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Burgess JK, Weiss DJ, Westergren-Thorsson G, Wigen J, Dean CH, Mumby S, Bush A, Adcock IM. Extracellular Matrix as a Driver of Chronic Lung Diseases. Am J Respir Cell Mol Biol 2024; 70:239-246. [PMID: 38190723 DOI: 10.1165/rcmb.2023-0176ps] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 01/05/2024] [Indexed: 01/10/2024] Open
Abstract
The extracellular matrix (ECM) is not just a three-dimensional scaffold that provides stable support for all cells in the lungs, but also an important component of chronic fibrotic airway, vascular, and interstitial diseases. It is a bioactive entity that is dynamically modulated during tissue homeostasis and disease, that controls structural and immune cell functions and drug responses, and that can release fragments that have biological activity and that can be used to monitor disease activity. There is a growing recognition of the importance of considering ECM changes in chronic airway, vascular, and interstitial diseases, including 1) compositional changes, 2) structural and organizational changes, and 3) mechanical changes and how these affect disease pathogenesis. As altered ECM biology is an important component of many lung diseases, disease models must incorporate this factor to fully recapitulate disease-driver pathways and to study potential novel therapeutic interventions. Although novel models are evolving that capture some or all of the elements of the altered ECM microenvironment in lung diseases, opportunities exist to more fully understand cell-ECM interactions that will help devise future therapeutic targets to restore function in chronic lung diseases. In this perspective article, we review evolving knowledge about the ECM's role in homeostasis and disease in the lung.
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Affiliation(s)
- Janette K Burgess
- Department of Pathology and Medical Biology
- Groningen Research Institute for Asthma and COPD, and
- W.J. Kolff Institute for Biomedical Engineering and Materials Science, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Daniel J Weiss
- Department of Medicine, University of Vermont, Burlington, Vermont
| | | | - Jenny Wigen
- Lung Biology Unit, Department of Experimental Medical Science, Lund University, Lund, Sweden
| | - Charlotte H Dean
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Sharon Mumby
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
| | - Andrew Bush
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
- Centre for Pediatrics and Child Health, Imperial College and Royal Brompton Hospital, London, United Kingdom
| | - Ian M Adcock
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; and
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2
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Papadopoulos NG, Apostolidou E, Miligkos M, Xepapadaki P. Bacteria and viruses and their role in the preschool wheeze to asthma transition. Pediatr Allergy Immunol 2024; 35:e14098. [PMID: 38445451 DOI: 10.1111/pai.14098] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Revised: 02/08/2024] [Accepted: 02/09/2024] [Indexed: 03/07/2024]
Abstract
Wheezing is the cardinal symptom of asthma; its presence early in life, mostly caused by viral infections, is a major risk factor for the establishment of persistent or recurrent disease. Early-life wheezing and asthma exacerbations are triggered by common respiratory viruses, mainly rhinoviruses (RV), and to a lesser extent, respiratory syncytial virus, parainfluenza, human metapneumovirus, coronaviruses, adenoviruses, influenza, and bocavirus. The excess presence of bacteria, several of which are part of the microbiome, has also been identified in association with wheezing and acute asthma exacerbations, including haemophilus influenza, streptococcus pneumoniae, moraxella catarrhalis, mycoplasma pneumoniae, and chlamydophila pneumonia. While it is not clear when asthma starts, its characteristics develop over time. Airway remodeling already appears between the ages of 1 and 3 years of age even prior to the presence of atopic inflammation or an asthma diagnosis. The role of genetic defect or variations hampering the airway epithelium in response to environmental stimuli and severe disease morbidity are now considered as major determinants for early structural changes. Repeated viral infections can induce and perpetuate airway hyperresponsiveness. Allergic sensitization, that often precedes infection-induced wheezing, shifts inflammation toward type-2, while common respiratory infections themselves promote type-2 inflammation. Nevertheless, most children who wheeze with viral infections during infancy and during preschool years do not develop persistent asthma. Multiple factors, including illness severity, viral etiology, allergic sensitization, and the exposome, are associated with disease persistence. Here, we summarize current knowledge and developments in infection epidemiology of asthma in children, describing the known impact of each individual agent and mechanisms of transition from recurrent wheeze to asthma.
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Affiliation(s)
- Nikolaos G Papadopoulos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
- Division of Infection, Immunity and Respiratory Medicine, University of Manchester, Manchester, UK
| | | | - Michael Miligkos
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
| | - Paraskevi Xepapadaki
- Allergy Department, 2nd Pediatric Clinic, National and Kapodistrian University of Athens, Athens, Greece
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3
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Arshad H, Lack G, Durham SR, Penagos M, Larenas-Linnemann D, Halken S. Prevention Is Better than Cure: Impact of Allergen Immunotherapy on the Progression of Airway Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2024; 12:45-56. [PMID: 37844847 DOI: 10.1016/j.jaip.2023.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2023] [Revised: 10/01/2023] [Accepted: 10/02/2023] [Indexed: 10/18/2023]
Abstract
Allergen immunotherapy is highly effective for seasonal pollinosis. Three years of treatment results in long-term efficacy. This disease modification is accompanied by downregulation of allergen-specific Th2 responses and the induction of persistent specific IgG- and IgA-associated IgE-blocking activity. In children with seasonal rhinitis, both subcutaneous and sublingual pollen immunotherapy have been shown to reduce the development of asthma symptoms and asthma medication requirements. House dust mite tablet allergen immunotherapy has been shown to be effective for perennial mite-driven rhinitis in adults and children and may suppress asthma exacerbations, whereas its long-term efficacy has yet to be explored. The success of primary prevention of peanut allergy in childhood by introduction of peanut into the diet during infancy provides a strong rationale to explore whether primary prevention of inhalant allergies and asthma may also be possible. House dust mite allergy is a major risk factor for developing asthma. Preliminary data in at-risk children suggest that sublingual house dust mite immunotherapy initiated during infancy could reduce the onset of multiple allergen sensitizations and prevent the development of asthma at age 6 years. This possibility should now be explored in an adequately powered, prospectively randomized controlled trial.
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Affiliation(s)
- Hasan Arshad
- Faculty of Medicine, University of Southampton, Southampton, United Kingdom; The David Hide Asthma and Allergy Centre, Isle of Wight, United Kingdom
| | - Gideon Lack
- Department of Women and Children's Health (Pediatric Allergy), School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, United Kingdom; Children's Allergy Service, Evelina London Children's Hospital, Guy's and St Thomas' Hospital, London, United Kingdom
| | - Stephen R Durham
- Allergy and Clinical Immunology, Division of Respiratory Science, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
| | - Martin Penagos
- Allergy and Clinical Immunology, Division of Respiratory Science, National Heart and Lung Institute, Imperial College London, Royal Brompton Hospital, London, United Kingdom
| | - Désireé Larenas-Linnemann
- Médica Sur, Clinical Foundation and Hospital, Centro de Excelencia en Asma y Alergia, Mexico City, Mexico
| | - Susanne Halken
- Hans Christian Andersen Children's Hospital, Odense University Hospital, Odense, Denmark.
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4
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Jensen SK, Melgaard ME, Pedersen CET, Yang L, Vahman N, Thyssen JP, Schoos AMM, Stokholm J, Bisgaard H, Chawes B, Bønnelykke K. Limited clinical role of blood eosinophil levels in early life atopic disease: A mother-child cohort study. Pediatr Allergy Immunol 2023; 34:e14050. [PMID: 38010010 DOI: 10.1111/pai.14050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 10/10/2023] [Accepted: 11/13/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Blood eosinophil count is a well-established biomarker of atopic diseases in older children and adults. However, its predictive role for atopic diseases in preschool children is not well established. OBJECTIVE To investigate the association between blood eosinophil count in children and development of atopic diseases up to age 6 years. METHODS We investigated blood eosinophil count at age 18 months and 6 years in relation to recurrent wheeze/asthma, atopic dermatitis, allergic rhinitis, and allergic sensitization during the first 6 years of life in the two Copenhagen Prospective Studies on Asthma in Childhood cohorts (n = 1111). Blood eosinophil count was investigated in association with remission of existing atopic disease, current atopic disease, and later development of atopic disease. RESULTS Blood eosinophil count at 18 months was not associated with current wheezing/asthma or atopic dermatitis, while blood eosinophil count at age 6 years was associated with increased occurrence of current wheezing/asthma (OR = 1.1; 1.04-1.16, p = .0005), atopic dermatitis (OR = 1.06; 1.01-1.1, p = .02), and allergic rhinitis (OR = 1.11; 1.05-1.18, p = .0002). Blood eosinophil count at 18 months did not predict persistence or development of recurrent wheeze/asthma or atopic dermatitis at age 6 years. CONCLUSION Blood eosinophil count at 18 months was not associated with current wheezing/asthma or atopic dermatitis and did not predict persistence or development of disease. This implies a limited clinical role of blood eosinophil levels in early-life atopic disease and questions the clinical value of blood eosinophil counts measured in toddlers as a predictive biomarker for subsequent atopic disease in early childhood.
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Affiliation(s)
- Signe Kjeldgaard Jensen
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Mathias Elsner Melgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Casper-Emil Tingskov Pedersen
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Luo Yang
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Nilo Vahman
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
| | - Jacob P Thyssen
- Department of Dermatology, Bispebjerg Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Ann-Marie M Schoos
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
| | - Jakob Stokholm
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Pediatrics, Slagelse Hospital, Slagelse, Denmark
- Section of Microbiology and Fermentation, Department of Food Science, University of Copenhagen, Copenhagen, Denmark
| | - Hans Bisgaard
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Bo Chawes
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Klaus Bønnelykke
- Copenhagen Prospective Studies on Asthma in Childhood (COPSAC), Department of Pediatrics, Herlev and Gentofte Hospital, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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5
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Cherrez-Ojeda I, Osorio MF, Robles-Velasco K, Calderón JC, Cortés-Télles A, Zambrano J, Guarderas C, Intriago B, Gochicoa-Rangel L. Small airway disease in post-acute COVID-19 syndrome, a non-conventional approach in three years follow-up of a patient with long COVID: a case report. J Med Case Rep 2023; 17:386. [PMID: 37691104 PMCID: PMC10494419 DOI: 10.1186/s13256-023-04113-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 08/03/2023] [Indexed: 09/12/2023] Open
Abstract
BACKGROUND Small airways disease (SAD), a novel finding described in post-acute COVID-19 patients, should be suspected when respiratory symptoms continue, air trapping persists on expiratory CT scans, and imaging findings fail to improve despite objectively better conventional pulmonary function test (PFT) parameters. The forced oscillation technique (FOT) and Multiple breathing washout (MBW) are both very sensitive methods for detecting anomalies in the peripheral airways. CASE PRESENTATION We discuss the case of a 60-year-old Hispanic patient who had severe COVID-19 pneumonia and developed dyspnea, fatigue, and limited daily activity a year later. The PFTs revealed restrictive lung disease, as seen by significant diffusing capacity of the lungs for carbon monoxide (DLCO) decrease, severe desaturation, and poor 6-min walk test (6MWT) performance. The patient was treated with lowering corticosteroids as well as pulmonary rehabilitation (PR). During the 24-month follow-up, the dyspnea and fatigue persisted. On PFTs, 6MWT performance and restricted pattern improved slightly, but MBW discovered significant ventilatory inhomogeneity. FOT revealed substantial peripheral airway obstructive abnormalities. On CT scans, air trapping and ground-glass opacities (GGO) improved somewhat. The patient used a bronchodilator twice a day and low-dose inhaled corticosteroids (160 µg of budesonide and 4.5 µg of formoterol fumarate dihydrate) for nine months. PR sessions were resuming. The restricting parameters were stabilized and the DLCO had normalized after 36 months, with a 6MWT performance of 87% but significant desaturation. The CT scan revealed traction bronchiectasis, low GGO, and persistent air trapping. Without normalization, FOT and MBW scores improved, indicating small airway disease. CONCLUSIONS The necessity of integrating these tests when detecting SAD is emphasized in our paper. This article lays the foundation for future research into the best ways to manage and monitor SAD in post-acute COVID-19 patients.
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Affiliation(s)
- Ivan Cherrez-Ojeda
- Universidad Espíritu Santo, Km. 2.5 Vía La Puntilla, Samborondón, 0901-952, Ecuador.
