Relationship between FEV1/FVC and age in children with asthma

INTRODUCTION

Forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) normally decreases through childhood, increases briefly during early adolescence, and then declines throughout life. The physiology behind this temporary increase during early adolescence is not well understood. The objective of this study was to determine if this pattern occurs in children with asthma.

DESIGN

Single-center, cross-sectional, retrospective analysis of pulmonary function tests obtained over a 5-year period in children 5-18 years of age with persistent asthma.

RESULTS

A total of 1793 patients satisfied all inclusion and exclusion criteria. The mean age (±SD) was 10.4 ± 3.8 years. Forty-eight percent were female. Mean FEV1/FVC was 0.83 ± 0.09. FEV1/FVC was lower at 5 years of age than in healthy children, declined from age 5 to 11 by 5.7% compared to 7.3% in healthy girls, and 5.8% compared to 9.4% in healthy boys. FEV1/FVC increased in early adolescence, but at age 16, was 5.6% lower in male children compared to healthy children, and 5.4% lower in females. The ratio was lower in obese children at all ages but demonstrated the same curvilinear shape as healthy children. In absolute terms, FEV1 grew proportionately more than FVC during early adolescence, so the ratio of FEV1/FVC increased during that period. The curvilinear shape of the curve remained in postbronchodilator testing, though significantly blunted.

CONCLUSIONS

FEV1/FVC is lower in children with persistent asthma than healthy children, but the "Shepherd's Hook" pattern is preserved. This was true in obese patients with asthma, although their FEV1/FVC ratios were lower throughout all stages of childhood and adolescence.

Changes in Body Mass Index in Children and Adolescents with Asthma during the COVID-19 Pandemic

Background: Increased weight gain in children during the COVID-19 pandemic has been reported. Changes in weight in children with asthma during this period have not been well described. Methods: Retrospective review of children with asthma, 6-18 years of age, seen in 2019 and 2020. Mean monthly rates of change in body mass index (BMI) were compared between years. Demographic and asthma-related factors were examined. Results: Two hundred sixty-seven patients were enrolled. BMI increased by 0.128 ± 0.283 kg/m²/month during the pandemic year as compared with 0.084 ± 0.160 kg/m²/month during the previous year (P = 0.03). Patients with baseline overweight or obesity trended toward higher rates of BMI increase than those starting with normal weight, with the greatest BMI increase occurring in the severely obese. Conclusions: In this single-site study of children with asthma, there was a greater monthly rate of BMI gain during the early pandemic as compared with that observed in the previous year.

The relationship between weight and pulmonary outcomes in overweight and obese people with cystic fibrosis: A retrospective observational study

Background

A major focus in cystic fibrosis (CF) care aims to increase weight gain. Rates of overweight and obese people with CF have gradually increased over the past decade. Obesity could be a risk for restriction of lung volumes and airway obstruction as well as increase rates of pulmonary exacerbations in people with CF.

Aim

To assess the relationship between weight categories and pulmonary outcomes in children and adults with CF.

Methods

Patients 6 years of age and older were categorized into weight categories based on the Centers for Disease Control and Prevention (CDC) definitions. A retrospective chart review was conducted to obtain lung function testing and other outcomes.

Results

One hundred five patients with a median age of 20.6 years were included in this analysis. 8.4%, 64%, 18%, and 10% of patients were underweight, normal/healthy weight, overweight, and obese, respectively. Forced expiratory volume in 1 s (FEV₁) and forced vital capacity (FVC) (% predicted) did not differ between patients with weights in the normal range versus patients in the overweight/obese categories. Linear regression analysis showed a direct correlation between body mass index (BMI) and FEV₁ that continued as BMI entered overweight and obese categories in both pediatric and adult patients. Overweight/obese patients did not have increased rates of pulmonary exacerbations compared to those in the normal/healthy weight category.

Conclusion

As CF therapies continue to improve, an increasing number of people with CF are exceeding the CDC's normal-weight range. Gaining weight past the normal range does not appear to negatively impact pulmonary health of people with CF. If this trend of increased weight gain continues, it remains to be seen if it will eventually negatively affect lung health.

Airway closing index in school-age children during exercise bronchoprovocation

OBJECTIVE

Airway Closing Index (ACI), the ratio of % change in FVC to % change in FEV₁ with bronchoprovocation, may represent changes in airflow due to airway closure, as opposed to airway narrowing. The objective of this study was to evaluate ACI during exercise bronchoprovocation (EB) in children.

METHODS

Children, 6 to 18 years of age, who underwent EB using a stationary bicycle ergometer over a 6-year period were reviewed. Pulmonary function, including ACI, in patients with a positive exercise challenge, defined as ≥10% decrease in FEV₁ following exercise, were compared to patients with a negative challenge.

RESULTS

A total of 1030 children with a median age of 13 (IQR 11-15) underwent EB, of which 376 (37%) had a positive exercise challenge. There was wide variability in ACI, with a median of 0.75 (0.28-1.21). Median ACI in those with a positive test was 0.68 (IQR 0.41-0.93) compared to 0.84 (IQR 0.09-1.06) for those with a negative test, p = 0.017. Median ACI was higher in older children (p < 0.001) and females (p < 0.0001). Median percent change in FEV₁ following bronchodilator for children in the highest quintile for ACI was 4.5 (IQR 1.3-8.1) compared to 5.5 (IQR 2-9.2) for children in the lowest quintile, p = 0.04.

CONCLUSIONS

There is wide variability in the ACI in children undergoing EB. ACI was lower in children with a positive challenge, the significance is unknown. Children with higher ACI may have increased airway closure with bronchoprovocation, and less response to bronchodilators.

Perceptions of safety monitoring in CF clinical studies and potential impact on future study participation

BACKGROUND

Individuals with CF and their parents cite safety concerns as barriers to participating in clinical studies. We assessed whether a brochure/infographic describing patient safety monitoring processes could reduce knowledge and attitude barriers regarding safety monitoring. We also identified factors associated with likely participation in future CF studies.

METHODS

Respondents from three CF centers in the U.S. were randomly assigned to receive the safety monitoring brochure/infographic or an unrelated brochure. Fifty parents of children with CF <16, 50 adolescents with CF 16-21, and 50 adults with CF ≥22 years old were recruited to complete the study survey. Factors associated with survey responses and with reported likelihood of participating in future studies were assessed.

