Pediatric Asthma Severity Research Articles

Clinical Experience with Anti-IgE Monoclonal Antibody (Omalizumab) in Pediatric Severe Allergic Asthma-A Romanian Perspective.

Background: Asthma is the most common chronic disease affecting children, with a negative impact on their quality of life. Asthma is often associated with comorbid allergic diseases, and its severity may be modulated by immunoglobulin E (IgE)-mediated allergen sensitization. Omalizumab is a humanized monoclonal anti-IgE antibody, the first biological therapy approved to treat patients aged ≥6 years with severe allergic asthma. The primary objective of our study was to investigate the efficacy and safety of Omalizumab in Romanian children with severe allergic asthma. Methods: In this observational real-life study, 12 children and adolescents aged 6 to 18 years (mean 12.4 years) with severe allergic asthma received Omalizumab as an add-on treatment. Asthma control, exacerbations, lung function, and adverse events were evaluated at baseline and after the first year of treatment. Results: We observed general improvement in total asthma symptom scores and reduction in the rate of exacerbation of severe asthma. Omalizumab treatment was associated with improvement in the measures of lung function, and no serious adverse reactions were reported. FEV1 improved significantly after one year of treatment with Omalizumab [ΔFEV1 (% pred.) = 18.3], and [similarly, ΔMEF50 (%) = 25.8]. The mean severe exacerbation rate of asthma decreased from 4.1 ± 2.8 to 1.15 ± 0.78 (p < 0.0001) during the year of treatment with Omalizumab. Conclusions: This study showed that Omalizumab can be an effective and safe therapeutic option for Romanian children and adolescents with severe allergic asthma, providing clinically relevant information on asthma control and exacerbation rate in children and adolescents. The results demonstrated the positive effect of Omalizumab in young patients with asthma, starting from the first year of treatment.

Asthma Control and Psychological Health in Pediatric Severe Asthma

To determine the prevalence of anxiety and depression and impact on asthma control in pediatric patients with severe asthma.Children aged ≥4 years who were referred to the Boston Children’s Hospital Severe Asthma Program by a pediatric pulmonologist, allergist, or intensivist after a life-threatening asthma exacerbation.This was a single-center prospective cohort study from March 2017 to December 2019. Asthma severity for each participant was defined on the basis of the National Heart, Lung, and Blood Institute (NHLBI) asthma medication steps. At each clinical encounter, children completed the Patient Health Questionnaire (PHQ-4) and the Asthma Control Test (ACT) or childhood ACT with parental assistance and had spirometry done to assess lung function, including forced expiratory volume in 1 second (FEV1) to forced vital capacity. The association of the longitudinal psychological assessments and pulmonary function measures were determined by using a linear mixed model (adjusted for sex, age, race, and NHLBI asthma medication step).Data were obtained for 93 clinical encounters from 43 patients. The mean age was 11.7 (+/− 4.2) years; 65% were male (n = 28 of 43); 49% were White (n = 22 of 43). The median NHLBI asthma medication step was 5.5 (interquartile range: 4.5–6.0). A total of 58% (n = 25 of 43) had at least 1 symptom of anxiety and depression, and 19% (n = 8 of 43) had a PHQ-4 score >2, indicating at least mild impairment. Bivariate analyses after adjusting for age, sex, race, and medication step revealed a significant difference in mean ACT scores (7 points lower) for girls with a PHQ-4 score >2 versus that of those with a score ≤2 (95% confidence interval [CI]: −10.88 to −3.12; P = .01); this effect was not seen in mean ACT scores for boys with PHQ-4 scores >2 versus that of those with scores ≤2. Compared with girls, boys with PHQ-4 scores >2 had a mean ACT score that was 4.18 points higher (95% CI: 0.63 to 7.73; P = .03). A PHQ-4 score >2 was significantly associated with percent FEV1 predicted but not with FEV1 to forced vital capacity (95% CI: −33.83 to 1.12; P = .06).Pediatric patients with severe asthma often have comorbid mental health impairment, which is associated with poor asthma-related quality of life. Girls with greater anxiety and depression perceived significantly worse asthma control. No difference in perceived asthma control was seen in boys, regardless of anxiety or depression level.Individuals with poorly controlled asthma can have psychological comorbidities including anxiety and depression, whereas, conversely, these factors can exacerbate asthma and negatively impact asthma control and severity. The perception of asthma control may impact self-care, asthma self-management, and inaccurate perception of symptoms, potentially resulting in higher rates of asthma-related health care use. Just as women often are more likely to report symptoms than men, the girls in this study had the higher level of mental health impairment and more negatively perceived asthma control. Although sex differences were observed in the association between psychological impairment and perceived asthma control, there was no association with objective spirometry results. Study limitations include the small sample size and use of PHQ-4, which is not a standard psychological screening tool. However, with these results, the authors highlight the potential impact of psychological symptoms in our clinical management of patients with asthma.

