|Year : 2021 | Volume
| Issue : 1 | Page : 17-22
Asthma monitoring and lung function in children with physician-diagnosed asthma
Esther S Yiltok1, Helen O Akhiwu2
1 Department of Paediatrics, Jos University Teaching Hospital/College of Health Sciences, University of Jos, Jos, Nigeria
2 Department of Paediatrics, Jos University Teaching Hospital, Jos, Nigeria
|Date of Submission||28-Aug-2020|
|Date of Decision||18-Sep-2020|
|Date of Acceptance||26-Sep-2020|
|Date of Web Publication||28-Apr-2021|
Dr. Esther S Yiltok
Department of Paediatrics, College of Health Sciences, University of Jos, Jos
Source of Support: None, Conflict of Interest: None
Background: Childhood asthma is the most common chronic lung disease of childhood that requires monitoring including lung function test. This study aimed to evaluate the lung function and the monitoring strategies of children with physician-diagnosed asthma. Methods: Children aged 6 to 18 years attending the respiratory clinic with physician-diagnosed asthma were studied. Clinical status and asthma monitoring strategies were obtained followed by spirometry. The tools used for monitoring asthma included symptom diary, peak expiratory flow meter, exacerbations, and use of rescue bronchodilator in the past 1 year. Results: There were 45 children aged between 6 and 18 years with 29 (64.4%) females and 16 (35.6%) males. There was no seasonal variation in the development of symptoms and most of the parents and siblings had no allergic conditions. Nearly all children did not use monitoring tools; none of them kept a symptom diary and only one (2.2%) and three (6.7%) had an action plan and peak flow meter, respectively. Only one (2.2%) had a history of being admitted to the intensive care unit (ICU). Thirty-three (73.3%) patients had identifiable triggers (single or multiple) with cold being the most common. Eleven (24.4%) patients had the need to use a rescue bronchodilator in the past 12 months. Thirteen (28.9%) patients had an abnormal spirometric pattern and the most common being the obstructive type. Conclusion: The majority of the children had no asthma monitoring tools and a third of them had an abnormal spirometric pattern with the obstructive type being the most common.
Keywords: Asthma, children, physician diagnosis, monitoring, spirometry
|How to cite this article:|
Yiltok ES, Akhiwu HO. Asthma monitoring and lung function in children with physician-diagnosed asthma. J Med Trop 2021;23:17-22
| Introduction|| |
Childhood asthma is the most common chronic lung disease of childhood and its presentation varies over time. Its diagnosis in childhood is mainly clinical using history, symptoms, and signs., The successful long-term management of these children will require adequate monitoring with the aim of reaching the ultimate goal of treatment that is to obtain clinical control and reduce the future risk that can accompany the disease.  Asthma monitoring in clinical practice primarily involves reviewing disease activity such as the symptoms, use of relieving medication, exacerbations requiring frequent use of relieving medication, and emergency room visits to the healthcare professional as well as the impact of the disease on children’s daily activities, including sports and play. In addition to these, regular assessment of lung function is an important tool in the monitoring of children with asthma, as children with poor perception of bronchial obstruction may be at higher risk of developing severe asthma episodes and reduced lung function is associated with poorer asthma outcomes.
There are different asthma monitoring tools that include self-reporting of symptoms, the use of symptom diary, assessment of asthma exacerbation, use of rescue medication, use of peak expiratory flow meter, spirometry, asthma score chart, and fraction exhaled nitric oxide (FeNO) among others., There are new monitoring tools that have been developed and added to the list of monitoring tools that include the use of electronic devices (applications, apps) for monitoring symptoms and real-time medication. In asthmatic patients, the desire is optimal disease management to ensure a steady state is attained, therefore, asthma monitoring is very important using these monitoring tools. In asthmatic children, the lung function tests are required not only for the diagnosis and monitoring of asthma but also to help in predicting the future risk of exacerbations and progression into an asthmatic adult. It is therefore important to institute monitoring strategies early to prevent the progression of the disease and the subsequent impairment of lung function.