RESULTS

Overall the safety monitoring brochure/infographic was associated with increased likelihood of future participation in non-drug studies (aOR 2.30, CI₉₅ 1.01-5.28), but not in drug studies. Non-Hispanic respondents reported greater likelihood of participating in a future drug study than Hispanic respondents (aOR 3.18, CI₉₅ 1.30-7.74). Adults with CF (aOR 2.62, CI₉₅ 1.05-6.51) and parents (aOR 4.49, CI₉₅ 1.66-12.15) were more likely than adolescents to report they would ask their care team about clinical trials. Confidence in safety monitoring was associated with reported likelihood of future participation in drug studies.

CONCLUSIONS

Potential future participation in CF drug and/or non-drug studies was associated with respondent age and ethnicity, receiving the safety monitoring brochure/infographic, and confidence in safety monitoring. Our findings underscore the need for education about safety monitoring, with targeted approaches for the Hispanic CF population and adolescents.

Incidence and prevalence of common respiratory pathogens before and after implementation of the Cystic Fibrosis Foundation Infection Prevention and Control Guideline

BACKGROUND

The 2013 Cystic Fibrosis Foundation's Infection Prevention and Control Guideline (CFF IP&C) was developed to reduce the risk of acquisition and transmission of respiratory pathogens in patients with cystic fibrosis (CF).

OBJECTIVE

We hypothesised that the incidence of common CF respiratory pathogens would decrease at our centre after implementation of the guideline.

METHODS

All patients with CF seen at our centre from August 2012 through August 2017 who had respiratory cultures were included. Patients were excluded from incidence analysis if they did not have at least one culture per year. Quarterly data were collected for one year before and three years after implementation of the guidelines to determine the incidence and prevalence of seven organisms commonly found in respiratory cultures of patients with CF.

RESULTS

Quarterly and annual incidence and prevalence rates of common organisms did not change during the study period.

DISCUSSION

There were no significant differences in the incidence or prevalence of common respiratory organisms in the first three years after implementation of the CF IP&C guideline. Long-term follow-up is needed to determine if changes occur over time.

Bronchodilators, Antibiotics, and Oral Corticosteroids Use in Primary Care for Children With Cough

Real-world management decisions for acute cough in children in primary care practice are not well understood. This study is an analysis of 560 encounters for children with cough, 19 days to 18 years of age, seen in a predominantly suburban academic pediatric practice, over 1 year. Past history, cough duration, and cough characteristics significantly affected treatment decisions. Children with cough frequently had a history of preterm birth, allergies, asthma, and neurological conditions. Most common therapies were bronchodilators, antibiotics, and oral corticosteroids. Children prescribed antibiotics were older, more likely to have a wet or productive cough, history of sinusitis, pneumonia or dysphagia, and longer cough duration. Children prescribed oral corticosteroids were younger, less likely to be wet or productive and more likely to have history of asthma or dysphagia. Children prescribed bronchodilators were more likely to have fever, nasal congestion, and wheezing and history of previous asthma, pneumonia, or dysphagia.

Clinical characterization of children with resistant airflow obstruction, a multicenter study

OBJECTIVE

To characterize a cohort of children with airflow limitation resistant to bronchodilator (BD) therapy.

METHODS

Pulmonary function tests performed in children 6-17 years of age at 15 centers in a clinical research consortium were screened for resistant airflow limitation, defined as a post-BD FEV₁ and/or an FEV₁/FVC less than the lower limits of normal. Demographic and clinical data were analyzed for associations with pulmonary function.

RESULTS

582 children were identified. Median age was 13 years (IQR: 11, 16), 60% were males; 62% were Caucasian, 28% were African-American; 19% were obese; 32% were born prematurely and 21% exposed to second hand smoke. Pulmonary diagnoses included asthma (93%), prior significant pneumonia (28%), and bronchiectasis (5%). 65% reported allergic rhinitis, and 11% chronic sinusitis. Subjects without a history of asthma had significantly lower post-BD FEV₁% predicted (p = 0.008). Subjects without allergic rhinitis had lower post-BD FEV₁% predicted (p = 0.003). Children with allergic rhinitis, male sex, obesity and Black race had better pulmonary function post-BD. There was lower pulmonary function in children after age 11 years without a history of allergic rhinitis, as compared to those with a history of allergic rhinitis.

CONCLUSIONS

The most prevalent diagnosis in children with BD-resistant airflow limitation is asthma. Allergic rhinitis and premature birth are common co-morbidities. Children without a history of asthma, as well as those with asthma but no allergic rhinitis, had lower pulmonary function. Children with BD-resistant airflow limitation may represent a sub-group of children with persistent obstruction and high risk for life-long airway disease.

Clinical Sensitivity of Cystic Fibrosis Mutation Panels in a Diverse Population

Infants are screened for cystic fibrosis (CF) in New York State (NYS) using an IRT-DNA algorithm. The purpose of this study was to validate and assess clinical validity of the US FDA-cleared Illumina MiSeqDx CF 139-Variant Assay (139-VA) in the diverse NYS CF population. The study included 439 infants with CF identified via newborn screening (NBS) from 2002 to 2012. All had been screened using the Abbott Molecular CF Genotyping Assay or the Hologic InPlex CF Molecular Test. All with CF and zero or one mutation were tested using the 139-VA. DNA extracted from dried blood spots was reliably and accurately genotyped using the 139-VA. Sixty-three additional mutations were identified. Clinical sensitivity of three panels ranged from 76.2% (23 mutations recommended for screening by ACMG/ACOG) to 79.7% (current NYS 39-mutation InPlex panel), up to 86.0% for the 139-VA. For all, sensitivity was highest in Whites and lowest in the Black population. Although the sample size was small, there was a nearly 20% increase in sensitivity for the Black CF population using the 139-VA (68.2%) over the ACMG/ACOG and InPlex panels (both 50.0%). Overall, the 139-VA is more sensitive than other commercially available panels, and could be considered for NBS, clinical, or research laboratories conducting CF screening.

