Serum eosinophilic cationic protein and blood eosinophil counts for the prediction of the presence of airways inflammation in children with wheezing

Eosinophil cell count in bronchoalveolar lavage fluid in early childhood wheezing: is it predictive of future asthma?

Objective: Increased eosinophil level in bronchoalveolar lavage fluid (BALF) characterizes asthma in school-age children and adults and has been suggested as a marker for disease severity and response to treatment. We aimed to investigate the occurrence and yield of BALF eosinophil cell count in preschool children with recurrent wheezing and its possible relation to future diagnosis of asthma. Methods: BALF was retrospectively studied in young wheezy children and its relation to asthma at age 6 years was evaluated. BALF from children aged 1-48 months (mean = 20.4) was analyzed in preschool wheezy children. Children with anatomical airway obstruction and other lower airway/lung diseases who underwent BALF served as controls. Assessment of asthma was accomplished at 6 years. Results: Eighty-two children were included. The mean age during bronchoscopy and BAL was 20.4 ± 14.4 months (range: 1-48 months). Twenty-six patients had recurrent preschool wheezing, 13 anatomical airway obstruction and 43 had other lower airways/lung diseases. Groups were comparable for age during bronchoscopy and gender. No difference was found between groups for any of the BALF cell types. Eosinophils were very low in all three groups [mean (interquartile range): 0 (0-0.4), 0 (0-0.8), and 0.4 (0-1), respectively, p = 0.25]. No difference in eosinophil levels during bronchoscopy was found between asthmatic children to non-asthmatic as defined at age 6 years. Conclusions: Wheezing in preschool children is not associated with increased BALF eosinophils; hence, at this age, the diagnostic yield of BALF for cell count analysis for diagnosing asthma is limited and is not routinely indicated.

Blood Eosinophil Count and Outcomes in Severe Uncontrolled Asthma: A Prospective Study

BACKGROUND

Severe uncontrolled asthma (SUA) is associated with increased asthma exacerbations. Whether high blood eosinophil counts are related to this burden is uncertain.

OBJECTIVES

To determine the relationship of blood eosinophil counts to asthma exacerbations, utilization, and cost in patients with SUA.

METHODS

Patients with persistent asthma (age ≥ 12 years) were identified administratively with SUA in phase I by evidencing (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting β₂-agonist; and (3) 3 or more dispensed non-ICS controllers. Of the 541 patients with SUA invited to participate in the prospective phase II follow-up study, 261 (48.2%) had blood tests (index date) to determine eosinophil count and other atopic biomarkers. The relationship of blood eosinophil cutoff points to asthma exacerbations and direct costs 1 year after the index date were determined by multivariable regression.

RESULTS

A blood eosinophil cutoff point of greater than or equal to 400 cells/mm³ compared with less than 400 cells/mm³, but not 150 cells/mm³ or 300 cells/mm³, was a risk factor in the outcome year in adjusted analyses for 2 or more asthma exacerbations (risk ratio, 1.55; 95% CI, 1.02-2.35; P =.04) and any asthma emergency department visit or hospitalization (risk ratio, 2.29; 95% CI, 1.16-4.55; P =.02), but not for rate of asthma exacerbations or incremental total direct asthma costs per patient ($202; 95% CI, -286 to 691).

CONCLUSIONS

A high blood eosinophil count was an independent risk factor for 2 or more asthma exacerbations or any asthma emergency department visit or hospitalization, but not direct costs in patients with SUA, possibly constrained by limited power.

Blood eosinophils as a marker of likely corticosteroid response in children with preschool wheeze: time for an eosinophil guided clinical trial?

Childhood wheezing is common particularly in children under the age of 6 years and in this age group is generally referred to as preschool wheezing. Particular diagnostic and treatment uncertainties exist in these young children due to the difficulty in obtaining objective evidence of reversible airways narrowing and inflammation. A diagnosis of asthma depends on the presence of relevant clinical signs and symptoms and the demonstration of reversible airways narrowing on lung function testing, which is difficult to perform in young children. Few treatments are available and inhaled corticosteroids are the recommended preventer treatment in most international asthma guidelines. There is, however, considerable controversy about its effectiveness in children with preschool wheeze and a corticosteroid responder phenotype has not been established. These diagnostic and treatment uncertainties in conjunction with the knowledge of corticosteroid side effects, in particular the reduction of growth velocity, have resulted in a variable approach to inhaled corticosteroid prescribing by medical practitioners and a reluctance in carers to regularly administer the treatment. Identifying children who are likely responders to corticosteroid therapy would be a major benefit in the management of this condition. Eosinophils have emerged as a promising biomarker of corticosteroid responsive airways disease, and evaluation of this biomarker in sputum has successfully been employed to direct management in adults with asthma. Obtaining sputum from young children is time consuming and difficult, and it is hard to justify more invasive procedures such as a bronchoscopy in young children routinely. Recently, in children, interest has shifted to assessing the value of less invasive biomarkers of likely corticosteroid response and the biomarker 'blood eosinophils' has emerged as an attractive candidate. The aim of this review was to summarize the evidence for blood eosinophils as a predictive biomarker for corticosteroid responsive disease with a particular focus on the difficult area of preschool wheeze.

Japanese pediatric guideline for the treatment and management of bronchial asthma 2012

A new version of the Japanese pediatric guideline for the treatment and management of bronchial asthma was published in Japanese at the end of 2011. The guideline sets the pragmatic goal for clinicians treating childhood asthma as maintaining a "well-controlled level" for an extended period in which the child patient can lead a trouble-free daily life, not forgetting the ultimate goal of obtaining remission and/or cure. Important factors in the attainment of the pragmatic goal are: (i) appropriate use of anti-inflammatory drugs; (ii) elimination of environmental risk factors; and (iii) educational and enlightening activities for the patient and caregivers regarding adequate asthma management in daily life. The well-controlled level refers to a symptom-free state in which no transient coughs, wheezing, dyspnea or other symptoms associated with bronchial asthma are present, even for a short period of time. As was the case in the previous versions of the guideline, asthmatic children younger than 2 years of age are defined as infantile asthma patients. Special attention is paid to these patients in the new guideline: they often have rapid exacerbation and easily present chronic asthmatic conditions after the disease is established.

Can we predict sputum eosinophilia from clinical assessment in patients referred to an adult asthma clinic?

