Abstract

Abstract

TITLE: Concomitant Chronic Sinusitis Treatment in Children with Mild Asthma. The Effect on Bronchial Hyperresponsiveness

AUTHORS: Tsao CH, Chen LC, Yeh KW.

JOURNAL: CHEST 2003; 123:750–764

Background. Bronchial hyperresponsiveness is an indicator of airways abnormalities and is central to pathophysiology of asthma. Frequent association of asthma and sinusitis has been noted with 80%–90% of children with asthma having concomitant nasal symptoms, and half of all individuals with asthma having radiographic evidence of sinusitis. Several investigators have noted an incidence of chronic sinusitis in the range of 40%–60% of children with bronchial asthma

Objective. The objective of the authors was to ascertain whether effective treatment of sinusitis could decrease bronchial hyperresponsiveness.

The clinical population included 61 children with a history of mild asthma with an age range of 7–10 years, and 10 age‐matched health controls followed from 1999 to 2000. All children were mite sensitive in the asthmatic group. They also had occasional symptoms controlled only by betaagonists; 41 of the 61 children with mild asthma had allergic rhinitis.

The children with chronic sinusitis were placed in two groups; one group was treated with amoxicillin clavulanate for 6 weeks and then with nasal saline irrigation for 6 weeks. In the other group, the treatment order was reversed. The children without chronic sinusitis received nasal saline irrigation for 12 weeks.

Clinical Findings. The clinical findings were that there was a significant amelioration in clinical signs and symptoms of sinusitis, but not in FEV₁, after antibiotic treatment. Following aggressive therapy for sinusitis, it was discovered that the provocative concentration of methacholine causing a 20% decline in FEV₁ of children with mild asthma and sinusitis was significantly higher than before antibiotic treatment. PC₂₀s values of children with normal radiographic findings, who were only treated with intranasal salinc for 12 weeks, did not change significantly from baseline.

Conclusion. The result indicate that every asthmatic subject needs to be carefully assessed for concomitant sinusitis. Respiratory infections that meet the criteria for sinusitis even if they do not apparently trigger asthma should be aggressively treated. This study suggests that sinusitis should be kept in mind as a possible factor for producing increased bronchial hyperresponsiveness, and then aggressive therapy for chronic sinusitis is indicated when dealing with an asthmatic patient who has an unacceptable response to appropriate therapy.

Reviewer's Comment. In this study sign and symptoms of sinusitis disappeared after treatment. In a number of patients, nocturnal cough also markedly declined. In contrast with previous reports, however, there is no difference in FEV₁ before and after treatment for sinusitis and this maybe due to the fact that the subjects enrolled had only mild asthma, unlike subjects in previous reports. This study supports the relationship between sinusitis and asthma, the bronchial hyperresponsiveness, and the importance of aggresively treating chronic sinusitis to minimize symptoms of sinusitis, as well as to improve bronchial hyperresponsiveness.

Christopher Randolph, M.D.

Waterbury, CT

Abstract

TITLE: Growth and Bone Density in Children with Mild to Moderate Asthma: Cross‐Sectional Study in Children in Entering the Childhood Asthma Management Program (CAMP)

AUTHORS: Kelly HW, Strunk RC, Donthan M, et al.

JOURNAL: Journal of Pediatrics, 2003; 142:286–291

Background. Asthma is the most common chronic disease of childhood affecting 68.6 of 1000 chilren younger than 18 years of age in the United States. It has previously been discussed that persistent poorly controlled asthma may lead to growth decline. In addition, bone mineral density may be impacted by chronic diseases and administration of corticosteroids. The purpose of this report was to examine the relationship between measures of asthma severity, asthma burden, and previous medications on linear growth and bone mineral density.

Objective. The objective of this study was to evaluate whether mild‐to‐moderate persistent asthma would produce a decrease in pulmonary fuction and would be related to an adverse impact on growth and bone mineral density in children.

Method. This is a cross‐sectional study of 1041 children, 5–12 years of age, 40% females, who were enrolled in childhood asthma management program (CAMP). The measures and parameters of asthma severity include spirometry, bronchial hyperreactivity, the duration of asthma symptoms and symptom‐based asssessment of severity. Multiple‐regression evaluation was used to determine the relationship of asthma severity and the primary outcome variables: height by stadiometer and bone mineral density by dual‐energy radiographic episotometry.

Clinical Findings. The only significant relationship encountered was between asthma severity and methacoline provocation in girls. The mean SD ± of bone mineral density was 0.65 ± 0.10 cm² for the population. Past therapy with corticosteroids did not impact either growth or bone mineral density.

Conclusion. The conclusion of the authors was that neither mild nor moderate asthma, for as long as 7 year's duration, in children did not have an impact on growth or bone mineral density.