Effect of a soy isoflavone supplement on lung function and clinical outcomes in patients with poorly controlled asthma: a randomized clinical trial

IMPORTANCE

Soy isoflavone supplements are used to treat several chronic diseases, although the data supporting their use are limited. Some data suggest that supplementation with soy isoflavone may be an effective treatment for patients with poor asthma control.

OBJECTIVE

To determine whether a soy isoflavone supplement improves asthma control in adolescent and adult patients with poorly controlled disease.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter, randomized, double-blind, placebo-controlled trial conducted between May 2010 and August 2012 at 19 adult and pediatric pulmonary and allergy centers in the American Lung Association Asthma Clinical Research Centers network. Three hundred eighty-six adults and children aged 12 years or older with symptomatic asthma while taking a controller medicine and low dietary soy intake were randomized, and 345 (89%) completed spirometry at week 24.

INTERVENTIONS

Participants were randomly assigned to receive soy isoflavone supplement containing 100 mg of total isoflavones (n=193) or matching placebo (n=193) in 2 divided doses administered daily for 24 weeks.

MAIN OUTCOMES AND MEASURES

The primary outcome measure was change in forced expiratory volume in the first second (FEV1) at 24 weeks. Secondary outcome measures were symptoms, episodes of poor asthma control, Asthma Control Test score (range, 5-25; higher scores indicate better control), and systemic and airway biomarkers of inflammation.

RESULTS

Mean changes in prebronchodilator FEV1 over 24 weeks were 0.03 L (95% CI, -0.01 to 0.08 L) in the placebo group and 0.01 L (95% CI, -0.07 to 0.07 L) in the soy isoflavone group, which were not significantly different (P = .36). Mean changes in symptom scores on the Asthma Control Test (placebo, 1.98 [95% CI, 1.42-2.54] vs soy isoflavones, 2.20 [95% CI, 1.53-2.87]; positive values indicate a reduction in symptoms), number of episodes of poor asthma control (placebo, 3.3 [95% CI, 2.7-4.1] vs soy isoflavones, 3.0 [95% CI, 2.4-3.7]), and changes in exhaled nitric oxide (placebo, -3.48 ppb [95% CI, -5.99 to -0.97 ppb] vs soy isoflavones, 1.39 ppb [95% CI, -1.73 to 4.51 ppb]) did not significantly improve more with the soy isoflavone supplement than with placebo. Mean plasma genistein level increased from 4.87 ng/mL to 37.67 ng/mL (P < .001) in participants receiving the supplement.

CONCLUSIONS AND RELEVANCE

Among adults and children aged 12 years or older with poorly controlled asthma while taking a controller medication, use of a soy isoflavone supplement, compared with placebo, did not result in improved lung function or clinical outcomes. These findings suggest that this supplement should not be used for patients with poorly controlled asthma.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01052116.

Low-level environmental tobacco smoke exposure and inflammatory biomarkers in children with asthma

OBJECTIVE

The effects of low-level environmental tobacco smoke (ETS) exposure, on asthma control, lung function and inflammatory biomarkers in children with asthma have not been well studied. The objective of the study was to assess ETS exposure in school-age children with asthma whose parents either deny smoking or only smoke outside the home, and to assess the impact of low-level ETS exposure on asthma control, spirometry and inflammatory biomarkers.

METHODS

Forty patients age 8-18 years with well-controlled, mild-to-moderate persistent asthma treated with either inhaled corticosteroids (ICS) or montelukast were enrolled. Subjects completed an age-appropriate Asthma Control Test and a smoke exposure questionnaire, and exhaled nitric oxide (FeNO), spirometry, urinary cotinine and leukotriene E(4) (LTE(4)) were measured. ETS-exposed and unexposed groups were compared.

RESULTS

Only one parent reported smoking in the home, yet 28 (70%) subjects had urinary cotinine levels ≥1 ng/ml, suggesting ETS exposure. Seven subjects (18%) had FeNO levels >25parts per billion, six of whom were in the ETS-exposed group. In the ICS-treated subjects, but not in the montelukast-treated subjects, ETS exposure was associated with higher urinary LTE(4), p = 0.04, but had no effect on asthma control, forced expiratory volume in 1 s or FeNO.

CONCLUSIONS

A majority of school-age children with persistent asthma may be exposed to ETS, as measured by urinary cotinine, even if their parents insist they don't smoke in the home. Urinary LTE(4) was higher in the ETS-exposed children treated with ICS, but not in children treated with montelukast.

The effects of low-level environmental tobacco smoke exposure on pulmonary function tests in preschool children with asthma

OBJECTIVES

Though parents of children with asthma smoke, they often avoid smoking in their homes or near their children, thus limiting exposure. It is not known if such low-level environmental tobacco smoke (ETS) results in measurable exposure or affects lung function. The objectives of this study were to measure urinary cotinine in preschool children with asthma, and to examine the relationship between low-level ETS exposure and pulmonary function tests (PFTs).

METHODS

Preschool children with asthma were enrolled. Parents completed questionnaires on ETS exposure and asthma control, urinary cotinine concentrations were measured and PFTs were compared between subjects with and without recent ETS exposure.

RESULTS

Forty one subjects were enrolled. All parents denied smoking in their home within the last 2 weeks, but 14 (34%) parents admitted to smoking outside their homes or away from their children. Fifteen (37%; 95%CI: 23-53) of the children had urinary cotinine levels ≥1 ng/ml, of which seven (17%; 95%CI: 8-32) had levels ≥5 ng/ml. FEV1 and FEV0.5 were lower in subjects with a urinary cotinine level ≥5 ng/ml as compared to those with levels <1 ng/ml or between 1 and 5 ng/ml; both at baseline and after inhalation of albuterol. Five of seven subjects with urinary cotinine levels ≥5 ng/ml had FEV0.5 less than 65% of predicted values. There were no significant differences in IOS measures.

CONCLUSIONS

Despite parental denial of smoking near their children, preschool children may be exposed to ETS. Such low-level ETS exposure may affect lung function, possibly in a dose-dependent manner.

ALOX5 polymorphism associates with increased leukotriene production and reduced lung function and asthma control in children with poorly controlled asthma

BACKGROUND

Identification of risk factors for reduced asthma control could improve the understanding and treatment of asthma. A promoter polymorphism in the 5-lipoxygenase gene affects gene expression and response to asthma therapy, but its impact on disease control remains unclear.