BACKGROUND

There is overwhelming evidence that asthma guidelines aimed at reducing airway inflammation are superior to those based on clinical symptoms alone. This involves targeting eosinophilic inflammation with inhaled corticosteroids.

AIM

Because induced sputum is not readily available, our study set out to investigate whether the collective or singular use of routine asthma investigations can predict sputum eosinophilia.

METHODS

Eighty patients underwent skin prick testing, blood tests (IgE, full blood count), spirometry, exhaled fraction nitric oxide (FeNO), PD15 to hypertonic saline, and induced sputum testing at first assessment. A predictive model for sputum eosinophilia (defined as ≥3% eosinophils) was sought using routinely available tests.

RESULTS

Fifty-four subjects underwent both induced sputum and FeNO testing. Seventeen (30%) revealed eosinophilic inflammation, nine (16%) neutrophilic, four (7%) mixed granulocytic and 26 (46%) paucigranulocytic. Positive predictors for sputum eosinophilia included low forced expiratory volume in 1 s (FEV(1))% predicted, raised serum eosinophil, positive smoking history, Polynesian ethnicity and negative asthma family history. There was a non-statistically significant trend for FeNO predicting sputum eosinophilia. The best combination of predictors was low FEV(1)% predicted, raised serum eosinophil, positive smoking history and negative family history of asthma.

CONCLUSION

This study demonstrates that the serum eosinophil count and FEV(1) combined with aspects of a clinical history may provide a simple and practical alternative to assessment of airway (sputum) eosinophilia in the clinical setting. A full blood count can be performed at a substantially lesser cost and with greater accessibility than induced sputum. We feel the time has come for the clinical utility of the serum eosinophil count to be revisited.

Distribution of sputum cellular phenotype in a large asthma cohort: predicting factors for eosinophilic vs neutrophilic inflammation

Background

Phenotyping asthma according to airway inflammation allows identification of responders to targeted therapy. Induced sputum is technically demanding. We aimed to identify predictors of sputum inflammatory phenotypes according to easily available clinical characteristics.

Methods

This retrospective study was conducted in 508 asthmatics with successful sputum induction recruited from the University Asthma Clinic of Liege. Receiver-operating characteristic (ROC) curve and multiple logistic regression analysis were used to assess the relationship between sputum eosinophil or neutrophil count and a set of covariates. Equations predicting sputum eosinophils and neutrophils were then validated in an independent group of asthmatics.

Results

Eosinophilic (≥3%) and neutrophilic (≥76%) airway inflammation were observed in 46% and 18% of patients respectively. Predictors of sputum eosinophilia ≥3% were high blood eosinophils, FE_NO and IgE level and low FEV₁/FVC. The derived equation was validated with a Cohen’s kappa coefficient of 0.59 (p < 0.0001). ROC curves showed a cut-off value of 220/mm³ (AUC = 0.79, p < 0.0001) or 3% (AUC = 0.81, p < 0.0001) for blood eosinophils to identify sputum eosinophilia ≥3%. Independent predictors of sputum neutrophilia were advanced age and high FRC but not blood neutrophil count.

Conclusion

Eosinophilic and paucigranulocytic asthma are the dominant inflammatory phenotypes. Blood eosinophils provide a practical alternative to predict sputum eosinophilia but sputum neutrophil count is poorly related to blood neutrophils.

Asthma in children and adolescents: a comprehensive approach to diagnosis and management

Asthma is a chronic disease that has a significant impact on quality of life and is particularly important in children and adolescents, in part due to the higher incidence of allergies in children. The incidence of asthma has increased dramatically during this time period, with the highest increases in the urban areas of developed countries. It seems that the incidence in developing countries may follow this trend as well. While our knowledge of the pathophysiology of asthma and the available of newer, safer medication have both improved, the mortality of the disease has undergone an overall increase in the past 30 years. Asthma treatment goals in children include decreasing mortality and improving quality of life. Specific treatment goals include but are not limited to decreasing inflammation, improving lung function, decreasing clinical symptoms, reducing hospital stays and emergency department visits, reducing work or school absences, and reducing the need for rescue medications. Non-pharmacological management strategies include allergen avoidance, environmental evaluation for allergens and irritants, patient education, allergy testing, regular monitoring of lung function, and the use of asthma management plans, asthma control tests, peak flow meters, and asthma diaries. Achieving asthma treatment goals reduces direct and indirect costs of asthma and is economically cost-effective. Treatment in children presents unique challenges in diagnosis and management. Challenges in diagnosis include consideration of other diseases such as viral respiratory illnesses or vocal cord dysfunction. Challenges in management include evaluation of the child’s ability to use inhalers and peak flow meters and the management of exercise-induced asthma.

Predictive capabilities of serum eosinophil cationic protein, percentage of eosinophils and total immunoglobulin E in allergic rhinitis without bronchial asthma

This study identified cut-off values for allergy markers for use in the diagnosis of allergic rhinitis in the absence of other allergic diseases. Total immunoglobulin E (IgE), eosinophil cationic protein (ECP) and the numbers of eosinophils were measured in serum samples from 442 patients with typical symptoms of allergic rhinitis. A definite diagnosis was made on the basis of the presence of specific IgE levels. Cut-off values with a maximal discrimination to diagnose allergic rhinitis were found to be 98.7 IU/ml, 24.7 μg/ml and 4.0% for total IgE, ECP and eosinophils, respectively. Sensitivity, specificity and odds ratio for these values were 75.2%, 69.7% and 6.93, respectively, for total IgE, 55.7%, 74.4% and 3.70 for ECP, and 57.5%, 72.0% and 3.47 for eosinophils. A composite score representing positive results for all three markers had a positive predictive value of 85.3%, with an odds ratio of 8.55. It was concluded that total serum IgE, ECP and eosinophil percentage are strong predictors of allergic rhinitis and the determination of cut-off values for these markers can aid in the diagnosis of allergic rhinitis in the clinical setting.

The Pediatric Asthmatic

The incidence of allergies and asthma in the Western world has been increasing over the past 30 years. However, more recent data suggests that over the past 5–10 years, the overall global trends of asthma incidence have begun to stabilize (1). Urbanization and industrialization has contributed to the increase in developed countries, but the reasons for this are still unclear. Asthma is estimated to be responsible for 1 in every 250 deaths worldwide. Many of these deaths are preventable, and specific issues have been identified that may contribute to this high mortality rate. Factors that contribute to high ­mortality and morbidity include slow access to care and medications, inadequate environmental control of allergens and irritants, dietary changes, genetic variations, cultural barriers, lack of education amongst patients and providers, insufficient resources, and improper use of health care dollars.

