Asthma 2016

There is clear evidence to support the use of written asthma action plans. They are a tool to support a strategic partnership between patients with asthma and their healthcare providers. Specifically they are aimed at providing guidance about controlling patient's asthma as well steps to take if the patient develops acute or worsening symptoms. Ideally, asthma action plans are reviewed at every follow-up visit and adjusted as needed.

The CDC recommends them. EPR-3 and the GINA guidelines recommend them. Some managed care organizations and hospital systems use them as quality indicators. Yet, a new study by Simon and Akinbami ¹ confirms what many of us in the field already know. They are neither universally used nor are they used routinely in most children with asthma. These authors showed that although the percentage of children in their study who had EVER received an asthma action plan rose from 41.7% in 2002 to 50.7% in 2013, there were still about 50% of children who had NEVER had a written asthma action plan. This article was published at about the same time the same authors published “Changing Trends in Asthma Prevalence Among Children,” ² in which they demonstrated that after an increase in overall asthma prevalence rates from 2001 to 2009, there was a plateau and then a decline in 2013. Is it time to reevaluate the recommendations for asthma action plans?

In this issue, Dr. John Kelso from The Scripps Clinic in San Diego, California, asks the important question “Do Written Asthma Action Plans Improve Outcomes?.” ³ In his review, he critically examines the evidence regarding the effectiveness of asthma action plans in children beyond that of asthma education alone. We think you will find his review of interest and welcome your comments and discussion.

Results from the University of Michigan's Children's Asthma Wellness program are presented by Dr. Khalid Safi and colleagues. ⁴ In their study, they emphasize the importance of close follow-up and asthma education in reducing both emergency department visits and hospitalizations. In their study, asthma action plans were used. They reported that a significant percentage of their patients required additional visits to gain complete control. Their program supports the need for an ongoing and multipronged approach to asthma management.

Respiratory tract infections, especially those with viral etiologies, are well-known triggers for asthma symptoms. Levine, Datta, and Babbitt examined the relationship between infections and asthma in a 3-year retrospective review of 448 children admitted to their Pediatric Intensive Care Unit at Miller Children's Hospital with status asthmaticus and acute asthma exacerbations. ⁵ Viral infections predominated in this group of children with a prevalence rate of 37%. Rhinovirus and enterovirus comprised 37%; respiratory syncytial virus 20%, and influenza 20%. A clear seasonal variation was identified. Bacterial infections were less common. Regardless of the etiology of the infection, children requiring ICU care for an asthma exacerbation associated with a documented respiratory tract infection had longer ICU and overall hospital lengths of stay than those without infection.

This issue also highlights Blake and Raissy's “Mepolozumab—A New Class of Treatment for Adolescents with Severe Persistent Asthma” in our pharmacology update. ⁶ Recently approved (November 2015) by the Food and Drug Administration as an add-on therapy for children of ages 12 years and above with severe persistent asthma and an eosinophilic phenotype, mepolozumab is a humanized IgG 1K monoclonal antibody that binds to IL-5. We know that severe asthma accounts for significant healthcare costs in both adults and children, although it accounts for only 5%–10% of the asthmatic population. Phenotype-directed treatment strategies offer new hope for patients with severe asthma. Further research to learn about specific phenotypes in children is needed.