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador.
| | - Maria F Osorio
- Universidad Espíritu Santo, Km. 2.5 Vía La Puntilla, Samborondón, 0901-952, Ecuador
| | - Karla Robles-Velasco
- Universidad Espíritu Santo, Km. 2.5 Vía La Puntilla, Samborondón, 0901-952, Ecuador
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador
| | | | - Arturo Cortés-Télles
- Departamento de Neumología y Cirugía de Tórax, Hospital Regional de Alta Especialidad de Yucatán, Mérida, Mexico
| | - Jorge Zambrano
- Centro de enfermedades respiratorias, rehabilitación y sueño (CERS), Guayaquil, Ecuador
| | - Cristian Guarderas
- Centro de enfermedades respiratorias, rehabilitación y sueño (CERS), Guayaquil, Ecuador
| | - Belen Intriago
- Universidad Espíritu Santo, Km. 2.5 Vía La Puntilla, Samborondón, 0901-952, Ecuador
- Respiralab, Respiralab Research Group, Guayaquil, Ecuador
| | - Laura Gochicoa-Rangel
- Departamento de Fisiología Respiratoria, Instituto Nacional de Enfermedades Respiratorias "Ismael Cosío Villegas", Ciudad de México, Mexico
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6
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Chatziparasidis G, Bush A, Chatziparasidi MR, Kantar A. Airway epithelial development and function: A key player in asthma pathogenesis? Paediatr Respir Rev 2023; 47:51-61. [PMID: 37330410 DOI: 10.1016/j.prrv.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2023] [Revised: 04/07/2023] [Accepted: 04/25/2023] [Indexed: 06/19/2023]
Abstract
Though asthma is a common and relatively easy to diagnose disease, attempts at primary or secondary prevention, and cure, have been disappointing. The widespread use of inhaled steroids has dramatically improved asthma control but has offered nothing in terms of altering long-term outcomes or reversing airway remodeling and impairment in lung function. The inability to cure asthma is unsurprising given our limited understanding of the factors that contribute to disease initiation and persistence. New data have focused on the airway epithelium as a potentially key factor orchestrating the different stages of asthma. In this review we summarize for the clinician the current evidence on the central role of the airway epithelium in asthma pathogenesis and the factors that may alter epithelial integrity and functionality.
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Affiliation(s)
- Grigorios Chatziparasidis
- Paediatric Respiratory Unit, IASO Hospital, Larissa, Thessaly, Greece; Faculty of Nursing, Thessaly University, Greece.
| | - Andrew Bush
- National Heart and Lung Institute, Royal Brompton & Harefield NHS Foundation Trust, London, UK
| | | | - Ahmad Kantar
- Pediatric Asthma and Cough Centre, Instituti Ospedalieri Bergamaschi, University and Research Hospitals, Bergamo, Italy
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7
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Romero-Tapia SDJ, Becerril-Negrete JR, Castro-Rodriguez JA, Del-Río-Navarro BE. Early Prediction of Asthma. J Clin Med 2023; 12:5404. [PMID: 37629446 PMCID: PMC10455492 DOI: 10.3390/jcm12165404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 07/26/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
The clinical manifestations of asthma in children are highly variable, are associated with different molecular and cellular mechanisms, and are characterized by common symptoms that may diversify in frequency and intensity throughout life. It is a disease that generally begins in the first five years of life, and it is essential to promptly identify patients at high risk of developing asthma by using different prediction models. The aim of this review regarding the early prediction of asthma is to summarize predictive factors for the course of asthma, including lung function, allergic comorbidity, and relevant data from the patient's medical history, among other factors. This review also highlights the epigenetic factors that are involved, such as DNA methylation and asthma risk, microRNA expression, and histone modification. The different tools that have been developed in recent years for use in asthma prediction, including machine learning approaches, are presented and compared. In this review, emphasis is placed on molecular mechanisms and biomarkers that can be used as predictors of asthma in children.
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Affiliation(s)
- Sergio de Jesus Romero-Tapia
- Health Sciences Academic Division (DACS), Juarez Autonomous University of Tabasco (UJAT), Villahermosa 86040, Mexico
| | - José Raúl Becerril-Negrete
- Department of Clinical Immunopathology, Universidad Autónoma del Estado de México, Toluca 50000, Mexico;
| | - Jose A. Castro-Rodriguez
- Department of Pediatric Pulmonology, School of Medicine, Pontificia Universidad Católica de Chile, Santiago 8330077, Chile;
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8
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Saglani S, Yates L, Lloyd CM. Immunoregulation of asthma by type 2 cytokine therapies: Treatments for all ages? Eur J Immunol 2023; 53:e2249919. [PMID: 36932669 DOI: 10.1002/eji.202249919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/08/2023] [Accepted: 03/10/2023] [Indexed: 03/19/2023]
Abstract
Asthma is classically considered to be a disease of type 2 immune dysfunction, since many patients exhibit the consequences of excess secretion of cytokines such as IL-4, IL-5, and IL-13 concomitant with inflammation typified by eosinophils. Mouse and human disease models have determined that many of the canonical pathophysiologic features of asthma may be caused by these disordered type 2 immune pathways. As such considerable efforts have been made to develop specific drugs targeting key cytokines. There are currently available multiple biologic agents that successfully reduce the functions of IL-4, IL-5, and IL-13 in patients, and many improve the course of severe asthma. However, none are curative and do not always minimize the key features of disease, such as airway hyperresponsiveness. Here, we review the current therapeutic landscape targeting type 2 immune cytokines and discuss evidence of efficacy and limitations of their use in adults and children with asthma.
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Affiliation(s)
- Sejal Saglani
- National Heart and Lung Institute, Imperial College London, London, UK
- Royal Brompton and Harefield Hospitals, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Laura Yates
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Clare M Lloyd
- National Heart and Lung Institute, Imperial College London, London, UK
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9
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Bush A. Basic clinical management of preschool wheeze. Pediatr Allergy Immunol 2023; 34:e13988. [PMID: 37492909 DOI: 10.1111/pai.13988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 07/27/2023]
Abstract
Preschool wheeze is very common and often difficult to treat. Most children do not require any investigations; only a detailed history and physical examination to ensure an alternative diagnosis is not being missed; and the differential diagnosis, and hence investigation protocols for the child in whom a major illness is suspected, shows geographical variation. The pattern of symptoms may be divided into episodic viral and multiple trigger to guide treatment, but the pattern of symptoms must be re-assessed regularly. However, symptom patterns are a poor guide to underlying pathology. Attention to the proper use of spacers, and adverse environmental exposures such as tobacco smoke exposure, is essential. There are no disease-modifying therapies, so therapy is symptomatic. This paper reviews recent advances in treatment, including new data on the place of leukotriene receptor antagonists, prednisolone for acute attacks of wheeze, and antibiotics, based on new attempts to understand the underlying pathology in a way that is clinically practical.
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Affiliation(s)
- Andrew Bush
- Imperial College, London, UK
- National Heart and Lung Institute, London, UK
- Royal Brompton Harefield NHS Foundation Trust, London, UK
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10
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Fitzpatrick AM, Grunwell JR, Cottrill KA, Mutic AD, Mauger DT. Blood Eosinophils for Prediction of Exacerbation in Preschool Children With Recurrent Wheezing. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2023; 11:1485-1493.e8. [PMID: 36738927 PMCID: PMC10164693 DOI: 10.1016/j.jaip.2023.01.037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 01/22/2023] [Accepted: 01/24/2023] [Indexed: 02/05/2023]
Abstract
BACKGROUND Although clinical features of type 2 inflammation have been associated with poorer longitudinal outcomes in preschool children with recurrent wheezing, it remains difficult to predict which children are at highest risk for poor outcomes during a routine clinical encounter. OBJECTIVE We tested the hypothesis that prespecified cut points of blood eosinophil counts would predict exacerbation and treatment response outcomes in preschool children with recurrent wheezing and that prediction could be improved with the addition of a second biomarker. METHODS Data from 3 clinical trials of 1,074 preschool children aged 12 to 71 months with recurrent wheezing were merged. The primary outcome was the occurrence of any exacerbation during follow-up. Secondary outcomes included the annualized rate of wheezing exacerbations and the occurrence of any exacerbation requiring hospitalization. Exploratory analyses focused on exacerbation outcomes, offline exhaled nitric oxide concentrations, and caregiver-reported asthma control scores after inhaled corticosteroid treatment initiation. RESULTS Each blood eosinophil cut point was associated with increased odds of exacerbation, higher exacerbation rates, and greater hospitalization occurrence in preschool children with recurrent wheezing. However, outcome detection was improved in children with more elevated blood eosinophil counts. Addition of a second biomarker of type 2 inflammation improved outcome detection and was further associated with an improved response to initiation of daily inhaled corticosteroids in exploratory analyses. However, the specificity of blood eosinophils was poor. CONCLUSIONS Although validation studies are warranted, blood eosinophil cut points may be useful for clinical assessment and future studies of exacerbation and treatment response in preschool children with recurrent wheezing.
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Affiliation(s)
- Anne M Fitzpatrick
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Pulmonary Medicine, Children's Healthcare of Atlanta, Atlanta, Ga.
| | - Jocelyn R Grunwell
- Department of Pediatrics, Emory University, Atlanta, Ga; Division of Critical Care Medicine, Children's Healthcare of Atlanta, Atlanta, Ga
| | | | - Abby D Mutic
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Ga
| | - David T Mauger
- Department of Statistics, Pennsylvania State University, Hershey, Pa
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11
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Fayon M, Beaufils F, Esteves P, Campagnac M, Maurat E, Michelet M, Siao-Him-Fa V, Lavrand F, Simon G, Begueret H, Berger P. Bronchial Remodeling-based Latent Class Analysis Predicts Exacerbations in Severe Preschool Wheezers. Am J Respir Crit Care Med 2023; 207:416-426. [PMID: 36108144 DOI: 10.1164/rccm.202205-0913oc] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Rationale: Children with preschool wheezing represent a very heterogeneous population with wide variability regarding their clinical, inflammatory, obstructive, and/or remodeling patterns. We hypothesized that assessing bronchial remodeling would help clinicians to better characterize severe preschool wheezers. Objectives: The main objective was to identify bronchial remodeling-based latent classes of severe preschool wheezers. Secondary objectives were to compare cross-sectional and longitudinal clinical and biological data between classes and to assess the safety of bronchoscopy. Methods: This double-center prospective study (NCT02806466) included severe preschool wheezers (1-5 yr old) requiring fiberoptic bronchoscopy. Bronchial remodeling parameters (i.e., epithelial integrity, reticular basement membrane [RBM] thickness, mucus gland, fibrosis and bronchial smooth muscle [BSM] areas, the density of blood vessels, and RBM-BSM distance) were assessed and evaluated by latent class analysis. An independent cohort of severe preschool wheezers (NCT04558671) was used to validate our results. Measurements and Main Results: Fiberoptic bronchoscopy procedures were well tolerated. A two-class model was identified: Class BR1 was characterized by increased RBM thickness, normalized BSM area, the density of blood vessels, decreased mucus gland area, fibrosis, and RBM-BSM distance compared with Class BR2. No significant differences were found between classes in the year before fiberoptic bronchoscopy. By contrast, Class BR1 was associated with a shorter time to first exacerbation and an increased risk of both frequent (3 or more) and severe exacerbations during the year after bronchoscopy in the two cohorts. Conclusions: Assessing bronchial remodeling identified severe preschool wheezers at risk of frequent and severe subsequent exacerbations with a favorable benefit to risk ratio.
