Discrepancy between clinical asthma control assessment tools and fractional exhaled nitric oxide

Utility of exhaled nitric oxide to guide mild asthma treatment in atopic patients and its correlation with asthma control test score: a randomized controlled trial

BACKGROUND

Fractional exhaled nitric oxide (FeNO) is used for the diagnosis and monitoring of asthma, although its utility to guide treatment and its correlation with other tools is still under discussion. We study the possibility to withdraw inhaled corticosteroid treatment in atopic patients with mild asthma based on the FeNO level, as well as to study its correlation with other clinical control tools.

METHODS

Prospective and randomized study including atopic patients aged 18 to 65 with mild asthma, stable, on low-dose inhaled corticosteroid (ICS) treatment, who had their treatment withdrawn based on a FeNO level of 40 ppb. Patients were randomized into two groups: control group (treatment with ICS was withdrawn regardless of FeNO level) and experimental group (according to the FeNO levels, patients were assigned to one of two groups: FeNO > 40 ppb on treatment with budesonide 200 mcg every 12 h and SABA on demand; FeNO ≤ 40 ppb only with SABA on demand). Follow-up was conducted for one year, during which medical assessment was performed with FeNO measurements, asthma control test (ACT), lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC), and recording of the number of exacerbations.

RESULTS

Ninety-two patients were included, with a mean age of 39.92 years (SD 13.99); 46 patients were assigned to the control group, and 46 patients to the experimental group. The number of exacerbations was similar between the groups (p = 0.301), while the time to the first exacerbation was significantly shorter in the control group (30.86 vs. 99.00 days), p < 0.001, 95% CI (43.332-92.954). Lung function tests (FEV1, FEV1/FVC, PEF, and RV/TLC) showed no differences between the groups (p > 0.05). Both FeNO and ACT showed significant changes in the groups in which ICS was withdrawn (p < 0.05 for both parameters). A significant negative correlation was observed between FeNO and ACT (r = -0.139, p = 0.008).

CONCLUSIONS

In atopic patients with mild asthma, withdrawal of ICS based on an FeNO of 40 ppb led to worsened symptoms but without changes in lung function tests or an increase in exacerbations. There was a negative correlation between FeNO values and symptomatic control measured by the ACT.

TRIAL REGISTRATION

Clinical Trial Number: 2012-000372-42. Start Date: 2012-07-23. Trial registered prospectively ( https://www.clinicaltrialsregister.eu/ctr-search/search?query=2012-000372-42 ). This study adheres to CONSORT guidelines of randomised control trials.

1-Year Prospective Study of the Relationship of Serial Exhaled Nitric Oxide Level and Asthma Control

Background and Objective

Previous studies found that the fractional nitric oxide concentration in exhaled breath (FeNO) levels in healthy Chinese adults was higher than in White adults. More understanding of serial changes of FeNO levels with asthma control in a real-life clinical setting would be important to explore the utility of this biomarker in routine asthma management. This study assessed the FeNO levels of Chinese asthma subjects with different levels of asthma control and the serial changes with respect to the changes in asthma control over 1 year.

Methods

A 12-month prospective study (subjects recruited between November 2019 and January 2021) with serial measurement of FeNO levels at baseline, 4, 8 and 12 months. Asthma control was assessed by the Global Initiative for Asthma classification, Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ).

Results

Altogether, 136 subjects (mean age 51.51±15.09 years, 46[33.8%] male) had successful baseline FeNO measurements. At baseline, the FeNO levels did not show a statistically significant difference for controlled, partly controlled and uncontrolled asthma according to GINA classification, ACT and ACQ. FeNO levels decreased with improving asthma control and stayed at similar levels with unchanged or worsening asthma control for all subjects. For subjects with baseline blood eosinophil levels ≥300 cells/µL(n=59), FeNO levels decreased with improving asthma control, stayed similar without change for asthma control and increased with worsening asthma control. Receiver operating characteristic (ROC) analysis with the highest area under curve (AUC) for changes in FeNO levels for improving asthma control was between ≤ -10 to -25 ppb at various time points in the 12-month study.

Conclusion

Changes in FeNO levels over time were associated with changes in clinical asthma control, particularly in those with higher blood eosinophil count and are likely more useful than a single time point measurement in managing asthma.

Improving Asthma Outcomes During Pregnancy in Underserved Communities

It is known that poor asthma control is common in pregnancy, and asthma in general disproportionally affects underserved communities. However, there is a paucity of data examining strategies to improve asthma control specifically among pregnant women from vulnerable populations. Identified barriers to optimal asthma care in other underserved groups include health literacy, financial constraints, cultural differences, and poor environmental controls. These deficiencies may also be targets for multimodal interventions geared toward improving asthma outcomes for underserved women during pregnancy.

Prevalence of Asthma among Norwegian Elite Athletes

Objective

Asthma is a common problem among elite athletes and represents a health risk interfering with the athlete's performance status. This study aimed to evaluate the asthma prevalence among Norwegian summer and winter elite athletes and asthma prevalence across sport categories. We also aimed to examine whether bronchial hyperresponsiveness (BHR), lung function, fraction of exhaled nitric oxide (FENO), and allergy status differed between asthmatic and non-asthmatic elite athletes.

Methods

Norwegian athletes qualifying for the Beijing Olympic Summer Games 2008 (n = 80) and the Vancouver Olympic Winter Games 2010 (n = 55) were included. The athletes underwent clinical respiratory examination including lung function measurement, methacholine bronchial challenge for assessment of BHR, FENO, and skin prick testing. Asthma was diagnosed based on respiratory symptoms and clinical examination including objective measurements.

Results

Asthma was more prevalent among winter athletes (50%) than summer athletes (20%). Thirty-three (52%) endurance athletes, 3 (6%) team sport athletes, and 7 (33%) technical sport athletes had medically diagnosed asthma. Significantly lower lung function (p < 0.001) and higher prevalence of severe BHR (p < 0.001) were found in asthmatic athletes compared with non-asthmatic athletes.

Conclusion

Asthma is common among Norwegian elite athletes, with winter and endurance athletes showing the highest prevalence. Asthmatic athletes were characterized by lower lung function and more severe BHR compared with non-asthmatic counterparts. The high prevalence among winter and endurance athletes demonstrates a need for increased attention to prevent and reduce the prevalence of asthma among those athletes.

Management of asthma exacerbations in the paediatric population: a systematic review

BACKGROUND

Asthma exacerbations in children is one of the most common medical conditions requiring urgent visits to primary healthcare providers or emergency departments, and even hospitalisations. Currently, there is significant variation in the management of asthma exacerbations expressed in guideline recommendations versus clinical practice. This disconnect affects diagnostic and treatment decisions for the clinician and patient.

OBJECTIVE

We systematically reviewed the available guidelines providing recommendations for diagnostic and therapeutic management of asthma exacerbations in the paediatric population.

METHODS

A systematic review of the literature for guidelines published between January 2009 and October 2019 was conducted, using a protocol registered with the international prospective register of systematic reviews (PROSPERO CRD42020221562).

RESULTS

16 asthma exacerbation clinical practice guidelines for children were included. Despite general agreement between guidelines on the definition of asthma exacerbation, there was great variability in the definition of disease severity and assessment of asthma control. This systematic review also highlighted a paucity of recommendations for criteria for hospitalisation and discharge. Many guidelines scored poorly when measured for stakeholder involvement and editorial independence.

CONCLUSION

Comprehensive and updated guidelines compliant with international standards for clinical guidelines may significantly improve clinical practice quality, promote evidence-based recommendations and provide uniformity of treatment between countries.

The association between serum apolipoprotein B and fractional exhaled nitric oxide in bronchial asthma patients

Background

Asthma and lipid metabolism are associated with systemic inflammation. However, the studies about the relationship between lipid profile, fractional exhaled nitric acid (FeNO) and pulmonary function test (PFT) results are currently lacking.