Paediatric Severe Asthma Biologics Service: From Hospital to Home

To assess whether biologics could be given safely at home in children with severe asthma, including measuring spirometry and quality of life.Children with severe asthma who had received omalizumab or mepolizumab and were willing to administer medication by supervised video calls in London, England, during the coronavirus disease 2019 pandemic from April to July 2020.In the study, children were identified who previously received at least 3 doses of biologics in the clinic or hospital setting safely with no reactions, were deemed suitable by a multidisciplinary team, and had no previous experience with home medication administration. Patients and their caretakers were trained for 1 to 2 hours, after which clinical nurse specialists virtually observed them during home medication administration. Patients and their families were given a home spirometer that measured forced expiratory volume in 1 second and forced vital capacity (FVC) to track asthma status. They were then managed every 2 to 4 weeks, with video calls to assist with medication dosing, assess asthma control, determine if oral corticosteroids (OCSs) were required or unscheduled health care visits, and determine general well-being the preceding 4 weeks.A total of 16 of 23 patients with a median age of 14.5 years (6 to 18 years) fulfilled the criteria for homecare and consented. A total of 14 adolescents independently completed home administration, and 2 required community nursing to administer the medication. Seven patients who did not participate in home administration served as the control group. Video calls with medication dosing were completed on 75 occasions. The drug was administered improperly on 2 of 75 occasions. Spirometry was used before each virtual appointment to assess asthma control. Patients and parents felt confident with video monitoring at the time of injection and felt relieved that they did not have to travel to the hospital for drug administration. Overall, patients felt monitoring devices were easy to use. Both Asthma Control Test and mini Pediatric Asthma Quality of Life Questionnaire scores improved within the first 3 months during home administration.Home administration of biologics with virtual monitoring is feasible and acceptable for patients and their families.Mepolizumab and omalizumab are available for home infusion for children ≥12. There is concern over which patients will be the “right” patient for this treatment method. Indeed, during the height of the coronavirus disease 2019 pandemic, home infusion options would have been beneficial. Although the number of patients with home infusions is small in this study, it does suggest a valuable combination of parameters to follow at home with a portable forced expiratory volume in 1 second meter and asthma control tests. Video supervision and telehealth is a practical option, ensures safety and support for families, and reinforces asthma medication adherence. Telehealth administration of biologics could reduce severe asthma attacks, increase patient satisfaction and convenience, and decrease the burden of coming to the hospital/clinic for the severe child with asthma.

Caregiver-perceived neighborhood safety and pediatric asthma severity: 2017-2018 National Survey of Children's Health.