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Affiliation(s)
- Michael Fayon
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Fabien Beaufils
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Pauline Esteves
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Maryline Campagnac
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Elise Maurat
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Marine Michelet
- CHU Toulouse, Hôpital des Enfants, Service de pneumologie-allergologie pédiatrique, Service d'Anatomopathologie; and.,University Toulouse Paul Sabatier, INSERM U1043 (CPTP), F-31059 Toulouse, France
| | - Valerie Siao-Him-Fa
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
| | - Frederic Lavrand
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Guillaume Simon
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Hugues Begueret
- CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France
| | - Patrick Berger
- Bordeaux University, Centre de Recherche Cardio-Thoracique de Bordeaux, Institut National de la Santé et de la Recherche Médicale (INSERM) U1045, Bordeaux Imaging Center, Bordeaux, France.,CHU Bordeaux, Département de Pédiatrie, Centre d'Investigation Clinique-Pédiatrique (CIC-P 1401), Service d'Anatomopathologie, Service d'Exploration Fonctionnelle Respiratoire, Bordeaux, France.,INSERM, Centre de Recherche Cardio-Thoracique de Bordeaux, U1045, Centre d'Investigation Clinique-Pédiatrique 1401, Bordeaux, France
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12
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Stolz D, Mkorombindo T, Schumann DM, Agusti A, Ash SY, Bafadhel M, Bai C, Chalmers JD, Criner GJ, Dharmage SC, Franssen FME, Frey U, Han M, Hansel NN, Hawkins NM, Kalhan R, Konigshoff M, Ko FW, Parekh TM, Powell P, Rutten-van Mölken M, Simpson J, Sin DD, Song Y, Suki B, Troosters T, Washko GR, Welte T, Dransfield MT. Towards the elimination of chronic obstructive pulmonary disease: a Lancet Commission. Lancet 2022; 400:921-972. [PMID: 36075255 DOI: 10.1016/s0140-6736(22)01273-9] [Citation(s) in RCA: 165] [Impact Index Per Article: 82.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2021] [Revised: 05/23/2022] [Accepted: 06/28/2022] [Indexed: 10/14/2022]
Affiliation(s)
- Daiana Stolz
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland; Department of Clinical Research, University Hospital Basel, Basel, Switzerland; Clinic of Respiratory Medicine and Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Takudzwa Mkorombindo
- Lung Health Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Desiree M Schumann
- Clinic of Respiratory Medicine and Pulmonary Cell Research, University Hospital Basel, Basel, Switzerland
| | - Alvar Agusti
- Respiratory Institute-Hospital Clinic, University of Barcelona IDIBAPS, CIBERES, Barcelona, Spain
| | - Samuel Y Ash
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Mona Bafadhel
- School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK; Department of Respiratory Medicine, Nuffield Department of Medicine, University of Oxford, Oxford, UK
| | - Chunxue Bai
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, China
| | - James D Chalmers
- Scottish Centre for Respiratory Research, University of Dundee, Dundee, UK
| | - Gerard J Criner
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine, Temple University, Philadelphia, PA, USA
| | - Shyamali C Dharmage
- Centre for Epidemiology and Biostatistics, School of Population and Global health, University of Melbourne, Melbourne, VIC, Australia
| | - Frits M E Franssen
- Department of Research and Education, CIRO, Horn, Netherlands; Department of Respiratory Medicine, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Urs Frey
- University Children's Hospital Basel, Basel, Switzerland
| | - MeiLan Han
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Nadia N Hansel
- Pulmonary and Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Nathaniel M Hawkins
- Centre for Cardiovascular Innovation, University of British Columbia, Vancouver, BC, Canada
| | - Ravi Kalhan
- Department of Preventive Medicine and Division of Pulmonary and Critical Care Medicine, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Melanie Konigshoff
- Division of Pulmonary, Allergy and Critical Care Medicine, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Fanny W Ko
- The Chinese University of Hong Kong, Hong Kong Special Administrative Region, China
| | - Trisha M Parekh
- Lung Health Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA
| | | | - Maureen Rutten-van Mölken
- Erasmus School of Health Policy & Management and Institute for Medical Technology Assessment, Erasmus University Rotterdam, Rotterdam, Netherlands
| | - Jodie Simpson
- Priority Research Centre for Healthy Lungs, Faculty of Health and Medicine, University of Newcastle, Newcastle, NSW, Australia
| | - Don D Sin
- Centre for Heart Lung Innovation and Division of Respiratory Medicine, Department of Medicine, University of British Columbia, St Paul's Hospital, Vancouver, BC, Canada
| | - Yuanlin Song
- Department of Pulmonary and Critical Care Medicine, Zhongshan Hospital and National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China; Shanghai Respiratory Research Institute, Shanghai, China; Jinshan Hospital of Fudan University, Shanghai, China
| | - Bela Suki
- Department of Biomedical Engineering, Boston University, Boston, MA, USA
| | - Thierry Troosters
- Department of Rehabilitation Sciences, Research Group for Rehabilitation in Internal Disorders, KU Leuven, Leuven, Belgium
| | - George R Washko
- Division of Pulmonary and Critical Care Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Tobias Welte
- Department of Respiratory Medicine, Hannover Medical School, Hannover, Germany; Biomedical Research in Endstage and Obstructive Lung Disease, German Center for Lung Research, Hannover, Germany
| | - Mark T Dransfield
- Lung Health Center, Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, University of Alabama at Birmingham, Birmingham, AL, USA; Birmingham VA Medical Center, Birmingham, AL, USA.
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13
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Kotaniemi-Syrjänen A, Klemola T, Koponen P, Jauhola O, Aito H, Malmström K, Malmberg LP, Rahiala E, Sarna S, Pelkonen AS, Mäkelä MJ. Intermittent Tiotropium Bromide for Episodic Wheezing: A Randomized Trial. Pediatrics 2022; 150:188736. [PMID: 35942814 DOI: 10.1542/peds.2021-055860] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/18/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Options to treat and prevent episodic wheezing in children are scarce. Our objective was to assess the efficacy of intermittent tiotropium bromide treatment in early childhood episodic wheezing. METHODS This 48-week, randomized, open-label, controlled, parallel-group trial was conducted at 4 hospitals in Finland. Children aged 6 to 35 months with 2 to 4 physician-confirmed episodes of wheeze and/or shortness of breath were considered eligible. Study participants were randomly allocated to receive 1 of 3 treatments: once-daily tiotropium bromide 5 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 27), twice-daily fluticasone propionate 125 µg for 7 to 14 days during respiratory tract infections and as-needed albuterol sulfate 0.2 mg (n = 25), or as-needed albuterol sulfate 0.2 mg alone (n = 28). The primary outcome was efficacy, assessed as intention-to-treat by comparing the proportion of episode-free days (the days lacking symptoms or treatments) between the treatment groups. RESULTS The proportion of episode-free days was higher in those receiving intermittent tiotropium bromide (median 97% [interquartile range, 93% to 99%]) than in those receiving intermittent fluticasone propionate (87% [78% to 93%], P = .002), or with as-needed albuterol sulfate alone (88% [79% to 95%], P = .003). Adjustment with allergic sensitization, the baseline number of physician-confirmed episodes of wheeze and/or shortness of breath, or short-course glucocorticoid treatment in the 2 weeks before the enrollment, did not affect the result. Intervention-related adverse events were not seen. CONCLUSIONS Intermittent tiotropium bromide treatment may be an effective alternative to current therapies for episodic wheezing. Before implementation of use, further research on safety and efficacy is indicated.
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Affiliation(s)
- Anne Kotaniemi-Syrjänen
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | | | | | - Kristiina Malmström
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - L Pekka Malmberg
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | | | - Anna S Pelkonen
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika J Mäkelä
- HUS Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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14
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Levina D, Leontjeva M, Abbasova N, Petrova Y, Bitieva R, Erdes SI, Aminova AI, Nurtazina A, Blyuss B, Pikuza M, Avdeenko NV, Gadetskaya S, Ivanova YV, Saglani S, Bush A, Munblit D. Changes in blood eosinophil levels in early childhood and asthma development: A case-control study. Pediatr Allergy Immunol 2022; 33:e13734. [PMID: 35212040 DOI: 10.1111/pai.13734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2022] [Revised: 01/19/2022] [Accepted: 01/21/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Daria Levina
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Marina Leontjeva
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Nilgyun Abbasova
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Yulia Petrova
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Rita Bitieva
- Department of Propedeutics of Paediatric Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Svetlana I Erdes
- Department of Propedeutics of Paediatric Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Alfiya I Aminova
- Department of Propedeutics of Paediatric Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Asel Nurtazina
- Department of Clinical Immunology and Allergology, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Boris Blyuss
- Prydniprovsky Scientific Centre of the National Academy of Sciences of Ukraine and of the Ministry of Education and Science of Ukraine, Dnipro, Ukraine
| | - Maria Pikuza
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Nina V Avdeenko
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Svetlana Gadetskaya
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Yulia V Ivanova
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia
| | - Sejal Saglani
- Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Inflammation, Repair and Development Section, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Bush
- Paediatric Respiratory Medicine, Royal Brompton and Harefield NHS Foundation Trust, London, UK.,Inflammation, Repair and Development Section, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK
| | - Daniel Munblit
- Department of Paediatrics and Paediatric Infectious Diseases, Institute of Child's Health, Sechenov First Moscow State Medical University (Sechenov University), Moscow, Russia.,Inflammation, Repair and Development Section, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, UK.,Research and Clinical Center for Neuropsychiatry, Moscow, Russia
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15
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Cherrez-Ojeda I, Robles-Velasco K, Osorio MF, Calderon JC, Bernstein JA. Current Needs Assessment for Using Lung Clearance Index for Asthma in Clinical Practice. Curr Allergy Asthma Rep 2022; 22:13-20. [DOI: 10.1007/s11882-022-01025-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/13/2021] [Indexed: 11/03/2022]
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16
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Bush A. How to Choose the Correct Drug in Severe Pediatric Asthma. Front Pediatr 2022; 10:902168. [PMID: 35722499 PMCID: PMC9201103 DOI: 10.3389/fped.2022.902168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/02/2022] [Indexed: 12/01/2022] Open
Abstract
When a child with severe asthma (asthma defined clinically for the purposes of this review as wheeze, breathlessness, and chest tightness sometimes with cough) does not respond to treatment, it is important to be sure that an alternative or additional diagnosis is not being missed. In school age children, the next step is a detailed protocolized assessment to determine the nature of the problem, whether within the airway or related to co-morbidities or social/environmental factors, in order to personalize the treatment. For example, those with refractory difficult asthma due to persistent non-adherence may benefit from using budesonide and formoterol combined in a single inhaler [single maintenance and reliever treatment (SMART)] as both a reliever and preventer. For those with steroid-resistant Type 2 airway inflammation, the use of biologicals such as omalizumab and mepolizumab should be considered, but for mepolizumab at least, there is a paucity of pediatric data. Protocols are less well developed in preschool asthma, where steroid insensitive disease is much more common, but the use of two simple measurements, aeroallergen sensitization, and peripheral blood eosinophil count, allows the targeted use of inhaled corticosteroids (ICSs). There is also increasing evidence that chronic airway infection may be important in preschool wheeze, increasing the possibility that targeted antibiotics may be beneficial. Asthma in the first year of life is not driven by Type 2 inflammation, so beyond avoiding prescribing ICSs, no evidence based recommendations can be made. In the future, we urgently need to develop objective biomarkers, especially of risk, so that treatment can be targeted effectively; we need to address the scandal of the lack of data in children compared with adults, precluding making evidence-based therapeutic decisions and move from guiding treatment by phenotypes, which will change as the environment changes, to endotype based therapy.
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Affiliation(s)
- Andrew Bush
- National Heart and Lung Institute, Imperial College, London, United Kingdom.,Imperial Centre for Paediatrics and Child Health, London, United Kingdom.,Royal Brompton Hospital, London, United Kingdom
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17
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Bush A. Impact of early life exposures on respiratory disease. Paediatr Respir Rev 2021; 40:24-32. [PMID: 34144911 DOI: 10.1016/j.prrv.2021.05.006] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Accepted: 05/20/2021] [Indexed: 12/21/2022]
Abstract
The antecedents of asthma and chronic obstructive pulmonary disease (COPD) lie before school age. Adverse effects are transgenerational, antenatal and in the preschool years. Antenatal adverse effects impair spirometry by causing low birth weight, altered lung structure and immune function, and sensitizing the foetus to later insults. The key stages of normal lung health are lung function at birth, lung growth to a plateau age 20-25 years, and the phase of decline thereafter; contrary to perceived wisdom, accelerated decline is not related to smoking. There are different trajectories of lung function. Lung function usually tracks from preschool to late middle age. Asthma is driven by antenatal and early life influences. The airflow obstruction, emphysema and multi-morbidity of COPD all start early. Failure to reach a normal plateau and accelerated decline in lung function are risk factors for COPD. Airway disease cannot be prevented in adult life; prevention must start early.