Does airway allergic inflammation pre-exist before late onset wheeze in children?

Epidemiological studies show that some children develop wheezing after 3 yr of age which tends to persist. It is unknown how this starts or whether there is a period of asymptomatic inflammation. The aim of this study is to determine whether lower airway allergic inflammation pre-exists in late onset childhood wheeze (LOCW). Follow-up study of children below 5 yr who had a non-bronchoscopic bronchoalveolar lavage (BAL) performed during elective surgery. The children had acted as normal controls. A modified ISAAC questionnaire was sent out at least 7 yr following the initial BAL, and this was used to ascertain whether any children had subsequently developed wheezing or other atopic disease (eczema, allergic rhinitis). Cellular and cytokine data from the original BAL were compared between those who never wheezed (NW) and those who had developed LOCW. Eighty-one normal non-asthmatic children were recruited with a median age of 3.2. Of the 65 children contactable, 9 (16.7%) had developed wheeze, 11 (18.5%) developed eczema and 14 (22.2%) developed hay fever. In five patients, wheeze symptoms developed mean 3.3-yr (range: 2-5 yr) post-BAL. Serum IgE and blood eosinophils were not different in the LOCW and NW, although the blood white cell count was lower in the LOCW group. The median BAL eosinophil % was significantly increased in the patients with LOCW (1.55%, IQR: 0.33 to 3.92) compared to the children who never wheezed, NW (0.1, IQR: 0.0 to 0.3, p = 0.01). No differences were detected for other cell types. There were no significant differences in BAL cytokine concentrations between children with LOCW and NW children. Before late onset childhood wheezing developed, we found evidence of elevated eosinophils in the airways. These data suggest pre-existent airways inflammation in childhood asthma some years before clinical presentation.

Comparative clinical evaluation of ketotifen and montelukast sodium in asthmatic Iraqi patients

Asthma is a common and chronic inflammatory condition of the airways whose cause is not completely understood. Although many classes of drugs are used for management of asthma, the response is variable due to multifactor reasons. This study was designed to evaluate the outcome of using ketotifen or montelukast sodium in Iraqi asthmatic patients. Single blinded randomized clinical trial was utilized, in which 100 asthmatic patients were recruited from Al-Karama hospital and randomized into two groups; 1st group (50 patients, treated with ketotifen for 4 weeks) and 2nd group (50 patients treated with montelukast sodium for 4 weeks). Asthma symptom score and wheezing were recorded at the beginning (first visit) and at the end of the study (after one month). Pulmonary function tests (PFTs) were performed by spirometry, and the patients' use of asthma drugs and their symptoms were evaluated at each visit. The result showed that asthma symptom, chest wheezing, and PFT values were significantly improved in the two groups at the end of the study compared to first visit (p < 0.05). All symptoms were significantly lower and PFT values were higher in the 2nd group compared to 1st group (p < 0.05). In conclusion, both ketotifen and montelukast sodium showed significant changes in asthma symptoms and PFT after one month of treatment, but the changes were more significant with montelukast group (2nd group) compared with ketotifen group (1st group) and this indicate that montelukast was more effective than ketotifen in treatment of asthmatic patients.

Eosinophil activity in infants hospitalized for wheezing and risk of persistent childhood asthma

Eosinophilic inflammation has a central role in the pathogenesis of asthma. We aimed to elucidate whether elevated blood eosinophil count (B-EOS), eosinophil cationic protein in serum (S-ECP) or in nasopharyngeal aspirate (NPA-ECP) predict later asthma after hospitalization for wheezing in infancy. In 1992-1993, 100 infants aged <24 months were hospitalized for wheezing associated with respiratory infection. B-EOS, S-ECP and NPA-ECP were measured on admission. Asthma status was evaluated at the follow-up visits at the median ages of 4.0, 7.2 and 12.3 yr. Twenty (25%) of 81 children had asthma at all three visits and were considered to have persistent childhood asthma (PCA). Children with B-EOS >or= 0.450 x 10(9) cells/l had a 2.9-fold PCA risk compared with other children. The risk was 6.1-fold when S-ECP was >or=20.0 microg/l and 6.7-fold when NPA-ECP was >or=815.0 ng/g. By these cut-off limits, all these markers were specific (75-93%), but not very sensitive (30-58%) in predicting PCA. At least one marker was elevated in 75% of the children with PCA. The respective figure for NPA-ECP alone was 58%. In adjusted analyses, only elevated NPA-ECP was an independent risk factor for PCA (OR 4.09). In conclusion, eosinophil activity in early life predicts the development of childhood asthma after hospitalization for wheezing in infancy. The results highlight NPA-ECP as an independent predictor of the persistence of asthma at school age.

Randomized, placebo-controlled study of a selective PDE4 inhibitor in the treatment of asthma

BACKGROUND

Phosphodiesterase-4 (PDE4) inhibitors have potential utility as a new therapeutic approach to improving symptoms and pulmonary function in asthma and COPD. This study evaluated the efficacy and safety of MK-0359, a selective and potent oral PDE4 inhibitor, in chronic asthma.

METHODS

Adults (N=88) with > or =1 year asthma history and an FEV(1) 50-80% predicted were randomized to double-blind treatment with MK-0359 (15mg/day) or placebo for 14 days, then crossed-over to the other treatment for 14 days. The primary endpoint was the change from baseline in FEV(1) at the end of each 2-week treatment period. Secondary and other endpoints included the changes from baseline in Daytime asthma symptom score, Nighttime asthma symptom score, Total daily beta-agonist use (puffs/day), AM and PM peak expiratory flow (PEF) and overall asthma-specific quality-of-life. Safety and tolerability were assessed by clinical adverse experiences.

RESULTS

MK-0359 significantly improved the primary endpoint (versus placebo): the least-squares mean difference in change from baseline in FEV(1) (L) was 0.09L (95% CI 0.01, 0.18). Endpoints of Daytime asthma symptom score, Nighttime asthma symptom score, Total daily beta-agonist use, AM PEF, PM PEF, and quality-of-life were also significantly improved. Nineteen patients (24.1%) on MK-0359 and 8 patients (10.4%) on placebo reported gastrointestinal clinical adverse experiences. Serious gastrointestinal clinical adverse experiences were reported in 3 patients while receiving MK-0359.

