Expert Panel Report Research Articles

Exercise-induced bronchospasm, asthma control, and obesity.

Exercise-induced bronchospasm (EIB) commonly affects patients with asthma. However, the relationship between EIB and asthma control remains unclear. Exercise limitation due to asthma might lead to reduced physical activity, but little information is available regarding obesity and EIB in asthma. A recent survey evaluated the frequency of EIB and exercise-related respiratory symptoms in a large number of patients with asthma. The survey results were reanalyzed to address any relationship between EIB and asthma control and obesity. A nationwide random sample of children aged 4-12 years (n = 250), adolescents aged 13-17 years (n = 266), and adults aged ≥18 years (n = 1001) with asthma were interviewed by telephone. Questions in the survey addressed asthma symptoms in general, medication use, and height and weight. Asthma control was categorized using established methods in the Expert Panel Report 3. Body mass index (BMI) was calculated using standard nomograms and obesity was defined as a BMI ≥ 30 kg/m(2). Most children (77.6%), adolescents (71.1%), and adults (83.1%) had either "not well" or "very poorly" controlled asthma. Children with "not well" controlled asthma reported a history of EIB significantly more often than those with "well" controlled" asthma. Asthma patients of all ages who had "not well" and "very poorly" controlled asthma described multiple (four or more) exercise-related respiratory symptoms significantly more often than those with "well-controlled" asthma. Obesity was significantly more common in adolescents with "not well" and "very poorly" controlled asthma and adults with "very poorly" controlled asthma. Children, adolescents, and adults with asthma infrequently have well-controlled disease. A history of EIB and exercise-related respiratory symptoms occur more commonly in patients with not well and very poorly controlled asthma. Obesity was found more often in adolescents and adults, but not children, with asthma, which was not well and very poorly controlled.

The misuse of asthma drugs

There are three major problems with asthma care in the USA and misuse of asthma drug therapy contributes to each. Asthma patients suffer from symptoms regularly partly because healthcare providers do not understand the Expert Panel Report III (EPR3) recommendations on assessing asthma symptoms to determine drug treatment and, consequently, undertreat the disease. Asthma patients experience exacerbations often in part because the EPR3 provides limited guidance on using exacerbation risk to guide asthma treatment, again leading to undertreatment. The EPR3 recommends inhaled corticosteroids as the preferred therapy for mild persistent asthma but American healthcare providers disregard this recommendation based on different perceptions about the risks and benefits of inhaled corticosteroids and choose drug treatments with higher healthcare costs.

The Ethicist as Language Czar, or Cop: “End of Life” v. “Ending Life”

Bioethics promises a considered, unprejudicial approach to areas of medical decision-making. It does this, in theory, from the perspective of moral philosophy. But the promise of fairly considered, insightful commentary fails when word choices used in ethical arguments are prejudicial, foreclosing rather than opening an area of moral discourse. The problem is illustrated through an analysis of the language of The Royal Society Expert Panel Report: End of Life Decision Making advocating medical termination.