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Affiliation(s)
- Andrew Bush
- Paediatrics and Paediatric Respirology, Imperial College, UK; Imperial Centre for Paediatrics and Child Health, UK; Consultant Paediatric Chest Physician, Royal Brompton Harefield NHS Foundation Trust, UK.
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18
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Duan P, Wang Y, Lin R, Zeng Y, Chen C, Yang L, Yue M, Zhong S, Wang Y, Zhang Q. Impact of early life exposures on COPD in adulthood: A systematic review and meta-analysis. Respirology 2021; 26:1131-1151. [PMID: 34541740 DOI: 10.1111/resp.14144] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Revised: 07/16/2021] [Accepted: 08/29/2021] [Indexed: 02/06/2023]
Abstract
Early life represents a critical period for the development and growth of the lungs. Adverse exposures in this stage may drive the development of chronic obstructive pulmonary disease (COPD). Thus, we quantitatively evaluated the impact of different early life exposures on COPD in adulthood. The PubMed, Embase and Cochrane Library electronic databases were searched for articles published from January 2001 to October 2020. A total of 30 studies (795,935 participants) met the criteria and were included in the review. We found a significant association of COPD with childhood serious respiratory infections, pneumonia or bronchitis (pooled adjusted OR [aOR], 2.23 [95% CI, 1.63-3.07]). The probability of COPD was increased 3.45-fold for children with than without asthma (pooled aOR, 3.45 [95% CI, 2.37-5.02]). In addition, the probability of COPD was associated with maternal smoking (pooled aOR, 1.42 [95% CI, 1.17-1.72]), any child maltreatment (pooled aOR, 1.30 [95% CI, 1.18-1.42]) and low birth weight (pooled aOR, 1.58 [95% CI, 1.08-2.32]) but not childhood environmental tobacco smoke exposure (pooled aOR, 1.15 [0.83-1.61]) or premature birth (pooled aOR, 1.17 [95% CI, 0.87-1.58]). Furthermore, subgroup analyses revealed that probability was increased for only women with childhood physical abuse, sexual abuse and exposure to intimate partner violence. Factors resulting in COPD in adults could trace back to early life. Childhood respiratory disease, maltreatment, maternal smoking and low birth weight increase the risk of COPD. Promising advances in prevention strategies for early life exposures could markedly decrease the risk of COPD.
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Affiliation(s)
- Pengfei Duan
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
- Department of Infectious Disease Prevention and Control, The Zhongshan Second People's Hospital, Zhongshan, China
| | - Yao Wang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Rongqing Lin
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Yiming Zeng
- Department of Pulmonary and Critical Care Medicine, Respiratory Medicine Center of Fujian Province, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, China
| | - Chengshui Chen
- Respiratory Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Li Yang
- Respiratory Department, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Minghui Yue
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
| | - Shan Zhong
- Center for Research and Technology of Precision Medicine, College of Life Sciences and Oceanography, Shenzhen University, Shenzhen, China
| | - Yun Wang
- Center for Research and Technology of Precision Medicine, College of Life Sciences and Oceanography, Shenzhen University, Shenzhen, China
| | - Qingying Zhang
- Department of Preventive Medicine, Shantou University Medical College, Shantou, China
- Guangdong Provincial Key Laboratory for Breast Cancer Diagnosis and Treatment, Cancer Hospital of Shantou University Medical College, Shantou, China
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19
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Fang L, Roth M. Airway Wall Remodeling in Childhood Asthma-A Personalized Perspective from Cell Type-Specific Biology. J Pers Med 2021; 11:jpm11111229. [PMID: 34834581 PMCID: PMC8625708 DOI: 10.3390/jpm11111229] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/12/2021] [Accepted: 11/17/2021] [Indexed: 12/16/2022] Open
Abstract
Airway wall remodeling is a pathology occurring in chronic inflammatory lung diseases including asthma, chronic obstructive pulmonary disease, and fibrosis. In 2017, the American Thoracic Society released a research statement highlighting the gaps in knowledge and understanding of airway wall remodeling. The four major challenges addressed in this statement were: (i) the lack of consensus to define “airway wall remodeling” in different diseases, (ii) methodologic limitations and inappropriate models, (iii) the lack of anti-remodeling therapies, and (iv) the difficulty to define endpoints and outcomes in relevant studies. This review focuses on the importance of cell-cell interaction, especially the bronchial epithelium, in asthma-associated airway wall remodeling. The pathology of “airway wall remodeling” summarizes all structural changes of the airway wall without differentiating between different pheno- or endo-types of asthma. Indicators of airway wall remodeling have been reported in childhood asthma in the absence of any sign of inflammation; thus, the initiation event remains unknown. Recent studies have implied that the interaction between the epithelium with immune cells and sub-epithelial mesenchymal cells is modified in asthma by a yet unknown epigenetic mechanism during early childhood.
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20
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Bush A, Pavord ID. Challenging the paradigm: moving from umbrella labels to treatable traits in airway disease. Breathe (Sheff) 2021; 17:210053. [PMID: 35035544 PMCID: PMC8753662 DOI: 10.1183/20734735.0053-2021] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Accepted: 05/11/2021] [Indexed: 12/15/2022] Open
Abstract
Airway diseases were initially described by nonspecific patterns of symptoms, for example "dry and wheezy" and "wet and crackly". The model airway disease is cystic fibrosis, which has progressed from nonspecific reactive treatments such as antibiotics for airway infection to molecular sub-endotype, proactive therapies with an unequivocal evidence base, early diagnosis, and biomarkers of treatment efficacy. Unfortunately, other airway diseases lag behind, not least because nonspecific umbrella labels such as "asthma" are considered to be diagnoses not mere descriptions. Pending the delineation of molecular sub-endotypes in other airway disease the concept of treatable traits, and consideration of airway disease in a wider context is preferable. A treatable trait is a characteristic amenable to therapy, with measurable benefits of treatment. This approach determines what pathology is actually present and treatable, rather than using umbrella labels. We determine if airway inflammation is present, and whether there is airway eosinophilia which will likely respond to inhaled corticosteroids; whether there is variable airflow obstruction due to bronchoconstriction which will respond to β2-agonists; and whether there is unsuspected underlying airway infection which should be treated with antibiotics unless there is an underlying endotype which can be addressed, as for example an immunodeficiency. The context of airway disease should also be extrapulmonary comorbidities, social and environmental factors, and a developmental perspective, particularly this last aspect if preventive strategies are being contemplated. This approach allows targeted treatment for maximal patient benefit, as well as preventing the discarding of therapies which are useful for appropriate subgroups of patients. Failure to appreciate this almost led to the discarding of valuable treatments such as prednisolone. EDUCATIONAL AIMS To use cystic fibrosis as a paradigm to show the benefits of the journey from nonspecific umbrella terms to specific endotypes and sub-endotypes, as a road map for other airway diseases to follow.Demonstrate that nonspecific labels to describe airway disease can and should be abandoned in favour of treatable traits to ensure diagnostic and therapeutic precision.Begin to learn to see airway disease in the context of extrapulmonary comorbidities, and social and environmental factors, as well as with a developmental perspective.
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Affiliation(s)
- Andrew Bush
- Paediatrics and Paediatric Respirology, Imperial Centre for Paediatrics and Child Health, Imperial College London, London, UK
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | - Ian D. Pavord
- Respiratory Medicine, Respiratory Medicine Unit and Oxford Respiratory NIHR BRC, Nuffield Dept of Medicine, University of Oxford, Oxford, UK
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Mthembu N, Ikwegbue P, Brombacher F, Hadebe S. Respiratory Viral and Bacterial Factors That Influence Early Childhood Asthma. FRONTIERS IN ALLERGY 2021; 2:692841. [PMID: 35387053 PMCID: PMC8974778 DOI: 10.3389/falgy.2021.692841] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Accepted: 06/18/2021] [Indexed: 12/12/2022] Open
Abstract
Asthma is a chronic respiratory condition characterised by episodes of shortness of breath due to reduced airway flow. The disease is triggered by a hyperreactive immune response to innocuous allergens, leading to hyper inflammation, mucus production, changes in structural cells lining the airways, and airway hyperresponsiveness. Asthma, although present in adults, is considered as a childhood condition, with a total of about 6.2 million children aged 18 and below affected globally. There has been progress in understanding asthma heterogeneity in adults, which has led to better patient stratification and characterisation of multiple asthma endotypes with distinct, but overlapping inflammatory features. The asthma inflammatory profile in children is not well-defined and heterogeneity of the disease is less described. Although many factors such as genetics, food allergies, antibiotic usage, type of birth, and cigarette smoke exposure can influence asthma development particularly in children, respiratory infections are thought to be the major contributing factor in poor lung function and onset of the disease. In this review, we focus on viral and bacterial respiratory infections in the first 10 years of life that could influence development of asthma in children. We also review literature on inflammatory immune heterogeneity in asthmatic children and how this overlaps with early lung development, poor lung function and respiratory infections. Finally, we review animal studies that model early development of asthma and how these studies could inform future therapies and better understanding of this complex disease.
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Affiliation(s)
- Nontobeko Mthembu
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Paul Ikwegbue
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Frank Brombacher
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
- Division of Immunology, Health Science Faculty, International Centre for Genetic Engineering and Biotechnology (ICGEB) and Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
- Faculty of Health Sciences, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
| | - Sabelo Hadebe
- Division of Immunology, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
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22
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Robinson PFM, Fontanella S, Ananth S, Martin Alonso A, Cook J, Kaya-de Vries D, Polo Silveira L, Gregory L, Lloyd C, Fleming L, Bush A, Custovic A, Saglani S. Recurrent Severe Preschool Wheeze: From Pre-Specified Diagnostic Labels to Underlying Endotypes. Am J Respir Crit Care Med 2021; 204:523-535. [PMID: 33961755 PMCID: PMC8491264 DOI: 10.1164/rccm.202009-3696oc] [Citation(s) in RCA: 36] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
Rationale: Preschool wheezing is heterogeneous, but the underlying mechanisms are poorly understood. Objectives: To investigate lower airway inflammation and infection in preschool children with different clinical diagnoses undergoing elective bronchoscopy and BAL. Methods: We recruited 136 children aged 1–5 years (105 with recurrent severe wheeze [RSW]; 31 with nonwheezing respiratory disease [NWRD]). Children with RSW were assigned as having episodic viral wheeze (EVW) or multiple-trigger wheeze (MTW). We compared lower airway inflammation and infection in different clinical diagnoses and undertook data-driven analyses to determine clusters of pathophysiological features, and we investigated their relationships with prespecified diagnostic labels. Measurements and Main Results: Blood eosinophil counts and percentages and allergic sensitization were significantly higher in children with RSW than in children with a NWRD. Blood neutrophil counts and percentages, BAL eosinophil and neutrophil percentages, and positive bacterial culture and virus detection rates were similar between groups. However, pathogen distribution differed significantly, with higher detection of rhinovirus in children with RSW and higher detection of Moraxella in sensitized children with RSW. Children with EVW and children with MTW did not differ in terms of blood or BAL-sample inflammation, or bacteria or virus detection. The Partition around Medoids algorithm revealed four clusters of pathophysiological features: 1) atopic (17.9%), 2) nonatopic with a low infection rate and high use of inhaled corticosteroids (31.3%), 3) nonatopic with a high infection rate (23.1%), and 4) nonatopic with a low infection rate and no use of inhaled corticosteroids (27.6%). Cluster allocation differed significantly between the RSW and NWRD groups (RSW was evenly distributed across clusters, and 60% of the NWRD group was assigned to cluster 4; P < 0.001). There was no difference in cluster membership between the EVW and MTW groups. Cluster 1 was dominated by Moraxella detection (P = 0.04), and cluster 3 was dominated by Haemophilus or Staphylococcus or Streptococcus detection (P = 0.02). Conclusions: We identified four clusters of severe preschool wheeze, which were distinguished by using sensitization, peripheral eosinophilia, lower airway neutrophilia, and bacteriology.