Methods

We enrolled asthma patients who had serum lipid profiles including apolipoprotein levels from March 1, 2019 to December 31, 2019. We classified the asthma patients into two groups according to the diagnosis method: (I) patients who were diagnosed based on clinical symptoms/signs and PFT results and (II) patients diagnosed with clinical symptoms/signs. Clinical characteristics including age, underlying diseases, smoking status, allergy test results and treatment agents were compared between the two groups. The associations between blood cholesterol levels including apolipoprotein and pulmonary functions were analyzed. Moreover, patients were divided into two groups according to the median value of apolipoprotein B (Apo B), and lung function test results were compared between the patients who had high and low Apo B levels.

Results

Among the 167 patients, 93 (55.7%) were PFT-proven asthma patients. In PFT-proven asthma patients, the levels of total cholesterol (TC) (r =0.37, P=0.03), low-density lipoprotein (LDL) (r =0.46, P=0.01) and Apo B (r =0.38, P=0.02) showed a significant correlation with FeNO, which had no statistical significance in physician-diagnosed asthma group. In multivariate regression analysis, log (FeNO) showed a significant correlation with Apo B (P<0.01) after adjustment for presence of PFT-proven asthma (P=0.01) and current smoking (P=0.01). Patients with high Apo B levels had a lower post-bronchodilator (BD) forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio (69.8 vs. 74.9, P=0.02) and lower post-BD FEV1 (%) (77.5 vs. 85.0, P=0.04) compared with those showing low Apo B levels.

Conclusions

The levels of Apo B and FeNO had positive correlations and high Apo B levels were associated with severe airflow obstruction and low FEV1 (%). Apo B could reflect the uncontrolled status of bronchial asthma and poor lung function.

The Role of Nasal Nitric Oxide and Anterior Active Rhinomanometry in the Diagnosis of Allergic Rhinitis and Asthma: A Message for Pediatric Clinical Practice

Background

Allergic rhinitis (AR) and asthma are two common atopic diseases, often associated with a common ethiopathogenesis characterized by a Th2 inflammatory response with the release of many biomarkers, such as nitric oxide (NO).

Purpose

To evaluate and compare inflammatory (nFeNO and eFeNO) and functional (mNF and FEV1) parameters in AR children with or without asthma in comparison to controls. Secondly, we aimed to identify nFeNO cut-off values and verify their reliability to predict the presence of rhinitis or asthma alone or in combination.

Patients and Methods

We enrolled 160 children (6-12 years of age) with AR and/or asthma divided into four groups: controls, AR, asthma, and AR + asthma. All children underwent the following inflammatory and functional measurements: nFeNO, eFeNO, mNF and FEV1.

Results

We observed that levels of nFeNO were extremely higher in children with AR and even more in those with AR + asthma in respect to controls. Notably, all the pathological conditions, especially AR + asthma, showed significantly lower values of mNF compared to healthy children. A negative correlation linked mNF and nFeNO. Then, we found eFeNO values significantly higher in all the pathological groups compared to controls, with major values of this marker in patients affected by asthma and AR + asthma, as well as FEV1 values significantly lower in all the disease groups, especially in children with asthma and AR+ asthma. ROC curve analysis showed that nFeNO was a great predictor for rhinitis alone or with asthma, revealing an accurate cut-off of 662 ppb.

Conclusion

nFeNO measurement is non-invasive, easy to perform, economic and a valuable test in case of AR alone or in association with asthma. Thus, it should be used in patients with rhinitis, together with anterior active rhinomanometry (AAR) to diagnose and estimate the degree of nasal obstruction but also in children with asthma to assess their nasal involvement and improve the therapeutic management.

Concordance for changes in allergic asthma domain variables after short-term corticosteroid therapy

Background

Asthma is a complex syndrome with multiple domains including symptoms, lung function, asthma control, and airway inflammation. A study of Fenom PRO™, a novel monitor for exhaled nitric oxide (FeNO), provided an opportunity to look at concordance/discordance (C/D) for changes in multiple asthma domains over a 2-week period after corticosteroid therapy.

Methods

Non-steroid-treated adults and children with uncontrolled asthma had asthma domain measures, (FeNO), forced expired volume in 1 s (FEV₁), the 6-item Asthma Control Questionnaire scores (ACQ6), and daily asthma symptoms, assessed before and after a 2-week course of corticosteroids. Asthma symptoms were assessed using a custom novel twice-daily symptom scale (ASX). C/D bidirectional changes in all domains were calculated around both the zero point, and around the minimal important difference (MID) in relevant subjects.

Results

There was a highly significant fall in mean FeNO of 51.7% over 2 weeks (p < 0.0001) accompanied by significant improvements in mean FEV₁, ACQ6 and ASX scores. However, C/D between individual domains varied considerably between subjects. The C/D between parameters for any change around zero for the combined adults and pediatric population was best for FeNO and ACQ6, 79.3/20.7% while FEV₁ was more discordant than other parameters in general. When considering changes around the minimal important difference (MID) in a subset, the level of concordance increased in general, with FeNO and ACQ6 demonstrating a C/D of 93.5/6.6%.

Conclusion

This data demonstrates that the concordance between changes in the asthma domains is often substantially less than 100%. Reasons for this may include different time courses for change of the separate domains, the degree of abnormality for each domain at baseline, as well as intrinsic limitations of each parameter.

Combination of Fractional Exhaled Nitric Oxide (FeNO) Level and Asthma Control Test (ATC) in Detecting GINA-Defined Asthma Control in Treated Asthmatic Patients in Vietnam

Background

FeNO has been used as a marker for Th2-mediated airway inflammation in asthma. There is evidence which recommends the use of this biomarker in asthma management. Little is known about whether the FeNO test alone or in combination with the ACT score can reflect asthma control in Vietnamese patients.

Materials and Methods

A cross-sectional study was conducted in asthmatic patients (≥18 years old) recruited at the University Medical Center, Ho Chi Minh City, Vietnam from March 2016 to March 2017. Asthma control levels were assessed following the GINA 2017 guidelines, and FeNO was measured by a Niox Mino device. FeNO cut-offs predicting asthma control status were determined using the ROC curve analysis. The combination of FeNO and ACT was investigated in detecting well-controlled and uncontrolled asthma. The results of the study are as follows: 278 patients with 68% females, mean age of 44 years, and mean asthma duration of 10 years were analyzed. All patients were treated following step 2 to 4 of GINA guidelines. Mean (SD) FeNO was 30.6 (24) ppb. Patients with uncontrolled (16%), partly controlled (29%), and well-controlled asthma (55%) had a median (IQR) FeNO of 50.0 (74), 25.0 (23), and 21.0 (22.3) ppb, respectively, and the mean of FeNO in the uncontrolled group was significantly higher than that in other groups (p < 0.001). The area under the ROC curve (AUC) for FeNO detecting uncontrolled asthma was 0.730 with an optimal cut-off point of FeNO > 50 ppb, and this AUC increased to 0.89 when combining FeNO and ACT. The AUC for FeNO detecting well-controlled asthma was 0.601 with an optimal cut-off point of FeNO <25 ppb and this AUC increased to 0.78 if combining FeNO and ACT.

Conclusions

FeNO can predict asthma control status with an estimated cut-off point of <25 ppb for well-controlled and >50 ppb for uncontrolled asthma. The combination of FeNO and ACT provides better information regarding asthma control than FeNO alone, and this combination is useful to predict asthma control statuses in asthmatic patients in Viet Nam.

Relationship between the Asthma Control Test (ACT) and other outcomes: a targeted literature review

BACKGROUND

The Asthma Control Test (ACT) has been used to assess asthma control in both clinical trials and clinical practice. However, the relationships between ACT score and other measures of asthma impact are not fully understood. Here, we evaluate how ACT scores relate to other clinical, patient-reported, or economic asthma outcomes.

METHODS

A targeted literature search of online databases and conference abstracts was performed. Data were extracted from articles reporting ACT score alongside one or more of: Asthma Control Questionnaire (ACQ) score; rescue medication use; exacerbations; lung function; health-/asthma-related quality of life (QoL); sleep quality; work and productivity; and healthcare resource use (HRU) and costs.

