Asthma guidelines recommend early home treatment of exacerbations. However, home treatment is often suboptimal and delayed.
To describe antecedent symptoms and signs of asthma exacerbations noticed by parents, and learn when and how parents intensify asthma treatment.
Parents of children 2-12 years old with asthma exacerbations requiring urgent care in the past 12 months completed telephone questionnaires. For some questions, multiple responses were possible and percentages for the frequency of responses may sum to more than 100%.
One hundred and one parents were enrolled and interviewed; 94% were the children's mothers. 70% of the children were African American and 64% had Medicaid insurance. Parents reported multiple antecedent symptoms and signs (median number per child = 3, range 1-6). These included respiratory symptoms (79%), allergy/cold symptoms (43%), behavioral changes (24%), and other non-specific symptoms (29%). Twenty-three parents reported late respiratory symptoms such as gasping for breath, and using accessory muscles to breath as the earliest antecedent signs. Treatment was most often intensified when the parent noticed cough (55%), shortness of breath (54%), and wheeze (25%), and included adding albuterol (92%), oral corticosteroid (17%), inhaled corticosteroid (8%) or other non-asthma medications (16%).
Although parents described antecedent symptoms and signs of impending asthma exacerbations they consistently noticed in their children, many waited for lower respiratory signs to be present before intensifying treatment. Oral corticosteroids were used infrequently. Interventions to improve the ability of parents and children to accurately recognize worsening symptoms and initiate timely, effective treatment are needed.
Childhood asthma; asthma exacerbation
Ectodermal dysplasia (ED) syndromes are a diverse group of disorders that affect multiple ectodermally derived tissues. Small studies and case reports suggest an increase in atopy and primary immunodeficiencies (PIDs) among patients with ED syndromes.
To determine the prevalence of clinical symptoms suggestive of atopy or immunodeficiency among a large cohort of children with ED syndromes.
A 9-page questionnaire was mailed to families who were members of the National Foundation for Ectodermal Dysplasias. The surveys were completed by parents of children younger than 18 years with a diagnosis of an ED syndrome or carrier state. Portions of the questionnaire were adapted from previously validated questionnaires developed by the International Study of Asthma and Allergies in Childhood (ISAAC).
We received 347 completed questionnaires (41%). When compared with the 13- to 14-year-old children surveyed by ISAAC, we found both all-aged and age-matched children with ED syndromes, respectively, had significantly higher rates of asthma (32.2% and 37.2% vs 16.4%), rhinitis symptoms (76.1% and 78.3% vs 38.9%), and eczema (58.9% and 48.9% vs 8.2%). The prevalence of physician-diagnosed food allergies (20.7%) and PIDs (6.1%) in these ED patients also exceeded known rates in the general pediatric population.
This large-scale, retrospective study demonstrates a greater reported prevalence of symptoms suggestive of atopic disorders and PIDs among children with ED syndromes than the general pediatric population. A combination of genetic and environmental factors in ED syndromes may contribute to breaches of skin and mucosal barriers, permitting enhanced transmission and sensitization to irritants, allergens, and pathogens.
Little is known about factors associated with systemic corticosteroid (SC) use in emergency department (ED) patients with acute asthma.
To determine the patient and system factors associated with delayed use or nonuse of SCs in the ED.
We analyzed the asthma component of the National Emergency Department Safety Study. Patients with acute asthma in 62 urban EDs in 23 US states between 2003 and 2006 were identified. The primary outcome measure was the pattern of SC use in the ED, which was categorized as timely use (≤60 minutes), delayed use (>60 minutes), or nonuse. Multinomial logistic regression was performed to identify factors associated with delayed use or nonuse of SCs.
A total of 2,559 of 3,798 patients with acute asthma (67.4%) received SCs. Of these, the median door-to-SC time was 62 minutes (interquartile range, 35–100 minutes), with 1,319 patients (51.5%) having delayed SC treatment. Nonuse of SCs was largely explained by markers of asthma exacerbations (never intubated for asthma, lower respiratory rate, and higher oxygen saturation). In contrast, in addition to these factors, delayed SC treatment was associated with age of 40 years or older, female sex, longer duration of symptoms, ED presentation between 8 AM and 11:59 PM, and ED with a longer average patient wait time.
Physicians in the ED seem to appropriately administer SCs to higher-acuity asthmatic patients; however, the additional nonmedical factors represent opportunities to improve the timeliness of SC treatment in the ED.
Asthma severity score; acute asthma exacerbation; asthma assessment
Small proline rich protein 2B (SPRR2B) is a skin and lung epithelial protein associated with allergic inflammation in mice that has not been evaluated in human atopic diseases.
To determine whether single-nucleotide polymorphisms (SNPs) in SPRR2B are associated with childhood eczema and with the phenotype of childhood eczema combined with asthma.
Genotyping for SPRR2B and filaggrin (FLG) was performed in 2 independent populations: the Cincinnati Childhood Allergy & Air Pollution Study (CCAAPS; N = 762; birth-age, 4 years) and the Greater Cincinnati Pediatric Clinical Repository (GCPCR;N = 1152; ages 5–10 years). Eczema and eczema plus asthma were clinical outcomes based on parental report and clinician’s diagnosis. Genetic analyses were restricted to whites and adjusted for sex in both cohorts and adjusted for environmental covariates in CCAAPS.