OBJECTIVE

We sought to determine if the ALOX5 promoter SP1 tandem repeat polymorphism was associated with changes in cysteinyl leukotriene production, lung function, airway inflammation and asthma control score.

METHODS

We analysed 270 children, 6- to 17-years old, with poorly controlled asthma enrolled in a 6-month clinical trial (NCT00604851). In secondary analysis, we associated the ALOX5 promoter SP1 tandem repeat polymorphism genotype (rs59439148) with asthma outcomes using both additive and recessive genetic models. We evaluated FEV1 percent predicted, symptom control, exhaled nitric oxide and urinary LTE4 levels.

RESULTS

Of all children, 14.8% (40/270) (and 28% (38/135) of African Americans) carried two non-5-repeat variant alleles of rs59439148. Children who were homozygous for variant alleles had significantly higher urinary LTE4 levels (38 vs. 30 nmol/mol creatinine, P = 0.0134), significantly worse FEV1% predicted (84 vs. 91, P = 0.017) and a trend towards worse asthma control. FEV1% predicted values were significantly negatively correlated with urinary LTE4 (r = -0.192, P = 0.009).

CONCLUSION AND CLINICAL RELEVANCE

Carrying two copies of a minor variant ALOX5 promoter SP1 tandem repeat allele contributes to increased cysLT exposure as determined by urinary LTE4 levels, reduced lung function and potentially worse asthma control. ALOX5 promoter SP1 tandem repeat genotype may be a risk factor for worse asthma outcomes.

Relationship between sweat chloride, sodium, and age in clinically obtained samples

BACKGROUND

The relationship between sweat electrolytes and age is uncertain, as is the value of measuring sodium or the chloride:sodium ratio.

METHODS

13,785 sweat tests performed over 23 years at one center through the Macroduct collection in clinically obtained samples were analyzed.

RESULTS

Sweat chloride tended to decrease over the first year of life, slowly increase until the fourth decade, then either level off or slightly decrease. In children, sweat sodium overlapped between those with positive and negative sweat tests, but not in adults. If the sweat test was positive, there was a higher likelihood of having a chloride:sodium ratio >1, but most subjects with a ratio >1 did not have CF.

CONCLUSIONS

Sweat chloride and sodium vary with age. Measurement of sweat sodium did not add discriminatory value. The proportion of subjects with a chloride:sodium ratio >1, with or without CF, varied greatly between age ranges.

Relationship between exhaled nitric oxide and exposure to low-level environmental tobacco smoke in children with asthma on inhaled corticosteroids

OBJECTIVES

The relationship between exhaled nitric oxide (FeNO) and asthma severity or control is inconsistent. Active smoking lowers FeNO, but the relationship between passive smoking and FeNO is less clear. Children may be exposed to low-level environmental tobacco smoke (ETS) or thirdhand smoke, even if parents avoid smoking in the presence of their children. Our hypothesis was that FeNO is lower in children with asthma exposed to low-level ETS when compared with those who are not exposed.

METHODS

Children with stable asthma, 8-18 years of age, on low- or medium-dose inhaled corticosteroids (ICS) were enrolled. Spirometry, Asthma Control Questionnaire (ACQ), FeNO, exhaled breath condensate pH (EBC pH), and EBC ammonia were compared between children with and without ETS exposure as determined by urinary cotinine.

RESULTS

Thirty-three subjects were enrolled, of which 10 (30%) had urinary cotinine levels ≥1 ng/ml. There were no significant differences between the two groups in age, sex, BMI percentile, atopy status, FEV(1), EBC pH, or EBC ammonia. Median ACQ was 0.29 (IQR: 0.22-0.57) for those with cotinine levels <1 ng/ml and 0.64 (IQR: 0.57-1.1) for those with cotinine levels of ≥1 ng/ml, p = .02. Median FeNO (ppb) was 23.9 (IQR: 15.2-34.5) for unexposed subjects and 9.6 (IQR: 5.1-15.8) for exposed subjects, p = .008.

CONCLUSIONS

Children with asthma on low to medium doses of ICS and recent low-level ETS exposure have lower FeNO levels when compared with non-ETS-exposed subjects. Exposure to low-level ETS or thirdhand smoke may be an important variable to consider when interpreting FeNO as a biomarker for airway inflammation.

Learning from a distance: effectiveness of online spirometry training in improving asthma care

OBJECTIVE

We evaluated the effectiveness of a virtually delivered quality improvement (QI) program designed to improve primary care management for children with asthma.

METHODS

Thirty-six physicians, nurses, and medical assistants from 14 primary care pediatric practices (7 matched practice pairs) participated in a cluster randomized trial from October 2007 to September 2008. All practices received a spirometer and standard vendor training. A 7-month QI program delivered during the study period included: 1) Spirometry Fundamentals™ CD-ROM, a multimedia tutorial; 2) case-based, interactive webinars led by clinical experts; and 3) an internet-based spirometry quality feedback reporting system. Practice pairs were compared directly to each other, and between-group differences were analyzed with the use of mixed effects regression models. Our main outcome measures were the frequency of spirometry testing, percentage of acceptable quality spirometry tests, asthma severity documentation, and appropriate controller medication prescribing.

RESULTS

Participating practices uploaded a total of 1028 spirometry testing sessions, of which 340 (33.1%) were of acceptable quality. During the 7-month intervention period, there was no difference between intervention and control practices in the frequency of spirometry tests performed. Intervention practices were estimated to have significantly greater odds of conducting tests with acceptable quality compared with matched control practices, adjusting for quality in the baseline period (odds ratio 2.85; 95% confidence interval 1.78-4.56, P < .001). Intervention providers also had significantly greater odds of documenting asthma severity during the intervention period (odds ratio 2.9, 95% confidence interval 1.8-4.5; P < .001). Although use of controller medications among patients with persistent asthma approached 100% for both groups, the proportion of asthma patients labeled as persistent increased from 43% to 62% among intervention practices, and decreased from 57% to 50% among controls (NS).

CONCLUSIONS

A multifaceted distance QI program resulted in increased spirometry quality and improved assessment of asthma severity levels. Successful participation in QI programs can occur over distance.

