Advanced Lung Function Testing in Children/Adolescents With Asthma

A major problem in pediatric asthma is getting objective, reliable data about how a child's lungs function.  Much of the testing available in children requires exceptional breathing efforts that force a child's lungs to perform in a somewhat artificial way.  These tests include spirometry, a highly researched and standardized test that is used to assess asthma control.  However, it is often difficult to perform in young children, fails to properly identify "small airways disease" in many cases, and is often too insensitive to diagnose asthma in some children.  Impulse oscillometry offers a solution to these problems by providing an effort independent, highly sensitive and reproducible test which can be performed in very young children (often as young as 3 years).  Moreover, it is the test of choice to identify the location of the problem in many children with asthma  --  the "small airways".  A growing body of research including the reference below suggest that impulse oscillometry (IOS) should have greater use in a pediatric asthma practice.  Dr. Susarla

Peripheral airway impairment measured by oscillometry predicts loss of asthma control in children.

Shi Y, Aledia AS, Galant SP, George SC.

Source

Department of Biomedical Engineering, University of California, Irvine, Calif.

Abstract

BACKGROUND:

We previously showed that impulse oscillometry (IOS) indices of peripheral airway function are associated with asthma control inchildren. However, little data exist on whether dysfunction in the peripheral airways can predict loss of asthma control.

OBJECTIVE:

We sought to determine the utility of peripheral airway impairment, as measured by IOS, in predicting loss of asthma control inchildren.

METHODS:

Fifty-four children (age, 7-17 years) with controlled asthma were enrolled in the study. Spirometric and IOS indices of airway function were obtained at baseline and at a follow-up visit 8 to 12 weeks later. Physicians who were blinded to the IOS measurements assessed asthma control (National Asthma Education and Prevention Program guidelines) on both visits and prescribed no medication change between visits.

RESULTS:

Thirty-eight (70%) patients maintained asthma control between 2 visits (group C-C), and 16 patients had asthma that became uncontrolled on the follow-up visit (group C-UC). There was no difference in baseline spirometric results between the C-C and C-UC groups, except for FEV(1)/forced vital capacity ratio (86% vs 82%, respectively; P < .01). Baseline IOS results, including resistance of the respiratory system at 5 Hz (R5; 6.4 vs 4.3 cm H(2)O · L(-1) · s), frequency dependence of resistance (difference of R5 and resistance of the respiratory system at 20 Hz [R5-20]; 2.0 vs 0.7 cm H(2)O · L(-1) · s), and reactance area (13.1 vs 4.1 cm H(2)O · L(-1)), of group C-UC were significantly higher than those of group C-C (P < .01). Receiver operating characteristic analysis showed baseline R5-20 and reactance area effectively predicted asthma control status at the follow-up visit (area under the curve, 0.91 and 0.90).

CONCLUSION:

Children with controlled asthma who have increased peripheral airway IOS indices are at risk of losing asthma control.

J Allergy Clin Immunol. 2012 Nov 10. pii: S0091-6749(12)01544-8. doi: 10.1016/j.jaci.2012.09.022.

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Health Tip: Does Asthma Affect Your Sleep?

Take medications as your doctor prescribes

By Diana Kohnle

Friday, January 25, 2013

(HealthDay News) -- Asthma can affect your sleep, as symptoms often worsen at night.

The National Sleep Foundation offers this advice to help control asthma and enjoy a better night's sleep:

• Take all medications as prescribed, at the same time each day.
• Use a peak flow meter regularly to monitor changes in lung function.
• Learn what your asthma triggers are, and take steps to avoid those triggers.
• Get plenty of sleep each night.
• Ask your doctor about the potential benefits of an anti-inflammatory medication.

HealthDay

Marfan Syndrome and Pulmonary Problems - Asthma, pneumothorax, apnea!

Sleep apnea is very common in marfan syndrome. See a sleep specialist for diagnosis and treatment. JR

Pulmonary Management

Pulmonary issues are not a major criteria for people with Marfan syndrome however many people with Marfan syndrome have serious pulmonary symptoms such pneumothorax, restrictive lung diseases, chest wall deformaties and sleep apnea.