Return on Investment of an Asthma Education Program

McQuaid EL, Garro A, Seifer R, et al. Integrating asthma education and smoking cessation for parents: financial return on investment. Pediatr Pulmonol. 2012; 47(10): 950– 955; doi: 10.1002/ppul.22559Investigators from Brown University and the University of California, Berkeley sought to determine the financial return on investment (ROI) of the Parents of Asthmatics Quit Smoking (PAQS) program. PAQS is a program for caregivers who are smokers and have a child with asthma. As part of the program, nurses provide asthma education and smoking cessation counseling in 3 home visits. Investigators calculated the ROI by analyzing claims data 12 months pre-enrollment and post-completion of the intervention in a subsample of PAQS participants who were on a Medicaid managed care plan. Total billable costs (TBC) were determined by summing the costs of short-acting β-agonists, controller medications, emergency department (ED) visits, hospitalizations, and outpatient visits for asthma. The cost of delivering the PAQS intervention was calculated by summing direct expenditures, start-up costs, and elements of overhead. The primary outcome was ROI, calculated as ([TBC pre-PAQS – TBC post-PAQS] – Intervention Costs) / Intervention Costs, for the total sample and for 3 subgroups (children <6 years old, children 6-18 years old, and children with moderate to severe persistent asthma).The analysis included 224 PAQS participant children. The cost of the PAQS intervention in this sample was $34,481. Postintervention, there was a significant increase in mean annual fills for β-agonist and controller medications and a corresponding increase in medication costs per participant. However, there was also a significant decrease in health care utilization including emergency room visits, hospitalizations, and outpatient visits postintervention. The ROI for the total sample was –21.8%. However, for children <6 years old it was 106.9%, and for children with moderate to severe persistent asthma, it was 6.9%. The ROI was –150.3% for children 6 to 18 years old.The authors conclude that while the overall ROI of PAQS was negative, PAQS yielded a highly positive ROI for children <6 years old.Adverse effects of tobacco smoke exposure on children’s health have been well documented.1 There has been a steady increase in the number of studies showing an association of environmental tobacco smoke (ETS) exposure and asthma. As a result, the Expert Panel Report-3 (EPR-3) 2007 Asthma Guidelines, citing this supporting evidence,2 published a longer statement regarding education on smoking cessation compared to EPR-2 (1997, revised in 2002).3 EPR-3 recommends assessing ETS exposure in the household and referring parents and caretakers who smoke to smoking cessation programs.A study prior to PAQS showed that reduced ETS exposure to asthmatic children in an urban setting was associated with a decrease in asthma-related exacerbations.4 Consequently, there has been substantial effort to develop effective asthma education and smoking cessation programs. A home-based educational program model is costly compared to the standard education given at patient encounters, yet these programs offer the benefit of reaching out to caregivers who may have limited access for follow-up. A recent Cochrane review, however, concluded that home-based educational programs are not more effective than standard educational programs given at medical visits.5 Furthermore, another Cochrane review concluded that there is inconclusive evidence that smoking cessation programs for caregivers are effective.6This study lends support to a combined smoking cessation and asthma program in a home-based setting, especially for children under 6 years old. Younger patients utilize more health care, so stand to benefit more. It is also possible parents of young children are more motivated. A recent study found caregivers of younger children seemed to be more receptive to an asthma education program and more likely to complete the intervention.7 Perhaps early intervention with parents of young children should be our focus: it is cost-beneficial and can help curtail the detrimental effects of ETS exposure on asthma severity long-term.The ROI analysis in this study is an elegant way to assess a program such as PAQS; we need more studies like this. However, the positive results (limited as they are) seem more related to asthma management education than counseling on smoking cessation.

Considerations for Care: Management of Asthma in the Child with Sickle Cell Disease.

Asthma is difficult to diagnose in the child with sickle cell disease because symptoms and pulmonary function abnormalities are similar to the spectrum of pulmonary manifestations in sickle cell disease. There are no published reports of controlled trials of asthma medications in children with sickle cell disease. Thus, treatment decisions should be guided by the Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf). However, issues specific to children with sickle cell disease should be considered. Initial strategies should focus on control of environmental triggers, as effectiveness on asthma outcomes is proven and the cost for implementation can be low. Use of short- and long-acting β2-agonists may prolong QTc, particularly in this population of children who already have a higher prevalence of prolonged QTc than the general population. Long-acting β2-agonist use has been associated with life-threatening asthma exacerbations with potentially higher risks in African Americans. Montelukast has been reported to increase suicidal thinking and behavior, and persons with asthma and sickle cell disease are already at risk for these events. Oral corticosteroids in the treatment of acute chest syndrome may increase risk of readmission even in children with asthma. The lack of prospective controlled trials of asthma drug treatment in children with asthma and sickle cell disease compels us to move this issue forward.