CONCLUSION

Over a 14-day treatment period, the oral PDE4 inhibitor MK-0359 improved lower airway function, symptoms and rescue medication use in chronic asthma, although at the expense of gastrointestinal adverse experiences. (Clinical trial registry number: NCT00482898.).

Presence of eosinophils in nasal secretion during acute respiratory tract infection in young children predicts subsequent wheezing within two months

BACKGROUND

In young children with wheezing or bronchiolitis, especially with respiratory syncitial virus, blood eosinophilia and a high eosinophil cationic protein level in nasal secretions predicts subsequent wheezing in later childhood. However, whether eosinophil activation results from virus-induced inflammation or local eosinophilia per se precedes the onset of wheezing remains unknown. In the present study, we examined the association between the presence of nasal eosinophils during respiratory tract infection (RTI) and subsequent wheezing in young children.

METHODS

A total of 35 young children less than 3 years of age who visited our outpatient clinic with rhinorrhea between April and July 2004 were enrolled in this prospective cohort study. Subjects who were given diagnoses of allergic rhinitis were excluded. In all the subjects, the presence of eosinophils in nasal secretions was determined. The subjects were followed, and the cumulative incidences of wheezing during the subsequent 2- and 12-month periods were examined.

RESULTS

According to a logistic regression analysis adjusted for age, sex, family history, allergies, and wheezing at entry, young children with nasal eosinophil infiltration during acute RTI had a significantly higher risk of wheezing during the subsequent 2 months, compared with those without nasal eosinophil infiltration (adjusted odds ratio, 27.618, p = 0.016).

CONCLUSIONS

Our findings not only suggest that nasal eosinophil testing may serve as a convenient clinical marker for identifying young children at risk for subsequent wheezing, but also shed new light on the role of eosinophils in the onset of wheezing in young children.

Eosinophil cationic protein and chemokines in nasopharyngeal secretions of infants with respiratory syncytial virus (RSV) bronchiolitis and non-RSV bronchiolitis

Bronchiolitis is a risk factor for the development of childhood asthma. Eosinophilic inflammation in airways plays an important role in the pathophysiology of both bronchiolitis and asthma. To investigate this inflammation, we measured the eosinophil cationic protein (ECP), regulated on activation normal T-cell expressed and secreted (RANTES) and eotaxin levels in nasopharyngeal secretions (NPS). Twenty-eight patients with RSV bronchiolitis (RSV group), 11 patients with non-RSV bronchiolitis (non-RSV group) and 7 controls were enrolled in this study. ECP, RANTES, and eotaxin levels were measured by enzyme immunoassays. The ECP level in the NPS of the RSV group was significantly higher than that in the NPS of the non-RSV group and controls. RANTES and eotaxin levels in infants with bronchiolitis were significantly higher than those in the controls, but there was no significant difference between the RSV and non-RSV groups. In conclusion, with regard to eosinophilic airway inflammation, as compared with non-RSV bronchiolitis, RSV bronchiolitis may be more similar to childhood asthma.

Airway hyper-responsiveness to adenosine 5'-monophosphate in preschool-age children with asthma

Airway hyper-responsiveness (AHR) to adenosine 5'-monophosphate (AMP) is closely associated with airway inflammation; however, not all asthmatic patients are responsive to it. This study was planned to investigate the predictive factors of AHR to AMP in asthmatic children aged between 3 and 6 yr. We performed a retrospective analysis of data from 63 asthmatic preschool-age children who were challenged by AMP in our department. All children were characterized by skin-prick tests, serum immunoglobulin E (IgE) levels, peripheral blood eosinophil percentage and bronchial challenge with methacholine (MCH) and AMP. Potential determinants for AHR to AMP were assessed within the group. AHR to AMP was found in 46% of preschool-age children with asthma, while that of MCH was 93.7%. All children responsive to AMP were also responsive to MCH. The geometric mean provocative concentration of MCH and AMP causing a 15% fall in transcutaneous oxygen tension (PC(15)PtcO(2)MCH and AMP) were 0.55 mg/ml (0.004-9.19) and 10.53 mg/ml (0.59-342.89), respectively. AMP-responsive children did not differ from non-responsive ones with respect to demographic factors, geometric mean PC(15)PtcO(2)MCH and atopic status. The median serum IgE level was significantly higher in AMP-responsive group than the non-responsive ones (p = 0.011). The peripheral blood eosinophilia was more frequent among responsive children (p = 0.019), and it was found as the only predictive factor for AMP responsiveness in preschool-age children with asthma in logistic regression model (odds ratio: 5.14; 95% CI: 1.23-21.47; p = 0.025). AMP responsiveness may be predicted by peripheral blood eosinophilia but not with atopy markers in young children with asthma.

A randomized open-label comparative study of montelukast versus theophylline added to inhaled corticosteroid in asthmatic children

BACKGROUND

Inhaled corticosteroids (ICSs) are widely used in combination with other classes of drugs for treatment of childhood asthma. The efficacy and the safety of montelukast added to low-dose ICS therapy were compared with those of sustained-release theophylline added to low-dose ICS therapy in asthmatic children in the present study.

METHODS

Following the 2-week run-in period, 6-to 14-year old patients receiving treatment with ICSs were randomized to treatment for 4 weeks with either montelukast 5 mg once daily or sustained release theophylline 5-8 mg/kg (dry syrup) or 100-200 mg (tablet) twice daily. Patients also received a fixed dose of ICS throughout the run-in and treatment periods. The primary efficacy endpoint was the change from baseline in peak expiratory flow (PEF) at Week 2.

RESULTS

A significant increase in morning PEF was observed in the add-on montelukast group as compared with the add-on theophylline group at Week 2 (change from baseline of 22.8 L/minvs. 8.7 L/min; p = 0.041 for between-group difference) and at Week 4 (31.0 L/minvs. 9.8 L/min; p = 0.012). A significant increase in evening PEF was observed in the add-on montelukast group as compared with the add-on theophylline group at Week 4 (24.7 L/minvs. 8.7 L/min; p = 0.027). There were no significant differences between the treatment groups in incidences of clinical and laboratory adverse experiences.

CONCLUSIONS

The results indicate that montelukast added to low-dose ICS is an effective and safe option for the treatment of asthma in children.