Overview

Q & A

• Is it possible to confuse lung symptoms of Marfan syndrome with asthma and incorrectly make an asthma diagnosis?
• What are the pulmonary function tests needed to evaluate lung function In people with Marfan syndrome?
• What is the appropriate management of restrictive lung disease? Is it different for people with Marfan syndrome?
• Is there a recommendation regarding chemical versus mechanical scarring for the treatment of repeated collapsed lungs (spontaneous pneumothorax)?

   

OVERVIEW 

Because fibrillin is expressed in the lung and is associated with elastin there, it is thought to affect both lung development and homeostasis. One possible effect of fibrillin-1 deficiency is pneumothorax. The symptoms of this are shortness of breath, dry cough or an acute onset of pleuritic chest pain. People with Marfan syndrome are at-risk of pneumothorax although they might not smoke. For them, it can be recurrent, present in both lungs and frequently associated with emphysema.

"Small" pneumothorax is treated in the hospital with supplemental oxygen. “Moderate to large” pneumothorax is treated by chest tube evacuation and possibly pleurodesis if necessary.

Restrictive lung disease occurs in more than 70 percent of people with Marfan syndrome. Often, this is due to severe pectus abnormalities and/or scoliosis. In either case, the result is that the chest cannot expand fully. The primary symptom is shortness of breath during exertion.

Emphysema, which results from loss of alveolar walls and enlargement of the air spaces, causes airway obstruction and inflammation. Approximately 10-15 percent of people with Marfan syndrome have emphysema, but it is probably under-diagnosed. It is the structural predisposition of the lungs in people with Marfan syndrome that is probably to blame. Symptoms include shortness of breath during activity, frequent bronchitis (often as a result of common colds or viruses settling in the chest) and low blood oxygen. The diagnosis can be confirmed by a chest x-ray, CT scan, pulmonary function test or arterial blood test. The conventional treatment for emphysema is supplemental oxygen, bronchodilator and aggressive treatment of infections. Research is underway on other pharmaceutical agents that may be useful.

Asthma, which is very common in the general population, is also present in the Marfan community.  Respiratory specialists should coordinate care with the other Marfan specialists because the conventional treatments for asthma (beta-agonists) have the opposite effect of beta-blockers which are prescribed to many people with Marfan syndrome.

Pectus deformaties can influence pulmonary function.  While surgery can correct the pectus, there is no evidence that pulmonary function will improve. Scoliosis is typically corrected early, but it can be progressive and cause more problems with pulmonary restriction. Serial pulmonary function tests can determine the progress of the lung restriction. Lung dysfunction can be worse if another airway disease, such as asthma or emphysema, is present. Supplemental oxygen and pulmonary rehabilitation are recommended to improve the quality of life.

Some people with Marfan syndrome have sleep apnea, which can have a number of causes.  One seems to be laxity of the connective tissues of the airways, which then further relax during sleep and cause partial obstruction to air flow.  Often persons with sleep apnea are overweight, but thin persons with Marfan syndrome are also at risk. 

Q & A

Is it possible to confuse lung symptoms of Marfan syndrome with asthma and incorrectly makde an asthma diagnosis?This is often a problem because people who are first diagnosed with Marfan syndrome are frequently children or young adults, an age group in which asthma is a common cause of shortness of breath. Making the correct diagnosis of asthma or another lung problem is important because the beta blocker medication often prescribed to minimize aortic enlargement in people with Marfan syndrome may complicate asthma treatment or make the asthma worse. If the asthma diagnosis is questionable, other explanations for the shortness of breath should be explored.

What are the pulmonary function tests needed to evaluate lung function in people with Marfan syndrome?In order to rule out asthma, emphysema and restrictive lung disease, people should typically have tests including: routine spirometry with and without bronchodilators, lung volume measurements and a diffusing capacity study. If asthma is a strong possibility, provocative testing should be performed. If there is any evidence of restrictive lung disease, maximal inspiratory and expiratory flows should be tested. When sleep apnea is a concern, measurement of upper airway resistance during sleep is a required part of any study for a person with Marfan syndrome.