The Global Initiative for Asthma (GINA) guidelines are the most specific in asthma management and it states that asthma control should be monitored by the healthcare professionals and preferably also by the patient at regular intervals. However, there is a knowledge gap in the monitoring strategies of asthma in children with physician-diagnosed asthma in our setting. Additionally, these children have never had a spirometry reading done due to the unavailability of the equipment and monitoring strategies are therefore urgently needed. This study aimed to evaluate the lung function of children using spirometry and the monitoring strategies of children with physician-diagnosed asthma in Jos, Nigeria. The findings of this study will help identify the loopholes and hence the measures needed to monitor asthma effectively in the future.
| Materials and methods|| |
All children aged 6 to 18 years attending the respiratory clinic of Jos University Teaching Hospital (JUTH), Jos, Nigeria with physician-diagnosed asthma were studied. This study was conducted over a period of 8 months after written consent was obtained from the parents and assent from the child. Ethical approval was obtained from Health Research Ethical Committee of JUTH. The clinical diagnosis of asthma was based on classical symptoms of asthma that were recurrent cough, chest tightness, breathlessness, wheezing, and nocturnal cough., Additional clinical histories were exercise limitation, history of atopic conditions in the patient or family members, and associated triggers.
The information obtained from the participants were socio-demographic characteristics, asthma triggers, rapid bronchodilator use in the past 1 year, appropriateness of inhaler technique, use of symptom diary, peak expiratory flow (PEF) meter, and written action plan. Spirometry was performed in all the children studied.
The spirometer was factory calibrated to read in liters at body temperature, barometric pressure saturated with water vapor. All the participants were instructed to observe all the American Thoracic Society/European Respiratory Society (ATS/ESR) preconditions for spirometry before performing the test. , Testing was performed using a CareFusion Microlab ML3500 MK8 spirometer (product of BD with Headquarters in Franklin Lakes, New Jersey, US) (Serial #- 085-70237, Software Serial #- 107-132036593), which has a digital ultrasonic flow measurement and displays graphs. The spirometer meets the ATS/ERS standard and predicted values based upon age, sex, ethnicity, height, weight, and smokers/non-smokers., The bronchodilator reversibility (BDR) test and exercise challenge tests (ECT) were performed according to the standard protocol. The quality of the spirometry was graded according to established criteria. The highest readings of forced expiratory volume at first second (FEV1) and forced vital capacity (FVC) from acceptable and reproducible efforts were selected. These values were used for the FEV1/FVC ratio. The abnormal values for the FEV1/FVC ratio were taken as <0.90, and positive BDR and positive ECT were taken as an increase in FEV1 of >12% predicted and fall of FEV1 of 12% predicted, respectively. The spirometric numeric parameters were interpreted along with the flow-volume and volume-time graphs. The spirometric patterns were then interpreted.
All the data were analyzed using SPSS version 23 statistical software. The results were summarized using a frequency table and patients’ characteristics were compared with the spirometric patterns. A P-value < 0.05 at 95% CI was considered statistically significant.
| Results|| |
This study recruited 45 children between the ages of 6 and 18 years made up of 29 (64.4%) females and 16 (35.6%) males. The socio-demographic characteristics of the children are shown in [Table 1]. Most of them (73.3%) were delivered at term and the majority (95.6%) resided in the urban area. Other socio-demographic characteristics are presented in [Table 1].
[Table 2] shows the clinical characteristics of the children studied. The frequency of acute exacerbations was almost equal across all seasons. Most of the parents and siblings had no allergic conditions (fathers = 84.4%; mothers = 71.1%; siblings = 82.2%). Other clinical characteristics are shown in [Table 2].
[Table 3] shows the tools usually used for monitoring of the children. None of them kept a symptom diary and only one and three of the children had an action plan and peak flow meter, respectively. Only one (2.22%) of them had to be admitted into the ICU before. Thirty-three (73.3%) of them have identifiable triggers, either single or multiple with the most common being cold. Only 11 (24.4%) had the need to use a rescue bronchodilator in the past 1 year at the time of conducting the study. The tools used for monitoring asthma in these children were symptom diary, PEF, exacerbations, and use of rescue bronchodilator in the past 1 year.