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Affiliation(s)
- Polly F M Robinson
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Sara Fontanella
- Imperial College London, Department of Paediatrics, London, United Kingdom of Great Britain and Northern Ireland
| | - Sachin Ananth
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Aldara Martin Alonso
- Imperial College London, London, United Kingdom of Great Britain and Northern Ireland
| | - James Cook
- Royal Brompton and Harefield NHS Foundation Trust, 4964, Paediatric Respiratory Medicine, London, United Kingdom of Great Britain and Northern Ireland
| | - Daphne Kaya-de Vries
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland.,Royal Brompton and Harefield NHS Foundation Trust, 4964, Paediatric Respiratory Medicine, London, United Kingdom of Great Britain and Northern Ireland
| | - Luisa Polo Silveira
- Imperial College London, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Lisa Gregory
- Imperial College, Leukocyte Biology, South Kensington, United Kingdom of Great Britain and Northern Ireland
| | - Clare Lloyd
- Imperial College, Leukocyte Biology, London, United Kingdom of Great Britain and Northern Ireland
| | - Louise Fleming
- Royal BRompton Hospital, Respiratory Paediatrics, London, United Kingdom of Great Britain and Northern Ireland
| | - Andrew Bush
- Imperial College and Royal Brompton Hospital, London, London, United Kingdom of Great Britain and Northern Ireland
| | - Adnan Custovic
- Imperial College London, 4615, National Heart and Lung Institute, London, United Kingdom of Great Britain and Northern Ireland
| | - Sejal Saglani
- Royal Brompton Hospital, Respiratory Paediatrics, London, United Kingdom of Great Britain and Northern Ireland;
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23
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Bonner K, Scotney E, Saglani S. Factors and mechanisms contributing to the development of preschool wheezing disorders. Expert Rev Respir Med 2021; 15:745-760. [PMID: 33881953 DOI: 10.1080/17476348.2021.1913057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION Half of all children will experience an episode of wheezing by their sixth birthday and acute episodes of wheezing in preschool children account for the majority of all childhood hospital admissions for wheeze. Recurrent preschool wheezing associates with early loss of lung function and a life-long impact on lung health. AREAS COVERED We reviewed the literature on PubMed from August 2010-2020 focussing on factors associated with wheeze inception and persistence, paying specific attention to mechanistic studies that have investigated the impact of early life exposures in shaping immune responses in children with underlying susceptibility to wheezing. In particular, the role of early allergen sensitization, respiratory infections, and the impact of the environment on shaping the airway microbiome and resulting immune responses are discussed. EXPERT OPINION There is an abundance of associative data showing the role of in utero and postnatal factors influencing wheeze onset and persistence. However, mechanistic and stratified, biomarker-based interventional studies that confirm these associations are now needed if we are to impact the significant healthcare burden resulting from preschool wheezing disorders.
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Affiliation(s)
- Katie Bonner
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Elizabeth Scotney
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
| | - Sejal Saglani
- Inflammation, Repair & Development Section, National Heart & Lung Institute, Imperial College London, London, UK.,Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, London, UK
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24
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Beaufils F, Esteves P, Enaud R, Germande O, Celle A, Marthan R, Trian T, Fayon M, Berger P. Mitochondria are involved in bronchial smooth muscle remodeling in severe preschool wheezers. J Allergy Clin Immunol 2021; 148:645-651.e11. [PMID: 33819511 DOI: 10.1016/j.jaci.2021.03.027] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2020] [Revised: 02/01/2021] [Accepted: 03/09/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Bronchial remodeling is a key feature of asthma that is already present in preschoolers with wheezing. Moreover, bronchial smooth muscle (BSM) remodeling at preschool age is predictive of asthma at school age. However, the mechanism responsible for BSM remodeling in preschoolers with wheezing remains totally unknown. In contrast, in adult asthma, BSM remodeling has been associated with an increase in BSM cell proliferation related to increased mitochondrial mass and biogenesis triggered by an altered calcium homeostasis. Indeed, BSM cell proliferation was decreased in vitro by the calcium channel blocker gallopamil. OBJECTIVE Our aim was to investigate the mechanisms involved in BSM cell proliferation in preschoolers with severe wheezing, with special attention to the role of mitochondria and calcium signaling. METHODS Bronchial tissue samples obtained from 12 preschool controls without wheezing and 10 preschoolers with severe wheezing were used to measure BSM mass and establish primary BSM cell cultures. BSM cell proliferation was assessed by manual counting and flow cytometry, ATP content was assessed by bioluminescence, mitochondrial respiration was assessed by using either the Seahorse or Oroboros technique, mitochondrial mass and biogenesis were assessed by immunoblotting, and calcium response to carbachol was assessed by confocal microscopy. The effect of gallopamil was also evaluated. RESULTS BSM mass, cell proliferation, ATP content, mitochondrial respiration, mass and biogenesis, and calcium response were all increased in preschoolers with severe wheezing compared with in the controls. Gallopamil significantly decreased BSM mitochondrial biogenesis and mass, as well as cell proliferation. CONCLUSION Mitochondria are key players in BSM cell proliferation in preschoolers with severe wheezing and could represent a potential target to treat BSM remodeling at an early stage of the disease.
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Affiliation(s)
- Fabien Beaufils
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; CHU de Bordeaux, Service d'exploration fonctionnelle respiratoire, Service de Pédiatrie médicale, Bordeaux, France
| | - Pauline Esteves
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France
| | - Raphaël Enaud
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; CHU de Bordeaux, Service d'exploration fonctionnelle respiratoire, Service de Pédiatrie médicale, Bordeaux, France
| | - Ophélie Germande
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France
| | - Alexis Celle
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France
| | - Roger Marthan
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; CHU de Bordeaux, Service d'exploration fonctionnelle respiratoire, Service de Pédiatrie médicale, Bordeaux, France
| | - Thomas Trian
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France
| | - Michael Fayon
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; CHU de Bordeaux, Service d'exploration fonctionnelle respiratoire, Service de Pédiatrie médicale, Bordeaux, France
| | - Patrick Berger
- Univ-Bordeaux, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; INSERM, Centre de Recherche Cardio-thoracique de Bordeaux, U1045, CIC 1401, Bordeaux, France; CHU de Bordeaux, Service d'exploration fonctionnelle respiratoire, Service de Pédiatrie médicale, Bordeaux, France.
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25
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Chen S, Gu W, Wu M, Hao C, Zhu C, Shao X, Wang Y. Risk factors for recurrent wheezing after bronchiolitis in infants: 2-year follow up in China. BMC Infect Dis 2021; 21:250. [PMID: 33691633 PMCID: PMC7945297 DOI: 10.1186/s12879-021-05937-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2020] [Accepted: 02/25/2021] [Indexed: 12/02/2022] Open
Abstract
Background Infants with bronchiolitis have an increased risk of developing recurrent wheezing and asthma. However, the risk factors for the development of recurrent wheezing after bronchiolitis remains controversial. Our study was to investigate risk factors of post-bronchiolitis recurrent wheezing. Methods Infants with bronchiolitis were enrolled from November 2016 through March 2017. Nasopharyngeal aspirates were obtained for detection of respiratory viruses which were analyzed by reverse transcriptase polymerase chain reaction (RT-PCR) and direct immunofluorescent assay. Serum cytokines including TSLP, IL2, IL13, TIMP-1, MMP-9, IL33, IL5, IL4, IL25, TNF- α and MIP-1α were measured by flow cytometry. Patients were followed up every 3 months for a duration of 2 years by telephone or at outpatient appointments. Results We enrolled 89 infants, of which 81 patients were successfully followed up. In total, 22.2% of patients experienced recurrent wheezing episodes. The proportion of patients with history of eczema, systemic glucocorticoid use and patients with moderate-to-severe disease were significantly higher in the recurrent wheezing group than the non-recurrent wheezing group (83.3% vs 52.4%; 66.7% vs 36.5%; 61.1% vs 33.3%, respectively, all P < 0.05); There were no significant differences between patients with and without recurrent wheezing episodes in the levels of TSLP, IL2, IL13, TIMP-1, MMP-9, IL33, IL5, IL4, IL25, TNF- α and MIP-1α (P > 0.05). Logistic regression analysis showed that history of eczema was an independent risk factor for post-bronchiolitis recurrent wheezing (odds ratio [OR] = 5.622; 95% confidence interval [CI], 1.3–24.9; P = 0.023). Conclusion The incidence of recurrent wheezing among infants after contracting bronchiolitis was 22.2% during a 2-year follow-up. History of eczema was the only independent risk factor identified and no correlation was found between the specific virus and disease severity in children with post-bronchiolitis recurrent wheezing.
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Affiliation(s)
- Sainan Chen
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China
| | - Wenjing Gu
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China
| | - Min Wu
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China
| | - Chuangli Hao
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China
| | - Canhong Zhu
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China
| | - Xuejun Shao
- Department of Laboratory Medicine, Department of Clinical laboratory, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China
| | - Yuqing Wang
- Department of Respiratory Medicine, Children's Hospital of Soochow University, Jingde Road No. 303, Suzhou, 215003, China.
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26
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Affiliation(s)
- Steve Turner
- Child Health University of Aberdeen Aberdeen, United Kingdom
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27
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Cheng SL. Immunologic Pathophysiology and Airway Remodeling Mechanism in Severe Asthma: Focused on IgE-Mediated Pathways. Diagnostics (Basel) 2021; 11:diagnostics11010083. [PMID: 33419185 PMCID: PMC7825545 DOI: 10.3390/diagnostics11010083] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Revised: 01/02/2021] [Accepted: 01/04/2021] [Indexed: 12/27/2022] Open
Abstract
Despite the expansion of the understanding in asthma pathophysiology and the continual advances in disease management, a small subgroup of patients remains partially controlled or refractory to standard treatments. Upon the identification of immunoglobulin E (IgE) and other inflammatory mediators, investigations and developments of targeted agents have thrived. Omalizumab is a humanized monoclonal antibody that specifically targets the circulating IgE, which in turn impedes and reduces subsequent releases of the proinflammatory mediators. In the past decade, omalizumab has been proven to be efficacious and well-tolerated in the treatment of moderate-to-severe asthma in both trials and real-life studies, most notably in reducing exacerbation rates and corticosteroid use. While growing evidence has demonstrated that omalizumab may be potentially beneficial in treating other allergic diseases, its indication remains confined to treating severe allergic asthma and chronic idiopathic urticaria. Future efforts may be bestowed on determining the optimal length of omalizumab treatment, seeking biomarkers that could better predict treatment response and as well as extending its indications.
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Affiliation(s)
- Shih-Lung Cheng
- Department of Internal Medicine, Far Eastern Memorial Taipei Hospital, Department of Chemical Engineering and Materials Science, Yuan Ze University, Zhongli, Taoyuan 32056, Taiwan
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28
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de Vos G, Viswanathan S, Pichardo Y, Nazari R, Jorge Y, Ren Z, Serebrisky D, Rosenstreich D, Wiznia A. A randomized trial of subcutaneous allergy immunotherapy in inner-city children with asthma less than 4 years of age. Ann Allergy Asthma Immunol 2021; 126:367-377.e5. [PMID: 33418053 DOI: 10.1016/j.anai.2020.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 12/03/2020] [Accepted: 12/28/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Allergic sensitization to environmental allergens in the first years of life is a strong predictor of asthma morbidity in children. Allergy immunotherapy can improve asthma and allergy outcomes, but its efficacy in inner-city, atopic children of less than 4 years of age with recurrent wheezing has not yet been established. OBJECTIVE To determine whether subcutaneous allergy immunotherapy improves asthma in a population of US inner-city children when started at less than 4 years of age. METHODS In a randomized controlled, open-label phase I-II single-center trial in the Bronx, New York, 58 children with recurrent wheezing or physician-diagnosed asthma were randomized to receive asthma standard of care treatment with or without a 3-year course of multiple allergen subcutaneous immunotherapy. RESULTS A total of 23 children in the control group and 27 children in the immunotherapy group began the study. A total of 20 of 27 children commencing immunotherapy completed at least 2 years of immunotherapy. There was no difference in asthma medication and symptom scores between the treatment or control groups over time. Similarly, naso-ocular symptoms and allergy medication use were similar in both groups over time. Nevertheless, asthma-related quality of life improved in the immunotherapy group compared with the control group (P = .03). CONCLUSION With the exception of asthma-related quality of life, allergy immunotherapy was ineffective in improving asthma outcomes in this population of inner-city children of less than 4 years of age. These findings suggest that the effects of allergy immunotherapy depend on population-specific factors and highlight the importance of precise predictors of immunotherapy efficacy. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01028560.