What is the appropriate management of restrictive lung disease?  Is it difference for people with Marfan syndrome?Restrictive lung disease is an inability of the lung to expand adequately in order to take in a full breath. This can be caused by either structural abnormalities of the thoracic cage, such as pectus abnormalities or scoliosis, weak respiratory muscles or lung scarring. For people with Marfan syndrome, the most common causes are chest wall structure or function. Lung scarring is unusual in people with Marfan syndrome. Therefore, the first task for the physician is to determine whether it is a skeletal, muscle or lung problem. This can be accomplished with appropriate pulmonary function testing and a chest CT. Unfortunately, sometimes the degree of restriction does not correlate with the extent of breathlessness or functional impairment. Additionally, apart from early correction of scoliosis, which does improve respiratory function, other surgical measures to normalize the dimensions of the thoracic cage do not always help. Thus, choices about interventions should be individualized to address cosmetic and functional concerns.

Is there a recommendation regarding chemical versus mechanical scarring for the treatment of repeated spontaneous pneumothorax?Physicians who care for people with Marfan syndrome should assume that all patients will eventually require aortic replacement. Therefore, any thoracic procedure should respect the anatomic mandates of future aortic surgery. If supplemental oxygen or chest tube insertion does not successfully treat the pneumothorax, doctors may recommend pleurodesis, which involves "scarring" the lung surface to attach the lung to the chest wall. The best pleurodesis method for individuals with Marfan syndrome is mechanical rather than chemical pleurodesis, as the former makes cardiac surgery easier.

http://www.marfan.org/marfan/2366/Pulmonary-Management

Junk food linked to asthma and eczema in children

Asthma is a complex chronic medical condition with many genetic and environmental contributors.  Although food exposure does not suggest cause, research like this is certainly relevant and deserves attention.  Dr. Susarla

The high saturated fat levels in food such as burgers lower children's immune systems, it is believed.

A research project involving more than 50 countries found that teenagers who ate junk food three times a week or more were 39 per cent more likely to get severe asthma. Younger children were 27 per cent more at risk.

Both were also more prone to the eye condition rhinoconjunctivitis, according to The Sun newspaper

But just three weekly portions of fruit and vegetables could cut that risk by 14 per cent in the younger group and 11 per cent among the teens, it is believed.

Researchers from New Zealand's Auckland University looked at the diets of 181,000 youngsters aged six to seven and 319,000 aged 13-14.

The scientists then asked if the children had allergy symptoms.

They wrote in the journal Thorax, where the study is published: "Fast food may be contributing to increasing asthma, rhinoconjunctivitis and eczema.

"Regular consumption of fruit and vegetables is likely to protect against these diseases."

In the UK alone 1.1 million children already suffer with asthma and one in five get eczema.

The team of researchers warn that their results do not prove cause and effect.

Read article here.

Asthma, Insomnia Make Each Other Worse

One of the reasons asthma can present insidiously is it may manifest more at night.   You may not awaken with obvious symptoms of breathing problems, but sleep is disrupted enough to affect daytime function.  This is a problem I see frequently in children and adolescents.  Parents are often surprised to see how effective treating asthma can be at improving sleep quality.  Dr. Susarla

Asthma, Insomnia Make Each Other Worse

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If you experience breathing problems, you might need to actively treat those symptoms, or you could find that you’re being kept awake at night. According to a recent Swedish study, asthma sufferers are far more likely to suffer from insomnia than others.

The trial was a large one, with data collected from 25,610 adults in four Swedish cities. The participants were given a questionnaire that asked questions about insomnia, asthma, rhinitis, weight, height, tobacco use, and physical activity. For the purposes of the study, the researchers defined asthma as taking current medication for the condition or experiencing at least one asthma attack during the last 12 months. Of the 25,610 participants, 1,830 people were defined as being asthmatics. Here’s what the researchers found when they compared asthma and sleep quality:

• The prevalence of insomnia symptoms was significantly higher among asthmatics than non-asthmatics

• For those with nasal congestion and asthma, insomnia symptoms were worse

• The risk of insomnia increased with the severity of asthma

• Asthmatics who had three or more symptoms were more than twice as likely to suffer from insomnia

• Nasal congestion, obesity, and smoking also increased the risk of insomnia

Insomnia is a common problem among asthmatics. The researchers concluded by saying that asthmatics should treat their symptoms, including nasal congestion, to make sure that they get a good night’s sleep. Other lifestyle factors, like smoking and obesity, will also increase your chances of suffering from insomnia if you’re an asthmatic.

