In some cases, home visits may be useful [ 43 ]. Correct inhaler technique is one of the prerequisites of successful asthma treatment. The evidence suggests that inhalation technique should be taught, taught back and checked at least twice when new drugs or devices are prescribed, when asthma control deteriorates or at least annually [ , ].
In addition, in young children, parents are usually asked to demonstrate inhaler technique at each visit and advice may be given about correct administration. Adrenal suppression is more frequently seen during treatment with high-dose ICS; however, the frequency and severity of hypothalamic-pituitary-adrenal axis suppression is highly dependent on the tests used to assess this axis, and one should be aware that adrenal insufficiency may occur at low-to-moderate doses of ICS [ , ].
More research is needed to define which tests for adrenal suppression are useful in which children. Nasal and dermal corticosteroids have to be considered in assessing total corticosteroid dose.
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Local side-effects, such as thrush and hoarseness, are rare and are in general easily managed by teeth brushing or mouth rinsing after administration of ICS [ ]. However, there is limited evidence to support the need for specific investigations that monitor drugs other than corticosteroids. In children using ICS, all Task Force members measure height and weight at least annually, but preferably at every visit. Children using high doses of ICS deserve special attention and monitoring for possible adrenal suppression.
Rhinitis, food allergy, gastro-oesophageal reflux GOR and obesity are conditions that may aggravate or mimic asthma; however, there is currently no evidence that treatment of these conditions improves asthma control [ ]. There is no role for routine monitoring of these diseases in children with asthma; however, appropriate diagnostics might be considered for these diseases in children with uncontrolled asthma.
Asthmatic children with rhinitis, compared to those without, have poorer asthma control, reduced QoL, an increased risk of emergency visits or hospitalisations, and higher healthcare costs [ 41 , — ]. Therefore, signs and symptoms suggestive of rhinitis and rhinosinusitis are often discussed and although treatment for rhinitis has not been proven to improve asthma control, it is considered good practise to ensure that rhinitis symptoms are managed appropriately in children with asthma.
Food allergy is commonly considered to be a risk factor for poor asthma control, and it may cause severe and even fatal asthma exacerbations, although food allergy in most studies has not been diagnosed with a double-blind-placebo-controlled food challenge [ 86 , ]. However, it appears that not the food allergy per se but sensitisation to multiple foods and aeroallergens is a risk factor associated with poor asthma control or severe exacerbations [ — ].
After appropriate counselling, children with comorbid food anaphylaxis might be considered for receiving an adrenaline auto-injector and appropriate training in its use [ ]. GOR has been suggested as a cause of poor asthma control in children but treatment with lansoprazole in children with poorly controlled asthma, without symptoms of GOR, improves neither symptoms nor lung function [ — ]. There is no role for the routine assessment of GOR or swallowing abnormalities in children with asthma.
The relationship between obesity and asthma is complex and as yet not completely understood [ — ]. All Task Force members measure height and weight during routine clinical monitoring, with calculation of body mass index or percentile estimates of weight and height based on a relevant population.
Multiple indoor and outdoor environmental stimuli are known to worsen asthma symptoms. The most common stimuli are discussed here; these include exposure to tobacco smoke, combustion-derived air pollutants, house dust mites, fungal spores, pollens and pet dander. There is good evidence that second-hand tobacco smoke exposure causes asthma, more severe asthma symptoms, BHR, airways inflammation and adverse effects on respiratory health in children [ — ]. There can be no doubt that smoking in the parents or caregivers should be strongly discouraged [ 44 , — , ].
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Success rates in asthma education, including second-hand smoke harm awareness, are low but in children who live in households where tobacco smoke exposure was successfully reduced, hospital admissions were halved over the following year [ ]. A better understanding of how to motivate parents of children with asthma to change their smoking habits is urgently needed [ , ]. Several methods are used to objectively measure children's second hand smoke exposure cotinine, hair or nail nicotine, exhaled carbon monoxide, airborne nicotine but a gold standard is lacking and currently there is no single recommended method for monitoring such exposure in children with asthma or for monitoring maternal smoking during pregnancy.
Children are more vulnerable to the health effects of outdoor and indoor air pollution than adults as their lungs are still developing, they have a higher minute ventilation, and they have higher levels of physical activity outdoors [ — ]. There is a positive association between exposure to traffic-related air pollution and exacerbation of asthma symptoms in children and reduced growth in lung function [ 47 , 52 , 54 , , ].
However, the measurement of outdoor pollutants is mainly performed for regulatory purposes and is not currently used to monitor asthma in children. Indoor pollutants are mainly derived from incomplete combustion of biomass and solid fuels e. Children seem to be more vulnerable to the effects of indoor pollution, and chronic exposure to indoor pollutants is associated with persistent wheeze, current asthma and use of asthma medication in children [ 45 , 46 , 49 , 51 ].