2003 canadian asthma consensus guidelines executive summary

BACKGROUND

Guidelines for the diagnosis and management of asthma have been published over the last 15 years; however, there has been little focus on issues relating to asthma in childhood. Since the last revision of the 1999 Canadian Asthma Consensus Report, important new studies, particularly in children, have highlighted the need to incorporate new information into the asthma guidelines. The objectives of this article are to review the literature on asthma published between January 2000 and June 2003 and to evaluate the influence of new evidence on the recommendations made in the 1999 Canadian Asthma Consensus Report and its 2001 update, with a major focus on pediatric issues.

METHODS

The diagnosis of asthma in young children and prevention strategies, pharmacotherapy, inhalation devices, immunotherapy, and asthma education were selected for review by small expert resource groups. The reviews were discussed in June 2003 at a meeting under the auspices of the Canadian Network For Asthma Care and the Canadian Thoracic Society. Data published through December 2004 were subsequently reviewed by the individual expert resource groups.

RESULTS

This report evaluates early-life prevention strategies and focuses on treatment of asthma in children, emphasizing the importance of early diagnosis and preventive therapy, the benefits of additional therapy, and the essential role of asthma education.

CONCLUSION

We generally support previous recommendations and focus on new issues, particularly those relevant to children and their families. This document is a guide for asthma management based on the best available published data and the opinion of health care professionals, including asthma experts and educators.

Additive effect of eosinophilia and atopy on exhaled nitric oxide levels in children with or without a history of respiratory symptoms

Although atopy and blood eosinophilia both influence exhaled nitric oxide (eNO) measurements, no study has quantified their single or combined effect. We assessed the combined effect of atopy and blood eosinophilia on eNO in unselected schoolchildren. In 356 schoolchildren (boys/girls: 168/188) aged 9.0-11.5 yr, we determined eNO, total serum IgE, blood eosinophil counts and did skin prick tests (SPT) and spirometry. Parents completed a questionnaire on their children's current or past respiratory symptoms. Atopy was defined by a SPT >3 mm and eosinophilia by a blood cell count above the 80th percentile (>310 cells/ml). eNO levels were about twofold higher in atopic-eosinophilic subjects than in atopic subjects with low blood eosinophils [24.3 p.p.b. (parts per billion) vs. 14.1 p.p.b.] and than non-atopic subjects with high or low blood eosinophils (24.3 p.p.b. vs. 12.2 p.p.b. and 10.9 p.p.b.) (p <0.001 for both comparisons). The additive effect of atopy and high eosinophil count on eNO levels remained unchanged when subjects were analyzed separately by sex or by a positive history of wheeze (n=60), respiratory symptoms other than wheeze (n=107) or without respiratory symptoms (n=189). The frequency of sensitization to Dermatophagoides (Dpt or Dpf) was similar in atopic children with and without eosinophilia (66.2% and 67.4%, respectively); eosinophilia significantly increased eNO levels in Dp-sensitized children as well in children sensitized to other allergens. In a multiple linear regression analysis, eNO levels were mainly explained by the sum of positive SPT wheals and a high blood eosinophil count (t=4.8 and 4.3, p=0.000), but also by the presence of respiratory symptoms (especially wheeze) and male sex (t=2.6 and 2.0, p=0.009 and 0.045, respectively). Measuring eNO could be a simple, non-invasive method for identifying subjects at risk of asthma in unselected school populations.

High levels of cord serum eosinophil cationic protein predict the risk of atopy

BACKGROUND

Transient tachypnoea of the newborn is a transient respiratory disturbance characterized by tachypnoea shortly after birth, which resolves within 2 to 5 days. The basic pathogenetic mechanism is the delayed resorption of the alveolar fluid of which the exact triggering mechanism still remains unknown. An etiological link associated with parenteral history of atopy was proposed by several studies. Some laboratory studies also revealed that serum IgE, eosinophil cationic protein (ECP) and cord IgE were higher among infants with maternal history of atopy.

OBJECTIVE

The purpose of this study was to investigate the possible association of parental history of atopy with cord blood ECP and IgE concentrations in infants with transient tachypnoea of the newborn.

METHODS

ECP and IgE levels were quantified in cord blood samples of 30 infants who were diagnosed as having transient tachypnoea of the newborn. The control group (N=30) was selected among healthy newborns with similar birth weight and gestational age.

RESULTS

Cord blood ECP concentrations were significantly higher in the study group (17.6 microg/L) than in healthy control subjects (7.89 microg/L). In addition, transient tachypnoea of the newborn was more frequent in infants with a family history of atopic disease (p<0.01). Cord blood IgE concentrations were also higher in the study group than the controls (4.1 versus 3.28 mg/L) but the difference was not statistically significant (p>0.05).

CONCLUSION

Family history of atopy and elevated levels of cord blood ECP are risk factors for transient tachypnoea of the newborn. In addition cord blood ECP level is a useful marker for predicting the risk of atopy.

Clinical usefulness of inflammatory markers in asthma

Asthma is a significant and increasing health problem. Airway inflammation and hyperresponsiveness are key pathophysiological mechanisms underlying asthma. Currently, effective treatments target these two processes and can lead to clinically important improvements in disease control. At present, decisions to initiate or modify therapy are based on symptoms and measures of airway caliber, with no direct assessment of airway inflammation or hyperresponsiveness. It is now possible to measure airway inflammation using noninvasive markers such as exhaled gases, induced sputum and serum measurements. Exhaled nitric oxide (eNO) and induced sputum eosinophils show the greatest promise as clinically useful markers of airway inflammation in asthma. Induced sputum can now be applied to the diagnosis of airway diseases, based on its ability to detect eosinophilic bronchitis in cough, and to differentiate between eosinophilic and non-eosinophilic asthma. The place of induced sputum and eNO in the ongoing monitoring of patients with asthma are now being investigated in controlled trials.

Efficacy of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years: randomised controlled trial

BACKGROUND

Episodic wheeze triggered by viral colds is common in children aged between 1 and 5 years (preschool viral wheeze). Most affected children are asymptomatic by age 6 years. Persistence of wheeze is associated with above-average systemic eosinophil priming. Use of parental-initiated oral prednisolone is recommended at the first sign of preschool viral wheeze. However, evidence for this treatment strategy is conflicting. We therefore aimed to assess the efficacy of a short course of oral prednisolone for preschool viral wheeze, with stratification for systemic eosinophil priming.

