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Spirometry remains an unfulfilled right for children with asthma
Vol. 166, No. 5 May 2015 asthma symptom and spirometry in childhood has been documented.2 There is little evidence that addition of biomarkers and spirometry to validate symptom score improves asthma control.3 From Schifano et al we can infer that a substantial number of children with mild asthma should be treated with inhaled steroids based on a spirometry-determined severity. Conversely, we believe that this is a deleterious consequence of the customary use of spirometry. The majority of children have mild asthma, with a good long-term prognosis.4 In mild asthma, spirometric abnormalities are infrequent, with a risk of serious asthma exacerbations identical to that of children with normal spirometry.5 Strunk et al demonstrated that the clinical improvement in the control of asthma achieved during 4-6 years of continuous treatment with budesonide does not persist after treatment is discontinued; conversely, a significant height reduction persists.6 Therefore, we should be careful when prescribing treatments based only on spirometric criteria in patients who are clinically well. In our experience, the limitation of treatment to clinically-determined persistent asthma led to an important reduction of inhaled corticosteroid prescription without any increase in reliever drug use.7 Finally, we should not forget that therapy directed by spirometry removes any meaning to self-management, which is essentially based on a careful evaluation of symptom scores.
Cristina Bibalo, MD Giorgio Longo, MD University of Trieste Alessandro Ventura, MD University of Trieste Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste, Italy
7. Berti I, Longo G, Visintin S. Treatment of mild asthma. N Engl J Med 2005;353:424-7. author reply 424-7.
Reply To the Editor: We appreciate the comments by Bibalo et al regarding the use of spirometry in children with asthma. Our sample population is not representative of the general population but is representative of a low-income, publicly-insured, underserved, minority population, a group with high asthma morbidity. For this population, spirometry abnormalities were common and are consistent with poorer outcomes. What is not known, however, is whether these abnormalities are reversible with therapy. Use of inhaled corticosteroids, however, has clearly been shown to increase the number of symptom-free days in children with persistent disease. Thus, we concur with the current National Asthma Education and Prevention Program Expert Panel Report 3 (NAEPP-EPR-3) recommendation that the risk of a small decrease in height (approximately 0.9 cm in total) is balanced by the benefits of inhaled corticosteroids for children with persistent asthma, and that spirometry plays an important part in asthma management in children. Michelle M. Cloutier, MD Jessica P. Hollenbach, PhD Department of Pediatrics University of Connecticut Health Center Children’s Center for Community Research Connecticut Children’s Medical Center Hartford, Connecticut http://dx.doi.org/10.1016/j.jpeds.2015.01.035
Spirometry remains an unfulfilled right for children with asthma
http://dx.doi.org/10.1016/j.jpeds.2015.01.029
References 1. Schifano ED, Hollenbach JP, Cloutier MM. Mismatch between asthma symptoms and spirometry: implications for managing asthma in children. J Pediatr 2014;165:997-1002. 2. Bacharier LB, Strunk RC, Mauger D, White D, Lemanske RF Jr, Sorkness CA. Classifying asthma severity in children mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med 2004;170:426-32. 3. Turner S, Paton J, Higgins B, Douglas G. British guidelines on the management of asthma: what’s new for 2011? Thorax 2011;66:1104-5. 4. Tai A, Tran H, Roberts M, Clarke N, Gibson AM, Vidmar S, et al. Outcomes of childhood asthma to the age of 50 years. J Allergy Clin Immunol 2014;133:1572-8.e3. 5. Fuhlbrigge AL, Weiss ST, Kuntz KM, Paltiel AD, CAMP Research Group. Forced expiratory volume in 1 second percentage improves the classification of severity among children with asthma. Pediatrics 2006;118:e347-55. 6. Strunk RC, Sternberg AL, Szefler SJ, Zeiger RS, Bender B, Tonascia J, Childhood Asthma Management Program (CAMP) Research Group. Long-term budesonide or nedocromil treatment, once discontinued, does not alter the course of mild to moderate asthma in children and adolescents. J Pediatr 2009;154:682-7.