To examine the association between caregiver-perceived neighborhood safety and pediatric asthma severity using a cross-sectional, nationally representative sample. Using data from the 2017-2018 National Survey of Children's Health, children aged 6-17 years with primary caregiver report of a current asthma diagnosis were included (unweighted N = 3209; weighted N = 3,909,178). Perceived neighborhood safety, asthma severity (mild vs. moderate/severe), demographic, household, and health/behavioral covariate data were collected from primary caregiver report. Poisson regression with robust error variance was used to estimate the association between perceived neighborhood safety and caregiver-reported pediatric asthma severity. Approximately one-third of children studied had moderate/severe asthma. A total of 42% of children with mild asthma and 52% of children with moderate/severe asthma identified as Hispanic or non-Hispanic Black. Nearly 20% of children with mild asthma and 40% of children with moderate/severe asthma were from families living below the federal poverty level (FPL). Children living in neighborhoods perceived by their caregiver to be unsafe had higher prevalence of moderate/severe asthma compared to those in the safest neighborhoods (adjusted prevalence ratio: 1.34; 95% confidence interval: 1.04-1.74). This association was found to be independent of race/ethnicity, household FPL, household smoking, and child's physical activity level after adjusting for covariates. Children living in neighborhoods perceived by their caregiver to be unsafe have higher prevalence of moderate or severe asthma. Further investigation of geographic context and neighborhood characteristics that influence childhood asthma severity may inform public health strategies to reduce asthma burden and improve disease outcomes.

Evaluation of Risk Scores to Predict Pediatric Severe Asthma Exacerbations

Asthma exacerbations commonly lead to unplanned health care utilization and are costly. Early identification of children at increased risk of asthma exacerbations would allow a proactive management approach. We evaluated common asthma risk factors to predict the probability of exacerbation for individual children aged 0-21 years using data from the electronic medical record (EMR). We analyzed longitudinal EMR data for over 3000 participants with asthma seen at Cincinnati Children's Hospital Medical Center over a 7-year period. The study population was divided into 3 age groups: 0-4, 5-11, and 12-21 years. Each age group was divided into a derivation cohort and a validation cohort, which were used to build a risk score model. We predicted risk of exacerbation in the next 12 months, validated the scores by risk stratum, and developed a clinical tool to determine the risk level based on this model. Risk model results were confirmed with validation cohorts by calendar year and age groups. Race, allergic sensitization, and smoke exposure were each important risk factors in the 0-4 age group. Abnormal spirometry and obesity were more sensitive predictors of exacerbation in children >12 years. For each age group, a higher expanded score was associated with a higher predicted probability of an asthma exacerbation in the subsequent year. This asthma exacerbation prediction model, and the associated clinical tool, may assist clinicians in identifying children at high risk for exacerbation that may benefit from more aggressive management and targeted risk mitigation.

Pediatric problematic severe asthma: Recent advances in management.

Problematic severe asthma remains a significant challenge to manage, accounting for the majority of healthcare utilization among children with asthma. The heterogeneity is recognized and the clinical phenotypes of "difficult-to-treat" asthma (DA) and "severe therapy-resistant asthma" (STRA) help to guide management. Recent evidence supports molecular distinctions between these phenotypes and shows poor correlations between peripheral and airway markers of inflammation, especially in STRA. Airway neutrophils in the context of childhood severe asthma have been explored, but their role in disease causation, protection, or as bystanders remain unknown, and thus, treatment implications are unclear. Several novel management strategies, including once-daily maintenance therapy, single-device maintenance and reliever therapy, and novel biological treatments are being increasingly used for DA and STRA. However, pediatric data for efficacy of novel treatments is scarce, and when available, is restricted to adolescents. The aim of this review is to highlight recent advances in objective biomarkers that aid stratification and management of childhood severe asthma and to highlight gaps in pediatric evidence. Specifically, the urgent need for efficacy studies to improve the management of problematic severe asthma in children younger than 12years.

Precision Medicine for Paediatric Severe Asthma: Current Status and Future Direction.