METHODS

Children aged 1-5 years admitted to hospital with viral wheeze were allocated to either a high-primed or low-primed stratum according to amounts of serum eosinophil cationic protein and eosinophil protein X, and randomised to parent-initiated prednisolone (20 mg one daily for 5 days) or placebo for the next episode. The primary outcomes were the 7-day mean daytime and night-time respiratory symptom scores, which were analysed by mean differences between treatment groups.

FINDINGS

108 children were randomised to placebo and 109 to prednisolone. Outcome data were available for 120 (78%) of 153 children who had a further episode of viral wheeze, of whom 51 received prednisolone and 69 placebo. Mean daytime (difference in means -0.01 [-0.22 to 0.20]) and night-time (0.10 [-0.12 to 0.32]) respiratory symptom scores and need for hospital admission did not differ between treatment groups. Within the high-primed (n=59) and low-primed (n=61) strata there was no difference in primary outcome between treatment groups.

INTERPRETATION

There is no clear benefit of a short course of parent-initiated oral prednisolone for viral wheeze in children aged 1-5 years even in those with above-average eosinophil priming.

Non-bronchoscopic sampling and culture of bronchial epithelial cells in children

BACKGROUND

The bronchial epithelium is likely to play a vital role in airway diseases in children, such as asthma and viral-associated wheeze. In adults, studies with primary bronchial epithelial cells cultured from samples obtained by fibre-optic bronchoscopy have provided key insights into the role of the epithelial cell. However, it is difficult to justify bronchoscopy in children to obtain epithelial cells for research purposes.

OBJECTIVE

To examine the possibility of retrieving and culturing viable epithelial cells using a blind non-bronchoscopic method from children undergoing elective surgery.

METHODS

Subjects were children undergoing elective surgery under general anaesthesia. Following intubation, non-bronchoscopic bronchoalveolar lavage and non-bronchoscopic bronchial brushing were performed. A sheathed bronchial cytology brush was advanced through the endotracheal tube, wedged and then withdrawn 2-3 cm before gentle sampling was used to collect bronchial epithelial cells. Initial samples were used to characterize the number, type and viability of epithelial cells recovered compared to a control group of adults undergoing standard bronchoscopic sampling. Subsequent samples were used to establish primary bronchial epithelial cell cultures in children both with and without wheezing illness.

RESULTS

A total of 63 children underwent bronchial brushing [38 male; median age 7.1 years (1.0-14.2 years]. Initial samples (n=30) showed recovery of viable epithelial cells comparable to that from a single brush obtained via a bronchoscope in an adult control group (n=11). In 27 (82%) of the subsequent 33 samples obtained non-bronchoscopically from children, primary bronchial epithelial cell cultures were successfully established. There were no adverse effects attributable to sampling.

CONCLUSION

We have shown that non-bronchoscopic bronchial brushing is a safe and effective technique for recovering viable bronchial epithelial cells that consistently yield primary cultures. This method will facilitate examination of the role of the epithelium in paediatric disease.

Antioxidants and oxidative stress in BAL fluid of atopic asthmatic children

Earlier studies in adults have indicated that increased oxidative stress may occur in the blood and airways of asthmatic subjects. Therefore the aim of this study was to compare the concentrations of antioxidants and protein carbonyls in bronchoalveolar lavage fluid of clinically stable atopic asthmatic children (AA, n = 78) with our recently published reference intervals for nonasthmatic children (C, n = 124). Additionally, lipid peroxidation products (malondialdehyde) in bronchoalveolar lavage fluid and several antioxidants in plasma were determined. Bronchoalveolar lavage concentrations (median and interquartile range) of ascorbate [AA: 0.433 (0.294-0.678) versus C: 0.418 (0.253-0.646) micromol/L], urate [AA: 0.585 (0.412-0.996) versus C: 0.511 (0.372-0.687) micromol/L], alpha-tocopherol [AA: 0.025 (0.014-0.031) versus C: 0.017 (0.017-0.260) micromol/L], and oxidized proteins as reflected by protein carbonyls [AA: 1.222 (0.970-1.635) versus C: 1.243 (0.813-1.685) nmol/mg protein] were similar in both groups (p > 0.05 in all cases). The concentration of protein carbonyls correlated significantly with the number of eosinophils, mast cells, and macrophages in AA children only. Concentrations of oxidized proteins and lipid peroxidation products (malondialdehyde) correlated significantly in AA children (r = 0.614, n = 11, p = 0.044). Serum concentrations of ascorbate, urate, retinol, alpha-tocopherol, beta-carotene, and lycopene were similar in both groups whereas alpha-carotene was significantly reduced in asthmatics. Overall, increased bronchoalveolar lavage eosinophils indicate ongoing airway inflammation, which may increase oxidatively modified proteins as reflected by increased protein carbonyl concentrations.

Eosinophils and eosinophilic cationic protein in induced sputum and blood: effects of budesonide and terbutaline treatment

BACKGROUND

There is a need for easily measurable markers of airway inflammation to guide the use of anti-inflammatory treatment in asthma. Eosinophilic cationic protein (ECP) levels in sputum and blood correlate with clinical severity, and serial measurements of ECP have been proposed as a suitable candidate.

AIMS AND METHODS

Our aim was to confirm that sputum and serum ECP measurements would provide a more sensitive indicator of responses to asthma treatment than eosinophil counts per se, in a randomized, placebo-controlled, crossover study of terbutaline, budesonide, and their combination in patients with chronic persistent asthma. We compared the changes in eosinophil counts and ECP in induced sputum and blood during each treatment period.

RESULTS

Budesonide and combined treatment caused a significant reduction in sputum eosinophils (-2.7% and -2.3%, respectively, P < 0.05). Sputum eosinophils increased with terbutaline (+3.9%, P = 0.049). In contrast, the changes for sputum ECP were not significant. There was a similar treatment effect on blood eosinophils, but not for serum ECP. Correlations between sputum and blood eosinophils were significant with and without budesonide, but were nonsignificant between sputum and blood ECP during the active treatments. Correlations between sputum eosinophils and ECP, and between blood eosinophils and serum ECP were greatest during treatment with placebo or terbutaline alone: budesonide weakened or abolished these relationships.

CONCLUSIONS

Compared with eosinophil counts, ECP measurements in either induced sputum or serum failed to reflect treatment-related changes in chronic asthma. We conclude that ECP is not a sensitive or reliable means of evaluating airway inflammation, and can not be recommended for assessing responses to anti-inflammatory therapy.

