs for people with asthma. No studies have compared medical care costs of those with and without concomitant AR.
We sought to determine the prevalence and incremental medical care costs of concomitant AR.
For each member of a population-based asthma cohort, we used all their medical charts within Olmsted County to record age at first diagnosis of asthma; the presence and age of any diagnosis of AR; and the total, ambulatory, and respiratory care-related costs of medical care. Costs were compared for age- and sex-specific strata of people with asthma who did and did not have AR.
AR was most commonly diagnosed in people whose asthma was diagnosed before age 25 (prevalence of 59%) and uncommonly diagnosed in anyone after age 40 (prevalence <15%). Yearly medical care charges were on average 46% higher for those with asthma and concomitant AR than for persons with asthma alone, controlling for age and sex. We were unable to assess the impact of treatment of AR on medical care charges.
Physicians should consider the diagnosis of AR (prevalence >50%) in all symptomatic children and young adults with asthma. Further evaluation is necessary to evaluate the ability of treatment to decrease the incremental costs of AR in persons with asthma.
To examine the prevalence of asthma and hay fever, and the incidence and temporal relationships of asthma, hay fever, and chronic bronchitis among adult twins during a 15-year period.
Prospective cohort study.
A population of 11,540 Finnish adult men and women, initially 18 to 45 years of age, who returned a health questionnaire in 1975, 1981, and 1990 as part of the Finnish Twin Cohort study.
Age-standardized prevalences and cumulative incidences among individuals were calculated for asthma, hay fever, and chronic bronchitis. The incidence of asthma among subjects with and without hay fever or chronic bronchitis was analyzed in the entire cohort as well as in twin pairs discordant for incident asthma.
The prevalence of asthma increased slightly from 1975 (2.0% in men and 2.2% in women) to 1990 (2.9% in men and 3.1% in women). The prevalence of hay fever showed a larger increase in men and women (from 6.8% and 9.8% to 11.8% and 15.3%, respectively). Compared with figures for 1976 to 1981, no significant increase in asthma incidence occurred from 1982 to 1990, whereas the incidence of hay fever was lower during the latter period among men (incidence rate ratio, 0.7; 95% confidence interval, 0.6 to 0.9) as was the incidence of chronic bronchitis among women (incidence rate ratio, 0.7; 95% confidence interval, 0.6 to 0.9). Hay fever and chronic bronchitis were usually diagnosed before asthma. Both diseases increased the risk of asthma significantly on the basis of analyses of all individuals and of discordant twin pairs.
The pattern of increase in asthma and hay fever prevalence with time was similar, and hay fever was a strong predictor of asthma. These diseases showed no significant increase in incidence.
We evaluated 174 children with acute asthma and/or wheezing attending two different settings, the allergy clinic (AC) and the emergency room (ER), and compared clinical symptoms and spirometric findings with arterial oxygen saturation as measured by pulse oximetry (SpO2). Seventy-four children (4 months to 15 years old) seen at the AC and 100 children (2 months to 14 years old) seen at the ER for the treatment of acute asthma and/or wheezing were evaluated and a clinical score was attributed on the basis of their symptoms. In addition, the heart rate (HR) was recorded and SpO2 was measured. Among the children seen at the AC, 58 were able to perform pulmonary function tests, and the forced respiratory volume in 1 sec (FEV1) and forced expiratory flow between 25% and 75% of the forced vital capacity (FEF(25-75)) were determined. Children from both groups underwent treatment with a nebulized beta2-agonist (Fenoterol 0.5% solution, 0.08 mg/kg/dose, maximum 2.5 mg) and were re-evaluated after 30 min. Our results showed a significant correlation between decrease in clinical scores and increase of SpO2 following treatment with bronchodilator in both groups of children. SpO2 levels correlated positively with FEV1 and FEF(25-75) values, and negatively with clinical scores and heart rate. The data revealed that a clinical score greater than 3 and an SpO2 < 94% were associated with increased severity of the asthma attack. In addition, SpO2 levels < or = 92% were associated with a 6.3-fold greater relative risk for requiring additional treatment. We concluded that determination of oxygen saturation by pulse oximetry is helpful in monitoring the severity of an acute exacerbation of asthma and/or wheezing, and has a prognostic value.
Gastroesophageal reflux (GER) is a potential trigger of asthma. GER symptoms are more prevalent in asthma patients compared with control populations, with a prevalence of approximately 75%. GER symptoms are associated with respiratory symptoms and inhaler use. GER may also occur without esophageal symptoms. Abnormal esophageal acid contact times are also more prevalent in patients with asthma compared with control populations, with a prevalence of 80%. Pathophysiologic mechanisms of esophageal acid-induced bronchoconstriction include a vagally mediated reflex, heightened bronchial reactivity, and microaspiration. Esophageal acid may increase minute ventilation without evidence of bronchoconstriction. Esophageal acid is associated with the release of substance P in the bronchial mucosa, resulting in airway edema. Medical antireflux therapy with proton pump inhibitors results in asthma symptom improvement in approximately 70% of patients, similar to surgical results. Predictors of asthma response include the presence of regurgitation, proximal acid reflux, esophagitis healing with therapy, reflux-associated respiratory symptoms, or nocturnal asthma. Management of GER in adult patients with asthma should include a 3-month trial of high-dose proton pump inhibitor while monitoring asthma outcome. GER should be considered as a potential asthma trigger in all patients.