Asthma is a heterogeneous disease, characterised by different phenotypes and endotypes. Precision medicine in asthma refers to the implementation of a targeted therapy for each individual child, based on the identification of treatable traits, including environmental, immunological and genetic factors. Severe asthma in children is associated with increased hospitalisation rates, a lower quality of life, increased healthcare costs and an increased mortality. In the era of new molecular biologics treatments, it is essential to improve deep phenotyping of children with severe asthma in order to deliver the most effective treatment to each individual child. In this review, we discuss the personalised approach to the assessment and management of severe asthma. We explore the indications and use of the currently licensed biologics, as well as the potential of other emerging treatments.

Adverse Childhood Experiences and Association With Pediatric Asthma Severity in the 2016-2017 National Survey of Children's Health.

Prior studies have found that adverse childhood experiences (ACEs) are associated with asthma prevalence and onset, presumably related to stress and increased inflammation. We hypothesized that ACEs may be associated with asthma severity as well. We studied the 2016-2017 US National Survey of Children's Health dataset to explore the relationship between ACEs and pediatric asthma severity. We analyzed children ages 0 to 17 years old who had current caregiver-reported asthma diagnosed by a healthcare provider. We reported descriptive characteristics using chi-square analysis of variance (ANOVA) and used multivariable regression analysis to assess the relationship of cumulative and individual ACEs with asthma severity. Survey sampling weights and SAS survey procedures were implemented to produce nationally representative results. Our analysis included 3691 children, representing a population of 5,465,926. Unadjusted analysis demonstrated that ACEs - particularly household economic hardship, parent/guardian served time in jail, witnessed household violence, or victim/witness of neighborhood violence - were each associated with higher odds of moderate/severe caregiver-reported asthma. After controlling for confounders possibly associated with both exposure (ACEs) and outcome (asthma severity), children who witnessed parent/adult violence had higher adjusted odds of caregiver-reported moderate/severe asthma. (1.67, confidence interval 1.05-2.64, P = .03) CONCLUSIONS: Intrafamilial witnessed household violence is significantly associated with caregiver-reported moderate/severe asthma.

Single Nucleotide Polymorphisms (SNPs) in PRKG1 & SPATA13-AS1 are associated with bronchodilator response: a pilot study during acute asthma exacerbations in African American children.

Inhaled bronchodilators are the first-line treatment for asthma exacerbations, but individual bronchodilator response (BDR) varies by race and ethnicity. Studies have examined BDR's genetic underpinnings, but many did not include children or were not conducted during an asthma exacerbation. This pilot study tested single-nucleotide polymorphisms' (SNPs') association with pediatric African American BDR during an acute asthma exacerbation. This was a study of pediatric asthma patients in the age group 2-18 years treated in the emergency department for an asthma exacerbation. We measured BDR before and after inhaled bronchodilator treatments using both the Pediatric Asthma Severity Score (PASS) and asthma severity score. We collected genomic DNA and examined whether 21 candidate SNPs from a review of the literature were associated with BDR using crude odds ratios (OR) and adjusted analysis. The final sample population was 53 children, with an average age of 7.2 years. The average initial PASS score (scale of ascending severity from 0 to 6) was 2.5. After adjusting for BMI, age category, gender and smoke exposure, rs912142 was associated with decreased odds of having low BDR (OR, 0.20; 95% confidence interval (CI), 0.02-0.92), and rs7081864 and rs7903366 were associated with decreased odds of having high BDR (OR, 0.097; 95% CI, 0.009-0.62). We found three SNPs significantly associated with pediatric African American BDR that provide information regarding a child's potential response to emergency asthma exacerbation treatment. Once validated in larger studies, such information could guide pharmacogenomic evidence-based emergency asthma treatment to improve patient outcomes.