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Affiliation(s)
- Gabriele de Vos
- Division of Allergy and Immunology, Albert Einstein College of Medicine, Bronx, New York; Department of Pediatrcis, Jacobi Medical Center, Bronx, New York; Division of Allergy and Immunology, Department of Pediatrics, Montefiore Medical Center, Bronx, New York.
| | - Shankar Viswanathan
- Department of Epidemiology and Biostatistics, Albert Einstein College of Medicine, Bronx, New York
| | - Yikania Pichardo
- Department of Pediatrcis, Jacobi Medical Center, Bronx, New York
| | - Ramin Nazari
- Department of Medicine, Jacobi Medical Center, Bronx, New York
| | - Yurydia Jorge
- Department of Pediatrcis, Jacobi Medical Center, Bronx, New York
| | - Zhen Ren
- Department of Pediatrics, University of Central Florida, Florida Hospital Medical Center, Orlando, Florida
| | | | - David Rosenstreich
- Division of Pediatric Pulmonology, Jacobi Medical Center, Bronx, New York
| | - Andrew Wiznia
- Division of Allergy and Immunology, Department of Pediatrics, Montefiore Medical Center, Bronx, New York
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29
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van Weelden M, van Ewijk BE, Plötz FB. Age differentiation in children with asthma treated with intravenous magnesium sulphate. J Pediatr 2020; 225:282-283. [PMID: 32553871 DOI: 10.1016/j.jpeds.2020.06.042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 06/10/2020] [Indexed: 10/24/2022]
Affiliation(s)
| | - Bart E van Ewijk
- Department of Pediatrics, Tergooi Hospital, Blaricum, The Netherlands
| | - Frans B Plötz
- Department of Pediatrics, Tergooi Hospital, Blaricum, The Netherlands
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30
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Pijnenburg MW, Fleming L. Advances in understanding and reducing the burden of severe asthma in children. THE LANCET RESPIRATORY MEDICINE 2020; 8:1032-1044. [PMID: 32910897 DOI: 10.1016/s2213-2600(20)30399-4] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 01/16/2023]
Abstract
Severe asthma in children is rare, accounting for only a small proportion of childhood asthma. After addressing modifiable factors such as adherence to treatment, comorbidities, and adverse exposures, children whose disease is not well controlled on high doses of medication form a heterogeneous group of severe asthma phenotypes. Over the past decade, considerable advances have been made in understanding the pathophysiology of severe therapy-resistant asthma in children. However, asthma attacks and hospital admissions are frequent and mortality is still unacceptably high. Strategies to modify the natural history of asthma, prevent severe exacerbations, and prevent lung function decline are needed. Mechanistic studies have led to the development of several biologics targeting type 2 inflammation. This growing pipeline has the potential to reduce the burden of severe asthma; however, detailed assessment and characterisation of each child with seemingly severe asthma is necessary so that the most effective and appropriate management strategy can be implemented. Risk stratification, remote monitoring, and the integration of multiple data sources could help to tailor management for the individual child with severe asthma.
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Affiliation(s)
- Mariëlle W Pijnenburg
- Department of Paediatrics, Division of Respiratory Medicine and Allergology, Erasmus MC, University Medical Centre Rotterdam, Rotterdam, Netherlands.
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College, London, UK
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31
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What Have In Vitro Co-Culture Models Taught Us about the Contribution of Epithelial-Mesenchymal Interactions to Airway Inflammation and Remodeling in Asthma? Cells 2020; 9:cells9071694. [PMID: 32679790 PMCID: PMC7408556 DOI: 10.3390/cells9071694] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 07/11/2020] [Accepted: 07/13/2020] [Indexed: 12/14/2022] Open
Abstract
As the lung develops, epithelial-mesenchymal crosstalk is essential for the developmental processes that drive cell proliferation, differentiation, and extracellular matrix (ECM) production within the lung epithelial-mesenchymal trophic unit (EMTU). In asthma, a number of the lung EMTU developmental signals have been associated with airway inflammation and remodeling, which has led to the hypothesis that aberrant activation of the asthmatic EMTU may lead to disease pathogenesis. Monoculture studies have aided in the understanding of the altered phenotype of airway epithelial and mesenchymal cells and their contribution to the pathogenesis of asthma. However, 3-dimensional (3D) co-culture models are needed to enable the study of epithelial-mesenchymal crosstalk in the setting of the in vivo environment. In this review, we summarize studies using 3D co-culture models to assess how defective epithelial-mesenchymal communication contributes to chronic airway inflammation and remodeling within the asthmatic EMTU.
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32
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Malmberg LP, Malmström K, Kotaniemi‐Syrjänen A, Lohi J, Pelkonen AS, Sarna S, Mäkelä MJ. Early bronchial inflammation and remodeling and airway hyperresponsiveness at school age. Allergy 2020; 75:1765-1768. [PMID: 31984505 DOI: 10.1111/all.14198] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Revised: 12/13/2019] [Accepted: 01/19/2020] [Indexed: 01/06/2023]
Affiliation(s)
- Leo Pekka Malmberg
- Department of Allergy, Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Kristiina Malmström
- Department of Allergy, Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anne Kotaniemi‐Syrjänen
- Department of Allergy, Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Jouko Lohi
- Department of Pathology University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Anna S. Pelkonen
- Department of Allergy, Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
| | - Seppo Sarna
- Department of Public Health University of Helsinki Finland Helsinki Finland
| | - Mika J. Mäkelä
- Department of Allergy, Skin and Allergy Hospital University of Helsinki and Helsinki University Hospital Helsinki Finland
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33
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Fainardi V, Santoro A, Caffarelli C. Preschool Wheezing: Trajectories and Long-Term Treatment. Front Pediatr 2020; 8:240. [PMID: 32478019 PMCID: PMC7235303 DOI: 10.3389/fped.2020.00240] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 04/20/2020] [Indexed: 12/13/2022] Open
Abstract
Wheezing is very common in infancy affecting one in three children during the first 3 years of life. Several wheeze phenotypes have been identified and most rely on temporal pattern of symptoms. Assessing the risk of asthma development is difficult. Factors predisposing to onset and persistence of wheezing such as breastfeeding, atopy, indoor allergen exposure, environmental tobacco smoke and viral infections are analyzed. Inhaled corticosteroids are recommended as first choice of controller treatment in all preschool children irrespective of phenotype, but they are particularly beneficial in terms of fewer exacerbations in atopic children. Other therapeutic options include the addition of montelukast or the intermittent use of inhaled corticosteroids. Overuse of inhaled steroids must be avoided. Therefore, adherence to treatment and correct administration of the medications need to be checked at every visit.
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Affiliation(s)
| | | | - Carlo Caffarelli
- Clinica Pediatrica, Department of Medicine and Surgery, University of Parma, Parma, Italy
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Zazara DE, Wegmann M, Giannou AD, Hierweger AM, Alawi M, Thiele K, Huber S, Pincus M, Muntau AC, Solano ME, Arck PC. A prenatally disrupted airway epithelium orchestrates the fetal origin of asthma in mice. J Allergy Clin Immunol 2020; 145:1641-1654. [PMID: 32305348 DOI: 10.1016/j.jaci.2020.01.050] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2019] [Revised: 12/27/2019] [Accepted: 01/29/2020] [Indexed: 12/21/2022]
Abstract
BACKGROUND Prenatal challenges such as maternal stress perception increase the risk and severity of asthma during childhood. However, insights into the trajectories and targets underlying the pathogenesis of prenatally triggered asthma are largely unknown. The developing lung and immune system may constitute such targets. OBJECTIVE Here we have aimed to identify the differential sex-specific effects of prenatal challenges on lung function, immune response, and asthma severity in mice. METHODS We generated bone marrow chimeric (BMC) mice harboring either prenatally stress-exposed lungs or a prenatally stress-exposed immune (hematopoietic) system and induced allergic asthma via ovalbumin. Next-generation sequencing (RNA sequencing) of lungs and assessment of airway epithelial barrier function in ovalbumin-sensitized control and prenatally stressed offspring was also performed. RESULTS Profoundly enhanced airway hyperresponsiveness, inflammation, and fibrosis were exclusively present in female BMC mice with prenatally stress-exposed lungs. These effects were significantly perpetuated if both the lungs and the immune system had been exposed to prenatal stress. A prenatally stress-exposed immune system alone did not suffice to increase the severity of these asthma features. RNA sequencing analysis of lungs from prenatally stressed, non-BMC, ovalbumin-sensitized females unveiled a deregulated expression of genes involved in asthma pathogenesis, tissue remodeling, and tight junction formation. It was also possible to independently confirm a tight junction disruption. In line with this, we identified an altered perinatal and/or postnatal expression of genes involved in lung development along with an impaired alveolarization in female prenatally stressed mice. CONCLUSION Here we have shown that the fetal origin of asthma is orchestrated by a disrupted airway epithelium and further perpetuated by a predisposed immune system.
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Affiliation(s)
- Dimitra E Zazara
- Department of Obstetrics and Prenatal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Wegmann
- Division of Asthma Exacerbation & Regulation, Priority Area Asthma and Allergy, Leibniz Lung Center Borstel, Airway Research Center North, Member of the German Center for Lung Research, Borstel, Germany
| | - Anastasios D Giannou
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Alexandra Maximiliane Hierweger
- Department of Obstetrics and Prenatal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Institute for Immunology, Center for Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Malik Alawi
- Bioinformatics Core, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kristin Thiele
- Department of Obstetrics and Prenatal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Maike Pincus
- Pediatrics and Pediatric Pneumology Practice, Berlin, Germany
| | - Ania C Muntau
- University Children's Hospital, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Emilia Solano
- Department of Obstetrics and Prenatal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Petra C Arck
- Department of Obstetrics and Prenatal Medicine, Laboratory for Experimental Feto-Maternal Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Malmström K, Lohi J, Malmberg LP, Kotaniemi-Syrjänen A, Lindahl H, Sarna S, Pelkonen AS, Mäkelä MJ. Airway hyperresponsiveness, remodeling and inflammation in infants with wheeze. Clin Exp Allergy 2020; 50:558-566. [PMID: 32159879 DOI: 10.1111/cea.13598] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 01/23/2020] [Accepted: 03/08/2020] [Indexed: 01/06/2023]
Abstract
BACKGROUND The relationship of airway hyperresponsiveness to airway remodeling and inflammation in infants with wheeze is unclear. OBJECTIVE To investigate airway hyperresponsiveness, remodeling and inflammation in infants with wheeze and troublesome breathing. METHODS Inclusion criteria were as follows: full-term, 3-23 months of age; doctor -diagnosed wheeze and persistent recurrent troublesome breathing; without obvious structural defect, suspicion of ciliary dyskinesia, cystic fibrosis, immune deficiency or specified use of corticosteroids. Airway hyperresponsiveness (AHR) was evaluated by performing a methacholine bronchial challenge test combined with whole body plethysmography and rapid thoracoabdominal compression. Endobronchial biopsies were analysed for remodeling (thickness of reticular basement membrane and amount of airway smooth muscle) and for inflammation (numbers of inflammatory cells). Correlation analyses were performed. RESULTS Forty-nine infants fulfilled the inclusion criteria for the present study. Median age was 1.06 years (IQR 0.6; 1.5). Lung function was impaired in 39/49 (80%) children, at the median age of 1.1 years. Methacholine challenge was successfully performed in 38/49 children. Impaired baseline lung function was correlated with AHR (P = .047, Spearman). In children with the most sensitive quartile of AHR, the percentage of median bronchial airway smooth muscle % and the number of bronchial mast cells in airway smooth muscle were not significantly higher compared to others (P = .057 and 0.056, respectively). No association was found between AHR and thickness of reticular basement membrane or inflammatory cells. Only a small group of children with both atopy and AHR (the most reactive quartile) had thicker airway smooth muscle area than non-atopics with AHR (P = .031). CONCLUSIONS AND CLINICAL RELEVANCE These findings do not support the concept that AHR in very young children with wheeze is determined by eosinophilic inflammation or clear-cut remodeling although it is associated with impaired baseline lung function. The possible association of increased airway smooth muscle area among atopic children with AHR remains to be confirmed.
