Abstract
Mammen et al. examine the concept of adolescent asthma self-management. 2 For younger children, “self-management” is really the parents' responsibility. For adults, it is the individual's. But for adolescence, it is somewhere in between. To develop an operational definition of the concept of asthma self-management, the authors synthesized results of expert interviews and literature review, and examined their findings for common themes. Based on their systemic observations, they suggest a definition for adolescent asthma self management as “the set of behaviors which adolescents use to prevent, monitor, manage and communicate asthma symptoms with others for the purpose of controlling individually relevant outcomes, and which is influenced by complex reciprocally interacting intrapersonal and interpersonal factors.” 2
Pavic et al. provide a comprehensive, well-referenced review of evidence-based medicine in the management of chronic urticaria in children. 3 There is clear evidence to support the use of higher doses of H1-blockers should standard dosing be ineffective. Other modalities such as anti-leukotrienes, H2-blockers, and immunomodulators, including cylcosporine, dapsone, and omalizumab, are discussed as alternative sequential therapeutic options but with less strong evidence in children.
Original research in this issue includes an analysis of the Virtual PICU Systems (VPS) database (a national, multi-institutional database, created for the purpose of clinical quality improvement and outcomes research) to describe factors associated with respiratory failure among children admitted to the pediatric intensive care unit with status asthmaticus. 4 The strength of this study is the large sample size, with 3,318 pediatric intensive care unit (PICU) admissions for status asthmaticus from 48 institutions included, 6% of whom developed respiratory failure. Although it is not surprising that those who developed respiratory failure were sicker on admission and had longer length of stay, what is provocative is the substantial ethnic disparities in intubation rates—with individuals reported as African American presenting both sicker (with a worse PIM2 score) and with a higher rate of intubation for status asthmaticus than non-African Americans. These results expand on other findings demonstrating substantially higher asthma hospitalization and mortality rates in Americans of African ancestry, 5 and further highlights the importance of actions to improve asthma control in the African American population.
Scarlett et al. use respiratory inductance plethysmography (RIP) to examine medication responses in infants with bronchiolitis. Exploration of the use of this technique is important, as it can provide a non-invasive measure of treatment response in infants. Although in this small study they did not find any overall group differences in RIP measures pre- and post-administration of albuterol and normal saline, they did find several infants whose RIP phase angle did change substantially post-treatment in both groups. Although all infants were studied in quiet sleep, it cannot be concluded with certainty if these changes were medication effect, change in sleep state, or other factors. We are thrilled to see this simple, non-invasive technique being applied in clinical research on lung disease of infants, and look forward to further studies exploring its application and utility.
Motomura et al. examined Japanese children with a history of asthma with an exercise-induced component, performed exercise challenge testing on these children, and evaluated the associations of biomarkers of asthma, FeNO, urinary leukotrienes, and blood eosinophils, with exercise challenge responses. They found that the fall in FEV1 post-exercise was correlated with urinary leukotriene level pre-exercise, with a correlation coefficient (r) close to 0.4. 6 These results add to existing research confirming the associations of leukotriene production with asthma.
Do et al. compared responses of cells collected by bronchoalveolar lavage on a small sample of Cystic Fibrosis (CF) patients and patients without CF. The bronchoalveolar lavages were performed for clinical indications. They noted that previous research did not show inhibition of cytokine production by incubation of CF patient neutrophils with IL-10. Do et al. observed that incubation with IL-10 suppresses proinflammatory cytokines IL-8 and TNFα production in these cells, an effect lost at higher concentrations of IL-10. This effect was similar in cells from patients with and without CF. However, due to the small sample size, these results need to be considered as preliminary.
The Pharmacotherapy Update reviews the use of valved holding chambers with masks to deliver medication from a metered dose inhaler to a young child. Science supporting the use of valved holding chambers is reviewed, and practical obstacles to their use are commented on. 7
The Clinical Case of the Month discusses a patient with CF with delta F508/G551D mutations, severe end-stage lung disease, and features of cepacia syndrome who had a dramatic response to the CF transmembrane conductance regulator potentiator, Ivacaftor. 8 Recall that Ivacaftor has only been shown to be efficacious for individuals with the G551D mutation. This case report is important, as individuals this desperately ill were excluded from the pre-licensure efficacy studies, and as the medication response obtained was clearly life-saving. The accompanying commentary reflects on the ethical issues of the high price—close to $300,000 per year—of this medication. 9 One of us (HJF) recalls at a recent academic meeting going up to the representative of the company that markets Ivacaftor and inquiring about the price and how it is justified, with the reply of “don't worry, the insurance companies will pay for it.” If we think getting the most bang for the buck, how much more good could we do if we had even a small fraction of this, say $50,000 per year, to spend on each CF patient? How many lives could be substantially improved if a CF center in the developing world had an additional $300,000 per year? What are the ethics of having a medication that can make a dramatic difference, but is only affordable by few?
We hope that you find this issue of Pediatric Allergy, Immunology, and Pulmonology interesting and stimulating. Your contributions to this journal are valued. You can find instructions for authors online at www.liebertpub.com/manuscript/pediatric-allergy-immunology-and-pulmonology/48/.