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Asthma
the severity, control and management of asthma in children and significantly elevated at a stage before exacerbations were clinically
adults by means of cross-sectional surveys.
16,17
Despite variations at a evident.
72
However, sputum induction is not really feasible in children
country level, all of these studies indicated that the level of asthma and is time-consuming.
73
control falls short of the goals for long-term management in
international guidelines.
16–18
One of the explanations is probably that The hypothesis that control of childhood asthma can be improved by
the monitoring of asthma is currently performed by means of adding inflammatory markers to the guiding of treatment is attractive
symptoms and lung function but not by measurements of airway and logical, but so far has not been proved true. Future studies with
inflammation.
63,64
Generally, there is only a low correlation between new non-invasive methods such as inflammatory markers in exhaled
parameters of airway inflammation on the one hand and symptoms breath condensate or VOCs in exhaled breath will explore whether
and lung function on the other. Moreover, several children with these new non-invasive techniques will improve the control of
asthma have a poor perception of complaints, which results in childhood asthma. Moreover, there are indications that the use of a
under-reporting of symptoms and even underdiagnosis of asthma standardised questionnaire on asthma symptoms and control can add
in childhood.
18,65
Therefore, it is very interesting to assess the to the control of the disease.
additional value of inflammatory parameters for the guiding of
treatment of patients with asthma. The question is whether Inhaled Corticosteroids with Extra-fine
the treatment and management of asthma in childhood – as assessed Particle Size – The Smaller, The Better?
by exacerbation rate and levels of control – can be improved by It has been recognised for the past 10–15 years that chronic airway
adding standard measurements of inflammatory markers. inflammation has a central role in the pathogenesis of asthma.
22
It
has been assumed that asthma was predominantly a disease of the
Several studies on this topic investigated the additional value of FeNO central airways. However, in the past five to 10 years, has become
in this respect. The measurement of FeNO is well standardised in more evident that airway inflammation is also present in the small
older children.
66
A recent Cochrane review assessed the efficacy of peripheral airways.
19
What is the meaning of these findings for the
tailoring asthma interventions based on exhaled NO compared treatment of asthma? As inflammation in the small peripheral
with clinical symptoms (with or without spirometry/peak flow) for airways is important for the occurrence of asthma symptoms for
asthma-related outcomes in children and adults.
67
In general, the bronchial hyper-reactivity and airway remodelling,
19
it is important
guiding of treatment on the basis of FeNO did not result in a better to treat this inflammation. Anti-inflammatory therapy should be
outcome of asthma. A recent study investigated whether daily directed not only to the central airways but also to the small,
telemonitoring with FeNO resulted in better asthma control.
68
Allergic peripheral bronchi.
asthmatic children (n=151) were randomly assigned to two groups:
FeNO 0.05 plus symptom monitoring or monitoring of symptoms only Most conventional inhaled corticosteroids only reach the smaller
group. All children scored asthma symptoms in an electronic diary airways.
74
The distribution of inhaled medication in the central and
during 30 weeks, and 77 children received a portable NO analyser. peripheral airways is determined to a large extent by the particle
Data were transmitted daily to the co-ordinating centres. Patients size or mass median aerodynamic diameter (MMAD).
20
Particles
were phoned every three weeks and their steroid dose was adapted smaller than 4.7µm enter into the lung, whereas particles between
according to FeNO 0.05 and symptoms or to symptoms. Both groups 0.3 and 0.6µm are too small and will be exhaled again. Optimal
showed an increase in symptom-free days, improvement of FEV
1
and dosing will be reached with particles smaller than <2µm. In
quality of life, and a reduction in steroid dose. However, none of the children, an even smaller optimal particle size is assumed.
20,74,75
changes from baseline differed between the two groups. This study Theoretically, maintenance treatment with inhaled corticosteroids
found no added value of daily FeNO 0.05 monitoring compared with with extra-fine particles can increase the anti-inflammatory effect
daily symptom monitoring only. of inhaled corticosteroids because of a pronounced effect on small,
peripheral bronchi. Another advantage is less deposition in the
FeNO may be a useful parameter in some patients. In non-atopic oropharynx with fewer local side effects.
patients with asthma, FeNO is mostly not elevated.
69
It is questionable
whether one parameter provides sufficient information about the The question is whether inhaled steroids with extra-fine particles
complicated inflammatory process underlying asthma. Two other have more effect on peripheral airway inflammation than
potentially useful techniques are inflammatory markers in EBC and more conventional corticosteroids. To evaluate this, we analysed
VOCs in exhaled breath. the anti-inflammatory effects of extra-fine hydrofluoroalkane–
beclomethasone versus fluticasone dry powder inhaler (DPI) in
We investigated the ability of two-month assessments of inflammatory asthmatic children by measuring bronchial and alveolar NO and
markers in EBC for the prediction of asthma exacerbation in 40 inflammatory markers in EBC.
76
In a six-month cross-over study, 33
children between six and 16 years of age.
70
Both acidity of breath children between six and 12 years of age with moderate persistent
condensate and the Th-2 cytokine IL-5 were significant predictors of asthma were randomly treated with extra-fine hydrofluoroalkane–
asthma exacerbations. It is interesting that use of a standard beclomethasone 200 micrograms daily via an Autohaler and
questionnaire on asthma control also had significant predictive value fluticasone DPI (200 micrograms daily via a Diskus). The primary
for an asthma exacerbation. A Dutch multicentre study over two years outcome variables were alveolar NO concentration and bronchial NO
assessed whether measurements of bronchial hyper-reactivity to flux. The results demonstrated that levels of alveolar/bronchial NO,
metacholine resulted in better management of childhood asthma in a inflammatory markers in EBC, lung function indices and symptoms
group of 210 children with allergic asthma.
71
The intervention did not did not differ between treatments. The anti-inflammatory effects
result in more symptom-free days or fewer exacerbations. In a study of hydrofluoroalkane–beclomethasone are similar to those of
with adult atopic asthmatic patients, sputum eosinophils were fluticasone DPI in children with moderate persistent asthma.
76
In
18 EUROPEAN RESPIRATORY DISEASE
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