To the Editor: Spirometry testing continues to be underused even though, when appropriately used, its effectiveness is widely documented, and expert panel reports stress its utilization as part of asthma care. Schifano et al readdress the importance of spirometry and its implications in managing asthma in children.1 There are 2 main findings and implications from their work. The first relates to the role of pediatricians in diagnosing and monitoring childhood asthma appropriately, and the second has to do with the essential value of spirometry in defining asthma severity. Although the measurement of lung function should lead to more rational treatment and should, therefore, be of practical value, we have previously found that only 30% of Italian children with asthma are referred by their pediatrician/general practitioner to specialists for spirometry.2 This increases to 35% in severe cases of asthma (defined as frequent users of asthma medications). Furthermore, it has been reported that females have a lower level of asthma control in adulthood,3 yet females, independently of disease severity, are referred for spirometry less than males, with a 1325
THE JOURNAL OF PEDIATRICS
www.jpeds.com
ratio of 1 to 2.2 Moreover, only one-half of the children hospitalized for asthma underwent spirometry and/or a pulmonologist visit as a follow-up during the 12 months after hospitalization.4 In conclusion, given that spirometry would be an essential health care intervention affecting 10% of school-aged children, the planning and supporting (eg, by health stakeholders, scientific societies, patient associations) of continuous, systematic educational initiatives to encourage the use of spirometry with professional interpretation in the pediatric primary care setting should be urgently prioritized.
Marina Bianchi, MD, PhD Antonio Clavenna, MD, IRCCS Maurizio Bonati, MD, IRCCS Department of Public Health Laboratory for Mother and Child Health IRCCS Mario Negri Pharmacological Research Institute Milan, Italy
Vol. 166, No. 5 3. Temprano J, Mannino DM. The effect of sex on asthma control from the National Asthma Survey. J Allergy Clin Immunol 2009;123: 854-60. 4. Bianchi M, Clavenna A, Sequi M, Bortolotti A, Fortino I, Merlino L, et al. Childhood asthma management pre- and post-incident asthma hospitalization. PLoS One 2013;8:e76439.
Reply To the Editor: We agree with Bianchi et al that spirometry is underused, especially by primary case clinicians, but we also think that smaller practices may not have a sufficient number of children with asthma to warrant the training and costs associated with in-practice testing. For these practices, a readily available and accessible testing site is needed. We hope that our report contributes to the increasing evidence for the important role of spirometry in managing asthma in children by primary care clinicians.
http://dx.doi.org/10.1016/j.jpeds.2015.01.043
References 1. Schifano ED, Hollenbach JP, Cloutier MM. Mismatch between asthma symptoms and spirometry: implications for managing asthma in children. J Pediatr 2014;165:997-1002. 2. Bianchi M, Clavenna A, Sequi M, Bortolotti A, Fortino I, Merlino L, et al. Spirometry testing in a population of Italian children: age and gender differences. Respir Med 2012;106:1383-8.
1326
Michelle M. Cloutier, MD Jessica P. Hollenbach, PhD Department of Pediatrics Asthma Center and Easy Breathing University of Connecticut Health Center Connecticut Children’s Medical Center Hartford, Connecticut http://dx.doi.org/10.1016/j.jpeds.2015.01.046
Cristina Bibalo, MD Giorgio Longo, MD University of Trieste Alessandro Ventura, MD University of Trieste Institute for Maternal and Child Health IRCCS Burlo Garofolo Trieste, Italy
7. Berti I, Longo G, Visintin S. Treatment of mild asthma. N Engl J Med 2005;353:424-7. author reply 424-7.
Reply To the Editor: We appreciate the comments by Bibalo et al regarding the use of spirometry in children with asthma. Our sample population is not representative of the general population but is representative of a low-income, publicly-insured, underserved, minority population, a group with high asthma morbidity. For this population, spirometry abnormalities were common and are consistent with poorer outcomes. What is not known, however, is whether these abnormalities are reversible with therapy. Use of inhaled corticosteroids, however, has clearly been shown to increase the number of symptom-free days in children with persistent disease. Thus, we concur with the current National Asthma Education and Prevention Program Expert Panel Report 3 (NAEPP-EPR-3) recommendation that the risk of a small decrease in height (approximately 0.9 cm in total) is balanced by the benefits of inhaled corticosteroids for children with persistent asthma, and that spirometry plays an important part in asthma management in children. Michelle M. Cloutier, MD Jessica P. Hollenbach, PhD Department of Pediatrics University of Connecticut Health Center Children’s Center for Community Research Connecticut Children’s Medical Center Hartford, Connecticut http://dx.doi.org/10.1016/j.jpeds.2015.01.035
Spirometry remains an unfulfilled right for children with asthma
http://dx.doi.org/10.1016/j.jpeds.2015.01.029
References 1. Schifano ED, Hollenbach JP, Cloutier MM. Mismatch between asthma symptoms and spirometry: implications for managing asthma in children. J Pediatr 2014;165:997-1002. 2. Bacharier LB, Strunk RC, Mauger D, White D, Lemanske RF Jr, Sorkness CA. Classifying asthma severity in children mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med 2004;170:426-32. 3. Turner S, Paton J, Higgins B, Douglas G. British guidelines on the management of asthma: what’s new for 2011? Thorax 2011;66:1104-5. 4. Tai A, Tran H, Roberts M, Clarke N, Gibson AM, Vidmar S, et al. Outcomes of childhood asthma to the age of 50 years. J Allergy Clin Immunol 2014;133:1572-8.e3. 5. Fuhlbrigge AL, Weiss ST, Kuntz KM, Paltiel AD, CAMP Research Group. Forced expiratory volume in 1 second percentage improves the classification of severity among children with asthma. Pediatrics 2006;118:e347-55. 6. Strunk RC, Sternberg AL, Szefler SJ, Zeiger RS, Bender B, Tonascia J, Childhood Asthma Management Program (CAMP) Research Group. Long-term budesonide or nedocromil treatment, once discontinued, does not alter the course of mild to moderate asthma in children and adolescents. J Pediatr 2009;154:682-7.