Nonrespiratory symptoms before loss of asthma control in children

Nonrespiratory symptoms before loss of asthma control in children

Intermittent to Mild Asthma: The Need for Continued Treatment

Asthma is a chronic inflammatory disease of an airway characterized by recurrent attacks of airflow obstruction that is at least partially reversible.1,2 This definition of implies that asthma can be completely reversible. Therefore, most patients with asthma (except those with severe or difficult-to-treat asthma) show the greatest improvement of symptoms in the first few months of therapy. Many newly diagnosed asthma patients irregularly or hardly follow the treatment advice of a physician due to the definition and clinical course of asthma.3,4 According to the Global Initiative for Asthma (GINA) guideline and the Expert Panel Report 3, the goal of therapy in patients with asthma is to achieve asthma control. Asthma classification by severity (previously introduced by the previous GINA documents) is less important than before; however, it is still useful to decide the management at the initial assessment of a patient or when required to characterize a group of patients with asthma who are not in treatment. Recently, the severity of asthma means the intensity of the treatment required to achieve good asthma control.5 This issue of Allergy, Asthma & Immunology Research, Kang and colleagues6 evaluated patients who were newly diagnosed with asthma at a university hospital and were lost to follow-up within 3 years. The authors revealed that 73.9% of patients were lost to follow-up within 3 years and they were younger and had a lower severity of asthma at the time of diagnosis compared with those who had continued management at the hospital. They also showed that 63.3% of non-adherents (who responded to the telephone survey) had not taken any controller mainly due to improved symptoms. Those who did not follow up at the hospital but continued treatment at other hospitals were comparable to those that continued follow-up. Half of the survey respondents answered that the reason to discontinue treatment was due to the long distance to the hospital. Subsequently, the non-treatment group had distinctive characteristics of a young age, best FEV1 and highest PC20 of methacholine, compared to the previous 2 groups. The non-treatment group had intermittent or mild persistent severity of asthma at the time of diagnosis and none of them reported aggravation of asthma despite non-treatment. My colleagues analyzed the characteristics of drop-out patients compared with those who maintained attendance in the COhort for Reality and Evolution of Adult Asthma in Korea (COREA).7 Forty-four percent of the initial participants dropped out from the cohort in the first 18 months. Non-adherents (versus adherents) had a lower mean age, a shorter duration of treatment and lower physician-assessed severity of asthma; in addition, they used fewer controllers and experienced fewer exacerbations. The findings suggest that newly diagnosed patients as well as those previously diagnosed with asthma tend to have lower adherence to their treatment if they have a lower severity of asthma. The updated GINA guideline recommends controller treatment for 1 year even if the patient achieves asthma control and has no symptoms on the lowest dose of controller.1 However, the evidence of this recommendation is the lowest level and based on a panel consensus judgment. Asthma control can deteriorate in weeks to months when an inhaled steroid discontinued.8 There were non-responders to the telephone survey (in contrast to the current guideline or the previous report); however, this retrospective observational study identified no aggravation of asthma control in patients with mild asthma after they stopped the controllers themselves. This provides clinically valuable information in the context of the discrepancy between the doctor's recommendation and the patient's accordance. The choices by patients could be reasonable in light of economic costs and a possible adverse effect caused by unnecessary treatment if they had intermittent or mild persistent asthma. A limitation of this study was that the authors did not evaluate any previous exacerbations or any recurrences of asthma. The diagnosis of asthma was based on the bronchodilator/methacholine challenge testing as they described; however, episodic recurrences/exacerbations of the obstructive symptoms were necessary for the diagnosis of asthma. Frequent exacerbation of asthma is one of the important future risks in asthma control; subsequently, we cannot exclude the possibility that the diagnosis of the subjects included in this study may consist of asthma as well as asthma-like conditions that could show positive results to bronchodilator/Methacholine challenge testing.9-11 For example, a patient with postviral airway hyperresponsiveness could be included in this retrospective cohort and then show no recurrent symptom with no treatment. Further studies focused on mild asthma are necessary to identify patients that require continued treatment despite achieving prolonged asthma control. In terms of the heterogeneity of asthma, developing biomarkers and indices to distinguish the need-to-treat patients could be essential for an optimized and personalized management.