Lansoprazole for children with poorly controlled asthma: a randomized controlled trial

CONTEXT

Asymptomatic gastroesophageal reflux (GER) is prevalent in children with asthma. Untreated GER has been postulated to be a cause of inadequate asthma control in children despite inhaled corticosteroid treatment, but it is not known whether treatment with proton pump inhibitors improves asthma control.

OBJECTIVE

To determine whether lansoprazole is effective in reducing asthma symptoms in children without overt GER.

DESIGN, SETTING, AND PARTICIPANTS

The Study of Acid Reflux in Children With Asthma, a randomized, masked, placebo-controlled, parallel clinical trial that compared lansoprazole with placebo in children with poor asthma control who were receiving inhaled corticosteroid treatment. Three hundred six participants enrolled from April 2007 to September 2010 at 19 US academic clinical centers were followed up for 24 weeks. A subgroup had an esophageal pH study before randomization.

INTERVENTION

Participating children were randomly assigned to receive either lansoprazole, 15 mg/d if weighing less than 30 kg or 30 mg/d if weighing 30 kg or more (n = 149), or placebo (n = 157).

MAIN OUTCOME MEASURES

The primary outcome measure was change in Asthma Control Questionnaire (ACQ) score (range, 0-6; a 0.5-unit change is considered clinically meaningful). Secondary outcome measures included lung function measures, asthma-related quality of life, and episodes of poor asthma control.

RESULTS

The mean age was 11 years (SD, 3 years). The mean difference in change (lansoprazole minus placebo) in the ACQ score was 0.2 units (95% CI, 0.0-0.3 units). There were no statistically significant differences in the mean difference in change for the secondary outcomes of forced expiratory volume in the first second (0.0 L; 95% CI, -0.1 to 0.1 L), asthma-related quality of life (-0.1; 95% CI, -0.3 to 0.1), or rate of episodes of poor asthma control (relative risk, 1.2; 95% CI, 0.9-1.5). Among the 115 children with esophageal pH studies, the prevalence of GER was 43%. In the subgroup with a positive pH study, no treatment effect for lansoprazole vs placebo was observed for any asthma outcome. Children treated with lansoprazole reported more respiratory infections (relative risk, 1.3 [95% CI, 1.1-1.6]).

CONCLUSION

In this trial of children with poorly controlled asthma without symptoms of GER who were using inhaled corticosteroids, the addition of lansoprazole, compared with placebo, improved neither symptoms nor lung function but was associated with increased adverse events.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00442013.

The role of oxidative stress in the pathogenesis and treatment of asthma

The role of oxidative stress in asthma is gaining increasing scientific attention. The hallmark of asthma is airway inflammation. Oxidative stress may initiate and augment inflammation, and may also result from inflammation. Exposure to tobacco smoke, ozone, diesel exhaust, and a variety of other pollutants generates reactive oxygen species and other oxidative stressors. Some studies suggest that asthmatics have a decreased ability to respond to oxidative stress, while others find upregulated antioxidative function. Oxidative stress may alter the Th(1)/Th(2) immune response and result in activation of NF-kbeta, a powerful inducer of pro-inflammatory genes. Genetic polymorphisms may play an important role in determining susceptibility to oxidative stress. Many therapeutic strategies to decrease oxidative stress in asthma have been suggested. Dietary changes, antioxidant vitamins, other antioxidant drugs, Ayurvedic supplements, and even radon exposure in a hot bathroom have been studied. Minimizing exposure of young children to environmental tobacco smoke remains paramount.

Exhaled breath condensate pH and ammonia in cystic fibrosis and response to treatment of acute pulmonary exacerbations

Exhaled breath condensate (EBC) pH reflects the acid-base homeostasis of the airway lining fluid and is up to 3 log order lower in various inflammatory lung diseases including asthma, COPD, bronchiectasis, and cystic fibrosis (CF) than in normal controls. The aim of this study was to confirm this finding in CF and determine if there was a significant change in EBC pH after treatment of an acute pulmonary exacerbation. Ten subjects with CF and a pulmonary exacerbation, and 10 healthy age-matched control subjects were studied. EBC was collected at the onset of an acute pulmonary exacerbation and after treatment with intravenous antibiotics (median duration: 14 days (interquartile range, IQR): 12-14) when the exacerbation was considered resolved. The median age for CF patients was 15.9 years (IQR: 13-18.8), compared to 18 years (IQR: 15-24.8) for the control group, P = 0.242. All CF subjects had severe lung disease, median FEV(1) = 41.5% of predicted (IQR: 30.8-46.5%). Median EBC pH in CF subjects at the onset of a pulmonary exacerbation was 6.61 (IQR: 6.17-7.91) compared to median EBC pH of 8.14 (IQR: 7.45-9.08) in the control group, P < 0.02. Median EBC pH after resolution of an exacerbation was 7.02 (IQR: 5.8-8.64), not significantly different (P = 0.667) than during the acute exacerbation. EBC pH decreased in five subjects, increased in three subjects and there was no change in two subjects. There was no correlation between EBC pH and FEV(1) either before or after intravenous antibiotics. EBC ammonia, an important buffer of ASL, was also measured and similarly found to be lower than in normal controls. EBC pH is lower in CF than age-matched controls, and did not change consistently in response to treatment of an acute pulmonary exacerbation.

Use of decubitus radiographs in the diagnosis of foreign body aspiration in young children

BACKGROUND

Lateral decubitus radiographs are often obtained in young children with suspected foreign body aspiration. Their usefulness has not been well studied.

OBJECTIVES

To assess the value of decubitus radiographs in detecting foreign body aspiration in young children and compare their value to history and physical examination.

METHODS

Retrospective review of children younger than 4 years with suspected foreign body aspiration who had decubitus radiographs and underwent bronchoscopy over a 5-year period. Patients with proven foreign body aspiration were compared with those without foreign bodies for differences in symptoms, signs, location and character of the foreign body, and the diagnostic value of standard and decubitus chest radiographs.