To the Editor: Spirometry testing continues to be underused even though, when appropriately used, its effectiveness is widely documented, and expert panel reports stress its utilization as part of asthma care. Schifano et al readdress the importance of spirometry and its implications in managing asthma in children.1 There are 2 main findings and implications from their work. The first relates to the role of pediatricians in diagnosing and monitoring childhood asthma appropriately, and the second has to do with the essential value of spirometry in defining asthma severity. Although the measurement of lung function should lead to more rational treatment and should, therefore, be of practical value, we have previously found that only 30% of Italian children with asthma are referred by their pediatrician/general practitioner to specialists for spirometry.2 This increases to 35% in severe cases of asthma (defined as frequent users of asthma medications). Furthermore, it has been reported that females have a lower level of asthma control in adulthood,3 yet females, independently of disease severity, are referred for spirometry less than males, with a 1325
THE JOURNAL OF PEDIATRICS
www.jpeds.com
ratio of 1 to 2.2 Moreover, only one-half of the children hospitalized for asthma underwent spirometry and/or a pulmonologist visit as a follow-up during the 12 months after hospitalization.4 In conclusion, given that spirometry would be an essential health care intervention affecting 10% of school-aged children, the planning and supporting (eg, by health stakeholders, scientific societies, patient associations) of continuous, systematic educational initiatives to encourage the use of spirometry with professional interpretation in the pediatric primary care setting should be urgently prioritized.
Marina Bianchi, MD, PhD Antonio Clavenna, MD, IRCCS Maurizio Bonati, MD, IRCCS Department of Public Health Laboratory for Mother and Child Health IRCCS Mario Negri Pharmacological Research Institute Milan, Italy
Vol. 166, No. 5 3. Temprano J, Mannino DM. The effect of sex on asthma control from the National Asthma Survey. J Allergy Clin Immunol 2009;123: 854-60. 4. Bianchi M, Clavenna A, Sequi M, Bortolotti A, Fortino I, Merlino L, et al. Childhood asthma management pre- and post-incident asthma hospitalization. PLoS One 2013;8:e76439.
Reply To the Editor: We agree with Bianchi et al that spirometry is underused, especially by primary case clinicians, but we also think that smaller practices may not have a sufficient number of children with asthma to warrant the training and costs associated with in-practice testing. For these practices, a readily available and accessible testing site is needed. We hope that our report contributes to the increasing evidence for the important role of spirometry in managing asthma in children by primary care clinicians.
http://dx.doi.org/10.1016/j.jpeds.2015.01.043
References 1. Schifano ED, Hollenbach JP, Cloutier MM. Mismatch between asthma symptoms and spirometry: implications for managing asthma in children. J Pediatr 2014;165:997-1002. 2. Bianchi M, Clavenna A, Sequi M, Bortolotti A, Fortino I, Merlino L, et al. Spirometry testing in a population of Italian children: age and gender differences. Respir Med 2012;106:1383-8.
1326
Michelle M. Cloutier, MD Jessica P. Hollenbach, PhD Department of Pediatrics Asthma Center and Easy Breathing University of Connecticut Health Center Connecticut Children’s Medical Center Hartford, Connecticut http://dx.doi.org/10.1016/j.jpeds.2015.01.046