Safety and Feasibility of Bronchial Thermoplasty in Asthma Patients with Very Severe Fixed Airflow Obstruction: A Case Series

Objective. Bronchial thermoplasty (BT) can provide relief for patients with severe, uncontrolled asthma despite maximal medical therapy. However, it is unclear whether BT is safe in patients with very severe airflow obstruction. Methods. We performed BT in eight patients with severe asthma as defined by Expert Panel Report 3 (EPR-3) guidelines who were poorly controlled despite step 5 therapy. Data were available on each subject for 1 year prior to and 15–72 weeks following BT. Results. The mean (±SEM) pre-bronchodilator forced expiratory volume in one second (FEV1) prior to BT was 51.8 ± 8.6% of predicted, and the mean (±SEM) number of hospitalizations for asthma in the year prior to BT was 2.9 ± 1.2. No subject had an unexpected severe adverse event due to BT. Among the eight patients with follow-up of at least 15 weeks, there was no significant decline in FEV1 (p = .4). Conclusion. We suggest that BT may be safe for asthma patients with severe airflow obstruction and higher hospitalization rates than previously reported.

Climate change, fisheries, and aquaculture: trends and consequences for Canadian marine biodiversity1This manuscript is a companion paper to Vander Zwaag et al. (doi:10.1139/a2012-013) and Hutchings et al. (doi:10.1139/er-2012-0049) also appearing in this issue. These three papers comprise an edited version of a February 2012 Royal Society of Canada Expert Panel Report.

Climate change, fishing, and aquaculture have affected and will continue to influence Canadian marine biodiversity, albeit at different spatial scales. The Arctic is notably affected by reduced quality and quantity of sea ice caused by global warming, and by concomitant and forecasted changes in ocean productivity, species ecology, and human activity. The Atlantic has been especially impacted by severe overfishing and human-induced alterations to food webs. Climate change, fishing, and aquaculture have all affected, to varying degrees, biodiversity on Canada’s Pacific coast. Past and projected trends in key biodiversity stressors reveal marked change. Oceanographic trends include increasing surface water temperatures, reduced salinity, increased acidity, and, in some areas, reduced oxygen. Reductions in Canada’s fishery catches (those in 2009 were half those of the late 1980s), followed by reductions in fishing pressure, are associated with dramatic changes in the species composition of commercial catches in the Atlantic (formerly groundfish, now predominantly invertebrates and pelagic fish) and the Pacific (formerly salmon, now predominantly groundfish). Aquaculture, dominated by the farming of Atlantic salmon, grew rapidly from the early 1980s until 2002 and has since stabilized. Climate change is forecast to affect marine biodiversity by shifting species distributions, changing species community composition, decoupling the timing of species’ resource requirements and resource availability, and reducing habitat quality. Harvest-related reductions in fish abundance, many by 80% or more, coupled with fishing-induced changes to food webs, are impairing the capacity of species to recover or even persist. Open-sea aquaculture net pens affect biodiversity by (i) habitat alteration resulting from organic wastes, chemical inputs, and use of nonnative species; (ii) exchange of pathogens between farmed and wild species; and (iii) interbreeding between wild fish and farmed escapees. Physical and biological changes in the oceans, along with direct anthropogenic impacts, are modifying Canadian marine biodiversity with implications for food security and the social and economic well-being of coastal communities. To assess the consequences of changes in biodiversity for Canada’s oceans and society, it is necessary to understand the current state of marine biodiversity and how it might be affected by projected changes in climate and human uses.

Canada’s international and national commitments to sustain marine biodiversity1This manuscript is a companion paper to Hutchings et al. (doi:10.1139/a2012-011) and Hutchings et al. (doi:10.1139/er-2012-0049) also appearing in this issue. These three papers comprise an edited version of a February 2012 Royal Society of Canada Expert Panel Report.