RESULTS

A total of 1653 publications were identified, 74 of which were included in the final analysis. Of these, 69 studies found that improvement in ACT score was related to improvement in outcome(s), either as correlation or by association. The level of evidence for each relationship differed widely between outcomes: substantial evidence was identified for relationships between ACT score and ACQ score, lung function, and asthma-related QoL; moderate evidence was obtained for relationships between ACT score and rescue medication use, exacerbations, sleep quality, and work and productivity; limited evidence was identified for relationships between ACT score and general health-related QoL, HRU, and healthcare costs.

CONCLUSIONS

Findings of this review suggest that the ACT is an appropriate measure for overall asthma impact and support its use in clinical trial settings. GlaxoSmithKline plc. study number HO-17-18170.

Asthma control in children: Body plethysmography in addition to spirometry

BACKGROUND

There is a lack of agreement among measures of asthma control in children. In Central Europe, body plethysmography is additionally used for asthma monitoring. However, its value is still unclear.

OBJECTIVES

We investigated the possible additional value of body plethysmographic measures (specific resistance, residual volume-total lung capacity ratio [RV/TLC]) compared with spirometric measures forced expiratory volume in 1 second (FEV ₁ ), forced vital capacity (FVC), FEV ₁ /FVC, forced expiratory flow at 25% to 75% of forced vital capacity (FEF _25-75 ), and fraction of exhaled nitric oxide (FeNO) for assessment of asthma control.

METHODS

One hundred and forty-five asthmatic children aged 5 to 17 were included. All children performed measurements of FeNO, spirometry, and body plethymography. Asthma control was assessed by the asthma control test (c-ACT/ACT) and a doctor's assessment of asthma control.

RESULTS

Investigating single lung function parameters, FEV₁ , FEV ₁ /FVC, FEF _25-75 and RV/TLC differed between controlled and partly controlled asthma. However, we found no differences between controlled and uncontrolled asthma with regard to single lung function parameters or for any parameter if investigated in a multivariable approach. This was also true if we combined obtained parameters from spirometry (comparing pathologic vs normal spirometry). Investigating the combination of body plethysmography and doctor's assessment of asthma control a significant association was found ( P = 0.02). Furthermore, combined spirometry and body plethysmography showed a significant association with both doctor's assessed asthma control ( P = 0.009) and the c-ACT/ACT ( P = 0.04). The addition of FeNO did not improve the results.

CONCLUSIONS

The combination of body plethysmography and spirometry shows best agreement with asthma control in children compared with spirometry or body plethysmography alone. Further studies are needed to find out whether additional measurements of body plethysmography improve the outcome of children in asthma monitoring.

Small airway inflammation is associated with residual airway hyperresponsiveness in Th2-high asthma

Background: Asthma is characterized by airway inflammation, variable airflow obstruction, and airway hyperresponsiveness (AHR). Generally, AHR takes longer to resolve than does airflow obstruction or clinical symptoms. AHR occasionally persists despite adequate asthma treatment.Objective: To evaluate factors which associates with residual AHR in patients with seemingly remitted airway inflammation.Methods: Patients who exhibited high fractional exhaled nitric oxide (FeNO) levels (>25 ppb) at the first visit (Visit 1) and normalized FeNO levels (<25 ppb) after adequate asthma treatment, including inhaled corticosteroid administration (Visit 2), were analyzed. Patients underwent a blood test, FeNO and small airway/alveolar nitric oxide concentration (CANO) measurements and a methacholine challenge test (continuous inhalation method) at both visits. Clinical indices were compared between patients with and without residual AHR.Results: Fifty patients were analyzed. All exhibited high FeNO levels at Visit 1 [mean, 54.0 ppb (95% confidence interval, 42.4-65.5)] and improvement of FeNO levels at Visit 2 [20.4 (19.2-21.6)] (p < 0.0001). Thirty-three patients (66%) had remission of AHR at Visit 2. No significant differences were observed between patients with and without residual AHR in terms of FeNO levels, lung function parameters and blood eosinophil counts at both visits. CANO level at Visit 2 was the only factor that significantly differed between patients with residual AHR [2.7 (1.9-3.6)] and those who achieved AHR remission [0.8 (0.5-1.0)] (p < 0.0001).Conclusion: Small airway inflammation, as assessed by CANO, was associated with residual AHR in patients with Th2-high asthma.

Phenotypes favoring fractional exhaled nitric oxide discordance vs guideline-based uncontrolled asthma

BACKGROUND

Despite potential value of identification of allergic inflammation with fractional exhaled nitric oxide (FeNO) in managing asthma, randomized clinical trials have not consistently shown better outcomes compared with guideline management alone.

OBJECTIVE

To assess the effectiveness of FeNO vs non-FeNO-based therapeutic algorithms in managing asthma, and the phenotypic profile associated with FeNO >35 ppb yet well controlled by guidelines, as a potential model to predict better FeNO-based algorithm outcomes.

METHODS

This is a randomized controlled study (RCT) in 88 high-risk children with asthma 7 to 18 years of age across 352 visits over a 1-year period. Generalized estimating equations analysis assessed algorithm group differences in outcomes and characteristics associated with higher odds uncontrolled by FeNO alone in the treatment decision algorithm.

RESULTS

The FeNO treatment algorithm did not show superiority in reducing exacerbations and morbidity (P > .05). Phenotypes that more than doubled the odds FeNO alone identified uncontrolled asthma included adolescence, non-adherence, high atopy (>6+), and baseline FeNO >35 ppb, whereas obesity, FEF_25-75% < 65% predicted, and bronchodilator response >10% decreased the odds. Uncontrolled asthma by FeNO alone (F) vs guidelines alone (G) showed overall F/G > 1.0 in adolescents, but <1.0 in younger patients unless the FeNO threshold was reduced to >20 ppb.

CONCLUSION

Our study suggests that age and phenotypes play a key role in FeNO discordance compared with the conventional guideline-based uncontrolled asthma. The FeNO-based therapeutic algorithm, if confirmed further, could provide the clinician with an effective asthma management tool. The clinical implication could improve future FeNO-based RCTs and treatment decision algorithms in managing asthma by considering phenotypes and age-dependent FeNO thresholds.

Exhaled nitric oxide predicts loss of asthma control in children after inhaled corticosteroids withdrawal

BACKGROUND

Exhaled nitric oxide (eNO) has been proposed for monitoring airway inflammation, diagnosis, and prediction of steroid responsiveness in asthma. However, its utility after elective suspension of asthma medication is still unclear. We aimed to determine the association between eNO values and the subsequent loss of asthma control (LAC) in asymptomatic asthmatic children after inhaled corticosteroids (ICS) withdrawal.

METHODS

We conducted a prospective observational cohort study. Forty-two children (23 boys), mean age 11 years, with clinically controlled asthma, according to GINA guidelines, and receiving low-dose of ICS (budesonide 200 μg/day or equivalent) were included immediately after the withdrawal of ICS. eNO, Asthma Control Test (ACT) and spirometry were monthly assessed, during 54 weeks or until the presence of at least one of the following criteria of LAC: 1) asthma exacerbation, 2) obstructive spirometric pattern, 3) ACT ≤ 19.

RESULTS

eNO baseline geometric mean (eNO_b ), measured 4 weeks after discontinuation of ICS, was 23.7 ppb (SD: 1.16). An eNO_b cutoff point of 21.8 ppb was determined to better discriminate between high and low eNO groups. Twenty-five subjects (71.4%) had LAC. High eNO_b was associated to LAC (OR: 9.01; 95CI: 1.10-74.26). In addition, LAC occurred earlier in high eNO_b than in low eNO_b patients (8 vs 28 weeks, respectively; P = 0.017).

CONCLUSIONS

Our findings suggest that eNO predicts loss of asthma control and may contribute for clinical follow up decisions during childhood asthma after ICS withdrawal.