RESULTS

Twenty-eight of 41 children who underwent bronchoscopy for possible foreign body aspiration had decubitus radiographs. Foreign bodies were identified in 22 patients (79%). A total of 27% of children with foreign body aspiration and 33% of children without a foreign body had suggestive decubitus radiographs (P = not significant). As a measure of detecting foreign body aspiration, positive decubitus radiographs had a sensitivity of 27%, a specificity of 67%, a positive predictive value of 75%, and a negative predictive value of 20%. The odds ratio of finding a foreign body with suggestive decubitus radiographs was 0.75 (95% confidence interval [CI], 0.1-5.2; P = 0.57). Foreign body aspiration was confirmed in 94% of children if there was both a sudden onset of symptoms and a witnessed choking episode (odds ratio, 13.3; 95% confidence interval, 1.3-138.9; P = 0.02).

CONCLUSION

Decubitus chest radiographs, at least as routinely performed and interpreted, seem to add little to the evaluation of young children with suspected foreign body aspiration. A history of a witnessed choking episode combined with a sudden onset of respiratory symptoms remains the most important indication for bronchoscopy.

Lung lesions in children with Crohn's disease presenting as nonresolving pneumonias and response to infliximab therapy

Lung lesions in children with Crohn's disease are often difficult to diagnose and treat. We report here 3 children (aged 13, 14, and 17 years) on immunosuppressive therapy for previously diagnosed Crohn's disease who presented with nonresolving pneumonias. All 3 had unfavorable response to empiric antibiotics and had progression of lesions. Cultures of sputum and blood did not yield any organisms. Subsequent lung biopsies revealed noncaseating granulomas with giant cells in 2 subjects and bronchiolitis obliterans with organizing pneumonia in the third. All patients were treated with infliximab, a novel anti-tumor necrosis factor monoclonal antibody, and showed rapid clinical and radiologic response. We emphasize that a high index of suspicion for noninfectious etiologies needs to be maintained in patients with Crohn's disease who present with lung lesions to ensure timely intervention. Infliximab therapy seems to be effective and well tolerated in such patients.

Dietary intake of soy genistein is associated with lung function in patients with asthma

To determine if micronutrient intake is associated with asthma severity, we administered the Block food frequency questionnaire to participants in a randomized clinical trial of the safety of influenza vaccine for asthmatics. The nutrition substudy included 1033 participants, aged 12-75. Intake of antioxidant vitamins, soy isoflavones, total fruits and vegetables, fats, and fiber was compared with asthma severity at baseline [forced expiratory volume in 1 second (FEV1), peak expiratory flow rate (PEF), asthma symptoms] and the rate of asthma exacerbations during the 2 weeks following influenza vaccination. The only nutrient that had a consistent association with asthma severity was genistein, a soy isoflavone. None of the nutrients evaluated were related to asthma exacerbation rate when adjusted for known confounders. The FEV1 in genistein consumers of at least 250 microg/1000 Kcal/day was 82.1% predicted, 79.9% predicted for those who consumed between 1 and 249 microg/1000 kcal, and 76.2% predicted in genistein nonconsumers (p=0.006); the PEF was 82.7% predicted, 80.8% predicted, and 78.3% predicted, respectively (p=0.009). There were no differences in the Asthma Symptom Utility Index (ASUI). We could not account for these results based on differences in demographics, body mass index, or consumption of other nutrients. Thus, increasing consumption of genistein is associated with better lung function in patients with asthma. Further studies are needed to determine whether dietary supplementation with genistein can reduce asthma severity.

Effect of deep inspiration on airway caliber in children with asthma

The objective of this study was to assess the effect of deep inspiration (DI) on airway caliber in school-age children with asthma. Thirty children with asthma (10 from each group of mild, moderate, and severe persistent asthma as defined by the National Asthma Education and Prevention Program guidelines of the National Heart, Lung, and Blood Institute) were enrolled, and their results were compared to those obtained in 7 healthy children. Subjects performed a partial expiratory flow volume curve (P) initiated from approximately 70% of vital capacity (VC) followed by a maximal expiratory flow volume (M) maneuver begun from total lung capacity (TLC). The M/P ratio at 30% of the VC (M/P30) was calculated. Specific airway conductance (sGaw) was measured before and immediately after DI, using standard techniques. Differences in M/P30 and sGaw ratios between asthma and control groups were compared with Student's unpaired t-tests. One-way ANOVA was used to compare the effect of DI on M/P30 and sGaw ratios among the various asthma severity groups. The M/P30 ratio (mean +/- 1 SD) was significantly lower in children with moderate and severe persistent asthma (0.73 +/- 0.21 and 0.72 +/- 0.1, respectively) than in healthy controls (1.69 +/- 0.62) (P < 0.05). In mild persistent asthmatics, there was limited bronchodilation (M/P30 = 1.1 +/- 0.35, P = 0.052). There was a significant inverse correlation between M/P30 ratio and severity of asthma (r = -0.684, P < 0.01). The mean sGaw ratio was decreased in asthmatic subjects compared to healthy controls (0.98 +/- 0.17 vs. 1.13 +/- 0.16, P = 0.062). In conclusion, in school-age children, the effects of DI on airway caliber are similar in direction to those observed in adults, i.e., bronchodilation in healthy and mild asthmatics, and bronchoconstriction (BC) in moderate to severe asthmatics. This finding suggests that forces that determine airway caliber in school-age children are similar to those forces in adults.

Plasma and red blood cell zinc in cystic fibrosis

The objectives of this study were to measure plasma and red blood cell (RBC) zinc concentrations in patients with cystic fibrosis (CF), and examine their relationship to nutritional status and pulmonary function. Plasma and RBC zinc levels were compared in 53 CF patients ranging in age from 0.5-46 years. Their relationships to weight (% ideal weight) and forced expired volume in 1 sec (FEV(1)) (% predicted value) were examined. After excluding improperly handled specimens, RBC zinc levels in 51 patients and plasma zinc concentrations in 40 patients were included for analysis. Sixteen of 51 (31%) patients had low RBC zinc levels compared to 4 of 40 (10%) with low plasma zinc concentrations (P < 0.01). Thirteen of 38 patients (34%) in whom both values were obtained had low RBC zinc concentrations compared to 4 of 38 (11%) with low plasma zinc levels (P < 0.022). Neither low RBC nor plasma zinc levels correlated with nutritional status or lung function. In conclusion, about one third of patients with CF had low RBC zinc levels. Plasma zinc concentrations may not adequately reflect overall zinc status. This deficiency did not appear to be related to either nutritional status or lung function. The significance of low RBC zinc in CF is unknown.

