Predictors of Symptoms Are Different From Predictors of Severe Exacerbations From Asthma in Children

doi:10.1378/chest.10-2794

Chest

Volume 140, Issue 1, July 2011, Pages 100-107

https://doi.org/10.1378/chest.10-2794 Get rights and content

Background

Asthma therapy is typically prescribed and titrated based on patient or parent self-report of symptoms. No longitudinal studies have assessed the relationship between symptoms and severe asthma exacerbations in children. The goal of our study was (1) to assess the association of asthma symptoms with severe asthma exacerbations and (2) to compare predictors of persistent asthma symptoms and predictors of severe asthma exacerbations.

Methods

The Childhood Asthma Management Program was a multicenter clinical trial of 1,041 children randomized to receive budesonide, nedocromil, or placebo (as-needed β-agonist). We conducted a post hoc analysis of diary cards that were completed by subjects on a daily basis to categorize subjects as having persistent vs intermittent symptoms. We defined a severe asthma exacerbation as an episode requiring ≥ 3 days use of oral corticosteroids, hospitalization, or ED visit due to asthma based on self-report at study visits every 4 months.

Results

While accounting for longitudinal measures, having persistent symptoms from asthma was significantly associated with having severe asthma exacerbations. Predictors of having persistent symptoms compared with intermittent symptoms included not being treated with inhaled corticosteroids, lower FEV₁/FVC ratio, and a lower natural logarithm of provocative concentration of methacholine producing a 20% decline in FEV₁ (lnPC₂₀). Predictors of having one or more severe asthma exacerbations included younger age, history of hospitalization or ED visit in the prior year, ≥ 3 days use of oral corticosteroids in the prior 3 months, lower FEV₁/FVC ratio, lower lnPC₂₀, and higher logarithm to the base 10 eosinophil count; treatment with inhaled corticosteroids was predictive of having no severe asthma exacerbations.

Conclusions

Patients with persistent symptoms from asthma were more likely to experience severe asthma exacerbations. Nevertheless, demographic and laboratory predictors of having persistent symptoms are different from predictors of severe asthma exacerbations. Although symptoms and exacerbations are closely related, their predictors are different. The current focus of the National Asthma Education and Prevention Program guidelines on the two separate domains of asthma control, impairment and risk, are supported by our analysis.

Section snippets

Design

We conducted an analysis using data from the Childhood Asthma Management Program (CAMP), a multicenter trial of 1,041 children with mild to moderate persistent asthma between the ages of 5 and 12 years who were randomly assigned to receive budesonide, nedocromil, or placebo.²⁰ Details of the CAMP protocol have been previously published.²⁰ The institutional review board at each of the eight participating institutions approved the study, and parents or guardians of the subjects gave informed

Results

Of the 1,041 subjects in the trial, 1,019 met our inclusion criteria for having completed daily diary cards regularly. As shown in Table 1, the subjects in the budesonide group were less likely to have persistent symptoms. In the budesonide group, 26% (78) of subjects had persistent symptoms compared with 37% (115) in the nedocromil group and 44% (179) in the placebo group (P < .0001). Forty percent (197) of subjects who had a history of previous ED visit or hospitalization visit had persistent

Discussion

Our study suggests that experiencing persistent symptoms from asthma is closely associated with having severe exacerbations from asthma. The following predictors of experiencing persistent symptoms are similar to the predictors of experiencing severe exacerbations: (1) treatment with inhaled corticosteroids is protective against experiencing persistent symptoms and severe exacerbations, (2) lower lnPC₂₀ is associated with both persistent symptoms and severe exacerbations, and (3) lower FEV₁/FVC

Acknowledgments

Author contributions: Dr Wu: contributed to study design, data analysis, and manuscript preparation.

Dr Tantisira: contributed to study design and manuscript preparation.

Dr Li: contributed to data analysis and manuscript revision.

Ms Schuemann: contributed to data analysis and manuscript revision.

Dr Weiss: contributed to study design and manuscript preparation.

Dr Fuhlbrigge: contributed to study design and manuscript preparation.

Funding/Support: The Childhood Asthma Management Program (CAMP) is

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: Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

^*: A complete list of participants is located in e-Appendix 1.

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Chest

Original ResearchAsthmaPredictors of Symptoms Are Different From Predictors of Severe Exacerbations From Asthma in Children

Background

Methods

Results

Conclusions

Section snippets

Design

Results

Discussion

Acknowledgments

Chest

Chest

Chest

J Allergy Clin Immunol

Chest

Chest

Ann Allergy Asthma Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

National surveillance for asthma—United States, 1980-2004

MMWR Surveill Summ

Expert Panel Report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007

J Allergy Clin Immunol

Assessing symptoms and peak expiratory flow rate as predictors of asthma exacerbations

J Gen Intern Med

Changes in peak flow, symptom score, and the use of medications during acute exacerbations of asthma

Am J Respir Crit Care Med

Exacerbations of asthma: a descriptive study of 425 severe exacerbations

Am J Respir Crit Care Med

Factors associated with asthma exacerbations during a long-term clinical trial of controller medications in children

J Allergy Clin Immunol

Current asthma guidelines may not identify young children who have experienced significant morbidity

Pediatrics

Predictors of asthma control in a random sample of asthmatic patients

J Asthma

Original Research
Asthma
Predictors of Symptoms Are Different From Predictors of Severe Exacerbations From Asthma in Children