Canada has made numerous international and national commitments to sustain marine biodiversity. International commitments include the implementation of ecosystem-based management, the establishment a network of marine protected areas, and the restoration of commercially exploited fish stocks. However, the international commitments tend to be quite general in nature with the precise governance implications of key principles, such as precaution and the ecosystem approach, being open to interpretation, thus leaving considerable room for discretion in implementation. Consequently, a plethora of soft law documents has emerged to provide more specific guidance to decision-makers and progressively develop international law and policy. Nationally, Canada has embraced a long list of commitments that are supportive of sustaining marine biodiversity through legislation and numerous policy-related documents. Nonetheless, Canada has left many of these commitments unfulfilled or inadequately fulfilled, such as (i) the development of integrated management plans for coastal and marine waters, (ii) the implementation of the precautionary approach for Canada’s fisheries, and (iii) the establishment of recovery strategies and identification of critical habitat for species at risk. Although the goal of effective protection of marine biodiversity in Canada appears to be guided by international and national commitments, there remains a clear need to fully implement, operationalize, and strengthen these commitments as articulated in the Oceans Act, fisheries management-related policies, the Species at Risk Act, and others.

Is Canada fulfilling its obligations to sustain marine biodiversity? A summary review, conclusions, and recommendations1This manuscript is a companion paper to Hutchings et al. (doi:10.1139/a2012-011) and VanderZwaag et al. (doi:10.1139/a2012-013) also appearing in this issue. These three papers comprise an edited version of a February 2012 Royal Society of Canada Expert Panel Report.

Canada has made numerous national and international commitments to sustain marine biodiversity. Given current and potential threats to biodiversity from climate change, fisheries, and aquaculture, we provide a summary review of Canada’s progress in fulfilling its obligations to protect, conserve, recover, and responsibly exploit marine biodiversity. We conclude that Canada has made little substantive progress, when compared to most developed nations, in meeting its biodiversity commitments. Much of Canada’s policy and rhetoric has not been operationalised, leaving many of the country’s national and international obligations unfulfilled in some key areas, such as the establishment of marine protected areas and incorporation of the precautionary approach to fisheries management. We conclude that regulatory conflict within Canada’s Department of Fisheries and Oceans (DFO) and the absolute discretion exercised by the national Minister of Fisheries and Oceans contribute significantly to an unduly slow rate of policy and statute implementation. We recommend new approaches and measures to sustain Canadian marine biodiversity and new research initiatives to support scientific advice to decision-makers. Many recommendations focus on management actions required to meet existing commitments to biodiversity conservation. Overall, we conclude that the most effective strategy is to protect existing biological diversity and to rebuild depleted populations and species to restore natural diversity. By improving and protecting the biodiversity in Canada’s oceans, such a strategy will restore the natural resilience of Canada’s ocean ecosystems to adapt to the challenges posed by climate change and other anthropogenic activities with consequent long-term benefits for food security and social and economic well-being.

Using science to improve communications about suicide among military and veteran populations: looking for a few good messages.

Concern about suicide in US military and veteran populations has prompted efforts to identify more effective prevention measures. Recent expert panel reports have recommended public communications as one component of a comprehensive effort. Messaging about military and veteran suicide originates from many sources and often does not support suicide prevention goals or adhere to principles for developing effective communications. There is an urgent need for strategic, science-based, consistent messaging guidance in this area. Although literature on the effectiveness of suicide prevention communications for these populations is lacking, this article summarizes key findings from several bodies of research that offer lessons for creating safe and effective messages that support and enhance military and veteran suicide prevention efforts.

