Value of the Bronchodilator Response in Assessing Controller Naïve Asthmatic Children

doi:10.1016/j.jpeds.2007.05.004

The Journal of Pediatrics

Volume 151, Issue 5, November 2007, Pages 457-462.e1

https://doi.org/10.1016/j.jpeds.2007.05.004 Get rights and content

Objective

To define the bronchodilator response (BDR) cutoff point that best identified asthma to determine the frequency of abnormal spirometry results across severity.

Study design

Controller naïve children were evaluated with clinical criteria alone to establish a diagnosis of asthma and severity classification, then compared with the BDR, which was calculated as the percent change from the initial forced expiratory volume in 1 second. Receiver operator characteristic analysis determined the cutoff point for asthma diagnosis that gave the best combination of sensitivity and specificity.

Results

Children with asthma (n = 346) and 51 children without asthma, aged 4 to 17 years, who met entry criteria for spirometry were identified. The mean BDR in asthmatics was 8.6% (95% CI, 7.5-9.8), compared with 2.2% (95% CI, 0.2-4.3) for non-asthmatics (P < .001). A BDR ≥9% best differentiated these populations with a sensitivity rate of 42.5% and a specificity rate of 86.3%. Abnormal spirometry results, defined as a BDR ≥9%, a forced expiratory volume in 1 second <80% predicted, or both, ranged from 44.4% for mild intermittent bronchial asthma to 57.0% for severe persistent bronchial asthma.

Conclusion

Spirometric criteria that include BDR can potentially identify children who have clinically mild asthma and might benefit from controller therapy.

Section snippets

Patient Population

Children participating in a school-based, low-income asthma mobile van program, the Breathmobile (S.C. Johnson and Son, Inc., Racine, WI),¹⁶ were recruited from school nurses, community public health clinics, response to flyers, and an asthma screening questionnaire. Criteria for the diagnosis of asthma made by the asthma specialist included a history of recurrent coughing, wheezing, or shortness of breath at rest or with exercise, symptomatic improvement after bronchodilator use, and exclusion

Results

Demographic characteristics of both the asthmatic and non-asthmatic populations that successfully completed both pre- and post-BD maneuvers are shown in Table I. There were 346 children with asthma and 51 children without asthma, with an age range of 4.5 to 17.8 years and 4.2 to 15.5 years, respectively. The mean height for each group was similar. None of the group differences was statistically significant. Evaluation of symptom-based classification of asthma severity¹ revealed that 34% of

Discussion

We have shown in a controller naïve, inner city pediatric population that those in whom asthma is diagnosed on a clinical basis by an asthma specialist had significantly greater mean BDR, even at the mildest level, compared with those who were deemed non-asthmatic, regardless of age, sex, height, or ethnicity. This distinction was clearly better than that shown by means of baseline FEV₁ (Table II; Figure 2A and B). Several reports have shown that the mean BDR can differentiate BA from non-BA by

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Citation Excerpt :
In children, the validity of the 12% cut-off has been questioned by previous paediatric studies which have reported the mean change in FEV1 (L) post-bronchodilator to be 2.2–2.7% from baseline in healthy children [35,36]; compared with 8.6–10.7% in those with a history of asthma. A lower cut-off of 9% has been proposed, which differentiates between health and disease with a sensitivity of 43–50% and specificity of 78–86% [35–38]. Along similar lines, it is now almost impossible to discuss spirometric cut-offs including children without mention of the excellent work done by the Global lung initiative (GLI).
In many healthcare settings asthma in children is a clinical diagnosis based on parental reported symptoms. These include intermittent episodes of wheezing, breathlessness and periodic nocturnal dry cough. Increased symptoms often coincide with colds. Confirming a diagnosis of asthma in children can be difficult and recent reports highlight that misdiagnosis, including over- and under-diagnosis of asthma are common. Recent UK National Institute of Health and Care Excellence guidelines recommend diagnostic algorithms for children from five years and adults to support a clinical suspicion of asthma. Spirometry, bronchodilator reversibility and fractional exhaled nitric oxide testing are the first line tests to diagnose asthma in children. The introduction of these tests across all healthcare settings has the potential to reduce misdiagnosis, improve asthma management and reduce healthcare spending for asthma.

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: Supported by grants from the California Wellness Foundation, Tobacco Settlement Revenue, and Asthma Chronic Lung Disease.

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Original articleValue of the Bronchodilator Response in Assessing Controller Naïve Asthmatic Children

Objective

Study design

Results

Conclusion

Section snippets

Patient Population

Results

Discussion

J Pediatr

J Pediatr

J Allergy Clin Immunol

Chest

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

J Allergy Clin Immunol

Expert panel report: guidelines for the diagnosis and management of asthma—update on selected topics 2002

Quantitative assessment of the value of spirometry

Thorax

Providers underestimate symptom severity among urban children with asthma

Arch Pediatr Adolesc Med

The impact of spirometry on pediatric asthma diagnosis and treatment

J Asthma

Belief about diagnosing asthma in young children

Pediatrics

Classifying asthma severity in childrenMismatch between symptoms, medication use, and lung function

Am J Respir Crit Care Med

Is forced expiratory volume in one second the best measure of severity in childhood asthma?

Am J Respir Crit Care Med

Assessment of bronchodilator response in children with asthma

Eur Respir J

Diagnostic accuracy of bronchodilator responsiveness in wheezing children

Thorax

Original article
Value of the Bronchodilator Response in Assessing Controller Naïve Asthmatic Children