Asthma control test reflects not only lung function but also airway inflammation in children with stable asthma

Objective: Various numerical asthma control tools have been developed to distinguish different levels of symptom control. We aimed to examine whether the asthma control test (ACT) is reflective of objective findings such as lung function, fractional exhaled nitric oxide (FeNO) and laboratory data in patients with stable asthma.Methods: We included patients who were enrolled in the Korean Childhood Asthma Study. ACT, spirometry, blood tests and FeNO were performed in patients after stabilization of their asthma. We examined differences among spirometry parameters, blood tests and FeNO according to control status as determined by ACT and investigated for any significant correlations.Results: The study population consisted of 441 subjects. Spirometry showed that forced expiratory volume in one second (FEV₁), forced expiratory flow between 25% and 75% of forced vital capacity and FEV₁/forced vital capacity were all significantly higher in the controlled asthma group. Likewise, FeNO and percent-change in FEV₁ were both significantly lower in the controlled asthma group. In blood tests, the eosinophil fraction was significantly lower in the controlled asthma group while white blood cell count was significantly higher in the controlled asthma group. Lastly, among the various factors analyzed, only provocative concentration of methacholine causing a 20% fall in FEV₁ significantly correlated with ACT score.Conclusion: ACT is useful as part of the routine evaluation of asthmatic children and should be used as a complement to existing tools such as spirometry and FeNO measurement.

Comparing Asthma Control Questionnaire (ACQ) and National Asthma Education and Prevention Program (NAEPP) asthma control criteria

BACKGROUND

Adequate assessment of control is critical to asthma management. The Asthma Control Questionnaire (ACQ) and the National Asthma Education and Prevention Program (NAEPP) criteria are commonly used measures of asthma control.

OBJECTIVE

To examine the associations between the ACQ and NAEPP criteria and compare the validity in association with lung function, asthma exacerbation, and quality of life.

METHODS

The ACQ and the NAEPP criteria were administered to 373 adolescents with asthma aged 12 to 20 years. The 2 measures correlated with forced expiratory volume in 1 second (FEV₁), asthma exacerbation (oral corticosteroid use, hospitalization, and emergency department [ED] use) in the past 12 months, and quality of life.

RESULTS

Agreement between the ACQ and NAEPP criteria was moderate (κ = 0.40-0.61). Neither of the 2 measures was a reliable predictor of FEV₁ less than 80% because of the high rate of false-positive results for the ACQ (68%) and low sensitivity for the NAEPP (49%). The NAEPP identified more cases of uncontrolled asthma (84.6%) than the ACQ (64.6%). The ACQ was a significant predictor of recent oral corticosteroid use, hospitalization, and ED visits (area under the curve = 0.66, 0.66, and 0.64, respectively; P < .001), as was NAEPP (area under the curve = 0.63, 0.66, and 0.61, respectively; P < .001). Both measures were significantly associated with quality of life, and the associations were particularly strong for the ACQ (r = -0.87 for symptom subscale, r = -0.76 for activity subscale, and r = -0.78 for emotional function subscale).

CONCLUSION

Neither the ACQ nor the NAEPP appears to reliably predict lung function, whereas both measures reasonably associate with acute asthma exacerbation. The ACQ may be the superior measure in gauging the psychosocial effect of asthma control given its particularly strong associations with quality of life.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT02293499.

ASSOCIATION BETWEEN FRACTION OF EXHALED NITRIC OXIDE AND SPIROMETRY DATA AND CLINICAL CONTROL OF ASTHMA IN CHILDREN AND ADOLESCENTS

Objective:

To evaluate the association between fraction of exhaled nitric oxide (FeNO) values and forced expiratory volume in the first second (FEV1) and the level of asthma control, as proposed by the Global Initiative for Asthma (GINA), in asthmatic children and adolescents attended at the National Institute of Women, Children and Adolescents Health Fernandes Figueira of Fundação Oswaldo Cruz (IFF/FIOCRUZ).

Methods:

This was a cross-sectional study, with a review of medical records of 90 asthmatics between 7 and 17 years old, who were followed up at the IFF/FIOCRUZ Asthma Outpatient Clinic and were referred to perform respiratory function tests (RFT)between March 2013 and September 2014. After classification according to GINA, patients performed complete spirometry and FeNO measurement. Subsequently, they were separated into two groups: regular and non-regular inhaled corticosteroid (ICS) use, regardless of the ventilatory pattern in spirometry.

Results:

The association between FEV1 values and the degree of asthma control according to GINA (p=0.001) was observed in all patients, regardless of ICS use, but there was no association between FEV1 and levels of FeNO.

Conclusions:

The correlation observed between GINA and FEV1 reinforces the importance of spirometry in the clinical follow-up of these patients. Although no association was found between the value of FeNO and the degree of asthma control and FEV1, FeNO may be an early method to detect airway inflammation, even before the symptoms and spirometric changes.

Rationale and design of the multiethnic Pharmacogenomics in Childhood Asthma consortium

AIM

International collaboration is needed to enable large-scale pharmacogenomics studies in childhood asthma. Here, we describe the design of the Pharmacogenomics in Childhood Asthma (PiCA) consortium.

MATERIALS & METHODS

Investigators of each study participating in PiCA provided data on the study characteristics by answering an online questionnaire.

RESULTS

A total of 21 studies, including 14,227 children/young persons (58% male), from 12 different countries are currently enrolled in the PiCA consortium. Fifty six percent of the patients are Caucasians. In total, 7619 were inhaled corticosteroid users. Among patients from 13 studies with available data on asthma exacerbations, a third reported exacerbations despite inhaled corticosteroid use. In the future pharmacogenomics studies within the consortium, the pharmacogenomics analyses will be performed separately in each center and the results will be meta-analyzed.

CONCLUSION

PiCA is a valuable platform to perform pharmacogenetics studies within a multiethnic pediatric asthma population.

The relationship between migraine headache and asthma features

Migraine and asthma are comorbid chronic disorders with episodic attacks thought to involve inflammatory and neurological mechanisms. The objective of the present study is to investigate the relationship of asthma features between the asthma patients with migraine and those without migraine headache. A cross-sectional study was conducted from October 2015 to June 2016. Physician-diagnosed asthma patients aged 18 years and above were included. Demographic data, pulmonary function test and treatment of asthma were recorded. Asthma control was assessed using the asthma control test (ACT) and asthma control questionnaire (ACQ). The diagnosis of migraine was made by the neurologist with face-to face examinations based on the International Classification of Headache Disorders, third edition beta (ICHD-III-beta) criteria. Data about the age at onset, frequency of headache attacks, duration of headache attack, the presence of aura, and severity of headache were recorded. The severity of headache was evaluated using visual analogue scale (VAS). Overall 121 asthma patients were included in this study. Migraine was found to be present in 32 (26.4%) of patients. No statistically significant difference was found between asthma group and asthma with migraine groups in terms of pulmonary function test parameters. The mean ACT score in asthma with migraine patients group was significantly lower than the asthma groups. Morever, in the group asthma with migraine, a negative significant correlations were found between ACT scores with VAS scores. This study demonstrates that migraine headache may be associated with poor asthma control. On the other hand, it should not be forgotten that ACT is a subjective test and can be affected from by many clinical parameters.

Prevalence of high fractional exhaled nitric oxide among US youth with asthma

BACKGROUND

High fractional exhaled nitric oxide (FeNO) is an indicator of poor asthma control and has been proposed as a non-invasive assessment tool to guide asthma management.

OBJECTIVE

We aimed to describe the prevalence of and factors associated with high FeNO among US youth with asthma.

METHODS

Data from 716 children and adolescents with asthma ages 6-19 years who participated in the 2007-2012 National Health and Nutrition Examination Survey were analyzed. Using American Thoracic Society guidelines, high FeNO was defined as >50 ppb for ages 12-19 years and >35 ppb for ages 6-11 years. Multivariate logistic regression examined associations between high FeNO and age, sex, race/Hispanic origin, income status, weight status, tobacco smoke exposure, and other factors associated with asthma control (recent use of inhaled corticosteroids, recent respiratory illness, asthma-related respiratory signs/symptoms, and spirometry).