Sex differences in the relationship of sleep-disordered breathing and asthma control among children with severe asthma

Objective Children with severe asthma are underrepresented in studies of the relationship of sleep-disordered breathing (SDB) and asthma and little is known about sex differences of these relationships. We sought to determine the relationship of SDB with asthma control and lung function among boys and girls within a pediatric severe asthma cohort. Methods Patients attending clinic visits at the Boston Children’s Hospital Pediatric Severe Asthma Program completed the Pediatric Sleep Questionnaire (PSQ), Asthma Control Test (ACT) and Spirometry. The prevalence of SDB was defined as a PSQ score >0.33. We analyzed the association between PSQ score and both ACT score and spirometry values in mixed effect models, testing interactions for age and sex. Results Among 37 subjects, mean age was 11.8 years (4.4) and 23 (62.2%) were male, the prevalence of SDB was 43.2% (16/37). Including all 80 observations, there was a moderate negative correlation between PSQ and ACT scores (r=-0.46, p < 0.001). Multivariable linear regression models revealed a significant sex interaction with PSQ on asthma control (p = 0.003), such that for each 0.10 point increase in PSQ there was a 1.88 point decrease in ACT score for females but only 0.21 point decrease in ACT score for males. A positive PSQ screen was associated with a 9.44 point (CI 5.54, 13.34, p < 0.001) lower ACT score for females and a 3.22 point (CI 0.56, 5.88, p = 0.02) lower score for males. Conclusions SDB is common among children with severe asthma. Among children with severe asthma, SDB in girls portends to significantly worse asthma control than boys. Supplemental data for this article is available online at https://doi.org/10.1080/02770903.2021.1897838.

Evaluating post-bronchodilator response in well-controlled paediatric severe asthma using hyperpolarised 129Xe-MRI: A pilot study.

Pulmonary function tests (PFTs) are the main objective measures used to assess asthma in children. However, PFTs provide a global measure of lung function. Hyperpolarised xenon-129 magnetic resonance imaging (129Xe-MRI) can assess lung function spatially. This cross-sectional cohort study aimed to evaluate the use of 129Xe-MRI in detecting ventilation abnormalities in children with well-controlled severe asthma pre- and post-bronchodilator (BD). Six healthy children (aged 11±3) and six with well-controlled severe asthma (14±1) underwent spirometry, multiple breath washout (MBW), and 129Xe-MRI. These tests were repeated post-BD in the asthma cohort. Image analysis was performed in MATLAB. Wilcoxon signed-rank test, repeated measures analysis of variance (ANOVA), and Spearman's rank correlation coefficient were used for statistical analysis. A significantly higher number of ventilation defects were found in the asthma cohort pre-BD compared to the healthy participants and post-BD within the asthma cohort (p=0.02 and 0.01). A greater number of wedge-shaped defects were detected in the asthma cohort pre-BD compared to healthy participants and post-BD within the asthma cohort (p=0.01 and 0.008, respectively). 129Xe ventilation defect percentage (VDP) and coefficient of variation (CoV) were significantly higher in the asthma cohort pre-BD compared to the healthy cohort (p=0.006 for both). VDP and CoV were reduced significantly post-BD in the asthma cohort, to a level where there was no longer a significant difference between the two cohorts. 129Xe-MRI is a sensitive marker of ventilation inhomogeneity in paediatric severe asthma and may potentially be used as a biomarker to assess disease progression and therapeutic response.

Characterization of severe asthma in the pediatric population.

Relationship between the causal mechanisms of pediatric severe asthma and severity of symptoms would be helpful for developing personalized strategies for treatment and prevention. For this study, 698 medical histories of asthmatics between 6 and 18 years of age were reviewed in a period of 2 years. Variables analyzed were: age, sex, ethnicity, perinatological history, allergy history, asthma predictive index (API), exposure to tobacco, heavy traffic or epithelium, lung function, age of onset of symptoms, hospitalization admissions/PICU, systemic corticosteroids, daily symptoms control, device prescribe for daily control, and adherence. A total of 86 children with severe asthma were included (12.3%). Mean age 13.3 +/- 1.86 years, sex ratio1:1, mean age of symptom onset 2.765 +/- 3.06 years, mean IgE 1076.18KU / L +/- 1136, mean eosinophils 604c / mcl +/- 511.9, mean of FEV1 93.15% +/- 16.3. Evidently, 70 children (81.4%) had positive API, 68 (79.1%) rhinitis, 34 (39.5%) atopic dermatitis. 73 (83.9%) sensitized to inhalants and 56 (65.1%) to dermatophagoides, 39 (45.3%) passive smokers, 19 (22.1%) exposure to heavy traffic; 55 (64%) showed symptoms with exercise, 35 (40.7%) had audible wheezing. The mean systemic corticosteroid cycles/year was 3.63 +/- 3.23, mean PICU admissions 0.36 +/- 0.83, mean hospital admissions 4.31 +/- 5.3, average emergency room visits/year 19.44 +/- 16.28. 38 (56.7%) had good adherence, 44 (51%) used an MDI device and 39 (45.3%) used dry powder. Children with severe asthma meet the following criteria: premature, positive API, rhinitis, atopic dermatitis, high IgE, eosinophilia, passive smokers, exposure to heavy traffic, decreased lung function, and low adherence to controller medication.