Indoor dampness is another important factor that imposes a higher risk of asthma [ 48 , 53 ].
Home visits by an asthma nurse are often conducted in patients with severe uncontrolled asthma to check for aggravating factors in the home. House dust mites, pollens, pet allergens and fungal spores are amongst the most common allergens in the indoor and outdoor environment. Single measures to reduce indoor allergen loads are likely to be of little benefit; individualised intervention programmes may reduce exposure to indoor allergens and result in decreased asthma morbidity, but a recent meta-analysis showed that measures to reduce house dust mite exposure were not helpful [ — ].
Specific questions about environmental exposures that are likely to increase the risk of asthma or to trigger asthma exacerbations are generally included in the assessment of all asthmatic children table 5.
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Local air quality websites may be checked for warnings of high levels of air pollution and pollen loads, and precautions may be taken accordingly. Monitoring through home visits to specifically assess the environmental allergen load could assist in the management of children with difficult-to-treat asthma before any changes to treatment regimens are considered [ 43 ]. It is obvious that symptom control, prevention of exacerbations or lung function decline, and lack of lung growth represent three different clinical outcomes that may require different monitoring strategies.
In addition, several studies demonstrate a number of parameters that can be used to assess asthma control in children through a single examination, but follow-up studies assessing the usefulness of these parameters in monitoring asthma are lacking. The variability of the pathophysiology in asthma is not in parallel, e.
There is therefore an urgent need for studies that consider more targeted monitoring strategies in specific populations. Personalised medicine asks for personalised monitoring, which is not possible yet. To date, phenotypic description of asthma has not been helpful in choosing monitoring schemes, and studies are needed not only to assess the effectiveness of asthma phenotypes per se but also take complex allergic diseases into consideration, regardless of whether they constitute certain phenotypes.
Studies that assess the usefulness of composite asthma control scores and longitudinal QoL measures in improving asthma control in primary and secondary care are needed. Clinical trials that assess the utility of F eNO in adjusting treatment or in predicting exacerbations in specific phenotypes, such as obese children, children with severe persistent asthma or preschool children, have not been performed.
In addition, the meaning of significant changes in F eNO in a longitudinal setting is still unclear and needs further attention. In the same way, the feasibility and utility of induced sputum cytology to guide treatment in schoolchildren with mild-to-moderate asthma and preschool children with wheezing has yet to be investigated. The use of lung function testing and noninvasive markers in preschool children is of particular interest and although their role in monitoring may be limited, their role in predicting the development of asthma and showing those who might benefit from ICS is a real challenge.
There is a general lack of monitoring schemes that are optimal for different healthcare settings, disease severities and ages. Data on optimal frequency of follow-up, tools to be used at each level and health cost—benefit are lacking. All these issues warrant further study. Monitoring asthma in children requires careful review of the impact of asthma on the child's daily life, including sports and play.
The use of composite asthma control scores has not been shown to improve asthma outcome and QoL measures, and though potentially useful in research, they have limited value in clinical practise. Spirometry with BDR is of value and should be performed at least annually and more frequently in risk groups. There is no evidence that measurements of bronchial responsiveness and markers of inflammation are useful in the routine monitoring of children with asthma. Disclosures can be found alongside the online version of this article at erj. Four supporting documents will be published in the June issue of the European Respiratory Review : introduction; symptoms, exacerbations and quality of life; lung function, bronchial responsiveness and inflammation; and management-related issues.
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Pijnenburg , Eugenio Baraldi , Paul L. Rottier , Sejal Saglani , Peter D.
Sly , Stanley J. Abstract The goal of asthma treatment is to obtain clinical control and reduce future risks to the patient. Introduction Asthma is a chronic, heterogeneous disease with symptoms and features that include wheeze, cough particularly at night and during exertion , dyspnoea and chest tightness, variable airways obstruction and bronchial hyperresponsiveness BHR. Methods For many aspects of monitoring asthma in children there is a paucity of data. Limitations of this Task Force The present Task Force did not address the diagnosis and treatment of childhood asthma, nor did it consider monitoring of acute asthma exacerbations.
Recommendations on monitoring in asthma guidelines Over the years, the treatment goal has changed from reducing disease severity and improving long-term prognosis [ 15 ] to achieving asthma control and reducing the burden of asthma and future risks to the patient [ 1 , 4 — 7 ]. View this table: View inline View popup. Factors to consider when choosing monitoring tools Frequency of follow-up visits Asthma is a highly variable disease and periodic adjustment of treatment is recommended by all guidelines.