RESULTS

About 16.5% of youth with asthma had high FeNO. The prevalence of high FeNO was higher among non-Hispanic black (27%, P < 0.001) and Hispanic (20.2%, P = 0.002) youth than non-Hispanic white (9.7%) youth. Differences in high FeNO prevalence by sex (girls < boys), weight status (obese < normal weight), tobacco smoke exposure (smokers < home exposure < no exposure), and FEV1/FVC (normal < abnormal) were also observed. No differences were noted between categories for the remaining covariates.

CONCLUSION

High FeNO was observed to be associated with sex, race/Hispanic origin, weight status, tobacco smoke exposure, and abnormal FEV1/FVC, but was not associated with asthma-related respiratory symptoms. These findings may help inform future research and clinical practice guidelines on the use of high FeNO in the assessment of asthma control.

Follow-up of patients with uncontrolled asthma: clinical features of asthma patients according to the level of control achieved (the COAS study)

Our aim was to study the asthma control achieved in patients with uncontrolled asthma who had received appropriate treatment according to the Global Initiative for Asthma (GINA) 2010 (valid at the time the study was designed), and to analyse the factors associated with a lack of asthma control.This was a multicentre study in routine clinical practice performed in patients with uncontrolled asthma according to GINA 2010. At visit 1, we recorded demographics, asthma characteristics and spirometry. We assessed asthma control using GINA 2010 criteria and the Asthma Control Test (ACT). Treatment was optimised according to GINA 2010. At visit 2, 3 months later, we reassessed spirometry, asthma control and factors associated with failure to achieve control.We recruited 1299 patients with uncontrolled asthma (mean age 46.5±17.3 years, 60.7% women, 25.8% obese). The mean percentage of predicted forced expiratory volume in 1 s was 76.4±12.8% and the mean post-bronchodilator increase was 14.9±6.8%. We observed poor agreement between ACT and GINA 2010 when evaluating asthma control (kappa = -0.151). At visit 2, asthma in 71.2% of patients was still not fully controlled. Patients whose asthma remained uncontrolled were older, had a higher body mass index, greater disease severity, longer disease evolution and worse lung function.After treatment optimisation, most patients did not achieve optimal control according to GINA 2010. Risk factors for failure to achieve asthma control were time of disease evolution, severity, age, weight and lung function impairment (excluded in the GINA 2014).

Fractional Exhaled Nitric Oxide for Identification of Uncontrolled Asthma in Children

OBJECTIVE

To determine the utility of Fractional Exhaled Nitric Oxide (FENO) in the identification of uncontrolled asthma in children on therapy, and to identify its cut-off value for determining asthma control.

METHODS

207 children (age 5-15 y) with physician-diagnosed asthma on therapy with at least 12 months follow up were enrolled. Spirometry and FENO measurements were performed. Asthma control was assessed as per GINA guidelines. Sensitivity and specificity of various cut-off values of FENO (15 ppb, 20 ppb, 25 ppb, 30 ppb) for identification of status of control of asthma were calculated.

RESULTS

156 (75%) children had uncontrolled or partly controlled asthma and 51 children were assessed to have controlled asthma. Median (IQR) FENO in children with controlled and uncontrolled asthma was 16 (11-23) ppb and 13 (11-25) ppb, respectively (P=0.26). No FENO cut-off had a reasonable combination of sensitivity and specificity to discriminate between controlled and uncontrolled asthma.

CONCLUSIONS

FENO, in itself, does not have good discriminatory value in assessment of controlled and uncontrolled asthma in children on asthma therapy.

Clinical Utility of Fractional exhaled Nitric Oxide (FeNO) as a Biomarker to Predict Severity of Disease and Response to Inhaled Corticosteroid (ICS) in Asthma Patients

INTRODUCTION

Bronchial asthma is a common chronic inflammatory airway disease diagnosed and is based on symptomatic history and Pulmonary Function Tests (PFT). Fractional exhaled Nitric Oxide (FeNO) is exclusively a non-invasive biomarker of on-going eosinophilic airway inflammation which remains unpredictable only with PFTs. FeNO measurement is recommended in predicting asthma severity and Inhaled Corticosteroid (ICS) response but further research is required to understand its clinical utility and agreement with current recommendations in a specific population.

AIM

To estimate FeNO levels in Tamilian patients with mild-to-moderate persistent asthma and to correlate with disease severity and ICS response.

MATERIALS AND METHODS

The study was a prospective cohort with a single group of 102 persistent asthma patients under standard ICS regimen for 8 weeks (follow-up period). PFT and FeNO were measured using portable spirometry and chemiluminescence based exhaled breath analyser, at baseline and during follow-up visits. Based on PFT and FeNO parameters, the study population was sub-grouped with respect to asthma severity (as mild, moderate and moderately severe), FeNO cut-off (> or < 50ppb) and ICS response classification (good vs poor ICS responders).

RESULTS

Significant decrease in mean FeNO levels were found in mild, moderate and moderately severe asthmatic groups following ICS treatment (90.15±27.36, 75.74±31.98 and 77.18±32.79 ppb) compared to similar baseline FeNO levels (103.03±34.08, 91.38±37.60 and 97.90±43.84 ppb) in all the above groups. Similarly, significant decrease in mean FeNO levels was found - FeNO>50ppb, good and poor ICS responders groups, in post- ICS treatment (89.63±24.04, 77.90±31.12 and 86.49±32.57 ppb) compared to baseline levels (110.183±1.23, 97.12±42.04 and 99.68±34.71 ppb).

CONCLUSION

The observed baseline FeNO values in all groups as stated above did not show significant difference to differentiate asthma severity or ICS responders groups. The present study results do not support the predictive association of baseline FeNO levels with asthma severity and future ICS response, but the decrements in FeNO levels on ICS treatment, supports its clinical utility in monitoring of ongoing airway inflammation and understanding treatment response rate.

Asthma control questionnaires in the management of asthma in children: A review

Several self-administered questionnaires have been developed to assess childhood asthma control in a simple and standardized way. This review discusses the most commonly used questionnaires and explores their usefulness in asthma management in children. We conclude that the use of asthma control questionnaires in daily practice and in research contributes to the standardized evaluation of children with asthma and helps to track asthma symptoms, but validation studies in a wider range of settings are needed.

Clinical factors affecting discrepant correlation between asthma control test score and pulmonary function

The Asthma Control Test (ACT) score is widely used in asthma clinics, particularly with the recent emphasis on achievement and maintenance of optimal asthma control. However, this self-assessment score does not always correspond with lung function parameters, leading to uncertainty about each patient's control status; therefore, we investigated the clinical characteristics that are associated with discrepant correlation between the ACT score and pulmonary function. The 252 adult asthmatic subjects were divided into 5 groups according to their changes in FEV1% predicted values and ACT scores between 2 consecutive visits three months apart. The data were retrospectively reviewed and several clinical variables were compared. Elderly, non-eosinophilic, non-atopic asthma patients were more likely to show paradoxical changes of pulmonary function and ACT score. Female patients were prone to report exaggerated changes of ACT score compared with baseline lung function and changes in FEV1 levels. This group was using more medications for rhinosinusitis. Male patients seemed less sensitive to changes in lung function. From these findings, we conclude that when assessing asthma control status, physicians should carefully consider patient age, gender, atopy status, blood eosinophil levels, and comorbidities along with their ACT scores and pulmonary function test results.

Clinical and biological markers of asthma control

Asthma has substantial impact on the patient, their family and health systems, and its control has gained increasing attention. Perception of asthma control has varied widely among patients as well as healthcare providers. Several clinical markers have been developed to define and standardize the measurement of asthma control. They are based primarily on patients' symptoms and have been popular in clinical practice and in clinical studies. With the advances in basic research on the pathology of asthma, several biological markers have evolved that have the advantages of being objective, quantitative and more reflective of the underlying pathology, which makes them a better guide for selecting optimal therapy. In addition to the cost and expertise required, biological makers are influenced by multiple factors that limit their application in clinical practice. Ongoing research is expected to define the role of individual biological markers, the optimal method of their application, and their appropriate interpretation.

Asthma control: how it can be best assessed?

