Electronic monitoring of symptoms and lung function to assess asthma control in children.

BACKGROUND: Asthma remains poorly controlled in children. Home monitoring of asthma control may help to improve the level of asthma control. OBJECTIVES: To compare 2 methods to assess asthma control: (1) prospective home monitoring, based on daily assessment of forced expiratory volume in 1 second (FEV1) and electronic symptom score, and (2) Asthma Control Questionnaire (ACQ) with retrospective assessment of symptoms and FEV1. METHODS: Ninety-six children with asthma were prospectively followed up during 1 year. Asthma control was assessed by home monitoring, including an electronic symptom score based on Global Initiative for Asthma (GINA) criteria and FEV1 measurements. In the hospital, the ACQ was completed and FEV1 was measured. Kappa analysis was performed to assess levels of agreement between the 2 methods. RESULTS: Agreement between the 2 methods was low (κ coefficient of 0.393). In 29 children (37%), prospective home monitoring was less optimistic than the retrospective assessment of asthma control by the ACQ. CONCLUSION: This study found low agreement between asthma control based on GINA criteria by means of prospective home monitoring and the hospital ACQ. The prospective home monitor detected more cases of less well-controlled asthma than the ACQ. However, optimization of adherence to home monitor use is necessary. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01239238.

Feasibility of a new method to collect exhaled breath condensate in pre-school children.

Exhaled breath condensate (EBC) is a promising non-invasive method to assess respiratory inflammation in adults and children with lung disease. Especially in pre-school children, condensate collection is hampered by long sampling times because of open-ended collection systems. We aimed to assess the feasibility of condensate collection in pre-school children using a closed glass condenser with breath recirculation system, which also collects the residual non-condensed exhaled breath, and subsequently recirculates it back into the condenser. Condensate was collected before and after breath recirculation in 70 non-sedated pre-school children with and without recurrent wheeze. Cytokines (IL-4, IL-5, IL-6, IL-8, IL-10, IL-12p70, IL-13, TNF-α) were measured in 50 µl samples using ultrasensitive multiplexed liquid bead array. The success rate of condensate collection increased from 64% (without recirculation) to 83% (after breath recirculation), and mean condensate volume from 214 to 465 µl respectively. Detection of cytokines was successful in 95-100% of samples. Cytokine concentrations before and after breath recirculation were not different (p > 0.232). In asthmatic children, only TNF-α concentrations were significantly decreased, compared to non-asthmatics. In pre-school children, the collection of EBC is feasible using a new closed glass condenser with breath recirculation system. This new method may help to assess - non-invasively - cytokine profiles in asthmatic and non-asthmatic pre-school children.

Longitudinal Relationships between Asthma-Specific Quality of Life and Asthma Control in Children; The Influence of Chronic Rhinitis.

Abstract: Managing pediatric asthma includes optimizing both asthma control and asthma-specific quality of life (QoL). However, it is unclear to what extent asthma-specific QoL is related to asthma control or other clinical characteristics over time. The aims of this study were to assess in children longitudinally: (1) the association between asthma control and asthma-specific QoL and (2) the relationship between clinical characteristics and asthma-specific QoL. In a 12-month prospective study, asthma-specific QoL, asthma control, dynamic lung function indices, fractional exhaled nitric oxide, the occurrence of exacerbations, and the use of rescue medication were assessed every 2 months. Associations between the clinical characteristics and asthma-specific QoL were analyzed using linear mixed models. At baseline, the QoL symptom score was worse in children with asthma and concomitant chronic rhinitis compared to asthmatic children without chronic rhinitis. An improvement of asthma control was longitudinally associated with an increase in asthma-specific QoL (p-value < 0.01). An increased use of ß2-agonists, the occurrence of wheezing episodes in the year before the study, the occurrence of an asthma exacerbation in the 2 months prior to a clinical visit, and a deterioration of lung function correlated significantly with a decrease in the Pediatric Asthma Quality of Life Questionnaire (PAQLQ) total score (p-values ≤ 0.01). Chronic rhinitis did not correlate with changes in the PAQLQ score over 1 year. The conclusion was that asthma control and asthma-specific QoL were longitudinally associated, but were not mutually interchangeable. The presence of chronic rhinitis at baseline did influence QoL symptom scores. ß2-agonist use and exacerbations before and during the study were inversely related to the asthma-specific QoL over time.

Actual asthma control in a paediatric outpatient clinic population: do patients perceive their actual level of control?

Several epidemiological studies described poor asthma control in children. However, the diagnosis of childhood asthma in these studies is uncertain, and asthma control in children of an outpatient clinic population during treatment by a paediatrician is unknown. (1) to investigate the hypothesis that asthma control in a paediatric outpatient clinic population is better than epidemiological surveys suggest; (2) to find possible explanations for suboptimal asthma control. Asthmatic children aged 6-16 years, known for at least 6 months by a paediatrician at the outpatient clinic, were selected. During a normal visit, both the responsible physicians and parent/children completed a standardised questionnaire about asthma symptoms, limitation of daily activities, treatment, asthma attacks and emergency visits. Overall, excellent asthma control of 8.0% in this study was not significantly better than of 5.8% in the European AIR study (Chi-square, p = 0.24). Separate GINA goals like minimal chronic symptoms and no limitation of activities were better met in our study. Good to excellent controlled asthma was perceived by most children/parents (83%), but was less frequently indicated by the paediatrician (73%), or by objective criteria of control (45%) (chi-square, p = 0.0001). The agreement between patient-perceived and doctor assessed control was low, but improved in poorly controlled children. Patients were not able to perceive the difference between 'excellent asthma control' and 'good control' (p = 0.881).Too little children with uncontrolled disease got step-up of their asthma treatment. Although separate GINA goals like 'minimal chronic symptoms' and 'no limitation of activities' were significantly better in our study, overall, asthma control in this outpatient clinic population, treated by a paediatrician, was not significantly better than in the European AIR study. Poorly controlled disease was related to several aspects of asthma management, which are potentially accessible for improvements.