Reviewer's Comment. Further studies of a larger prospective nature would be worthwhile to document these findings and should include severe asthmatics to fully rule out any impact of asthma on growth.

Christopher Randolph, M.D.

Waterbury, CT

Abstract

TITLE: The Role of Fungal Spores in Thunderstorm Asthma

AUTHORS: Dales RE, Cakmak S, Judek S, et al.

JOURNAL: CHEST 2003; 123 745–750

Background. The role of airborne fungal spores, particularly sporobolomyces and didymella, and basidio spores have been correlated with an increase in visits to the hospital for asthma. The authors attempted to document the existence and to evaluate the etioloy of thunderstorm asthma.

Design. The study design was a retrospective valuation of thunderstorms, air pollutions, aeroallergens, and asthma admissions to Children's Hospital Emergency Department over a 6‐year period.

Results. The results of the study indicate that during thunderstorm days (n = 151 days), compared to days without thunderstorms (n = 119 days), daily asthma visits were increased from 8.6 to 10 (p < 0.05), and the air concentration or fungal spores doubled from 1512 to 2749 per cubic mm with relatively smaller alterations in pollens and air pollutants.

Conclusions. This study confirmed a relationship between thunderstorms and asthma and suugested that the mechanism may be through increasing airborne spores that exacerbate asthma.

Reviewer's Comment. Over 6 years of daily observations, both asthma and fungal spores are clearly increased during thuderstorms. Furthermore, over the same 6‐year period, day‐to‐day increses in fungal spores were demonstrated to be associated with an increase in asthma visits, irrespective of thunderstorm occurrence. The most likely explanation is that during the thunderstorm there is an increase in environmental allergenic fungal spores. The authors demonstrated that there is a clear dose–response relationship, and although the findings are limited to one geographical area, application of these findings is supported by previous observations and increased fugal spores occurring during thunderstorms in both Birmingham and Brighton. Further evaluation of these findings in other environments and other populations is recommended to determine their application to other aeroallergens.

Christopher Randolph, M.D.

Waterbury, CT

Abstract

TITLE: Early Intervention with Budesonide in Mild Persistent Asthma, a Randomized, Double‐Blind Trial

AUTHORS: Pauwels RA, Peterson S, Busse WW, et al.

JOURNAL: Lancet 2003; 361:1071–6

Background. The background is that despite NHBLI and global guidelines recommending inhaled corticosteroids for persistent asthma, their longitudinal effect on new‐onset mild persistent asthma has yet to be determined.

Objective. The objective of the investigators was to determine the longitudinal effect of inhaled corticosteroids on new onset mild persistent asthma.

The clinical population was 7241 subjects in 32 countries, who were recruited between October 1996 and January 1998, in the age groups of 5–66 years. Individuals had to have symptoms of mild asthma in the 3 months before trial entry defined by wheeze, cough, dyspnea, or chest tightness at least once a week, but not as often as daily, with demonstration of reversible airway disease by FEV₁ improvement or exercise testing. The subjects were entered either into budesonide or placebo once daily for 3 years in addition to their usual asthma therapy. The daily budesonide dose was 400 or 200 µg for children younger than 11 years. The parameters evaluated were time to the first severe asthma‐related event, mean proportion of symptom‐free days, and additional maintenance antiasthma medication, as well the overall change in pre‐ and‐post bronchodilator FEV1 percent predicted.

Findings. Individuals on budesonide had fever courses of systematics steroids and more symptom‐free days than those on placebo (p < 0.0001) and budesonide reduced the risk of the first severe asthma‐related event by 44% for all patients. Nine subjects in the budesonide group and 24 in the placebo group had a life‐threatening asthma exacerbation (p < 0.009); 45% of individuals on placebo received oral or systematic glucocorticoids during this study compared with only 31% on budesonide (p < 0.0001).

Compared with placebo, individuals on budesonide had a significant improved pre‐ and post‐bronchodilator FEV₁ after 1 year (p < 0.0001 for both). There were similar results after 3 years with pre‐bronchodilator improvement on budesonide (p < 0.002).

Conclusion. The author's conclusions are that longitudinal daily treatment with low‐dose budesonide diminishes the risk of severe episodes of asthma and improves asthma outcomes in individuals with mild persistent asthma of recent onset. These effects of budesonide were independent of baseline lung function. There was clear reduction in lung function in patients with mild persistent asthma, similar to those with severe and long‐standing asthma.

Reviewer's Comment. This is a superb prospective longitudinal study demonstrating that once‐a‐day budesonide in low doses of 200 µg improves long‐term outcomes and control of asthma and avoids severe exacerbations, as well as declining pulmonary function. There is a small impact on growth, which is attenuated over time; thus, early intervention with inhaled corticosteroids as per NHLBI guidelines is clearly recommended.

Christopher Randolph, M.D.

Waterbury, CT