Conference Coverage

Nonrespiratory Symptoms Precede Loss of Asthma Control



ORLANDO – Parents were able to identify patterns of nonrespiratory symptoms in their children that preceded loss of asthma control, a small study showed.

The findings, if replicated, suggest that parents could recognize these early patterns and potentially intervene to prevent loss of control, as well as asthma exacerbations. Currently, guidelines from the National Asthma Education Program recommend starting treatment once an asthma exacerbation has begun, and current asthma action plans focus mainly on respiratory tract symptoms. The guidelines do not provide specific information about what signs and symptoms might present before lower respiratory tract symptoms appear, said Dr. Lisanne Newton of the Cleveland Clinic.

Caregivers of children aged 2-11 years with persistent asthma completed daily diaries for 16 weeks, in which they categorized each of 41 signs and symptoms as usual, less than usual, or more than usual. The signs and symptoms were derived from a prior study in which caregivers had identified them as potential early warnings (J. Pediatr. 2009;154:877-81).

Of 33 caregivers (32 parents and 1 grandparent) enrolled, 27 completed at least some of the questionnaire, and 19 completed all 16 weeks. Nearly all of the parents were female, and two-thirds of the children were male. The parents had a mean age of 38 years, and the children had a mean age of 7 years. Two-thirds of the parents had a history of atopic disease themselves, Dr. Newton noted.

The caregivers completed diary entries for 82% of days overall. At least one episode of loss of control, defined as 2 or more consecutive days of increased lower respiratory symptoms, occurred in 78% of the children. A total of 41% had at least one course of oral corticosteroids, 22% had at least one emergency department visit, and 41% had at least one unexpected medical provider visit.

Overall there was a significant change from baseline in all symptom types during an episode, compared with a controlled period, which was defined as the days excluding the episodes and the 5 days prior and 2 days after an episode. The odds of a child having unusual nonrespiratory signs or symptoms were significant at 3 days, 2 days, and 1 day prior to an episode, compared with controlled periods, with odds ratios of 1.6, 2.1, and 2.3, respectively. The change from baseline in upper and lower respiratory symptoms in the 3 days prior to an episode was not significant, she said.

Specific nonrespiratory signs and symptoms included irritability, low activity levels, tiredness, and sunken eyes. Parents reported an unusual amount of irritability in their children starting 5 days before an episode, with odds ratios of 2.2 at 5 days ahead and 4.1 at 1 day ahead. Unusually low activity levels were significant starting at 3 days before an episode, with odds ratios of 2.7 at 3 days and 4.4 at 1 day prior to the episode. Tiredness was also significantly more common, with an odds ratio of 2.8 at 3 days and 7.6 at 1 day. Sunken eyes were reported starting at 2 days prior, with an odds ratio of 2.5. All of these signs and symptoms were even more common during an episode.

Surprisingly, the overall odds of a child having an unusual amount of an upper respiratory sign or symptom, compared with controlled periods, was not significant in the 5 days before an episode, though they were significant during an episode. An itchy throat was the only upper respiratory symptom that was significant, and only at 3 days (OR, 2.9) and 2 days (4.3) prior to and during an episode but not the day prior, she noted.

Though limited by a small sample size, some consistent symptom patterns were seen in 5 of the 12 children who had at least three episodes during the 16-week period. One child had an unusual amount of crying and irritability the day prior to two of his three episodes. Another child had an unusual amount of talking, activity, and energy in the 2 days before half of her episodes. A third child had sleeping problems in the 2 days prior to three-quarters of his episodes and watery eyes in the 2 days prior to half of his episodes.

There were no differences between episodes occurring during weeks when oral corticosteroids were prescribed versus episodes occurring during weeks when no oral corticosteroids were prescribed, Dr. Newton said.

Further investigation is needed to determine whether parents would treat their children when these symptoms occurred, and if treatment modification could prevent loss of asthma control and exacerbations, she said.


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