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Investigations into the Phenotypic Changes of Asthma
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Clinical Characteristics of Difficult to Control Pediatric Asthma in a Tertiary Pediatric Subspecialty Clinic C. S. Sendon; Eastern Virginia Medical School/Children Hospital of Kings Daughters, Norfolk, VA. RATIONALE: Due to the wide variation in prevalence and factors associated with difficult to control asthma, it is vital that common clinical characteristics be identified. METHODS: This is a retrospective chart review of 100 pediatric patients classified as having uncontrolled asthma based on NHBLI guidelines. An inclusion criterion was use of daily high doses of inhaled steroids, intermittent systemic steroid bursts, or daily use of oral steroids. Asthmatics patients with other chronic lung condition such as bronchopulmonary dysplasia, or restrictive lung disease were excluded. RESULTS: The following clinical characteristics were observed in this group: 95% are atopic based on history of allergic rhinitis, eczema, positive allergy prick skin test or RAST (radioallergosorbent test), 66% are African Americans, 27% have exposure to tobacco smoke (ETS), 51% have moderate to severe airway obstruction based on FEV1, 47% have sinusitis, 43% have GERD, 55% have a BMI percentile of 85 or above, 33% are obese. CONCLUSIONS: The great majority of pediatrics patients with difficult to control asthma are atopic and almost half of them have sinusitis and GERD as co-morbidities, 33% are also obese. Identifying the atopic condition and co-morbidities of asthma patients who continue to be symptomatic despite adequate therapy may help improve quality of life and better asthma control.
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Investigations into the Phenotypic Changes of Asthma J. L. Mutnick, W. Zhong, M. Miller, L. Fine, M. Blumenthal; University of Minnesota, Minneapolis, MN. RATIONAL: Asthma is a chronic inflammatory lung disease with a changing prevalence. This study is based on the hypothesis that asthma is influenced by genetic and environmental factors. METHODS: We investigated changes in variables used to define asthma including asthma symptoms, pulmonary function testing and serum IgE levels between 1995 and 2007. RESULTS: A total of 98 patients were analyzed for a diagnosis of asthma based on symptoms and reversibility and/or a positive methacholine challenges. Of 29 patients with asthma in 1995, 17 lost their diagnosis in 2007. Of 65 patients with no diagnosis of asthma in 1995, 8 developed a diagnosis of asthma in 2007. 99 subjects completed symptom questionnaires of cough, wheeze, and SOB. In 1995, 31/99 complained of no symptoms; 19/99 had one symptom; and 49/99 complained of two or more symptoms. In 2007, 31/99 complained of no symptoms; 16/99 had one symptom; and 52/99 complained of two or more symptoms. As with the diagnosis of asthma some with symptoms lost them while others gained them. Of 59 patients with IgE levels less than 100 IU in 1997 none changed in 2007 while of 39 subjects with elevated IgE levels 9 when retested were below 100 IU. CONCLUSIONS: This longitudinal study evaluated multiple variables to correlate objective data with subjective symptoms. Our findings would support that asthma continues to evolve and change over time. We found that symptoms and pulmonary function findings of asthma are influenced by many factors both genetic and environmental.
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Nocturnal Asthma Symptoms without Awakenings C. C. Horner, J. M. Garbutt, L. B. Bacharier, R. C. Strunk; Washington University, St. Louis, MO. RATIONALE: Although nocturnal awakenings are used to categorize asthma severity and control, night-time asthma symptoms that do not result in awakenings have not been studied. METHODS: Caregivers of children ages 2-11 years with a physician diagnosis of asthma for 1 year and without gastroesophageal reflux or sleep apnea completed the childhood Asthma Control Test (ACT) and a novel 41-item questionnaire at routine clinic visits. 19 additional items were abstracted from medical record data. Questions measured nocturnal symptoms with and without awakening over the past 6 months, asthma severity, treatment, allergy, and demographics. RESULTS: Of the 109 children, 72% were male, 69% were Caucasian, 38% had Medicaid, and 69% were atopic. Asthma severity was assessed as intermittent 16%, or persistent 84% (mild 24%, moderate 55%, severe 5%). The mean ACT score was 19 (SD56). In the past 6 months, 65% reported awakening at night because of asthma and 52% reported wheeze while sleeping (19% of this group reported solely wheeze without awakening). An IgE level within normal range was associated with continuation of sleep during wheeze (p50.046). Subjects who solely wheezed without awakening did not differ from subjects who wheezed with awakening by demographics, skin test positivity, smoke or pet exposure, hospitalization or prednisone use in the past 6 months, allergy medication use, asthma controller therapy, ACT score, or asthma severity. CONCLUSIONS: Children with asthma exhibit a variety of nocturnal symptoms including wheezing without awakening. Further investigation into the clinical implications of these symptoms may impact asthma treatment and control.