Exhaled nitric oxide correlates with airway eosinophils in childhood asthma

BACKGROUND

Exhaled nitric oxide has been proposed as a marker for airway inflammation in asthma. The aim of this study was to compare exhaled nitric oxide levels with inflammatory cells and mediators in bronchoalveolar lavage fluid from asthmatic and normal children.

METHODS

Children were recruited from elective surgical lists and a non-bronchoscopic bronchoalveolar lavage (BAL) was performed after induction of anaesthesia. Exhaled nitric oxide (parts per billion) was measured by two techniques: tidal breathing and restricted breath.

RESULTS

Median (interquartile range) exhaled nitric oxide measured by restricted breath was increased in asthmatics compared with normal children (24.3 (10.5-66.5) v 9.7 (6.5-16.5), difference between medians 14.6 (95% CI 5.1 to 29.9), p=0.001). In asthmatic children exhaled nitric oxide correlated significantly with percentage eosinophils (r=0.78, p<0.001 (tidal breathing) and r=0.78, p<0.001 (restricted breath)) and with eosinophilic cationic protein (r=0.53, p<0.01 (restricted breath)), but not with other inflammatory cells in the BAL fluid. The area under the receiver operator characteristic curves for the prediction of the presence of eosinophilic airways inflammation by exhaled nitric oxide (tidal and restricted) was 0.80 and 0.87, respectively.

CONCLUSIONS

Exhaled nitric oxide correlates closely with percentage eosinophils in BAL fluid in asthmatic children and is therefore likely to be a useful non-invasive marker of airway inflammation.

Blood eosinophil counts for the prediction of the severity of exercise-induced bronchospasm in asthma

It has been suggested that airway eosinophilic inflammation is associated with the severity of exercise-induced bronchospasm (EIB). Blood eosinophils are known to be an indirect marker of airway inflammation in asthma. The aim of this study is to investigate that a simple and easy blood test for blood eosinphil counts may predict the severity of EIB in asthma. Seventy-seven men with perennial asthma (age range 18-23 years) were included. Lung function test, skin prick test, and blood tests for eosinophils counts and total IgE levels were performed. Methacholine bronchial provocation test and, 24 h later, free running test were carried out. EIB was defined as a 15% reduction or more in post-exercise FEV1 compared with pre-exercise FEV1 value. Atopy score was defined as a sum of mean wheal diameters to allergens. EIB was observed in 60 (78%) of 77 subjects. Asthmatics with EIB showed significantly increased percentages of eosinophils (P<0.01), log eosinophil counts (P<0.001), and atopy scores (P<0.05) and decreased log PC20 values (P < 0.05) compared with asthmatics without EIB. Asthmatics with eosinophils of > 700 microl(-1) (36.9 +/- 12.7%) had significantly greater maximal % fall in FEV1 after exercise than asthmatics with eosinophils of < 350 microl(-1) (24.7 +/- 16.6%, P <0.05). Blood eosinophil counts > 350 microl(-1) yielded the specificity of 88% and positive predictive value of 93% for the presence of EIB. When a multiple regression analysis of maximal % fall in FEV1 according to log eosinophil counts, log PC20, log IgE and atopy score was performed, only blood eosinophil counts were significant factor contributing to the maximal % fall in FEV1 after exercise. These findings not only suggest that a simple blood test for eosinophils may be useful in the prediction of the severity of EIB, but also reinforce the view that airway eosinophilic inflammation may play a major role in EIB in asthma.

Circadian variation of exhaled nitric oxide and urinary eosinophil protein X in asthmatic and healthy children

Asthmatic symptoms and the frequency of admissions to hospital because of acute asthma tend to increase in the early morning hours, and it is therefore possible that airway inflammation increases during the night. To elucidate the hypothetical circadian variation of airway inflammation, we measured concentrations of exhaled nitric oxide (FeNo), urinary eosinophil protein X excretion (EPX), and forced expiratory volume in the first second (FEV1) in 20 asthmatic and 6 nonatopic nonasthmatic children every 3 h during a 21-h period. Compared with control subjects, asthmatic subjects had higher FeNo (median, 22.7 versus 10.3 ppb, p = 0.016) and lower FEV1 % predicted (median, 91.0 versus 101.9%, p = 0.045), but did not differ significantly in EPX (median, 153.8 versus 148.7 microg/mmol creatinine, p = 0.83) at 7 AM. However, differences in gender and age do not allow direct comparisons between asthmatic and control children. FeNo and EPX demonstrated a cosinelike circadian rhythm (log FeNo, p = 0.0001; log EPX, p = 0.0001) with lowest levels at 7 PM and highest at 7 AM. This was also the case for FEV1 % (p = 0.01). No difference in the amplitude of circadian rhythm was observed between asthmatic and healthy control children for log FeNo (p = 0.35), log EPX (p = 0.57), and FEV1 % (p = 0.17). A stratified analysis showed a significant circadian rhythm in the control group for log FeNo (p = 0.014) and log EPX (p = 0.0001). Our results therefore suggest a circadian rhythm of inflammatory markers, which peaks in the early morning. Rhythmicity of EPX excretion and FeNo in healthy children suggests a physiologic mechanism; however, pathologic effects during the night might occur under conditions of asthma-specific inflammation.

Clinical evaluation of changes in the morphology of eosinophils

In order to diagnose and monitor patients with allergic diseases, we studied parameters which reflect not only the amount of eosinophils but also their state of activation. Morphologic features reveal additional information on the activity state of eosinophils. The number of nuclear lobes, cell size, amount of vacuoles and density of specific granules are considered characteristic features of eosinophils. We conclude that the size of eosinophils is a useful parameter to distinguish patients with and without eosinophilia. The treatment with corticosteroids did not affect morphological characteristics such as the number of vacuoles, granulation density, cell diameter and the nucleus/cell surface ratio, but the number of lobes per nucleus, a marker of eosinophil maturation, decreased significantly.

Urinary leukotriene E(4), eosinophil protein X, and nasal eosinophil cationic protein are not associated with respiratory symptoms in 1-year-old children

BACKGROUND

Eosinophilic airways inflammation forms the pathophysiologic basis for a proportion of children at risk of developing recurrent wheezing. Early preventive measures and/or anti-inflammatory treatment may be guided by the identification of such children. We aimed to study the relationship between respiratory symptoms and indirect markers of airway inflammation.

