Global strategy for asthma management and prevention

Background Many young children wheeze during viral respiratory infections, but the pathogenesis of these episodes and their relation to the development of asthma later in life are not well understood. Methods In a prospective study, we investigated the factors affecting wheezing before the age of three years and their relation to wheezing at six years of age. Of 1246 newborns in the Tucson, Arizona, area enrolled between May 1980 and October 1984, follow-up data at both three and six years of age were available for 826. For these children, assessments in infancy included measurement of cord-serum IgE levels (measured in 750 children), pulmonary-function testing before any lower respiratory tract illness had occurred (125), measurement of serum IgE levels at nine months of age (672), and questionnaires completed by the children's parents when the children were one year old (800). Assessments at six years of age included measurement of serum IgE levels (in 460), pulmonary-function testing (526), and skin al...

Asthma and wheezing in the first six years of life. The Group Health Medical Associates.

I. Purpose and Scope II. Methacholine Challenge Testing A. Indications B. Contraindications C. Technician Training/Qualifications D. Safety E. Patient Preparation F. Choice and Preparation of Methacholine G. Dosing Protocols 1. Two-Minute Tidal Breathing Dosing Protocol 2. Five-Breath Dosimeter Protocol H. Nebulizers and Dosimeters I. Spirometry and Other End-point Measures J. Data Presentation K. Interpretation III. Exercise Challenge A. Indications B. Contraindications and Patient Preparation C. Exercise Challenge Testing D. Assessing the Response References Appendix A: Sample Methacholine Challenge Test Consent Form Appendix B: Sample Methacholine Challenge Pretest Questionnaire Appendix C: Sample Report Format Appendix D: Equipment Sources

Guidelines for methacholine and exercise challenge testing-1999. This official statement of the American Thoracic Society was adopted by the ATS Board of Directors, July 1999.

Background: Measurement of fractional nitric oxide (NO) concentration in exhaled breath (FeNO) is a quantitative, noninvasive, simple, and safe method of measuring airway inflammation that provides a complementary tool to other ways of assessing airways disease, including asthma. While FeNO measurement has been standardized, there is currently no reference guideline for practicing health care providers to guide them in the appropriate use and interpretation of FeNO in clinical practice.Purpose: To develop evidence-based guidelines for the interpretation of FeNO measurements that incorporate evidence that has accumulated over the past decade.Methods: We created a multidisciplinary committee with expertise in the clinical care, clinical science, or basic science of airway disease and/or NO. The committee identified important clinical questions, synthesized the evidence, and formulated recommendations. Recommendations were developed using pragmatic systematic reviews of the literature and the GRADE approach....

/pdf/an-official-ats-clinical-practice-guideline-interpretation-1iahut6ven.pdf

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

National Asthma Education and Prevention Program.

BACKGROUND--Bronchial hyperreactivity to methacholine is present in children with asthma and other types of paediatric chronic obstructive pulmonary disease (COPD), while hyperreactivity to exercise is more specific for asthma. Adenosine 5'-monophosphate (AMP) is a potent bronchoconstrictor and, like exercise, may provoke asthma by activating mast cells. This study investigated the suitability of AMP as a specific challenge for asthma in children. METHODS--Bronchial provocation challenges with methacholine and AMP were performed in a double blind fashion using tidal breathing in 51 children with asthma, 21 with paediatric COPD of various types, and in 19 control children. Each subject also underwent a standardised exercise challenge after inhalation challenges were completed. Sensitivity and specificity curves were constructed and the intersection point of sensitivity and specificity for each type of challenge was determined. RESULTS--When the asthmatic patients were compared with the children with COPD, the intersection points for AMP, exercise and methacholine were 90%, 85%, and 50%, respectively. When compared with the controls the same intersection points were 98%, 84%, and 92%, and when children with paediatric COPD were compared with controls they were 55%, 50%, and 82%. CONCLUSIONS--Methacholine distinguishes both asthma and paediatric COPD from controls with a sensitivity of 82-92%, but does not distinguish between asthma and paediatric COPD; exercise and AMP distinguish asthma from controls with a sensitivity and specificity of 84-98% but they also distinguish asthma from paediatric COPD with a sensitivity and specificity of 85-90%. AMP inhalation is a practical aid for diagnosing asthma and distinguishing it from COPD in children of all ages.

https://thorax.bmj.com/content/thoraxjnl/50/5/511.full.pdf

Adenosine, methacholine, and exercise challenges in children with asthma or paediatric chronic obstructive pulmonary disease.