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Mannitol and Methacholine Tests to Identify EIB & Asthma in Children with Symptoms but no Definite Diagnosis: A Phase 3 study S. D. Anderson1, D. S. Pearlman2, J. M. Weiler3, C. P. Perry4, B. Charlton5; 1Royal Prince Alfred Hospital, Camperdown, AUSTRALIA, 2 Colorado Allergy and Asthma Centers, Denver, CO, 3CompleWare Corporation, Iowa City, IA, 4Royal Prince Alfred Hospital, Camperdown NSW, AUSTRALIA, 5Pharmaxis Ltd, Frenchs Forest NSW, AUSTRALIA. RATIONALE: Exercise (Exc) & methacholine (Mech) are used to identify bronchial hyperresponsiveness (BHR) consistent with a diagnosis of exercise-induced bronchoconstriction (EIB) & asthma. Mannitol powder (Mann) is a new test for BHR. METHODS: Patients with signs & symptoms of asthma but without a definite respiratory physician diagnosis (PhysDx). The mannitol kit (AridolTM) has 9 dose steps 0,5,10,20,40,80,160,160,160 mg: FEV1 is measured 60s after each dose. We investigated the sensitivity & specificity of Mech (PC20 16 mg/ml) & Mann (PD15 635 mg or a 10% fall in FEV1 between doses) to identify EIB, (10% fall in FEV1) & a PhysDx of asthma based on history, examination, spirometry, skin tests, FEV1%reversibility & two exercise tests. RESULTS: Ninety-six children, median: NAEPPII score 1, 14 yr, 158 cm, 55 Kg, FEV1 92% predicted. Fifty children were Exc+ve (34+ve 1st test & 39+ve 2nd test). Mean maximum % fall FEV1 20.7%610.7, 49 were Mann+ve (Mean %fall FEV1 15.8%67) and 56 were Mech+ve (Mean %fall FEV1 26.9%66). Agreement for Ex/Mann/Mech was 39.6%, & Mann/Mech 53.7%. The sensitivity/specificity of Mann & Mech to identify Exc+ve was 60.1%/58.5% & 70.0%/54.5% respectively; to identify PhysDx+ve asthma it was 63.2%/81.4% & 66.2%/62.9% for Mann & Mech. CONCLUSION: Mannitol & methacholine were equivalent for identifying EIB and a PhysDx of asthma in children with mild symptoms of asthma without a definite diagnosis. Mannitol and methacholine were more sensitive than one exercise test to detect BHR. The %fall in FEV1 was less after mannitol and specificity for a PhysDx diagnosis was higher compared with methacholine.
SATURDAY
Abstracts AB3
J ALLERGY CLIN IMMUNOL VOLUME 125, NUMBER 2
Clinical Characteristics of Difficult to Control Pediatric Asthma in a Tertiary Pediatric Subspecialty Clinic C. S. Sendon; Eastern Virginia Medical School/Children Hospital of Kings Daughters, Norfolk, VA. RATIONALE: Due to the wide variation in prevalence and factors associated with difficult to control asthma, it is vital that common clinical characteristics be identified. METHODS: This is a retrospective chart review of 100 pediatric patients classified as having uncontrolled asthma based on NHBLI guidelines. An inclusion criterion was use of daily high doses of inhaled steroids, intermittent systemic steroid bursts, or daily use of oral steroids. Asthmatics patients with other chronic lung condition such as bronchopulmonary dysplasia, or restrictive lung disease were excluded. RESULTS: The following clinical characteristics were observed in this group: 95% are atopic based on history of allergic rhinitis, eczema, positive allergy prick skin test or RAST (radioallergosorbent test), 66% are African Americans, 27% have exposure to tobacco smoke (ETS), 51% have moderate to severe airway obstruction based on FEV1, 47% have sinusitis, 43% have GERD, 55% have a BMI percentile of 85 or above, 33% are obese. CONCLUSIONS: The great majority of pediatrics patients with difficult to control asthma are atopic and almost half of them have sinusitis and GERD as co-morbidities, 33% are also obese. Identifying the atopic condition and co-morbidities of asthma patients who continue to be symptomatic despite adequate therapy may help improve quality of life and better asthma control.
10
Investigations into the Phenotypic Changes of Asthma J. L. Mutnick, W. Zhong, M. Miller, L. Fine, M. Blumenthal; University of Minnesota, Minneapolis, MN. RATIONAL: Asthma is a chronic inflammatory lung disease with a changing prevalence. This study is based on the hypothesis that asthma is influenced by genetic and environmental factors. METHODS: We investigated changes in variables used to define asthma including asthma symptoms, pulmonary function testing and serum IgE levels between 1995 and 2007. RESULTS: A total of 98 patients were analyzed for a diagnosis of asthma based on symptoms and reversibility and/or a positive methacholine challenges. Of 29 patients with asthma in 1995, 17 lost their diagnosis in 2007. Of 65 patients with no diagnosis of asthma in 1995, 8 developed a diagnosis of asthma in 2007. 99 subjects completed symptom questionnaires of cough, wheeze, and SOB. In 1995, 31/99 complained of no symptoms; 19/99 had one symptom; and 49/99 complained of two or more symptoms. In 2007, 31/99 complained of no symptoms; 16/99 had one symptom; and 52/99 complained of two or more symptoms. As with the diagnosis of asthma some with symptoms lost them while others gained them. Of 59 patients with IgE levels less than 100 IU in 1997 none changed in 2007 while of 39 subjects with elevated IgE levels 9 when retested were below 100 IU. CONCLUSIONS: This longitudinal study evaluated multiple variables to correlate objective data with subjective symptoms. Our findings would support that asthma continues to evolve and change over time. We found that symptoms and pulmonary function findings of asthma are influenced by many factors both genetic and environmental.