Video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population

BACKGROUND AND OBJECTIVES

The purpose of the present study was to evaluate the application of video-assisted thoracoscopy in the management of recurrent spontaneous pneumothorax in the pediatric population.

PATIENTS AND METHODS

Between 1995 and 1997, four patients with recurrent spontaneous pneumothorax were treated. Ages varied from 14 to 17 years. There were three males and one female. Two patients had spontaneous pneumothorax twice, and the other two had it three times. Three patients had primary spontaneous pneumothorax, and the fourth one had spontaneous pneumothorax secondary to cystic fibrosis. Computerized tomography of the chest demonstrated blebs in two patients, and in the other two it was suggestive of apical blebs but not definitive. All patients had failed treatment by tube thoracostomy. Video-assisted thoracoscopy demonstrated blebs in all patients. Removal was easily accomplished with an endoscopic automatic stapling device. The procedure was completed with mechanical pleurodesis, multiple intercostal blocks and intrapleural bupivacaine for control of pain.

RESULTS

All patients had a quick and uneventful recovery. Follow-up ranged from one to three years. There were no complications or subsequent recurrences of the pneumothorax.

CONCLUSIONS

Video-assisted thoracoscopy is a safe and effective technique in recurrent spontaneous pneumothorax. It allows for accurate identification and removal of the blebs, with quick recovery, minimal discomfort and good cosmetic results.

Inspiratory flow limitation in children with bronchopulmonary dysplasia

The objective of this study was to compare pulmonary function tests of children with bronchopulmonary dysplasia (BPD) and asthma, and to evaluate children with BPD for evidence of upper airway obstruction. This is a case-control retrospective study of pulmonary function tests (PFTs) of 11 children with BPD between 5 and 8 years of age who were followed by pediatric pulmonologists, and of 32 age- and height-matched children with asthma. The median forced vital capacity (FVC), forced expiratory volume in one second (FEV1), and peak expiratory flow (PEF) were significantly lower in the BPD group (0.86 L, 0.79 L, 120 L/min) than in the asthmatic group (1.34 L, 1.21 L, 155 L/min; P = 0.002, P = 0.007, P = 0.004, respectively). Both groups were equally hyperinflated (median thoracic gas volume 155% of predicted values in the BPD compared to 152% predicted in the asthma group; P = 0.67), and both groups showed decreases in air-trapping after a bronchodilator. The ratios of forced expiratory flow at 50% of the FVC to forced inspiratory flow at 50% of the FVC (FEF50%/FIF50%) and FEV1 to PEF (FEV1/PEF) were used to assess upper airway obstruction and were higher in children with BPD than asthma (P = 0.0001 and P = 0.035, respectively). We conclude that pulmonary function of children with BPD who are still symptomatic after 5 years of age is different from age-matched children with asthma, and the children with BPD demonstrate significant inspiratory flow limitations.

Urokinase in the management of complicated parapneumonic effusions in children

OBJECTIVE

Use of intrapleural fibrinolytic agents in the management of complicated parapneumonic effusions has been widely reported in adults. Such agents promote drainage of fluid through the thoracostomy tube and may obviate surgery. Both streptokinase and urokinase have been used for this purpose, but there are few reports of their use in the children. The objective of this study was to evaluate the role of intrapleural urokinase in the management of complicated parapneumonic effusions in children.

METHODS

We reviewed the hospital course of nine children, ages 6 months to 6 years, with complicated parapneumonic effusions who received intrapleural urokinase after failing to respond to I.V. antibiotics and closed-tube thoracostomy drainage. Four subjects had additional thoroscopic adhesiolysis before intrapleural instillation of urokinase; 20,000 IU of diluted urokinase was instilled three times a day via the thoracostomy tube for 3 days.

RESULTS

Eight subjects responded to 3 days of urokinase instillation, with increased thoracostomy tube drainage and clinical resolution of symptoms. The remaining subject responded to a second course of instillation. Two subjects needed oral analgesic for transient chest pain. All subjects tolerated the procedure well. No bleeding, fever, anaphylaxis, or allergic reactions were noted. The coagulation parameters remained unchanged.

CONCLUSION

Intrapleural instillation of urokinase appears to be a useful and safe adjunct in the management of complicated parapneumonic effusions in children. Its use may be considered in potential decortication patients in an effort to prevent surgery and possibly shorten hospitalization.

Nebulized lidocaine administered to infants and children undergoing flexible bronchoscopy

STUDY OBJECTIVES

The purpose of this study was to evaluate the safety and efficacy of nebulized lidocaine hydrochloride as a topical anesthetic for use during flexible bronchoscopy in infants and children.

DESIGN

This was a prospective, randomized, double-blind study.

PATIENTS

Twenty consecutive patients scheduled for flexible bronchoscopy who were not intubated and had no known cardiac or hepatic disease comprised the study group.

INTERVENTIONS

The patients were randomized to receive either 8 mg/kg or 4 mg/kg of nebulized 2% lidocaine by face mask prior to bronchoscopy.

SETTING

The study took place in a bronchoscopy suite at an academic medical center.

MEASUREMENTS

To determine systemic absorption, serum lidocaine levels were obtained. To assess efficacy of nebulized lidocaine as a topical anesthetic, changes in heart rate and blood pressure were recorded, and the bronchoscopist (who did not know the lidocaine dose used) rated the ease of passage of the bronchoscope through nose, vocal cords, trachea, bronchi, and all sites overall, and the degree of cough.

RESULTS

Nebulized lidocaine was safe, was well-tolerated, and provided adequate anesthesia for half of the patients. The serum lidocaine levels were much lower than the levels in the toxic range. There was a trend toward easier passage of the bronchoscope in the high-dose group at all sites noted previously that were evaluated.

CONCLUSION

Nebulized lidocaine in doses up to 8 mg/kg appears to be safe and moderately effective as a topical anesthetic for flexible bronchoscopy in infants and children. The serum levels were remarkably low. Fifty percent of the subjects required no supplemental lidocaine.