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Affiliation(s)
- Kristiina Malmström
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jouko Lohi
- Dept. of Pathology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leo Pekka Malmberg
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne Kotaniemi-Syrjänen
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Harry Lindahl
- Children's Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Seppo Sarna
- Dept. of Public Health, University of Helsinki, Helsinki, Finland
| | - Anna S Pelkonen
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika J Mäkelä
- Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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36
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Januska MN, Goldman DL, Webley W, Teague WG, Cohen RT, Bunyavanich S, Vicencio AG. Bronchoscopy in severe childhood asthma: Irresponsible or irreplaceable? Pediatr Pulmonol 2020; 55:795-802. [PMID: 31730298 PMCID: PMC7385726 DOI: 10.1002/ppul.24569] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2019] [Accepted: 10/14/2019] [Indexed: 12/13/2022]
Abstract
For children with severe asthma, guideline-based management focuses on the escalation of anti-inflammatory and bronchodilatory medications while addressing comorbid conditions. Bronchoscopy, in this context, has been relegated to ruling out asthma mimickers. More recently, however, there have been questions surrounding the clinical utility of bronchoscopy in severe childhood asthma. In this solicited lecture summary, we discuss the past, present, and potential future applications of bronchoscopy in severe childhood asthma.
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Affiliation(s)
- Megan N. Januska
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
| | | | | | | | | | - Supinda Bunyavanich
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
- Ichan School of Medicine at Mount Sinai, Department of Genetics and Genomic Sciences, New York, NY
| | - Alfin G. Vicencio
- Icahn School of Medicine at Mount Sinai, Department of Pediatrics, New York, NY
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37
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To M, Tsuzuki R, Katsube O, Yamawaki S, Soeda S, Kono Y, Honda N, Kano I, Haruki K, To Y. Persistent Asthma from Childhood to Adulthood Presents a Distinct Phenotype of Adult Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1921-1927.e2. [PMID: 31981729 DOI: 10.1016/j.jaip.2020.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 12/21/2019] [Accepted: 01/07/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND In approximately 30% of children with asthma, the condition persists into adulthood. The longer duration of asthma in these patients is a risk factor for poor asthma control. However, the characteristics of adult patients with asthma that has persisted since childhood are not well documented. OBJECTIVE We sought to compare the clinical characteristics among patients with adult-onset asthma, patients who outgrew childhood asthma but relapsed, and patients with persistent asthma since childhood. METHODS We conducted a cross-sectional study of adult patients with asthma who visited our hospital. We classified them into 3 groups: those with adult-onset asthma (adult-onset), those who had remitted childhood asthma that relapsed (relapsed), and those who had asthma that had persisted since childhood (persistent). The clinical characteristics of these groups were compared. RESULTS A total of 1443 patients were enrolled. The persistent group was younger and included fewer patients with a smoking history. There were statistically significant differences among the 3 groups in the percentages of patients with a family history of asthma and comorbidities of allergic rhinitis and atopic dermatitis. The proportion of patients with severe asthma differed among the 3 groups (31% in the adult-onset group, 34% in the relapsed group, and 40% in the persistent group; P = .015). The values of forced expiratory flow at 75% of vital capacity were lower in the persistent group than the relapsed or adult-onset group. A multivariable logistic regression analysis (dependent variable: severe asthma) in each group revealed that the factors associated with severe asthma differed among the adult-onset, relapsed, and persistent groups. When we established an overall model that included interaction terms of cohort-by-other factors, there was a trend that comorbidity of allergic rhinitis affected the severity of asthma differently in the relapsed group compared with the other groups. CONCLUSION The clinical phenotype of asthma that persists from childhood to adulthood seems to be a distinct phenotype of adult asthma.
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Affiliation(s)
- Masako To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan; Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Ryuta Tsuzuki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Otohiro Katsube
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Satoshi Yamawaki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Seiko Soeda
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Yuta Kono
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Natsue Honda
- Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Ichino Kano
- Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Kosuke Haruki
- Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Yasuo To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan.
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Murphy KR, Chipps BE. Tiotropium in children and adolescents with asthma. Ann Allergy Asthma Immunol 2019; 124:267-276.e3. [PMID: 31805357 DOI: 10.1016/j.anai.2019.11.030] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 01/06/2023]
Abstract
BACKGROUND Asthma is a major cause of morbidity in children, despite the availability of various treatments. In adults, tiotropium-a long-acting muscarinic antagonist-as add-on therapy to an inhaled corticosteroid with or without a long-acting β2-agonist provides clinical benefit with a safety profile similar to placebo. OBJECTIVE To review published evidence on the efficacy and safety of tiotropium as add-on a long-acting muscarinic antagonist therapy in children and adolescents with asthma that is uncontrolled despite use of an inhaled corticosteroid with or without additional controller medication(s). METHODS We searched PubMed from inception until June 12, 2018, for randomized controlled trials of children and adolescents aged 1 to 17 years treated with tiotropium and reporting a primary outcome of any pulmonary function test and a secondary outcome of adverse events. RESULTS Overall, 7 randomized controlled trials of 1902 preschool children (aged 1-5 years; n = 102), school-age children (aged 6-11 years; n = 905), and adolescents (aged 12-17 years; n = 895) with moderate to severe asthma were included in the analysis. Once-daily tiotropium (5, 2.5, or 1.25 μg) improved lung function parameters, including peak and trough forced expiratory volume in 1 second, vs placebo. Commonly reported adverse events across treatment groups included asthma worsening or exacerbations, decreased peak expiratory flow rate, nasopharyngitis, viral respiratory tract infection, and respiratory tract infection. CONCLUSION Once-daily tiotropium as add-on therapy is efficacious and safe in adolescents and children with moderate to severe asthma. These results support the expanded indication by regulatory authorities for add-on tiotropium in patients 6 years or older.
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Affiliation(s)
- Kevin R Murphy
- Boys Town National Research Hospital, Boys Town, Nebraska
| | - Bradley E Chipps
- Capital Allergy & Respiratory Disease Center, Sacramento, California.
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39
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Hadebe S, Brombacher F. Environment and Host-Genetic Determinants in Early Development of Allergic Asthma: Contribution of Fungi. Front Immunol 2019; 10:2696. [PMID: 31824491 PMCID: PMC6879655 DOI: 10.3389/fimmu.2019.02696] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 11/01/2019] [Indexed: 12/16/2022] Open
Abstract
Asthma is a chronic debilitating airway disease affecting millions of people worldwide. Although largely thought to be a disease of the first world, it is now clear that it is on the rise in many middle- and lower-income countries. The disease is complex, and its etiology is poorly understood, which explains failure of most treatment strategies. We know that in children, asthma is closely linked to poor lung function in the first 3-years of life, when the lung is still undergoing post-natal alveolarization phase. Epidemiological studies also suggest that environmental factors around that age do play a critical part in the establishment of early wheezing which persists until adulthood. Some of the factors that contribute to early development of asthma in children in Western world are clear, however, in low- to middle-income countries this is likely to differ significantly. The contribution of fungal species in the development of allergic diseases is known in adults and in experimental models. However, it is unclear whether early exposure during perinatal or post-natal lung development influences a protective or promotes allergic asthma. Host immune cells and responses will play a crucial part in early development of allergic asthma. How immune cells and their receptors may recognize fungi and promote allergic asthma or protect by tolerance among other immune mechanisms is not fully understood in this early lung development stage. The aim of this review is to discuss what fungal species are present during early exposure as well as their contribution to the development of allergic responses. We also discuss how the host has evolved to promote tolerance to limit hyper-responsiveness to innocuous fungi, and how host evasion by fungi during early development consequentially results in allergic diseases.
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Affiliation(s)
- Sabelo Hadebe
- Division of Immunology and South African Medical Research Council (SAMRC) Immunology of Infectious Diseases, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa
| | - Frank Brombacher
- Division of Immunology and South African Medical Research Council (SAMRC) Immunology of Infectious Diseases, Department of Pathology, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa.,International Centre for Genetic Engineering and Biotechnology (ICGEB), Cape Town, South Africa.,Division of Immunology, Faculty of Health Sciences, Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa.,Faculty of Health Sciences, Wellcome Centre for Infectious Diseases Research in Africa (CIDRI-Africa), Institute of Infectious Diseases and Molecular Medicine (IDM), University of Cape Town, Cape Town, South Africa
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40
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Bonato M, Tiné M, Bazzan E, Biondini D, Saetta M, Baraldo S. Early Airway Pathological Changes in Children: New Insights into the Natural History of Wheezing. J Clin Med 2019; 8:jcm8081180. [PMID: 31394827 PMCID: PMC6723918 DOI: 10.3390/jcm8081180] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 07/31/2019] [Accepted: 08/04/2019] [Indexed: 01/09/2023] Open
Abstract
Asthma is a heterogeneous condition characterized by reversible airflow limitation, with different phenotypes and clinical expressions. Although it is known that asthma is influenced by age, gender, genetic background, and environmental exposure, the natural history of the disease is still incompletely understood. Our current knowledge of the factors determining the evolution from wheezing in early childhood to persistent asthma later in life originates mainly from epidemiological studies. The underlying pathophysiological mechanisms are still poorly understood. The aim of this review is to converge epidemiological and pathological evidence early in the natural history of asthma to gain insight into the mechanisms of disease and their clinical expression.
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Affiliation(s)
- Matteo Bonato
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Mariaenrica Tiné
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Erica Bazzan
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Davide Biondini
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
| | - Marina Saetta
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy.
| | - Simonetta Baraldo
- Department of Cardiac, Thoracic, Vascular Sciences and Public Health, University of Padova, 35128 Padova, Italy
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41
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Bush A, Saglani S. Structurally Unsound? Why Airways Become Asthmatic. Am J Respir Cell Mol Biol 2019; 59:405-406. [PMID: 29953256 DOI: 10.1165/rcmb.2018-0181ed] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Affiliation(s)
- Andrew Bush
- 1 Department of Paediatric Respiratory Medicine Imperial College and Royal Brompton Hospital London, United Kingdom
| | - Sejal Saglani
- 1 Department of Paediatric Respiratory Medicine Imperial College and Royal Brompton Hospital London, United Kingdom
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42
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Gut G, Armoni Domany K, Sadot E, Soferman R, Fireman E, Sivan Y. Eosinophil cell count in bronchoalveolar lavage fluid in early childhood wheezing: is it predictive of future asthma? J Asthma 2019; 57:366-372. [PMID: 30795692 DOI: 10.1080/02770903.2019.1579829] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
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.
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Affiliation(s)
- Guy Gut
- Pediatric Pulmonary Institute, Ruth Children's Hospital, Rambam Health Care Campus, Haifa, Israel
| | - Keren Armoni Domany
- The Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Efraim Sadot
- The Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Ruth Soferman
- The Department of Pediatric Pulmonology, Critical Care and Sleep Medicine, "Dana-Dwek" Children's Hospital, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Elizabeth Fireman
- Institute for Pulmonary and Allergic Diseases, and National Laboratory Service for Interstitial Lung Diseases, Tel Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Yakov Sivan
- Department of Pediatric Pulmonology, Safra Children's Hospital, Sheba Medical Center, Tel Aviv University, Sackler Faculty of Medicine, Tel Aviv, Israel
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Question 3: Can we diagnose asthma in children under the age of 5 years? Paediatr Respir Rev 2019; 29:25-30. [PMID: 30528365 PMCID: PMC6444340 DOI: 10.1016/j.prrv.2018.10.003] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 10/18/2018] [Indexed: 12/27/2022]
Abstract
The diagnosis of asthma in children under five years has been controversial due to changing concepts of what true asthma is in this age group. Previous diagnostic algorithms that used clinical indices to predict the persistence of asthma symptoms or phenotypes based on asthma triggers do not predict which children will benefit from asthma medication. A pragmatic approach to asthma diagnosis in this age group is based on identifying signs and symptoms of reversible airflow obstruction and documenting their response to asthma medication. Hopefully, this approach will provide clearer guidance to clinicians and improve asthma morbidity in these young children.