Methylprednisolone, dexamethasone or hydrocortisone for acute severe pediatric asthma: does it matter?

Objective Various intravenous (IV) corticosteroids are available for acute severe asthma (ASA) treatment. The choice of IV corticosteroids varies broadly and depends on institution, country, or physician preferences. In this study, we compared the efficacy of IV methylprednisolone, hydrocortisone and dexamethasone in ASA treatment during pediatric intensive care unit (PICU) admission. Methods The study was a prospective randomized clinical trial. We enrolled patients of 1–21 years after they were admitted to the PICU requiring continuous beta-2 agonist treatment. Patients were randomized into three groups: Group A: IV Methylprednisolone, Group B: IV Hydrocortisone and Group C: IV Dexamethasone. The primary outcomes measured were durations of beta-2 agonist continuous nebulization treatment. Secondary outcomes, included PICU and hospital length of stay (LOS), pediatric asthma severity score (PASS), need for mechanical ventilation and maximum dose of beta-2 agonist treatment. Results 61 patients were included in the analysis. 22 patients recruited in Group A, 20 in group B and 19 group C. Median durations of beta-2-agonist treatment were 23 h (QR 16–38) for methylprednisolone, 27 h (QR 16–40) for hydrocortisone, and 32 h (QR 16–48) for dexamethasone (p = 0.90). There was no difference in PICU LOS, hospital LOS, PASS score, B2 agonist maximum dose, or need for ventilation support. Conclusions The use of IV methylprednisolone, hydrocortisone, and dexamethasone have equivalent efficacy when used at the appropriate doses. Studies with larger cohorts are needed to compare the effectiveness of IV corticosteroids in the management of ASA in the PICU setting.

High-flow nasal cannula and bilevel positive airway pressure for pediatric status asthmaticus: a single center, retrospective descriptive and comparative cohort study

Introduction We aimed to describe patient characteristics and clinical outcomes for children hospitalized for status asthmaticus (SA) receiving high-flow nasal cannula (HFNC) or bilevel positive airway pressure (BiPAP). Methods We performed a single center, retrospective cohort study among 39 children admitted for SA aged 5–17 years from January 2016 to May 2019 to a quaternary pediatric intensive care unit (PICU). Cohorts were defined by BiPAP versus HFNC exposure and assessed to determine if differences existed in demographics, anthropometrics, comorbidities, asthma severity indices, historical factors, duration of noninvasive ventilation, and asthma-related clinical outcomes (i.e. length of stay, mechanical ventilation rates, exposure to concurrent sedatives/anxiolysis, and rate of adjunctive therapy exposure). Results Thirty-three percent (n = 13) received HFNC (33%) and 67% (n = 26) BiPAP. Children receiving BiPAP had greater age (10.9 ± 3.7 vs. 6.8 ± 2.2 years, P < 0.01), asthma severity (proportion with severe NHLBI classification: 38% vs. 0%, P < 0.01; median pediatric asthma severity score: 13[12,14] vs. 10[9,12], P < 0.01), previous PICU admissions (62% vs. 15%, P = 0.01), frequency of prescribed anxiolysis/sedation (42% vs. 8%, P = 0.02), and median duration of continuous albuterol (1.7[1,3.1] vs. 0.9[0.7,1.6] days, P = 0.03) compared to those on HFNC. Those on HFNC more commonly were treated comorbid bacterial pneumonia (69% vs. 19%, P < 0.01). No differences in NIV duration, mortality, mechanical ventilation rates, or LOS were observed. Conclusions Our data suggest a trial of BiPAP or HFNC appears well tolerated in children with SA. Prospective trials are needed to establish modality superiority and identify patient or clinical characteristics that prompt use of HFNC over BiPAP.