PURPOSE OF REVIEW

A control-based asthma assessment is recommended by guidelines, but questions remain about how to assess the level of asthma control, and how current control status relates to future risks and biomarkers of disease pathogenesis. This review summarizes recent published data relating to asthma control and describes the challenges created by currently available instruments.

RECENT FINDINGS

The current literature continues to show the widespread use of various assessment instruments for asthma control, in particular those with composite scores. However, poor correlations exist between the different assessment tools, and these instruments lack diagnostic accuracy to differentiate uncontrolled asthma. Whereas the concept of asthma control has been extended to add an assessment of future risks to the clinical control, clinical asthma control as measured by current available assessment tools does not necessary relate to the intrinsic disease activity which is typically characterized by inflammation in asthma.

SUMMARY

The application of asthma control assessment represents an improvement in asthma management. The measurement of underlying disease activity potentially by biomarkers to assess disease control will lead to an improved assessment of the overall control of asthma, and further studies addressing this are needed.

Statins in the treatment of asthma

PURPOSE

Current evidence on statin agents as potential alternatives or adjuncts to corticosteroid therapy for asthma is reviewed.

SUMMARY

Research showing antiinflammatory and antioxidant effects of statins in animal models suggested that the cholesterol-lowering drugs might be useful in mitigating the adverse effects of long-term corticosteroid therapy in patients with asthma, but studies in humans have yielded mixed results. Two small placebo-controlled clinical trials indicated that statins were not effective in combating asthmatic inflammatory processes, and trials of statins as adjunctive therapy have indicated minimal steroid-sparing benefits. In two studies involving a total of more than 1000 current and former smokers with asthma, statin use correlated with reduced acute asthma exacerbations and a slower decline of lung function in some patients. A large population-based study (n = 3965) found that statin therapy was associated with a significantly reduced risk of hospitalization for asthma after an average follow-up period of about 4.5 years; a smaller U.S. retrospective cohort study indicated a significantly lower 1-year rate of asthma-related emergency room visits among patients receiving statins relative to those not using statins (9.08% versus 4.18%). Much of the research on statins and asthma has not controlled for confounding influences such as patient comorbidities and concomitant medication use.

CONCLUSION

Clinical trials have shown that statin therapy is not superior to and does not enhance the beneficial effects of inhaled corticosteroids for the treatment of asthma. Some evidence suggests that statins may help preserve lung function in cigarette smokers with obstructive pulmonary disease and reduce hospitalizations in asthmatic smokers and nonsmokers.

Failure in asthma control: reasons and consequences

Clinical research showed that asthma control is an achievable target. However, real-life observations suggest that a significant proportion of patients suffer from symptoms and report lifestyle limitations with a considerable burden on patient's quality of life. The achievement of asthma control is the result of the interaction among different variables concerning the disease pattern and patients' and physicians' knowledge and behaviour. The failure in asthma control can be considered as the result of the complex interaction among different variables, such as the role of guidelines diffusion and implementation, some disease-related factors (i.e., the presence of common comorbidities in asthma such as gastroesophageal reflux disease (GERD), sleep disturbances and obstructive sleep apnea (OSA), and rhinitis) or patient-related factors (i.e., adherence to treatment, alexithymia, and coping strategies). Asthma control may be reached through a tailored treatment plan taking into account the complexity of factors that contribute to achieve and maintain this objective.

Could FEV₁ decline have a role in daily clinical practice for asthma monitoring?

OBJECTIVE

The aim of this review was to understand whether FEV1 decline measured during the follow-up of asthmatic subjects (FEV1 variation between two different measurements at a distance of at least 5 years) may have a role in their management.

METHODS

Articles, commentaries and reviews relating to the topic were searched in PubMed.

RESULTS

Patients with an accelerated FEV1 decline (>30 ml/year) may be either steroid-resistant/difficult-to-treat asthmatics or not adequately treated because they are either under-perceivers or poorly adherent to their therapy. Sometimes they may be unable to use devices correctly. Untreated rhinitis and incorrect lifestyle (obesity status, a high-fat diet and lack of exercise) must be considered when facing a pulmonary function decline. Identifying asthmatics with an accelerated FEV1 decline, even with well controlled symptoms, may allow us to make possible treatment adjustments or to remove potentially harmful environmental exposure and suggest a correct lifestyle. Depending on FEV1 decline severity, we may detect different asthma phenotypes. One type is characterized by no/low lung function reduction. Among moderate/severe 'declining' subjects, there may be a group that might be responsive to treatment and a second one with a quicker loss in lung function that may be unresponsive to therapy.

CONCLUSION

FEV1 decline calculation should be assessed early in clinical practice over the course of time in order to make all possible variations in treatment, environmental exposure and lifestyle more efficacious overall for declining subjects responsive to anti-inflammatory therapy. Further studies are necessary to validate this approach to asthma.

Clinical utility of asthma biomarkers: from bench to bedside

Asthma is a chronic disease characterized by airway inflammation, bronchial hyperresponsiveness, and recurrent episodes of reversible airway obstruction. The disease is very heterogeneous in onset, course, and response to treatment, and seems to encompass a broad collection of heterogeneous disease subtypes with different underlying pathophysiological mechanisms. There is a strong need for easily interpreted clinical biomarkers to assess the nature and severity of the disease. Currently available biomarkers for clinical practice - for example markers in bronchial lavage, bronchial biopsies, sputum, or fraction of exhaled nitric oxide (FeNO) - are limited due to invasiveness or lack of specificity. The assessment of markers in peripheral blood might be a good alternative to study airway inflammation more specifically, compared to FeNO, and in a less invasive manner, compared to bronchoalveolar lavage, biopsies, or sputum induction. In addition, promising novel biomarkers are discovered in the field of breath metabolomics (eg, volatile organic compounds) and (pharmaco)genomics. Biomarker research in asthma is increasingly shifting from the assessment of the value of single biomarkers to multidimensional approaches in which the clinical value of a combination of various markers is studied. This could eventually lead to the development of a clinically applicable algorithm composed of various markers and clinical features to phenotype asthma and improve diagnosis and asthma management.

Fractional exhaled nitric oxide has a good correlation with asthma control and lung function in latino children with asthma

BACKGROUND

Although the measurement of fractional exhaled nitric oxide (FE(NO)) has been recommended for observational studies and clinical trials of asthma, FE(NO) has not been examined in studies of childhood asthma in Latin America,

OBJECTIVE

To examine the relationship between FE(NO) and indicators of disease control or severity [asthma control test/childhood asthma control test (ACT/C-ACT), lung function, and exercise challenge test (ECT)] in Mexican children with persistent asthma,

METHODS

Children (6-18 years of age) with persistent asthma were consecutively recruited in a tertiary asthma clinic and divided into two groups, e.g. FE(NO) < 20 parts per billion (ppb) and ≥20 ppb.Adequate FE(NO) measurements were obtained in 134 (83.2%) of 161 eligible children,

RESULTS

Children with FE(NO)<20 ppb had significantly higher scores on the ACT/C-ACT than those with FE(NO) ≥ 20 ppb (median [interquartile range] :23 [20.8-25] vs. 21 [18-24], p = .002, respectively). Compared to children with FE(NO) ≥20 ppb, those with FE(NO) <20 ppb had a higher baseline predicted forced expiratory volume (FEV(1)) [94% (92.5%-99.4%) vs. 83% (81%-89.9%), p = .001] and a lower probability of having a positive ECT (42.7% vs. 71.2%, p = .001). In addition, FE(NO) was significantly inversely correlated with the participants' ACT/C-ACT score and predicted FEV1, and directly correlated with positive ECT, CONCLUSION: Among Mexican children with persistent asthma, low levels of FE(NO) ( <20 ppb) are associated with better asthma control, and higher lung function.

Alveolar nitric oxide and asthma control in mild untreated asthma

BACKGROUND

The role of the peripheral airways in asthma is increasingly being recognized as a potential target for the achievement of optimal control of the disease. We postulated that the inflammatory changes of the small airways are implicated in the lack of asthma control in mild asthma.

OBJECTIVE

To test this hypothesis, we measured the alveolar fraction of exhaled NO (CalvNO) in patients with mild asthma with different levels of control of symptoms.