Development and Validation of the Composite Asthma Severity Index—An Outcome Measure for Use in Children and Adolescents

JJ Wildfire, PJ Gergen, CA Sorkness. J Allergy Clin Immunol. 2012;129(3):694–701 To develop and validate a new instrument, the Composite Asthma Severity Index (CASI), which accounts for impairment, risk, and amount of medication to maintain control. Previous instruments do not take into account these measures in defining severity as outlined by the Expert Panel Report—3: For the Diagnosis and Management of Asthma . Data from 546 children and adolescents in the Asthma Control Evaluation (ACE) trial were used initially to determine outcome domains of asthma. External validation of the severity index was achieved by using data from 419 children and adolescents in the Inner City Anti-IgE Therapy for Asthma (ICATA) trial, a double-blind, placebo-controlled multicenter trial of omalizumab versus …

669 Monitoring the Asthmatic Children, A Prospective Study

BackgroundSpirometry and biomarkers such as immunoglobulin E (IgE) levels, fractional exhaled nitric oxide concentration (FeNO) have been proposed for assessing the risk of future adverse events in Expert Panel Report...

Not left to chance: Introducing an undergraduate interprofessional education curriculum

Teaching diverse health profession students to work in teams, communicate, understand each other's roles and responsibilities, and effectively collaborate is imperative for creating a practice-ready workforce. This short report introduces an innovative undergraduate interprofessional curriculum for students enrolled in the baccalaureate majors of applied exercise science, athletic training, dental hygiene, nursing and pre-occupational therapy. The process of designing this program of study, guided by the method of appreciative inquiry, is highlighted. The format and learning activities created for this novel curriculum are described. Congruence for this endeavor is explored through alignment with the recent national Interprofessional Education Collaborative expert panel report. Preparing graduates to fulfill the dual identity of discipline-specific clinician and interprofessional team member is an essential curricular consideration for contemporary health profession education.

Management of Wheezing in Preschool Children

Diagnosis and management of asthma in preschool children are challenging. The Expert Panel Report 3 has recommendations for specific illness phenotypes to start long-term controller medication to reduce risk and impairment in children ages 0–4-year old. The use of daily-inhaled corticosteroids has shown to be effective in preschool children with persistent asthma, but there are also reports of growth retardation. For children with recurrent or intermittent wheezing without symptoms in between episodes, the intermittent use of controller medications may be an option for certain phenotypes. This review will discuss the available data on use of intermittent controller medications in preschool children with wheezing.

PS2-02: Reducing Higher Prevalence of Diabetes Mellitus Among South Asian Populations in Canada

Background/Aims Statistical evidence confirms a disparity in diabetes mellitus prevalence by ethnicity in Canada. Diabetes mellitus (DM) prevalence was 6.4% of total populations for 2010 in Canada (PHAC, 2011). Canadian Diabetes Association (2006) reports that South Asian populations in Canada are at a greater risk of having DM. While DM prevalence in Canada was at 5.2% for total populations in 2005, it was almost three folds higher, at 14% for South Asian populations. Canada is a world leader in scholarship of social determinants of health (SDH). However a gap between knowledge and action in SDH is evident in policies and practices of the Canadian government. Expert Panel Report (PHAC, 2009) contends that increasing prevalence of DM poses significant threats to the sustainability of the public health care system in Canada. With increased disparity in population health outcome it is imperative to investigate alternative approaches to policies and practices that will effectively lessen the prevalence of DM among South Asian populations in Canada. In this paper, I study the dominant approach in health organizations that inform/formulate/direct policies and practices, to reduce prevalence and/or to delay the onset of DM among South Asian populations in Canada.

Urinary fluticasone propionate-17beta-carboxylic acid to assess asthma therapy adherence