Developing and evaluating a pediatric asthma severity computable phenotype derived from electronic health records

Extensive data available in electronic health records (EHRs) have the potential to improve asthma care and understanding of factors influencing asthma outcomes. However, this work can be accomplished only when the EHR data allow for accurate measures of severity, which at present are complex and inconsistent. Our aims were to create and evaluate a standardized pediatric asthma severity phenotype based in clinical asthma guidelines for use in EHR-based health initiatives and studies and also to examine the presence and absence of these data in relation to patient characteristics. We developed an asthma severity computable phenotype and compared the concordance of different severity components contributing to the phenotype to trends in the literature. We used multivariable logistic regression to assess the presence of EHR data relevant to asthma severity. The asthma severity computable phenotype performs as expected in comparison with national statistics and the literature. Severity classification for a child is maximized when based on the long-term medication regimen component and minimized when based only on the symptom data component. Use of the severity phenotype results in better, clinically grounded classification. Children for whom severity could be ascertained from these EHR data were more likely to be seen for asthma in the outpatient setting and less likely to be older or Hispanic. Black children were less likely to have lung function testing data present. We developed a pragmatic computable phenotype for pediatric asthma severity that is transportable to other EHRs.

Asthma control and psychological health in pediatric severe asthma.

Psychological comorbidities have been associated with asthma in adults and children, but have not been studied in a population of children with severe asthma. The aim of this study was to test the hypothesis that symptoms of anxiety or depression are highly prevalent in pediatric severe asthma and negatively effects asthma control. Longitudinal assessments of anxiety or depression symptoms (Patient Health Questionnaire-4 [PHQ-4]), asthma control (Asthma Control Test [ACT]), and lung function were performed in a single-center pediatric severe asthma clinic. Participant data were collected during routine clinical care. Primary outcomes were ACT and forced expiratory volume in 1 s per forced vital capacity (FEV1/FVC). Among 43 subjects (with total 93 observations), 58.1% reported at least one anxious or depressive symptom and 18.6% had a PHQ-4 more than 2, the threshold for an abnormal test result. After adjusting for age, sex, race, and asthma medication step, there was a significant reduction in ACT for girls with PHQ-4 more than 2 (adjusted mean [SE] ACT for PHQ-4 > 2: 13.64 [0.59], ACT for PHQ-4 ≤ 2: 20.64 [1.25], p = .02) but not boys. Moreover, there was a significant differential effect of mental health impairment for girls than boys. ACT for girls with PHQ more than 2: 13.64 (0.59) compared with boys with PHQ-4 more than 2: 17.82 (0.95), adjusted mean difference ACT by sex = 4.18 points; 95% confidence interval, 0.63-7.73; p = .033. In adjusted models, there was no association between PHQ-4 more than 2 and FEV1/FVC. Symptoms of anxiety and depression are common. In children with severe asthma, a PHQ-4 score more than 2 is associated with worse asthma symptom control in girls, but not boys.

First analysis of the Severe Paediatric Asthma Collaborative in Europe registry.