Read article here.

Can Eating Your Veggies Prevent Asthma?

This is an interesting study, especially for patients/parents who always ask me what can be done "naturally" to prevent asthma.  As always, it is not clear if there is cause and effect.  However, reducing airway hyperresponsiveness, or the tendency for airway to constrict, is on the main goals of asthma therapy.  Dr. Susarla.

Low vegetable intake is associated with allergic asthma and moderate-to-severe airway hyperresponsiveness

Abstract

Background

In recent decades, children's diet quality has changed and asthma prevalence has increased, although it remains unclear if these events are associated.

Objective

To examine children's total and component diet quality and asthma and airway hyperresponsiveness (AHR), a proxy for asthma severity.

Methods

Food frequency questionnaires adapted from the Nurses' Health Study and supplemented with foods whose nutrients which have garnered interest of late in relation to asthma were administered. From these data, diet quality scores (total and component), based on the Youth Healthy Eating Index (YHEI adapted) were developed. Asthma assessments were performed by pediatric allergists and classified by atopic status: Allergic asthma (≥1 positive skin prick test to common allergens >3 mm compared to negative control) versus non-allergic asthma (negative skin prick test). AHR was assessed via the Cockcroft technique. Participants included 270 boys (30% with asthma) and 206 girls (33% with asthma) involved in the 1995 Manitoba Prospective Cohort Study nested case-control study. Logistic regression was used to examine associations between diet quality and asthma, and multinomial logistic regression was used to examine associations between diet quality and AHR.

Results

Four hundred seventy six children (56.7% boys) were seen at 12.6 ± 0.5 years. Asthma and AHR prevalence were 26.2 and 53.8%, respectively. In fully adjusted models, high vegetable intake was protective against allergic asthma (OR 0.49; 95% CI 0.29–0.84; P < 0.009) and moderate/severe AHR (OR 0.58; 0.37–0.91; P < 0.019).

Conclusions

Vegetable intake is inversely associated with allergic asthma and moderate/severe AHR. Pediatr Pulmonol. 2012; 47:1159–1169. © 2012 Wiley Periodicals, Inc.

Read abstract here.

Does IVF Increase Risk for Asthma?

The cause of this association is not clear, but premature infants especially under 30 weeks gestation seem to be more prone to develop asthma symptoms like recurrent wheezing.  Dr. Susarla

Fertility treatment 'asthma link'

Continue reading the main story

In a study of more than 13,000 UK children, five-years-olds were about twice as likely to have asthma if they were not conceived naturally.Children born after fertility treatments, such as IVF, may have a slightly higher chance of developing asthma, research suggests.

The children were also more likely to need medication, which could be an indication of more severe asthma.

The findings were published in the journal Human Reproduction.

The researchers, at the Universities of Oxford and Essex, analysed data from children born between 2000 and 2002.

Researcher Dr Claire Carson said 15% of all the children in the study had had asthma at the age of five, but this proportion had risen to 24% among the 104 of them born through assisted-reproduction technologies.

She said it was interesting that the pattern had emerged, but far too soon to say if IVF treatment resulted in higher rates of asthma. Other explanations, such as genetics, may explain the association.

Dr Carson told the BBC that parents should not be put off IVF.

"Assisted reproduction technologies offer a chance to become a parent when there isn't another option," she said.

"For the majority of children asthma is quite manageable."

Malayka Rahman, from the charity Asthma UK, said: "This study suggests that there might be an association between IVF treatment and asthma developing in children, but the sample size for this study is small and currently the research in this area generally is not conclusive.

"Those considering IVF should speak to their GP about the benefits and health risks in order to make an informed decision."

Read article here.

Childhood Obesity Associated with Asthma

Asthma associated with childhood obesity may be unique in other ways since it is often harder to treat. Dr. Susarla

Research Supports Role of BMI in Incident Asthma in Children

(HealthDay News) – Overweight and obese children have a significantly increased risk of incident asthma, with evidence of a dose-response effect of elevated body mass index (BMI), according to a meta-analysis published online Nov. 12 in Obesity Reviews.