Variants in SPRR2B were not significantly associated with eczema in either cohort after Bonferroni adjustment. Children from both cohorts with the CC genotype of the SPRR2B rs6693927 SNP were at 4 times the risk for eczema plus asthma (adjusted odds ratio, 4.1; 95% confidence interval, 1.5– 10.9; P = .005 in CCAAPS; and adjusted odds ratio, 4.0; 95% confidence interval, 1.8 –9.1; P <.001 in the GCPCR), however. SNPs in SPRR2B were not in strong linkage disequilibrium with the R501X and del2282 FLG mutations, and these findings were independent of FLG.
An SNP in SPRR2B was predictive of asthma among white children with eczema from 2 independent populations. SPRR2B polymorphisms may serve as important predictive markers for the combined eczema plus asthma phenotype.
The incidence of wheeze is unknown and the role of early life wheeze in subsequent health is not clearly understood. Our goal was to calculate the age-specific incidence of wheeze and determine whether wheezing at particular times in early life was predictive of abnormal airway hyperresponsiveness (AHR), percent predicted FEV1 and current asthma at age 6 years.
Using data from a birth cohort study with annual report of wheezing (Childhood Allergy Study) and spirometry and methacholine challenge at age 6 years, the age-specific incidence of wheeze was determined using Kaplan-Meier estimates. Logistic and linear regression models were used to assess the associations between the presence of age-specific wheezing and the outcomes of current asthma, AHR and percent predicted FEV1 at age 6 years.
The 6-year cumulative incidence of wheezing was higher for boys (66.2%, 95% CI 59.8%, 72.6%) than girls (47.6% 95% CI 41.4%, 53.8%). There was no age when wheezing was more strongly associated with either AHR or percent predicted FEV1 at 6 years. Only wheeze in the fifth year among males and in females, both wheezing in the fourth and fifth years were positively predictive of current asthma at age 6. This is likely due to the definition of current asthma (ever doctor diagnosis and either medication or symptoms in last year). Eczema, parental asthma history and total cord blood IgE did not affect these associations.
Wheezing at any particular time in early life may not be predictive of early childhood lung function.
ACT; C-ACT; Hispanic; Spirometry
exhaled nitric oxide; FENO; exhaled breath condensate; cysteinyl leukotrienes; asthma; lung function; exacerbation; hospitalization
Studies looking at use of repeated doses of epinephrine in anaphylaxis are limited.
To determine which patients are most likely to receive repeated doses of epinephrine during anaphylaxis management.
A population-based study, with medical record review was conducted. All patients seen during the study period who met criteria for diagnosis of anaphylaxis were included.
The cohort included 208 patients (55.8% female). Anaphylaxis treatment included epinephrine in 104(50%) cases. Repeated doses were used in 27(13.0%) patients (48.1% female). The median age of those who received repeated doses was 18.9 years (IQR 10-34) versus 31.1 years (IQR 15-41), p=0.065 for those who did not. The inciting agents were food (29.6%), insects (11.1%), medications (22.2%), others (7.4%) and unknown (29.6%). Patients who received repeated doses were more likely to have wheezing (p=0.028), cyanosis (p=0.001), hypotension and shock (p=0.032), stridor and laryngeal edema (p=0.007), nausea and emesis (p=0.043), arrhythmias (p<0.01) and cough and less likely to have urticaria (p=0.049). They were more likely to be admitted to hospital (48.2% vs 15.6%, p=0.0007). There was no significant difference in history of asthma between patients who received repeated doses and those who did not (p=0.168).
Thirteen percent of patients received repeated doses of epinephrine. Patients were younger and were more likely to present with wheezing, cyanosis, arrhythmias, hypotension and shock, stridor, laryngeal edema, cough, nausea, and emesis, and less likely to have urticaria. History of asthma did not predict use of repeated doses of epinephrine. Our results help identify high risk patients who may benefit from carrying more than one dose of epinephrine.
Sensitivity to mold has been associated with asthma incidence, persistence, and severity.
To examine the relationship between skin test reactivity (STR) to molds and specifically to Alternaria and asthma severity in a group of ethnically diverse children in Connecticut.
Demographics and STR to 14 local allergens, including Alternaria, Penicillium, and mold mix, were obtained for 914 Puerto Rican, African American, and non-Hispanic white children.
A total of 126 children (14%) had a positive skin test result to mold, and 58 (6%) demonstrated STR to Alternaria. Compared with non-Hispanic white children, there was no difference in the likelihood of being sensitized to Alternaria for Puerto Rican and African American children (odds ratio [OR], 0.7; 95% confidence interval [CI], 0.3–1.5; and OR, 0.9; 95% CI, 0.4–2.2; respectively). In an adjusted analysis, Alternaria STR was associated with severe, persistent asthma (OR, 3.4; 95% CI, 1.2–8.6) but did not predict increasing asthma severity. STR to cat (OR, 2.5; 95% CI, 1.3–4.9) and dog (OR, 2.9; 95% CI, 1.3–6.0) was also associated with severe persistent asthma. Alternaria STR was associated with severe persistent asthma independent of the total number of positive skin test results.