Bronchial provocation challenges with exercise and methacholine were performed on the same day or within a short interval in 52 children with asthma, 22 with other types of chronic lung disease (including cystic fibrosis), and 19 control subjects with no evidence of chronic lung disease. There were no significant differences in the baseline lung function before the two types of challenge in the individual groups and differences between the patients with asthma and with chronic lung disease were minor. When the mean -2 SD of the methacholine response of the control group was taken as the lower limit of normal, 49/52 (94%) patients with asthma and 18/22 (82%) with chronic lung disease responded abnormally. In contrast, with the mean +2 SD of the exercise response of the control group as the upper limit of normal, 41/52 (79%) asthmatic patients responded but none of those with chronic lung disease. Thus the response to the two types of challenge helps to distinguish asthma from other types of chronic lung disease in children.

https://thorax.bmj.com/content/thoraxjnl/46/7/488.full.pdf

Exercise but not methacholine differentiates asthma from chronic lung disease in children.

Background: Bronchial provocation tests such as exercise, methacholine (MCH), and adenosine-5′-monophosphate (AMP) challenges are used extensively in the diagnosis of asthma. A study was undertaken to determine whether exhaled nitric oxide (eNO) can be used to diagnose asthma in patients with non-specific respiratory symptoms and to compare this test with conventional provocation tests. Methods: Patients with non-specific respiratory symptoms and normal spirometric parameters were included in the study. eNO was measured and exercise, MCH and AMP challenges performed in all subjects. Patients were defined as asthmatic based on clinical follow up 24 months after testing. Results: Forty patients were considered asthmatic and 45 were not. The area under receiver operating characteristic curves gave values of 0.896 for eNO, 0.781 for exercise, 0.924 for MCH, and 0.939 for AMP (p = 0.033, 0.575 and 0.085 for eNO v exercise, MCH and AMP respectively). From our data, a cut off value of NO >7 ppb at a flow rate of 250 ml/s best differentiates between asthmatics and non-asthmatics (sensitivity 82.5%, specificity 88.9%). Optimal cut off values for other tests were exercise: ΔFEV 1 ⩾10% (sensitivity 57.9%, specificity 100%); PC 20 -MCH: ⩽3 mg/ml (sensitivity 87.5%, specificity 86.7%); and PC 20 -AMP: ⩽150 mg/ml (sensitivity 89.5%, specificity 95.6%). Conclusions: Measurement of eNO can be used as a safe, simple and rapid test for the diagnosis of asthma and is as good as bronchial provocation tests.

https://thorax.bmj.com/content/thoraxjnl/60/5/383.full.pdf

Exhaled nitric oxide in the diagnosis of asthma: comparison with bronchial provocation tests.

The treatment of infants aged 1.5–11.0 months suffering from acute bronchiolitis with a combination of inhaled albuterol and systemic corticosteroids or inhaled albuterol and placebo was compared in 50 infants in a double blind study. The mean initial clinical score and the rate of improvement was similar in the two groups. The mean ± SD hospital stay was 5.0 ± 1.2 days for the steroid group and 5.2 ± 1.7 days for the placebo group. Lung function was measured in 14 infants (7 from each group) and showed evidence of increased lung volumes and severe airway obstruction in the acute stage (the mean values for the steroid group were: TGV, 31 mL/kg; SGaw, 0.104 L/s·cmH2O; VmaxFRC, 12.9 mL/s/kg; for the placebo group: TGV, 35 mL/kg; SGaw, 0.104 L/s·cmH2O; VmaxFRC, 8.5 mL/s/kg) which had improved 2–4 weeks later (steroid group: TGV, 25 mL/kg; SGaw, 0.168 L/s·cmH2O; VmaxFRC, 21.6 mL/s/kg; –placebo group: TGV, 24 mL/kg, SGaw, 0.198 L/s·cmH2O, VmaxFRC, 17.5 mL/s/kg). There were no significant differences of thoracic gas volume, specific airway conductance, and forced expiratory flow at resting lung volume between the two groups, either in the acute or convalescent stages. We conclude that corticosteroids do not change the rate of clinical improvement in acute bronchiolitis, nor do they effect lung function 2–4 weeks later. Pediatr Pulmonal 1990; 9:181–185.

Corticosteroids do not affect the clinical or physiological status of infants with bronchiolitis.

Suspected foreign body inhalation in children: what are the indications for bronchoscopy?

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