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Abstract
Asthmatic adults with lower lung function have been described as having had this worse condition early in life. Lung function is reduced in children with persistent asthma and continues low throughout adult life. The challenge is to know if impaired lung function is a risk factor of asthma, as a consequence of special congenital characteristics of the airways, or whether asthmatic patients suffer a loss in lung function as early as 9 years of age as a consequence of very precocious remodeling of the airways. The loss is so early in life that it is probably a congenital characteristic, however there is not a cut-off point with clinical interest to predict risk of asthma later in life. There are contradictory results regarding whether asthmatic children lose lung function as a consequence of the airway remodeling by the illness itself. This aspect seemed to be shown for children at risk-the offspring of asthmatic mothers. The early BHR seems to be very frequent even in healthy infants, but is probably not a risk factor for asthma years later; except in the offspring of asthmatic mothers in which it has been shown. There are still many uncertainties in this field; so, more research is needed in order to better understand the pathophysiology of asthma, the early risk factors and to design new therapeutic targets and early interventions to change the natural history of the disease.
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Affiliation(s)
- Manuel Sánchez-Solís
- Department of Pediatric, Hospital Universitario Virgen de la Arrixaca, Murcia, Spain.,Biomedical Research Institute of Murcia (IMIB), Palmar, Spain.,Department of Surgery, Pediatric, Obstetric and Gynaecology, University of Murcia, Murcia, Spain
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45
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Fleming L, Heaney L. Severe Asthma-Perspectives From Adult and Pediatric Pulmonology. Front Pediatr 2019; 7:389. [PMID: 31649906 PMCID: PMC6794347 DOI: 10.3389/fped.2019.00389] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2019] [Accepted: 09/09/2019] [Indexed: 12/11/2022] Open
Abstract
Both adults and children with severe asthma represent a small proportion of the asthma population; however, they consume disproportionate resources. For both groups it is important to confirm the diagnosis of severe asthma and ensure that modifiable factors such as adherence have, as far as possible, been addressed. Most children can be controlled on inhaled corticosteroids and long term oral corticosteroid use is rare, in contrast to adults where steroid related morbidity accounts for a large proportion of the costs of severe asthma. Atopic sensitization is very common in children with severe asthma as are other atopic conditions such as allergic rhinitis and hay fever which can impact on asthma control. In adults, the role of allergic driven disease, even in those with co-existent evidence of sensitization, is unclear. There is currently an exciting pipeline of novel biologicals, particularly directed at Type 2 inflammation, which afford the possibility of improved asthma control and reduced treatment side effects for people with asthma. However, not all drugs will work for all patients and accurate phenotyping is essential. In adults the terms T2 high and T2 low asthma have been coined to describe groups of patients based on the presence/absence of eosinophilic inflammation and T-helper 2 (TH2) cytokines. Bronchoscopic studies in children with severe asthma have demonstrated that these children are predominantly eosinophilic but the cytokine patterns do not fit the T2 high paradigm suggesting other steroid resistant pathways are driving the eosinophilic inflammation. It remains to be seen whether treatments developed for adult severe asthma will be effective in children and which biomarkers will predict response.
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Affiliation(s)
- Louise Fleming
- National Heart and Lung Institute, Imperial College, London and Royal Brompton Hospital, London, United Kingdom
| | - Liam Heaney
- Centre for Experimental Medicine, School of Medicine, Dentistry and Biomedical Sciences, Institute for Health Sciences, Queens University Belfast, Belfast, United Kingdom
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Abstract
Antenatal and preschool factors are key in determining the progression to pre-school wheeze and eosinophilic school age asthma. The conventional view of eosinophilic asthma is that airway inflammation is the fundamental underlying abnormality, and airway inflammation and hyper-responsiveness are secondary; in fact, these three are parallel processes. Very early structural changes, independent of inflammation and infection, are associated with early airway hyper-responsiveness and later adverse respiratory outcomes. There is a bidirectional relationship between structural airway wall changes and airway inflammation, with airway contraction per se leading to the release of growth factors, and inflammatory pathways promoting airway remodeling. Early viral infection (and increasingly being appreciated, bacterial infection) is important in wheeze outcomes. There is evidence of abnormal immune function including cytokine release before the onset of viral infections. However, viral infections may also have prolonged effects on the host immune system, and the evidence for beneficial and adverse effects of viral infection is conflicting. In older children and adults, asthmatic epithelial cells show impaired interferon responses to viral infection, but only in the presence of uncontrolled type 2 inflammation, implying these are secondary phenomena. There are also compelling data relating the innate immune system to later asthma and atopy, and animal studies suggest that the effects of a high endotoxin, microbiologically diverse environment may be modulated via the epithelial alarmin IL-33. Whereas, previously only viral infection was thought to be important, early bacterial colonization of the upper airway is coming to the fore, associated with a mixed pattern of TH1/TH2/TH17 cytokine secretion, and adverse long term outcomes. Bacterial colonization is probably a marker of a subtle immune deficiency, rather than directly causal. The airway and gut microbiome critically impacts the development of Type 2 inflammatory responses. However, Type 2 inflammatory cytokines, which are critical both to progression from pre-school wheeze to eosinophilic asthma, and sustaining the eosinophilic asthmatic state, are not implicated in the very early development of the disease. Taken together, the evidence is that the earliest cytokine and chemokine signals will come from the study of bronchial epithelial cell function and their interactions with viruses and the microbiome.
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Affiliation(s)
- Andrew Bush
- Departments of Paediatrics and Paediatric Respiratory Medicine, Royal Brompton Harefield NHS Foundation Trust and Imperial College, London, United Kingdom
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47
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Abstract
The recent Lancet commission has highlighted that "asthma" should be used to describe a clinical syndrome of wheeze, breathlessness, chest tightness, and sometimes cough. The next step is to deconstruct the airway into components of fixed and variable airflow obstruction, inflammation, infection and altered cough reflex, setting the airway disease in the context of extra-pulmonary co-morbidities and social and environmental factors. The emphasis is always on delineating treatable traits, including variable airflow obstruction caused by airway smooth muscle constriction (treated with short- and long-acting β-2 agonists), eosinophilic airway inflammation (treated with inhaled corticosteroids) and chronic bacterial infection (treated with antibiotics with benefit if it is driving the disease). It is also important not to over-treat the untreatable, such as fixed airflow obstruction. These can all be determined using simple, non-invasive tests such as spirometry before and after acute administration of a bronchodilator (reversible airflow obstruction); peripheral blood eosinophil count, induced sputum, exhaled nitric oxide (airway eosinophilia); and sputum or cough swab culture (bacterial infection). Additionally, the pathophysiology of risk domains must be considered: these are risk of an asthma attack, risk of poor airway growth, and in pre-school children, risk of progression to eosinophilic school age asthma. Phenotyping the airway will allow more precise diagnosis and targeted treatment, but it is important to move to endotypes, especially in the era of increasing numbers of biologicals. Advances in -omics technology allow delineation of pathways, which will be particularly important in TH2 low eosinophilic asthma, and also pauci-inflammatory disease. It is very important to appreciate the difficulties of cluster analysis; a patient may have eosinophilic airway disease because of a steroid resistant endotype, because of non-adherence to basic treatment, and a surge in environmental allergen burden. Sophisticated -omics approaches will be reviewed in this manuscript, but currently they are not being used in clinical practice. However, even while they are being evaluated, management of the asthmas can and should be improved by considering the pathophysiologies of the different airway diseases lumped under that umbrella term, using simple, non-invasive tests which are readily available, and treating accordingly.
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Affiliation(s)
- Andrew Bush
- Departments of Paediatrics and Paediatric Respiratory Medicine, Royal Brompton Harefield NHS Foundation Trust and Imperial College, London, United Kingdom
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Airway remodeling in asthma: update on mechanisms and therapeutic approaches. Curr Opin Pulm Med 2018; 24:56-62. [PMID: 29076828 DOI: 10.1097/mcp.0000000000000441] [Citation(s) in RCA: 121] [Impact Index Per Article: 20.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
PURPOSE OF REVIEW The term 'airway remodeling' reflects changes in the type, quantity, and nature of airway wall components and their organization. The purpose of this review is to look at recent publications on airway remodeling in asthma. RECENT FINDINGS Animal models and in-vitro studies have confirmed the involvement of airway epithelium, airway smooth muscle (ASM), and extracellular matrix components in asthma-related airway remodeling. They report influences on proliferation of ASM cells, and how their orientation or morphology, in addition to the heterogeneity of ASM mass at different levels of airways could influence their effects. Clinical benefits have been observed following reduction of ASM following bronchial thermoplasty. Asthmatic epithelial cell transcriptome alterations were found to involve metabolism and epigenetics, beyond epithelial mesenchymal trophic unit driven by injury and repair in chronic inflammation. New ways to explore airway remodeling such as imaging or endoscopic techniques have been evaluated. Finally, new data support the role of eosinophils and mast cells in remodeling and show the influence of new asthma drugs on this process. SUMMARY As recently stated by an American Thoracic Society task force, we need more research on airway remodeling, its determinants and clinical relevance, and on the effects of asthma drugs on its various components.
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Siu KK, Leung SY, Kong SY, Ng DKK. Management of Recurrent Preschool, Doctor-Diagnosed Wheeze. Indian J Pediatr 2018; 85:658-666. [PMID: 29308548 DOI: 10.1007/s12098-017-2537-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2017] [Accepted: 10/18/2017] [Indexed: 01/26/2023]
Abstract
Preschool wheeze occurs in half of the children before they reach 6 y of age and recurrence is also common. Recurrent preschool wheeze is classified as either typical or atypical. For typical recurrent preschool wheeze, the diagnoses are either asthma or bronchiolitis/bronchitis. Responsiveness to a properly administered bronchodilator confirms asthma, atopic or otherwise. All atypical preschool wheeze should be referred to pediatric respirologist for assessment. Lung function test by impulse oscillometry (IOS) before and after bronchodilator is helpful to confirm airway hyperresponsiveness, an essential feature of asthma. Assessment of atopy is important by either skin prick test or serum IgE level. Treatment of acute wheeze includes standard supportive care, bronchodilator for those diagnosed with asthma and hypertonic saline for those diagnosed as having acute bronchiolitis. Other treatments included nebulized adrenaline for acute bronchiolitis and systemic steroids for asthma. For those with significant respiratory distress, continuous positive airway pressure (CPAP) or heated humidified high flow should be considered. Daily or intermittent inhaled corticosteroid or intermittent montelukast would reduce asthma exacerbation rate. A significant proportion of preschool wheeze persists till school age. An early diagnosis of asthma would be important to allow early optimal management.
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Affiliation(s)
- Ka-Ka Siu
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China
| | - Shuk-Yu Leung
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China
| | - Sum-Yi Kong
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China
| | - Daniel Kwok-Keung Ng
- Department of Pediatrics, Kwong Wah Hospital, 25 Waterloo Road, Hong Kong, SAR, China.
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Translating Asthma: Dissecting the Role of Metabolomics, Genomics and Personalized Medicine. Indian J Pediatr 2018; 85:643-650. [PMID: 29185231 DOI: 10.1007/s12098-017-2520-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2017] [Accepted: 09/27/2017] [Indexed: 01/26/2023]
Abstract
The management of asthma has largely stagnated over the last 25 years, but we are at the dawning of a new age wherein -omics technology can help us manage the disease objectively and rationally. Even in this new scientific age, getting the basics of asthma management right remains essential. The new technologies which can be applied to multiple biological samples include genomics (study of the genome), transcriptomics (gene transcription), lipidomics, proteomics and metabolomics (lipids, proteins and metabolites, respectively) and breathomics, using exhaled breath as a source of biomarkers, which is of particular interest in view of its non-invasive nature in pediatrics. Important applications will include the diagnosis of airways disease, including its components; the pathways driving airway pathology; monitoring the response to treatment; and measuring future risk (asthma attacks, poor lung growth trajectory). With the advent of a wide range of novel biologicals to treat asthma, -omics technology to personalize therapy will be especially important. The U-BIOPRED (Europe) and SARP (USA) groups have been most active in this field, especially using bronchoscopically obtained samples to perform cluster analyses to define new asthma endotypes. However, stability over time and consistency between investigators is imperfect. This is perhaps unsurprising; results of biomarker studies in asthma will be a composite of the underlying disease, the (variable) effects of adverse drivers such as allergen exposure and pollution, the effects of treatment, and the effects of adherence or otherwise to treatment. Ultimately, the aim should be an exhaled breath based tool with a rapid result that can be used as a routine in the clinic. However, at the moment, there are as yet no clinical applications in children of -omics technology.
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