Although the National Asthma Education and Prevention Program Expert Panel Report 3 recommends referral to specialists to address adherence, guidelines do not provide a tool to determine nonadherence. This study was designed to prospectively evaluate the characteristics of urinary analysis of fluticasone propionate-17beta-carboxylic acid (FP17betaCA) as a test to verify if a specific patient has not taken fluticasone propionate (FP) within 16-24 hours. Urine of asthmatic subjects was prospectively analyzed 16-24 hours after witnessed administration of orally inhaled FP using liquid chromatography tandem mass spectrometry (LC-MS/MS) analysis; limit of quantitation was 10.3 pg/mL. Results were compared with those from asthmatic subjects not receiving inhaled FP. Thirty asthmatic subjects receiving inhaled FP (2 oral inhalations of FP at 110 micrograms each or 1 oral inhalation twice daily of fluticasone and salmeterol in fixed combination at 250/50 micrograms for 1 week) were compared with 30 asthmatic subjects not receiving FP. FP17betaCA was detected in the urine of 30 of 30 asthmatic subjects receiving FP (median, interquartile range [IQR; 413.5, 212.8-1230.0] range 12.4-3290.0 pg/mL [corrected for urine creatinine: median, IQR {576.2, 188.1-1306.6} range 6.3-5425.9 ng/g Cr]) and was undetectable in 30 of 30 subjects not receiving inhaled FP. The sensitivity and specificity of LC-MS/MS to detect FP17betaCA in urine were 100% (95% exact binomial confidence interval, 88-100) and 100% (95% exact binomial confidence interval, 88-100), respectively. Analysis of FP17betaCA in urine provides a sensitive method that may be used to verify that a specific patient may not have administered FP within a 16- to 24-hour window before testing.

Chapter 10: Pediatric asthma: Principles and treatment

Approximately one-half of children with asthma present with symptoms before 3 years of age. The typical history describes recurrent episodes of wheezing and/or cough triggered by a viral upper respiratory infection, activity, or changes in weather or seasons. When symptoms occur after a viral respiratory infection, children with asthma often take longer than the usual week to recover fully from their respiratory symptoms. Wheezing and coughing during exercise or during laughing or crying and episodes triggered in the absence of infection suggest asthma. A trial of bronchodilator medication should show symptomatic improvement. The goal of asthma therapy is to keep children "symptom free" by preventing chronic symptoms, maintaining lung function, and allowing for normal daily activities. Avoidance of triggers identified by history, such as second-hand cigarette smoke exposure and allergens identified by skin-prick testing, can significantly reduce symptoms. According to the National Asthma Education and Prevention Program 2007 report (Expert Panel Report 3 [EPR-3]. Guidelines for the diagnosis and management of asthma: Summary report 2007. J Allergy Clin Immunol 120:S94-S138, 2007.), if impairment symptoms are present >2 days/week or 2 nights/mo, the disease process is characterized as persistent, and in all age groupings, inhaled corticosteroids (ICS) are recommended as the preferred daily controller therapy. Other controller medications such as cromolyn must be given three to four times a day and provides less efficacy than ICS. Montelukast is approved for children ≥12 months old and is often used for its ease of daily oral dosing. Long-acting beta(2)-adrenergic agonists should not be used as monotherapy (i.e., should only be used with ICS).

Chapter 9: Asthma classification

Asthma is a chronic inflammatory disorder of the airways resulting physiologically in hyperreactivity and clinically in recurrent episodes of wheezing, chest tightness, or coughing. Airway inflammation, smooth muscle contraction, epithelial sloughing, mucous hypersecretion, bronchial hyperresponsiveness, and mucosal edema contribute to the underlying pathophysiology of asthma. Diagnostic tests such as methacholine or mannitol challenges or spirometry (pre- and postbronchodilator responses) help to identify such underlying pathophysiology via assessments of bronchial hyperreactivity and lung mechanics but are imperfect and ultimately must be viewed in the context of a patient's clinical presentation including response to pharmacotherapy. The National Asthma Education and Prevention Program Expert Panel Report (2007) classifies asthma into either intermittent or persistent, and the latter is either mild, moderate, or severe. Some patients change in either direction from intermittent to persistent asthma. In addition, patients with asthma may be classified as allergic (IgE mediated), nonallergic (often triggered by viral upper respiratory tract infections or no apparent cause), occupational, aspirin-exacerbated respiratory disease, potentially (near) fatal, exercise induced, and cough variant asthma. In the latter, the patients have a nonproductive cough that responds to treatment for asthma but not with antibiotics, expectorants, mucolytics, antitussives, beta(2)-adrenergic agonists, treatment for acid reflux, or rhinosinusitis. Thus, cough variant asthma is in the differential diagnosis of chronic cough.