Y.C. Chen, from the National Taiwan University in Taipei, and colleagues reviewed the literature and conducted a meta-analysis using a prospective cohort of pediatric studies that analyzed age- and sex-specific BMI (as a measure of childhood overweight) and the primary outcome of incident asthma.

Based on data from six studies meeting the inclusion criteria, the researchers found that, compared with non-overweight children, overweight children had increased risks of incident asthma (relative risk [RR], 1.19). When comparing obese vs. non-obese children, the association was further elevated (RR, 2.02). There was a significant dose-responsiveness of elevated BMI on asthma incidence (P for trend, 0.004). In addition, there was a gender difference noted, with obese boys exhibiting a significantly larger effect than obese girls (RR, boys: 2.47; girls: 1.25), also with a significant dose-dependent effect.

"Our findings support the impact of childhood obesity on incident asthma, and provide information to compel obese children to lose weight," the authors write. "Policy makers for children's health and parents should pay more attention on preventing obesity-associated risk and environments."

Read article here.

Asthma Patients Often Depressed

Adjustment to a chronic disease can be difficult.    This study suggests that patients with asthma should be closely monitored for depressive symptoms.  Every effort should be made to reduce the impact of asthma on daily life.

Asthma Patients Often Depressed

ANAHEIM, Calif. -- Depression and asthma appear to go hand in hand, even in patients whose asthma is relatively mild and who report generally good health, a researcher said here.

Analysis of some 13,000 participants in the Cooper Institute Longitudinal Study indicated that a diagnosis of asthma was a risk factor for reports of significant current depressive symptoms with an odds ratio of 1.41 (95% CI 1.16 to 1.65, P<0.001) after adjusting for asthma severity and self-assessment of overall health status.

Asthma and a previous history of depression also were significantly associated, with an odds ratio of 1.65 (95% CI 1.40 to 1.90,P<0.001), Tim Trojan, MD, of the University of Texas Southwestern Medical Center in Dallas, told attendees at the American College of Allergy, Asthma, and Immunology annual meeting.

Associations between asthma and depression have been reported before, Trojan explained, but those studies could not rule out the possibility that patients were simply sad about feeling sick with asthma.

Consequently, he and his colleagues utilized records from the Cooper Institute Longitudinal Study, begun in 1970 by the institute's founder, Kenneth Cooper, MD, the aerobics advocate. The database has unusually detailed information on patients including spirometry values, scores on the Center for Epidemiologic Studies Depression Scale (CES-D), medical history, body mass index, and lifestyle factors such as smoking and drinking status, as well as standard demographics.

Trojan and colleagues analyzed data on 12,944 study participants, including 1,169 with a diagnosis of asthma. Of these, only 187 were on controller medications, suggesting that the sample mostly included people with relatively mild asthma.

About 81% of the overall sample indicated that their health status was good or excellent, as opposed to fair or poor. Current depressive symptoms (CES-D scores of 10 or higher) were present in 11% and a past history of depression in 14%.

Bivariate analyses indicated that the risk of depressive symptoms was significantly increased, not only by a diagnosis of asthma, but also by female gender, hypertension, and current smoking. It was significantly decreased in nonwhites, those with more than a high school education, age older than 50, and current drinking.

Multivariate analysis produced the odds ratio 0f 1.40 for depressive symptoms with an asthma diagnosis. When expressed as an r² correlation coefficient, the value of 0.119 suggested that the relationship was only modest at best, Trojan said.

But a classification analysis based on the association correctly categorized 89.5% of study participants, he said.

The same held true for the association between asthma and depression history. The r² correlation coefficient was 0.110, but the classification analysis categorized 85.7% of participants correctly, Trojan said.

He noted that the study had a number of limitations including the fact that some of the data such as depression history and smoking and drinking status were self-reported, and the Cooper Institute database consists of people who are "mostly white and mostly healthy." Trojan added that they are probably relatively affluent as well, although income data are not collected.

Nevertheless, he said, the study findings "mean that your mild asthmatic ... who doesn't look or feel all that bad still has a significant risk, or could have a significant risk, of having depressive symptoms and should be evaluated for this."

Read article here.