METHODS

Seventy-eight patients with asthma (35 men, age, 37 ± 15 years; FEV1 percentage of predicted, 100% ± 9%) were studied. Asthma control was assessed by using the Asthma Control Test (ACT). Measurements of exhaled NO at multiple constant flows were performed.

RESULTS

Bronchial NO concentrations were 27.1 ± 20 nL/min, [corrected] and CalvNO levels were 5.7 ± 3.4 ppb. The ACT score was 20 ± 4.2. The level of asthma control was not associated with bronchial NO concentrations (rs = 0.16, P = .15). However, a significant correlation was found between the ACT score and CalvNO (rs = 0.25, P = .03). Moreover, CalvNO was significantly higher in patients with uncontrolled asthma than in patients with controlled/partially controlled asthma (6.7 ± 2.6 ppb vs 4.9 ± 2.6 nL/min, [corrected] respectively, P = .02). In the subgroup of patients with asthma who underwent extrafine inhaled corticosteroid treatment, the magnitude of the inhaled corticosteroid-induced improvement in asthma control positively correlated with baseline CalvNO at 1 month (rs = 0.39, P = .003) and at 3 months (rs = 0.49, P < .0001).

CONCLUSIONS

The alveolar component of exhaled NO is associated with the lack of asthma control in patients with mild, untreated asthma. This observation supports the notion that abnormalities of the peripheral airways are implicated in the mildest forms of asthma.

Disagreement among common measures of asthma control in children

BACKGROUND

Asthma is a worldwide problem. It cannot be prevented or cured, but it is possible, at least in principle, to control asthma with modern management. Control usually is assessed by history of symptoms, physical examination, and measurement of lung function. A practical problem is that these measures of control may not be in agreement. The aim of this study was to describe agreement among different measures of asthma control in children.

METHODS

A prospective sequential sample of children aged 4 to 11 years with atopic asthma attending a routine follow-up evaluation were studied. Patients were assessed with the following four steps: (1) fraction of exhaled nitric oxide (FENO), (2) spirometry, (3) Childhood Asthma Control Test (cACT), and (4) conventional clinical assessment by a pediatrician. The outcome for each test was coded as controlled or uncontrolled asthma. Agreement among measures was examined by cross-tabulation and κ statistics.

RESULTS

Eighty children were enrolled, and nine were excluded. Mean FENO in pediatrician-judged uncontrolled asthma was double that of controlled asthma (37 parts per billion vs 15 parts per billion, P < .005). There was disagreement among measures of control. Spirometric indices revealed some correlation, but of the unrelated comparisons, those that agreed with each other most often (69%) were clinical assessment by the pediatrician and the cACT. Worst agreement was noted for FENO and cACT (49.3%).

CONCLUSION

Overall, different measures to assess control of asthma showed a lack of agreement for all comparisons in this study.

The Asthma Control Test and Asthma Control Questionnaire for assessing asthma control: Systematic review and meta-analysis

BACKGROUND

Currently, the cornerstone of asthma management is the achievement and maintenance of optimal asthma control, but the diagnostic performances of the Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ) have not been evaluated systematically.

OBJECTIVE

We explored the diagnostic performances of and statistically compared the ACT and ACQ.

METHODS

Studies that examined the accuracy of the ACT, ACQ, or both in the assessment of asthma control were found by searching PubMed, CENTRAL, Web of Science, Ovid, and Embase. Summary estimates of sensitivity, specificity, and diagnostic odds ratios for the different levels of asthma control were determined by using bivariate random-effects models and hierarchical summary receiver operating characteristic models.

RESULTS

Twenty-one studies with 11,141 subjects assessed with the ACT and 12,483 assessed with the ACQ were identified. The ACT had good diagnostic accuracy for assessment of controlled and not well-controlled asthma, and the ACQ (ACQ-7 and ACQ-6) had good diagnostic accuracy for assessment of not well-controlled asthma at prespecified cutoff points. The ACT and ACQ had significant differences in the assessment of controlled and not well-controlled asthma after adjusting for potential factors (P = .001 and P = .015). For assessment of uncontrolled asthma, the ACT had poor accuracy, with a hierarchical summary receiver operating characteristic area under the curve of 0.69, and the cutoff point for the ACQ has not been established.

CONCLUSION

The ACT is preferable to the ACQ in clinical practice, and the ACQ requires further cross-validation. Moreover, neither the ACT nor the ACQ is useful for the assessment of uncontrolled asthma.

Identifying uncontrolled asthma in children with the childhood asthma control test or exhaled nitric oxide measurement

BACKGROUND

International guidelines highlight the importance of assessing asthma control status in children with asthma, and research on practical and objective instruments for assessing asthma control is ongoing.

OBJECTIVE

To determine the role of the Childhood Asthma Control Test (C-ACT) and fractional concentration of exhaled nitric oxide (FeNO) in identifying children with not well-controlled asthma.

METHODS

Children 6 to 11 years of age with asthma were enrolled in the study. They completed C-ACT and underwent FeNO and spirometric measurements during the monthly clinic visits. An asthma specialist assessed asthma control according to the gold standard Global Initiative for Asthma guideline and decided the treatment of the patients.

RESULTS

Seventy-six children with a mean (SD) age of 8.7 (1.4) years were evaluated in the first visit, whereas 64 and 51 children were admitted for second and third visits, respectively. A C-ACT score of 22 or less had 69% sensitivity and 77% specificity in determining not well-controlled asthma, whereas an FeNO value of 19 ppb or higher had 61% sensitivity and 59% specificity in patients who completed 3 visits. Receiver operating characteristic curve analysis revealed that the C-ACT was better than FeNO for identifying patients with not well-controlled asthma (area under the curve, 0.79; P < .001 [C-ACT] vs .58, P = .10 [FeNO]) Results of multivariate generalized estimating equation analysis revealed that a C-ACT score of 22 or less (odds ratio, 8.75; 95% confidence interval, 4.35-17.59; P < .001) and an FeNO of 19 ppb or greater (odds ratio, 2.60; 95% confidence interval, 1.07-6.29; P = .03) were significant indicators for the presence of not well-controlled asthma.

CONCLUSION

The C-ACT is superior to FeNO in determining the control status of children with asthma and may be used as a complementary tool in clinical practice to detect children with not well-controlled asthma.

Asthma outcomes: composite scores of asthma control

BACKGROUND

Current asthma guidelines recommend assessing the level of a patient's asthma control. Consequently, there is increasing use of asthma control as an outcome measure in clinical research studies. Several composite assessment instruments have been developed to measure asthma control.

OBJECTIVE

National Institutes of Health institutes and federal agencies convened an expert group to propose the most appropriate standardized composite score of asthma control instruments to be used in future asthma studies.

METHODS

We conducted a comprehensive search of PubMed using both the National Library of Medicine's Medical Subject Headings and key terms to identify studies that attempted to develop and/or test composite score instruments for asthma control. We classified instruments as core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop convened in March 2010 and finalized in September 2011.

RESULTS

We identified 17 composite score instruments with published validation information; all had comparable content. Eight instruments demonstrated responsiveness over time; 3 demonstrated responsiveness to treatment. A minimal clinically important difference has been established for 3 instruments. The instruments have demographic limitations; some are proprietary, and their use could be limited by cost.

CONCLUSION

Two asthma composite score instruments are sufficiently validated for use in adult populations, but additional research is necessary to validate their use in nonwhite populations. Gaps also exist in validating instruments for pediatric populations.

Exhaled nitric oxide in pediatrics: what is new for practice purposes and clinical research in children?

Fractional exhaled NO (FeNO) is universally considered an indirect marker of eosinophilic airways inflammation, playing an important role in the physiopathology of childhood asthma. Advances in technology and standardization have allowed a wider use of FeNO in clinical practice in children from the age of four years. FeNO measurements add a new dimension to the traditional clinical tools (symptoms scores, lung function tests) in the assessment of asthma. To date a number of studies have suggested a possible use of FeNO in early identification of exacerbation risk and in inhaled corticosteroids titration. The aim of this paper is to address practical issues of interest to paediatric clinicians who are attempting to use FeNO measurements as an adjunctive tool in the diagnosis and management of childhood airway diseases.