The spirometric pattern of the children studied. Thirteen (28.9%) had abnormal (obstructive and restrictive) pattern. Eleven of 37 who had the reversibility test had positive result, whereas four of the eight who had an excercise challenge test had a positive result
[Table 4] shows the patients’ characteristics that were compared with the spirometric patterns (abnormal or normal spirometry). The age group, sex, atopy in patient, inhaler technique, use of rescue medication in the past 1 year, seasonal variations, and asthma triggers were similar among children with abnormal and normal spirometric patterns. (P > 0.05)
| Discussion|| |
Asthma is one of the most widespread diseases in the world as it affects hundreds of millions of people. It is a chronic disease that usually starts manifesting its symptoms from childhood., Making a diagnosis of childhood asthma requires careful history taking physical examination and diagnostic testing especially where signs and symptoms are not conclusive. This study used physician-diagnosed asthma as the criteria for recruiting patients into the study. This method of physician-diagnosed asthma is recognized by GINA and it is the method that was used by Lai et al. The study had participants spread from the pre-adolescent age groups, a similar group of population that has been studied by others., There were more females in this study than males and this cut across all the age groups studied a finding that is at variance with some studies that showed a higher preponderance of males especially among the younger age group and the reversal at puberty. Asthma has been documented to be higher in prepubertal boys than females, but at a later age, more girls develop the symptom that coincides with puberty., The difference of the finding in this study compared to other studies could be attributed to the fewer number of males in this study compared to their female counterparts.
In this study, there was almost an equal number of children with seasonal variations in their symptoms and those whose symptoms were not affected by seasons (53% and 47%, respectively). For those with seasonal variations, they were equally distributed between the rainy season and dry season. This study also did not find a significant association between seasonal variations and abnormal spirometry findings. Seasonal variations in the symptoms seen in children with asthma have been shown in some studies.,,, In those studies, the acute exacerbations that required hospitalization during fall (autumn) coincided with the period in which the children returned to school after their summer break, whereas some other studies, from Nigeria have shown that the peak period of acute exacerbations was in the rainy season.
A review of the family history showed that few parents and siblings of the participants had a positive history of allergy and most of these conditions were either allergic rhinitis or conjunctivitis and a number of them also having asthma. This lends credence to the fact that genetic predisposition to allergic conditions in some children plays a role in the development of asthma. Heritable allergic conditions in parents have also been shown to confer a greater risk of a child developing asthma. 
In this study, the participants reported either a single or multiple triggers. The most common trigger was cold and this is not surprising as all of them live on the Jos Plateau that is one of the coldest parts of Nigeria, where temperatures can get as low as 11○C and below. Identifying triggers are helpful during monitoring in these children in order to allow for effective environmental manipulation. The children reported dust, cold, pollen of flowers, smoke, upper respiratory tract infection, perfume, and exercise as the common asthma triggers. However, not all of the children in this study were able to identify their triggers. This is not surprising because in children, trigger identification can be a complex task. Despite this, the information on the various triggers in these patients is important in order to develop an asthma trigger inventory among children attending our clinic. This information would help in drafting an appropriate management plan for these patients as asthma treatment has now been personalized for optimal care. The fact that some of the children studied had multiple triggers helps us to know that this could contribute to poor response to asthma medications and hence a lower quality of life because of poor asthma control.
The age of the child and the availability of equipment can limit the objective monitoring of asthma in these children. This can occur particularly in infants and pre-school children because the availability of objective measurements of asthma control (e.g., lung function and inflammatory markers) are scarce and, in general, their routine use in clinical practice in our setting and most countries is not feasible. 
In this study, for monitoring asthma, the tools assessed for monitoring asthma were symptom diary, PEF, asthma exacerbations assessment, and use of rescue bronchodilator in the past 1 year. None of them had a symptom diary, however, symptoms were self-reported that may not be reliable because these children or caregivers may forget some of the information that will affect the accurate assessment of asthma control.