11
Nocturnal Asthma Symptoms without Awakenings C. C. Horner, J. M. Garbutt, L. B. Bacharier, R. C. Strunk; Washington University, St. Louis, MO. RATIONALE: Although nocturnal awakenings are used to categorize asthma severity and control, night-time asthma symptoms that do not result in awakenings have not been studied. METHODS: Caregivers of children ages 2-11 years with a physician diagnosis of asthma for 1 year and without gastroesophageal reflux or sleep apnea completed the childhood Asthma Control Test (ACT) and a novel 41-item questionnaire at routine clinic visits. 19 additional items were abstracted from medical record data. Questions measured nocturnal symptoms with and without awakening over the past 6 months, asthma severity, treatment, allergy, and demographics. RESULTS: Of the 109 children, 72% were male, 69% were Caucasian, 38% had Medicaid, and 69% were atopic. Asthma severity was assessed as intermittent 16%, or persistent 84% (mild 24%, moderate 55%, severe 5%). The mean ACT score was 19 (SD56). In the past 6 months, 65% reported awakening at night because of asthma and 52% reported wheeze while sleeping (19% of this group reported solely wheeze without awakening). An IgE level within normal range was associated with continuation of sleep during wheeze (p50.046). Subjects who solely wheezed without awakening did not differ from subjects who wheezed with awakening by demographics, skin test positivity, smoke or pet exposure, hospitalization or prednisone use in the past 6 months, allergy medication use, asthma controller therapy, ACT score, or asthma severity. CONCLUSIONS: Children with asthma exhibit a variety of nocturnal symptoms including wheezing without awakening. Further investigation into the clinical implications of these symptoms may impact asthma treatment and control.
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Mannitol and Methacholine Tests to Identify EIB & Asthma in Children with Symptoms but no Definite Diagnosis: A Phase 3 study S. D. Anderson1, D. S. Pearlman2, J. M. Weiler3, C. P. Perry4, B. Charlton5; 1Royal Prince Alfred Hospital, Camperdown, AUSTRALIA, 2 Colorado Allergy and Asthma Centers, Denver, CO, 3CompleWare Corporation, Iowa City, IA, 4Royal Prince Alfred Hospital, Camperdown NSW, AUSTRALIA, 5Pharmaxis Ltd, Frenchs Forest NSW, AUSTRALIA. RATIONALE: Exercise (Exc) & methacholine (Mech) are used to identify bronchial hyperresponsiveness (BHR) consistent with a diagnosis of exercise-induced bronchoconstriction (EIB) & asthma. Mannitol powder (Mann) is a new test for BHR. METHODS: Patients with signs & symptoms of asthma but without a definite respiratory physician diagnosis (PhysDx). The mannitol kit (AridolTM) has 9 dose steps 0,5,10,20,40,80,160,160,160 mg: FEV1 is measured 60s after each dose. We investigated the sensitivity & specificity of Mech (PC20 16 mg/ml) & Mann (PD15 635 mg or a 10% fall in FEV1 between doses) to identify EIB, (10% fall in FEV1) & a PhysDx of asthma based on history, examination, spirometry, skin tests, FEV1%reversibility & two exercise tests. RESULTS: Ninety-six children, median: NAEPPII score 1, 14 yr, 158 cm, 55 Kg, FEV1 92% predicted. Fifty children were Exc+ve (34+ve 1st test & 39+ve 2nd test). Mean maximum % fall FEV1 20.7%610.7, 49 were Mann+ve (Mean %fall FEV1 15.8%67) and 56 were Mech+ve (Mean %fall FEV1 26.9%66). Agreement for Ex/Mann/Mech was 39.6%, & Mann/Mech 53.7%. The sensitivity/specificity of Mann & Mech to identify Exc+ve was 60.1%/58.5% & 70.0%/54.5% respectively; to identify PhysDx+ve asthma it was 63.2%/81.4% & 66.2%/62.9% for Mann & Mech. CONCLUSION: Mannitol & methacholine were equivalent for identifying EIB and a PhysDx of asthma in children with mild symptoms of asthma without a definite diagnosis. Mannitol and methacholine were more sensitive than one exercise test to detect BHR. The %fall in FEV1 was less after mannitol and specificity for a PhysDx diagnosis was higher compared with methacholine.
SATURDAY
Abstracts AB3
J ALLERGY CLIN IMMUNOL VOLUME 125, NUMBER 2