Asthma control test (ACT): comparison with clinical, functional, and biological markers of asthma control

BACKGROUND

Asthma Control Test (ACT) is a simple tool for assessing the level of asthma control in clinical practice, and it has been validated in comparison with a general clinical assessment of asthma control, including forced expiratory volume in the first second (FEV(1)).

OBJECTIVE

To evaluate the relationship between ACT score and clinical and functional findings of asthma control and biomarkers of airway inflammation.

METHODS

A total of 68 asthmatic patients observed in our asthma clinic (33 regularly treated with inhaled corticosteroids (ICS) and 35 ICS-naïve) filled ACT questionnaire and underwent the following measurements: (a) FEV(1) before and after salbutamol; (b) exhaled nitric oxide; (c) bronchial hyperresponsiveness to methacholine; (d) sputum eosinophil count; and (e) daytime and nighttime symptoms, rescue salbutamol, and twice-daily peak expiratory flow (PEF) recording on a 4-week diary card.

RESULTS

ACT score significantly correlated with symptom score, rescue medication use, and PEF variability, but not with FEV(1), FEV(1) reversibility, and markers of airway inflammation, which could not distinguish controlled from uncontrolled patients according to ACT, regardless of ICS treatment.

CONCLUSION

ACT score is a valid tool to simply assess the current level of asthma control in terms of symptoms, rescue medication use, and PEF variability. Pulmonary function and biomarkers of airway inflammation are not related to the clinical asthma control as assessed by ACT and may represent additional measurements potentially useful in asthma management.

Assessing asthma control: symptom scores, GINA levels of asthma control, lung function, and exhaled nitric oxide

BACKGROUND

The childhood asthma control test (C-ACT) is a validated symptom score for assessing asthma control in children. We used a slightly modified version (C-ACT(M) ) of the German C-ACT and compared our results with the literature, correlated the children's part of C-ACT (C-ACT(children) ) with a visual analogue scale (VAS(children) ), explored the agreement between C-ACT(M) and GINA levels of asthma control, as well as the relationship between C-ACT(M) and lung function and exhaled nitric oxide (FeNO).

METHODS

We investigated 107 children with a diagnosis of asthma. The study protocol consisted of a clinical examination, assessment of asthma control according to GINA guidelines, administration of C-ACT(M) , VAS(children) , lung function, and FeNO.

RESULTS

Of our patients 66% had, according to GINA, partly controlled-/uncontrolled asthma, 18% were uncontrolled according to C-ACT(M) . Children with partly controlled-/uncontrolled asthma according to GINA had lower C-ACT(M) scores than did children with controlled asthma (16.1 ± 3.6 SD vs. 25.4 ± 1.8 SD; P < 0.000), and children with a C-ACT(M) score ≤ 19 had poorer lung function (mean FEV1% predicted 81.5 ± 13.5 SD vs. 94.2 ± 12.1 SD; P = 0.002). Spearman's rank correlation coefficients revealed significant correlations between all symptom scores. Multiple linear regression adjusted for age, gender, FEV1 and FeNO demonstrated a significant relationship between C-ACT(M) , VAS(children) , and FEV1 (P = 0.003, resp. <0.000), but no significant correlation between C-ACT(M) , VAS(children) , and FeNO.

CONCLUSIONS

The German version of C-ACT(M) is valid and useful for monitoring children with asthma along with tests aimed to follow up lung function and airway inflammation. Concordance between C-ACT(M) and GINA is moderate, because asthma control assessed by C-ACT(M) allows more symptoms and lung function is not included in the scoring.

An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications

BACKGROUND

Measurement of fractional nitric oxide (NO) concentration in exhaled breath (Fe(NO)) is a quantitative, noninvasive, simple, and safe method of measuring airway inflammation that provides a complementary tool to other ways of assessing airways disease, including asthma. While Fe(NO) measurement has been standardized, there is currently no reference guideline for practicing health care providers to guide them in the appropriate use and interpretation of Fe(NO) in clinical practice.

PURPOSE

To develop evidence-based guidelines for the interpretation of Fe(NO) measurements that incorporate evidence that has accumulated over the past decade.

METHODS

We created a multidisciplinary committee with expertise in the clinical care, clinical science, or basic science of airway disease and/or NO. The committee identified important clinical questions, synthesized the evidence, and formulated recommendations. Recommendations were developed using pragmatic systematic reviews of the literature and the GRADE approach.

RESULTS

The evidence related to the use of Fe(NO) measurements is reviewed and clinical practice recommendations are provided.

CONCLUSIONS

In the setting of chronic inflammatory airway disease including asthma, conventional tests such as FEV(1) reversibility or provocation tests are only indirectly associated with airway inflammation. Fe(NO) offers added advantages for patient care including, but not limited to (1) detecting of eosinophilic airway inflammation, (2) determining the likelihood of corticosteroid responsiveness, (3) monitoring of airway inflammation to determine the potential need for corticosteroid, and (4) unmasking of otherwise unsuspected nonadherence to corticosteroid therapy.

Associations of Fraction of Exhaled Nitric Oxide with Beta Agonist Use in Children with Asthma

The fraction of exhaled nitric oxide (FeNO), a measure of airway inflammation, is a potential noninvasive tool to guide asthma management in children. It remains unclear, however, if FeNO adds any information beyond clinical assessment of asthma control. We evaluated the associations of FeNO level with short acting beta agonist use and compared it with other clinical asthma assessments. We examined a prospective cohort study of 225 tobacco-smoke-exposed children aged 6-12 years with doctor-diagnosed asthma, including measures of FeNO, reported days of short acting beta agonist use, and unscheduled asthma visits. FeNO was analyzed in relation to current and future (3 months later) short acting beta agonist use. Mean FeNO at baseline, 6, and 12 months was 15.5, 15.7, and 16.8 ppb. In multivariable analyses, higher FeNO level was associated with increased short acting beta agonist use but only among children who were not on inhaled corticosteroids. Among those not on an inhaled steroid, there was a 12% increase in current and 15% increase in future days of short acting beta agonist use for every 10 ppb increase in FeNO level. FeNO levels remained associated with current short acting beta agonist use even after adjusting for unscheduled asthma visits. FeNO levels remained associated with future short acting beta agonist use even after adjusting for current short acting beta agonist use or unscheduled asthma visits. We conclude that FeNO levels are associated with short acting beta agonist use but only among children who are not on an inhaled corticosteroid.

Exhaled breath condensate nitrates, but not nitrites or FENO, relate to asthma control

BACKGROUND

Asthma is a chronic respiratory disease, characterised by airways inflammation, obstruction and hyperresponsiveness. Asthma control is the goal of asthma treatment, but many patients have sub-optimal control. Exhaled NO and exhaled breath condensate (EBC) NO metabolites (nitrites and nitrates) measurements are non-invasive tools to assess airways inflammation. Our aim was to investigate the relationships between asthma control and the above-named biomarkers of airways inflammation.

METHODS

Thirty-nine non-smoking asthmatic patients (19 women) aged 50 (21-80) years performed measurements of exhaled NO (FENO), EBC nitrates, nitrites and pH, and answered Asthma Control Questionnaire (ACQ) and Asthma Control Test (ACT)-questionnaire.

RESULTS

The ACT and ACQ score were strongly interrelated (ρ = -0.84, p < 0.001). No relationships between ACT or ACQ score and FENO were found (p > 0.05). EBC nitrates were negatively related to ACT score (ρ = -0.34, p = 0.03) and positively related to ACQ score (ρ = 0.41, p = 0.001) while no relation of EBC nitrites to either ACQ or ACT score was found (p>0.05).

CONCLUSION

EBC nitrates were the only biomarker that was significantly related to asthma control. This suggests that nitrates, but not nitrites or FENO, reflect an aspect of airways inflammation that is closer related to asthma symptoms. Therefore there is a potential role for EBC nitrates in objective assessment of asthma control.