Only one person was using a PEF meter and the child could not use the instrument appropriately that meant it was not useful for the child. This implies that all asthmatics must be taught how to appropriately use the PEF meter if not their asthma control and prevention of acute exacerbations may be difficult. Additionally, although most of the participants demonstrated that they could use the inhaler device accurately, about a third of them were still using the device poorly. This implies that asthma drug delivery into the airway will be insufficient and this would affect asthma control in these children.Spirometry is suitable for children older than 5 years and helps to support the diagnosis of asthma. This instrument should not be used in isolation but in combination with clinical history. It is also important in monitoring and can show how the lungs respond to medications and asthma control. The functional hallmark of asthma is the demonstration of reversible airway obstruction in a lung function test. In this study, most of the children’s spirometric measurements showed a normal pattern. This normal spirometric pattern does not exclude asthma in these patients. In addition, the normal pattern may be that these children’s asthma was well controlled or some of these children are in complete remission because for unexplained reasons, they have been observed to outgrow their asthma during the adolescent period.
The patients’ clinical variables were not significantly associated with spirometric measurements. It is however worthy of note that patients with comorbidities such as rhinitis, sinusitis, and other atopic conditions have been documented to be at an increased risk of asthma exacerbation. Therefore, the need for intense monitoring in these patients cannot be overemphasized.
Asthma monitoring also involves monitoring of asthma symptoms. This study observed that majority of the children did not have a symptom diary that would have enabled a more objective in record of their symptoms. All the history of symptoms was self-reported that is subject to error or recall bias. PEF meter is an additional functional device for home monitoring of asthma and early detection of acute exacerbation. In addition to keeping a peak flow diary alongside tracking asthma symptoms, a patient can work out his/her asthma triggers especially in those who are unable to identify their triggers. However, the majority of these children did not have this monitoring device therefore self-management of asthma will be difficult.
Most of the children in this study did not have to use quick relieving medication in the past 1 year. This may imply that they have good asthma control because of adherence to asthma medications or they are in remission.
Asthma action plan is a written plan that is created with the child’s doctor to help control the child’s asthma by recognizing worsening asthma symptoms alone or in combination with the use of a peak flow meter. It also states the quick-relief and controller medications to readjust and when to seek medical help. Although it is recommended in asthma management to reduce flare-ups and emergency department visits, almost all the children in this study did not have it.
Allergy tests and tests for inflammatory markers such as FeNO were not assessed as monitoring tools in these children because these tests are not available in our environment. This may have impacted on our findings
In conclusion, the majority of these children had no monitoring tools to objectively monitor their asthma but only self-reporting of their symptoms. About a third of these children have abnormal spirometric pattern of which obstructive pattern was the most common.
Asthma monitoring using common asthma monitoring tools is deficient in our patients. Therefore, the routine use of these tools is recommended when caring for asthmatic children in order to reduce flare-up, emergency visits, miss school or activities, and development of airway remolding.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Guilbert TW, Bacharier LB, Fitzpatrick AM. Severe asthma in children. J Allergy Clin Immunol Pract 2014;2:489-500.
Anderson HR, Gupta R, Kapetanakis V, Asher MI, Clayton T, Robertson CF et al.
International correlations between indicators of prevalence, hospital admissions and mortality for asthma in children. Int J Epidemiol 2008;37:573-82.
Townshend J, Hails S, McKean M. Diagnosis of asthma in children. BMJ 2008;335:198-202.
Bacharier LB, Boner A, Carlsen KH, Eigenmann PA, Frischer T, Götz M et al.
Diagnosis and treatment of asthma in childhood: a PRACTALL consensus report. Allergy 2008;63:5-34.
Rottier BL, Eber E, Hedlin G, Turner S, Wooler E, Mantzourani E et al.
Monitoring asthma in childhood: management-related issues. Eur Respir Rev 2015;24:194-203.
Brand PL, Mäkelä MJ, Szefler SJ, Frischer T, Price D, ERS Task Force Monitoring Asthma in Children. Monitoring asthma in childhood: symptoms, exacerbations and quality of life. Eur Respir Rev 2015;24:187-93.
Moeller A, Carlsen KH, Sly PD, Baraldi E, Piacentini G, Pavord I et al.
Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Eur Respir Rev 2015;24:204-15.
Bijl-Hofland ID, Cloosterman SG, Folgering HT, Akkermans RP, van Schayck CP. Relation of the perception of airway obstruction to the severity of asthma. Thorax 1999;54:15-19.