Aerosolized recombinant human DNase in hospitalized cystic fibrosis patients with acute pulmonary exacerbations

The goal of this study was to evaluate the safety and efficacy of recombinant human DNase (rhDNase) in hospitalized patients with cystic fibrosis (CF) experiencing acute pulmonary exacerbations. Eighty patients with documented CF were enrolled at 11 CF centers when admitted for antibiotic therapy. Patients were at least 5 yr old with a forced vital capacity (FVC) > or = 35% of predicted and an oxygen saturation > or = 90% on a fraction of inspired oxygen (FIO2) < 0.5. Patients were randomized to receive rhDNase 2.5 mg in 2.5 ml excipient twice a day (n = 43) or 2.5 ml excipient alone twice daily (n = 37) along with conventional treatment for exacerbations. Administration of rhDNase was not associated with acute adverse events or deaths, and no patients experienced allergic or anaphylactic reactions. Although forced expiratory volume in one second (FEV1) and FVC improved in both treatment groups during the double-blind period, there were no statistically significant differences in the mean change from baseline in FEV1 or FVC between the two groups. rhDNase therapy is safe and well tolerated in CF patients with acute exacerbations requiring hospitalization, but the study did not demonstrate a statistically significant therapeutic effect of rhDNase when added to a regimen of antibiotics and chest physical therapy.

Evidence of airway obstruction in children with idiopathic scoliosis

Restrictive pulmonary function abnormalities are reported in children and adolescents with idiopathic scoliosis. We hypothesized that spirometry alone, without more extensive testing, including the measurement of lung volumes, is inadequate in characterizing lung function in these children and may miss obstructive abnormalities including significant gas trapping. To examine this hypothesis, we reviewed the pulmonary function tests of 44 children (36 female, 8 male) between the ages of 10 and 18 years with idiopathic scoliosis prior to surgical correction. Spirometry, measurements of lung volumes with both plethysmographic and helium dilution techniques, and bronchodilator response were analyzed for evidence of reversible airway obstruction and gas trapping. Eighteen of 44 (41%) subjects had significant restriction. Only 3 (7%) subjects met standard criteria for airflow obstruction. However, 20 (46%) subjects had an elevated total gas volume by plethysmography-functional residual capacity by helium dilution ratio indicative of moderate or severe gas trapping, 10 (23%) subjects showed mild gas trapping, 8 (18%) subjects had a ratio suggestive of gas trapping, and only 6 (14%) subjects were normal. Additionally, significant improvement in airway mechanics was noted after bronchodilator administration. Specific conductance improved in all subjects, with a mean increase of 62% +/- 8.0 (p<0.001). The residual volume-total lung capacity ratio and total gas volume by plethysmography also decreased significantly (mean decrease, 22.5% +/- 3.0 and 15% +/- 1.0, respectively, p<0.001) in response to inhaled bronchodilators. In conclusion, although restrictive defects are commonly present in children with idiopathic scoliosis, significant gas trapping and responses to bronchodilators also commonly occur. These abnormalities may be missed without extensive pulmonary function testing.

Spontaneous pneumothorax in children with AIDS

The incidence of pneumothorax in HIV-infected children has not been reported. In adults with AIDS, pneumothorax has been described exclusively in association with Pneumocystis carinii pneumonia (PCP). We report the cases of three children with AIDS, one with lymphoid interstitial pneumonitis (LIP) without evidence of PCP and two with PCP, all of whom developed spontaneous pneumothorax (SP). On presentation, none of the children had any risk factors for the development of pneumothorax, but all had radiographic evidence of subpleural cystic lesions and bilateral pleural adhesions. None of the patients responded to conservative medical management, which included chest tube thoracostomy and chemical pleurodesis. Two patients underwent pleurectomy that resulted in resolution of the pneumothorax. Both patients with PCP who developed pneumothorax died, but the patient with LIP and SP has had no recurrences of any serious respiratory problems 3 years after pleurectomy and excision of the intrathoracic cysts.

Forced expiratory maneuvers in children aged 3 to 5 years

There is no consensus about reproducibility and reliability of spirometry in young children. We evaluated forced expiratory maneuvers from 98 children aged 3 to 5 years with a variety of respiratory disorders before and after bronchodilator treatment. Forced vital capacity (FVC) and forced expiratory volume in 1 sec (FEV1) were analyzed for reproducibility by the American Thoracic Society criteria and for reliability based on the coefficient of variation (CV%). Over 90% of the patients cooperated, however, while 95% could exhale for at least 1 second, very few generated an FEV1 on all 6 "best" efforts. This clearly improved with age. Of all patients nearly 60% performed reproducible pre- and postbronchodilator sets of FVC but only 32% performed reproducible sets of FEV1. Based on the CV%, those patients who could reproducibly perform an FVC and FEV1 did it quite reliably (mean CV%, 9.38 and 7.01 for FVC and FEV1, respectively). We conclude that while some very young children can perform spirometry, reliability of performance cannot be assumed in this age group.

Effects of administration of aerosolized recombinant human deoxyribonuclease on resting energy expenditure in patients with cystic fibrosis

By improving pulmonary function in patients with cystic fibrosis (CF), recombinant human deoxyribonuclease (rhDNase) may affect resting energy expenditure (REE). To examine this hypothesis, we measured REE by indirect calorimetry in seven patients with CF before (day 0) and 2 weeks after (day 15) administration of aerosolized rhDNase. Baseline REE was higher in all patients than predicted for age, sex, and weight (mean +/- SEM 128 +/- 4.9%; range, 116-147%). After 2 weeks of aerosolized rhDNase, mean forced vital capacity (FVC) (in % of predicted values) improved significantly from 54.1 +/- 2.2 to 66.3 +/- 4.2% (mean improvement, 12.3%; 95% CI, 2.8, 21; P < 0.05) and REE decreased by 11.0% (95% CI 3.2, 17.5; P < 0.05). In addition, the larger the improvement in FVC in response to rhDNase the greater the decrease in energy expenditure (r - 0.88). The REE decreased in all patients who had an increase in FVC and remained unchanged in two patients who had no change in FVC. We conclude that patients with CF whose lung function improve in response to aerosolized rhDNase have an acute and proportionate reduction in their resting energy expenditure.