Free radicals in exhaled breath condensate in cystic fibrosis and healthy subjects.

Many markers of airway inflammation and oxidative stress can be measured non-invasively in exhaled breath condensate (EBC). However, no attempt has been made to directly detect free radicals using electron paramagnetic resonance (EPR) spectroscopy. Condensate was collected in 14 children with cystic fibrosis (CF) and seven healthy subjects. Free radicals were trapped by 5,5-dimethyl-1-pyrroline-N-oxide. EPR spectra were recorded using a Bruker EMX spectrometer. Secondly, to study the source of oxygen centered radical formation, catalase or hydrogen peroxide was added to the condensate. Radicals were detected in 18 out of 21 condensate samples. Analysis of spectra indicated that both oxygen and carbon centered radicals were trapped. Within-subject reproducibility was good in all but one subject. Quantitatively, there was a trend towards higher maximal peak heights of both oxygen and carbon centered radicals in the children with CF. Catalase completely suppressed the signals in condensate. Addition of hydrogen peroxide resulted in increased radical signal intensity. Detection of free radicals in EBC of children with CF and healthy subjects is feasible using EPR spectroscopy.

[A girl with bilateral periorbital edema]. / Een meisje met bilateraal periorbitaal oedeem.

An 11-year-old girl was seen with painless, bilateral periorbital edema, that had appeared a week before presentation. Additional symptoms included fever, headache and malaise. Serological tests performed three days later showed an active Epstein-Barr virus infection, which provided the diagnosis 'Pfeiffer's disease'. Bilateral periorbital edema can be the presenting manifestation of Epstein-Barr virus infection and should therefore be included in its differential diagnosis.

Prediction of asthma exacerbations in children by innovative exhaled inflammatory markers: results of a longitudinal study.

BACKGROUND: In asthma management guidelines the primary goal of treatment is asthma control. To date, asthma control, guided by symptoms and lung function, is not optimal in many children and adults. Direct monitoring of airway inflammation in exhaled breath may improve asthma control and reduce the number of exacerbations. AIM: 1) To study the use of fractional exhaled nitric oxide (FeNO) and inflammatory markers in exhaled breath condensate (EBC), in the prediction of asthma exacerbations in a pediatric population. 2) To study the predictive power of these exhaled inflammatory markers combined with clinical parameters. METHODS: 96 asthmatic children were included in this one-year prospective observational study, with clinical visits every 2 months. Between visits, daily symptom scores and lung function were recorded using a home monitor. During clinical visits, asthma control and FeNO were assessed. Furthermore, lung function measurements were performed and EBC was collected. Statistical analysis was performed using a test dataset and validation dataset for 1) conditionally specified models, receiver operating characteristic-curves (ROC-curves); 2) k-nearest neighbors algorithm. RESULTS: Three conditionally specified predictive models were constructed. Model 1 included inflammatory markers in EBC alone, model 2 included FeNO plus clinical characteristics and the ACQ score, and model 3 included all the predictors used in model 1 and 2. The area under the ROC-curves was estimated as 47%, 54% and 59% for models 1, 2 and 3 respectively. The k-nearest neighbors predictive algorithm, using the information of all the variables in model 3, produced correct predictions for 52% of the exacerbations in the validation dataset. CONCLUSION: The predictive power of FeNO and inflammatory markers in EBC for prediction of an asthma exacerbation was low, even when combined with clinical characteristics and symptoms. Qualitative improvement of the chemical analysis of EBC may lead to a better non-invasive prediction of asthma exacerbations.

Langerhans cell histiocytosis presenting with complicated pneumonia, a case report.

We describe a 2 ½ year old boy presenting with fever, abdominal pain and splinter haemorrhages of the nails. On further examination there were signs of pneumonia with pleural effusion. This was treated with mini-thoracotomy, drainage and intravenous antibiotics. Further diagnostic workup for underlying causes showed diffuse cystic lung disease, suggestive of Langerhans cell histiocytosis. This was confirmed on pathology specimens, which showed Langerhans cells in lung tissue, nail bed and skin biopsy samples, indicating multisystem Langerhans cell histiocytosis. The patient was treated with Prednisone and Vinblastin according to the LCH-III guidelines. In this case report we give a brief description on cystic lung disease in children, Langerhans cell histiocytosis and associated nail abnormalities.

Clinical presentation of Churg-Strauss syndrome in children: A 12-year-old-boy with ANCA-negative Churg-Strauss syndrome.

Churg-Strauss syndrome is an uncommon multisystem disorder characterized by asthma, eosinophilia and vasculitis. We report on a 12-year-old boy with asthma and deterioration of his general condition, who was eventually diagnosed with an ANCA-negative Churg-Strauss syndrome. The propositus included, 50 cases of childhood Churg-Strauss syndrome have been reported. The patient characteristics and clinical characteristics of these children are summarized. The respiratory tract is most frequently involved with pulmonary infiltrates, asthma and sinusitis. Early recognition of childhood Churg-Strauss syndrome is important as delayed diagnosis can lead to severe organ involvement, and possible fatal outcome.