Lødrup Carlsen KC, Pijnenburg MW, ERS Task Force Monitoring Asthma in Children. Monitoring asthma in childhood. Eur Respir Rev 2015;24:178-86.
Gallucci M, Carbonara P, Pacilli AMG, di Palmo E, Ricci G, Nava S. Use of symptoms scores, spirometry, and other pulmonary function testing for asthma monitoring. Front Pediatr 2019;7:54. doi: 10.3389/fped.2019.00054.
Ryan D, Price D, Musgrave SD, Malhotra S, Lee AJ, Ayansina D et al.
Clinical and cost effectiveness of mobile phone supported self-monitoring of asthma: multicentre randomised controlled trial. BMJ 2012;344:e1756. doi: 10.1136/bmj.e1756.
Bahadori K, Doyle-Waters MM, Marra C, Lynd L, Alasaly K, Swiston J et al.
Economic burden of asthma: a systematic review. BMC Pulm Med 2009;9:24. doi: 10.1186/1471-2466-9-24.
Naeem A, Silveyra P. Sex differences in paediatric and adult asthma. Eur Med J (Chelmsf) 2019;4:27-35.
Lai L, Zhang T, Zeng X, Tan W, Cai L, Chen Y. Association between physician-diagnosed asthma and weight status among Chinese children: the roles of lifestyle factors. Int J Environ Res Public Health 2020;17:1599. doi: 10.3390/ijerph17051599.
Akhiwu HO, Asani MO, Johnson AB, Ibrahim M. Epidemiology of pediatric asthma in a Nigerian population. J Health Res Rev 2017;4:130-6. [Full text]
Wisniewski JA, McLaughlin AP, Stenger PJ, Patrie J, Brown MA, El-Dahr JM et al.
A comparison of seasonal trends in asthma exacerbations among children from geographic regions with different climates. Allergy Asthma Proc 2016;37:475-81.
Almqvist C, Worm M, Leynaert B; Working Group of GA2LEN WP 2.5 Gender. Impact of gender on asthma in childhood and adolescence: a GA2LEN review. Allergy 2008;63:47-57.
Fuseini H, Newcomb DC. Mechanisms driving gender differences in asthma. Curr Allergy Asthma Rep 2017;17:19. doi: 10.1007/s11882-017-0686-1.
Kynyk JA, Mastronarde JG, McCallister JW. Asthma, the sex difference. Curr Opin Pulm Med 2011;17:6-11.
Vink NM, Postma DS, Schouten JP, Rosmalen JG, Boezen HM. Gender differences in asthma development and remission during transition through puberty: The tracking adolescents’ individual lives survey (TRAILS) study. J Allergy Clin Immunol. 2010;126:498-504.
Won YK, Hwang TH, Roh EJ, Chung EH. Seasonal patterns of asthma in children and adolescents presenting at emergency departments in Korea. Allergy Asthma Immunol Res 2016;8:223-9. doi:10.4168/aair.2016.8.3.223
Johnston NW, Johnston SL, Duncan JM, Greene JM, Kebadze T, Keith PK et al.
The September epidemic of asthma exacerbations in children: a search for etiology. J Allergy Clin Immunol 2005;115:132-8. doi:10.1016/j.jaci.2004.09.025.
Silverman RA, Ito K, Stevenson L, Hastings HM. The relationship of fall school opening and emergency department asthma visits in a large metropolitan area. Arch Pediatr Adolesc Med 2005;159:818-23.
Edelu BO, Eze JN, Ayuk AC, Oguonu T. Prevalence and pattern of asthma exacerbation in children seen at the University of Nigeria Teaching Hospital, Enugu. Niger J Paediatr 2016;43:78-82.
Onubogu UC, Owate E. Pattern of acute asthma seen in Children Emergency Department of the River State University Teaching Hospital Port Harcourt Nigeria. Open J Respir Dis 2019;9:101-11.
Arshad SH, Karmaus W, Raza A, Kurukulaaratchy J, Matthews SM, Holloway JW et al.
The effect of parental allergy on childhood allergic diseases depends on the sex of the child. J Allergy Clin Immunol 2012;130:427-34.e6. doi: 10.1016/j.jaci.2012.03.042.
[Table 1], [Table 2], [Table 3], [Table 4]