METHODS

We measured eosinophil protein X (EPX) and leukotriene E(4) (LTE(4)) in urine, as well as eosinophil cationic protein (ECP) in nasal lavages, in a random sample of 1-year-old children with a family history of atopy who participated in an international multicenter study on the prevention of allergy in Europe. For urine analyses, 10 children with upper respiratory illness and 19 healthy children without a family history of atopy were also enrolled. Endogenous urinary LTE(4) was separated by HPLC and determined by enzyme immunoassay with a specific antibody. The concentrations of nasal ECP and urinary EPX were determined by RIA analysis.

RESULTS

One hundred and ten children (mean age: 1.05+/-0.1 years) were enrolled. Prolonged coughing during the first year of life was reported in 29 children, wheezy breathing in 17 children, and dry skin in 33 children. A doctor's diagnosis of wheezy bronchitis was given to 17 children. Sensitization to dust mites (specific IgE > or =1.43 ML/units) was detected in two children. Children with a doctor's diagnosis of atopic dermatitis within the first 12 months of life (n=6) had significantly higher urinary EPX than children without this (66.7 vs 30.1 microg/mmol creatinine, P=0.01). Urinary excretion of EPX and LTE4 showed a weak correlation (r=0.22, P=0.02). There were no significant differences in urinary excretion of EPX and LTE(4) or nasal ECP between children with and without respiratory symptoms (P>0.1).

CONCLUSIONS

At the age of 1 year, urinary EPX is increased in children with atopic dermatitis. With regard to respiratory symptoms, urinary and nasal inflammatory parameters are not helpful in characterizing the phenotype of a single patient.

Increased eosinophil cationic protein levels in bronchoalveolar lavage from wheezy infants

Although studies examining the serum suggest a role for eosinophils in wheezing episodes in infants and toddlers, the presence of a chronic eosinophilic inflammation within their airways remains to be demonstrated. In this study we investigated whether eosinophil cationic protein (ECP) levels are increased in BAL fluid (BALF) from infants and toddlers with recurrent wheezing episodes, during an asymptomatic period. The levels of ECP in BALF were quantitated by radioimmunoassay in 61 children (36 with severe recurrent episodes of wheezing and 25 who were non-wheezy), aged 6-36 months, in whom flexible bronchoscopy was clinically indicated. BALF eosinophil counts were < or = 1% in all patients and did not differ in wheezers, compared to non-wheezers. In contrast, ECP levels in BALF were > or = 2.2 micrograms/l in 18 of 36 (50%) wheezy infants but in only three of 25 (12%) control infants (p < 0.01). Neutrophil counts were significantly higher in the wheezer group than in the non-wheezer group (8.1 x 10(3) cells/ml vs. 3.0 x 10(3) cells/ml). ECP levels in the BALF were not correlated with the absolute number of eosinophils (r = 0.03; p = 0.8) but were correlated with the absolute number of neutrophils (r = 0.54; p = 0.001). There was no association between high ECP levels in BALF and the atopic status of the wheezers. In conclusion, ECP levels are increased in BALF from young children with recurrent wheezing episodes, even during relatively quiescent periods, suggesting a chronic increased cell activation in the lower airways.

Eosinophil cationic protein (ECP) in school children living in a mountainous area of Norway: a population-based study of ECP as a tool for diagnosing asthma in children with reference values

BACKGROUND

Most previous studies on eosinophil cationic protein (ECP) have been performed on carefully selected groups of asthmatic patients. Few studies based upon population cohorts have been reported. The primary objective of the present study was to assess the usefulness of serum eosinophil cationic protein (s-ECP) in the diagnosis of asthma in schoolchildren and determine reference values based on measurements in healthy children.

METHODS

The population consisted of 216 schoolchildren (aged 7-16 years) who in a previous questionnaire had reported asthma or asthma-like symptoms and a control group. The questionnaire study comprised the entire population of schoolchildren in Upper Hallingdal. After clinical assessment, blood samples, and skin prick tests, these subjects were then reclassified into four groups: atopic and nonatopic asthmatic and nonasthmatics. S-ECP was assessed in relation to atopy, asthma severity, allergen exposure, and sex.

RESULTS

The asthma group (n = 105) had significantly higher mean s-ECP level than the nonasthma group (n = 111) (13.3 vs 8.3 microg/l, P < 0.001), with no significant difference between atopic asthmatics and atopic nonasthmatics. Mean s-ECP levels in children with mild, moderate, or severe asthma were 12.1, 18.5, and 12.2 microg/l, respectively. The children with animal dander allergy demonstrated higher levels of s-ECP than children without this allergy (12.9 vs 9.1 microg/l, P = 0.001). The upper reference limit (determined as the 95th percentile in healthy children) of 19.1 microg/l, showed low sensitivity (24%) and high specificity (93%) for the diagnosis of asthma. The positive and negative likelihood ratios for the asthma diagnosis were found to be 3.2 and 0.83, respectively.

CONCLUSIONS

The highest s-ECP values were found among children with moderate asthma. Animal dander allergy resulted in elevated s-ECP. However, mean values were still below the reference value of 19.1 microg/l, and the sensitivity was low, suggesting that s-ECP is not a useful parameter for diagnosing asthma in population-based studies.

Inflammatory mediators in blood and urine

Inflammation plays a major role in the pathophysiology of asthma. Therefore, monitoring of the disease and its management preferably should include assessment of mediators of airways inflammation. Much interest has been focused on using eosinophil granule proteins in blood and urine as markers of asthma inflammation. The eosinophil granule proteins are important mediators in allergic inflammation. They often function well as inflammatory markers when used in controlled clinical studies, and are therefore useful research tools. With urinary eosinophil-derived protein X (EPX) venous blood sampling is avoided. Disadvantages which limit usefulness in clinical practice are overlap between values in patients and controls, a rather weak correlation to traditional lung function variables, elevation of levels by concurrent allergic disease, and the delay between sampling and test results. Urinary excretion of leukotriene E4 (LTE(4)) reflects the production of cysteinyl leukotrienes, which are major mediators in asthma. The excretion of LTE4 possibly reflects lung function better than serum ECP. In the future, monitoring of cytokines may be used in clinical asthma to monitor control and aid in the prognosis of the disease in the young child. Techniques for simple and rapid monitoring of key type 1 and type 2 cytokines are needed.