Mold and Alternaria STR were uncommon among children in Connecticut. Alternaria STR was not associated with increasing asthma severity but was associated with severe, persistent asthma independent of the total number of positive skin test results. There was no association between ethnicity and Alternaria STR.
Asthma is a significant disease among children, and its prevalence has increased notably during the last 2 decades. A traditional Korean medicine, So-Cheong-Ryong-Tang (SCRT), has been used for the treatment of asthma in Asia for centuries, but its mechanism for reducing bronchopulmonary inflammation in asthma has yet to be elucidated.
To investigate whether the herbal extract SCRT inhibits inflammation in a mouse model of cockroach allergen–induced asthma.
A house dust extract containing endotoxin and cockroach allergens was used for immunization and 2 additional pulmonary challenges in BALB/c mice. Mice were treated with SCRT or vehicle 1 hour before each pulmonary challenge. Respiratory parameters were evaluated by whole-body plethysmography and forced oscillation methods 24 hours after the last challenge. Bronchoalveolar lavage (BAL) fluid was collected, and histologic sections of lung were prepared either 4 or 24 hours after the last house dust extract challenge.
SCRT treatment significantly reduced the hyperreactivity of the airways as measured by whole-body plethysmography and direct measurement of airway resistance. Inflammation was significantly inhibited by SCRT treatment as demonstrated by reduced plasma IgE levels and improved pulmonary histologic characteristics. SCRT significantly reduced the number of neutrophils in the BAL fluid and also significantly reduced the BAL levels of CXC chemokines, providing a potential mechanism for the reduced inflammation. In a similar fashion, SCRT reduced eosinophil recruitment and BAL levels of eotaxin and RANTES.
These data indicate that SCRT treatment alleviates asthma-like pulmonary inflammation via suppression of specific chemokines.
The fractional concentration of exhaled nitric oxide (FeNO) is a noninvasive marker for airway inflammation but requires further study in pre-school children to determine its clinical relevance.
To determine whether the risk of respiratory tract illnesses (RTI), disease burden and atopic features are related to FeNO in preschool children with moderate-to-severe intermittent wheezing.
We determined FeNO using the off-line tidal breathing technique in 89 children, 12–59 months old, with moderate-severe intermittent wheezing. Risk of RTI was determined by comparing participants with baseline FeNO >75th percentile (24.4ppb) to those with FeNO ≤75th percentile using Cox regression analysis.
The risk of RTI was significantly higher in children with FeNO >24.4ppb relative to those with lower FeNO values (adjusted RR= 3.8, 95% CI: 1.74–8.22; p=0.0008). FeNO levels >24ppb were associated with a greater number of positive skin tests to aeroallergens (p=0.03), but not with other atopic characteristics or historic parameters of illness burden.
Elevated FeNO in preschool children with moderate-to-severe intermittent wheezing was associated with an increased risk of RTI during a one-year follow-up. In addition, higher FeNO was associated with aeroallergen sensitization.
Preschool children; exhaled nitric oxide; respiratory tract illness; wheezing
urticaria; autoimmunity; thyroid antibodies; antinuclear antibodies
Food Allergy; Epinephrine; Anaphylaxis; Emergency Department; Admission
Exposure to traffic-related air pollutants, including polycyclic aromatic hydrocarbons (PAHs), can induce asthma. However, the effects of early repeated PAH exposure over time on different asthma phenotypes have not been examined.
To assess associations between repeated PAH exposure, measured from prenatal personal and residential indoor monitors in children's homes, and asthma in an inner-city cohort.
Prenatal exposure was assessed by personal air monitoring during 48 hours and exposure at 5 to 6 years of age by 2-week residential monitoring in the Columbia Center for Children's Environmental Health cohort. PAH was dichotomized into pyrene (representative semivolatile PAH) and the sum of 8 nonvolatile PAHs. High exposure to each was defined as measures above the median at both repeated time points. Asthma and wheeze were determined by validated questionnaires at ages 5 to 6 years. Children with specific IgE levels greater than 0.35 IU/mL to any of 5 indoor allergens were considered seroatopic.
Among all 354 children, repeated high exposure to pyrene was associated with asthma (odds ratio [OR], 1.90; 95% confidence interval [CI], 1.13-3.20). Among 242 nonatopic children, but not those sensitized to indoor allergens (n = 87) or with elevated total IgE levels (n = 171), high pyrene levels were associated positively with asthma (OR, 2.89; 95% CI, 1.77-5.69), asthma medication use (OR, 2.28; 95% CI, 1.13-4.59), and emergency department visits for asthma (OR, 2.43; 95% CI, 1.20-4.91). Associations between the levels of the 8 nonvolatile PAHs and asthma were not observed, even when stratifying by seroatopy.
Nonatopic children may be more susceptible to the respiratory consequences of early pyrene exposures.