New biologics are being continually developed for paediatric asthma, but it is unclear whether there are sufficient numbers of children in Europe with severe asthma and poor control to recruit to trials needed for registration. To address these questions, the European Respiratory Society funded the Severe Paediatric Asthma Collaborative in Europe (SPACE), a severe asthma registry. We report the first analysis of the SPACE registry, which includes data from 10 paediatric respiratory centres across Europe.Data from 80 children with a clinical diagnosis of severe asthma who were receiving both high-dose inhaled corticosteroid and long-acting β2-agonist were entered into the registry between January 2019 and January 2020. Suboptimal control was defined by either asthma control test, or Global Initiative for Asthma criteria, or ≥2 severe exacerbations in the previous 12 months, or a combination.Overall, 62 out of 80 (77%) children had suboptimal asthma control, of whom 29 were not prescribed a biologic. However, in 24 there was an option for starting a licensed biologic. 33 children with suboptimal control were prescribed a biologic (omalizumab (n=24), or mepolizumab (n=7), or dupilumab (n=2)), and for 29 there was an option to switch to a different biologic.We conclude that the SPACE registry provides data that will support the planning of studies of asthma biologics. Not all children on biologics achieve good asthma control, and there is need for new trial designs addressing biologic switching.

Pediatric Severe Asthma in the Era of Biologic Treatments.

Pediatric Severe Asthma in the Era of Biologic Treatments.

Screening Social Determinants of Health in a Multidisciplinary Severe Asthma Clinical Program.

Patients with 2 or more ED visits in the past 6 months or 2 or more hospitalizations in the previous year were recruited to Rady Children's Hospital Severe Asthma Clinic. A multidisciplinary team evaluated each patient systematically. A subset of patients on capitated Medicaid insurance plans also had a comprehensive asthma home visit with community health workers as part of the Community Approach to Severe Asthma (CASA) program. A significant reduction in ED visits (75%, P < 0.001) and hospitalization days (73%, P < 0.001) was demonstrated in 74 Severe Asthma Clinic participants with 1 year of pre-/postdata to analyze. In a subset of 12 patients in the CASA program, further reductions in ED visits (90%, P = 0.002) were also demonstrated. Basic needs, including shelter, food, and assistance with utilities, were the most common domain of SDH identified and addressed in CASA participants. We demonstrate that a novel pediatric severe asthma clinic with a multidisciplinary approach, including actively addressing SDH, is associated with decreasing health care utilization.

Intravenous methylprednisolone versus intravenous methylprednisolone combined with inhaled budesonide in acute severe pediatric asthma

Introduction Corticosteroids are important part of acute severe asthma (ASA) management in pediatric intensive care units. Few studies look at the efficacy of inhaled corticosteroids (ICS) in critical care settings. We aimed to investigate the potential beneficial effects of ICS when added to intravenous corticosteroids in pediatric patients with ASA admitted to the pediatric intensive care unit (PICU) Methods This was a randomized controlled trial involving pediatric patients aged 1–21 years admitted to PICU with ASA. Patients were randomized into 2 groups using block randomization. Patients in Group A received intravenous methylprednisolone (2 mg/kg/day) alone and patients in Group B received intravenous methylprednisolone (2 mg/kg/day) plus budesonide nebulization (0.5 mg every 12 h). Main outcomes were duration of continuous albuterol treatment, PICU and hospital length of stay (LOS), and need and duration of respiratory support. Kruskal-Wallis and Chi-square tests were used for statistical analysis, in which a p-value < 0.05 was considered statistically significant. Results Duration of continuous albuterol treatment was not different between the 2 groups median/(QR), 30/(18–51) vs. 25/(14–49). (p = 0.38) PICU and hospital LOS between the 2 groups was similar, median/(QR), 44/(30–64) vs. 46/(30–62), (p = 0.75) and 78/(65–95) vs.72/(58–92), (p = 0.19). Number of patients requiring respiratory support was 22(58%) in Group A and 25(64%) in Group B (p = 0.19). Conclusions In critically ill children with ASA, intravenous methylprednisolone combined with inhaled budesonide did not shorten the duration of continuous albuterol inhalation treatment, the PICU and hospital LOS, and the need for respiratory support.