NSAID‐exacerbated respiratory disease (N‐ERD) is a chronic eosinophilic, inflammatory disorder of the respiratory tract occurring in patients with asthma and/or chronic rhinosinusitis with nasal ...polyps (CRSwNP), symptoms of which are exacerbated by NSAIDs, including aspirin. Despite some progress in understanding of the pathophysiology of the syndrome, which affects 1/10 of patients with asthma and rhinosinusitis, it remains a diagnostic and therapeutic challenge. In order to provide evidence‐based recommendations for the diagnosis and management of N‐ERD, a panel of international experts was called by the EAACI Asthma Section. The document summarizes current knowledge on the pathophysiology and clinical presentation of N‐ERD pointing at significant heterogeneity of this syndrome. Critically evaluating the usefulness of diagnostic tools available, the paper offers practical algorithm for the diagnosis of N‐ERD. Recommendations for the most effective management of a patient with N‐ERD stressing the potential high morbidity and severity of the underlying asthma and rhinosinusitis are discussed and proposed. Newly described sub‐phenotypes and emerging sub‐endotypes of N‐ERD are potentially relevant for new and more specific (eg, biological) treatment modalities. Finally, the document defines major gaps in our knowledge on N‐ERD and unmet needs, which should be addressed in the future.
Inflammation, structural, and functional abnormalities within the airways are key features of asthma. Although these processes are well documented, their expression varies across the heterogeneous ...spectrum of asthma. Type 2 inflammatory responses are characterized by increased levels of eosinophils, FeNO, and type 2 cytokines in blood and/or airways. Presently, type 2 asthma is the best‐defined endotype, typically found in patients with allergic asthma, but surprisingly also in nonallergic patients with (severe) asthma. The etiology of asthma with non‐type 2 inflammation is less clear. During the past decade, targeted therapies, including biologicals and small molecules, have been increasingly integrated into treatment strategies of severe asthma. These treatments block specific inflammatory pathways or single mediators. Single or composite biomarkers help to identify patients who will benefit from these treatments. So far, only a few inflammatory biomarkers have been validated for clinical application. The European Academy of Allergy & Clinical Immunology Task Force on Biomarkers in Asthma was initiated to review different biomarker sampling methods and to investigate clinical applicability of new and existing inflammatory biomarkers (point‐of‐care) to support diagnosis, targeted treatment, and monitoring of severe asthma. Subsequently, we discuss existing and novel targeted therapies for asthma as well as applicable biomarkers.
Background The place of systemic corticosteroids in the treatment of children with chronic rhinosinusitis (CRS) remains unclear. Objective We sought to assess the effectiveness and tolerability of ...oral methylprednisolone as an anti-inflammatory adjunct in the treatment of CRS in children. Methods Forty-eight children (age, 6-17 years) with clinically and radiologically proved CRS were included. Patients were randomly assigned to either oral amoxicillin/clavulanate (AMX/C) and methylprednisolone or AMX/C and placebo twice daily for 30 days. Oral methylprednisolone was administered for the first 15 days with a tapering schedule. Primary parameters were mean change in symptom and sinus computed tomographic (CT) scan scores after treatment. Secondary study parameters were mean changes in individual symptom scores after treatment, relapse rate, and tolerability. Results Forty-five patients completed the study: 22 received AMX/C and methylprednisolone, and 23 received AMX/C and placebo. Both groups demonstrated significant improvements in symptom and sinus CT scores when comparing baseline values with end-of-treatment values ( P < .001). Methylprednisolone as an adjunct was significantly more effective than placebo in reducing CT scores ( P = .004), total rhinosinusitis symptoms ( P = .001), and individual symptoms of nasal obstruction ( P = .001), postnasal discharge ( P = .007), and cough ( P = .009). At the end of treatment, 48% of the children in the placebo group still had abnormal findings on CT scans versus 14% in the methylprednisolone group ( P = .013). Therapy-related adverse events were not different between groups. Although insignificant, the incidence of clinical relapses was also less in the methylprednisolone group (25%) compared with that in the placebo group (43%, P = .137). Conclusion Oral methylprednisolone is well tolerated and provides added benefit to treatment with antibiotics for children with CRS.
Diagnosis of asthma in childhood is challenging. Both underdiagnosis and overdiagnosis of asthma are important issues. The present review gives information about challenging factors for an accurate ...diagnosis of childhood asthma.
Although underdiagnosis of asthma in childhood has always been the most important diagnostic problem, overdiagnosis of asthma has also been increasingly recognized. This is probably due to diagnosis of asthma based on symptoms and signs alone. Demonstration of variable airflow obstruction by lung function tests is the most common asthma diagnostic tests used in practice and is therefore strongly recommended in children who can cooperate. Recently, an asthma guideline combining the clinical and economic evidences with sensitivity and specificity of diagnostic procedures was developed to improve accuracy of diagnosis and to avoid overdiagnosis. This guideline provided an algorithmic clinical and cost-effective approach and included fractional exhaled nitric oxide measurement as one of the diagnostic tests in addition to lung function.
Diagnosis of asthma in children should be made by combining relevant history with at least two confirmatory diagnostic tests whenever possible. Diagnosis based on short-period treatment trials should be limited to young children who are unable to cooperate with these tests.
Background This study observed children with chronic nonspecific isolated cough (NIC) to investigate clinical differences between children whose symptoms resolved spontaneously and those who ...eventually developed asthma and then explored the differences among the children who eventually developed asthma in terms of their time of response to a trial of inhaled corticosteroid (ICS). Methods Children with chronic NIC were managed either with a wait-and-review approach or with a 2-week trial with 400 μg/d inhaled budesonide according to the preference of their parents. Responses were monitored with a validated cough score. Treatment was prolonged to 8 weeks in the case of partial responders. All children were followed up at 3-month intervals. Results A total of 109 children (median interquartile range age, 5 3.5-9 years; cough duration, 8-16 weeks) were followed for a mean (± SD) time of 21(± 5) months. Cough did not recur in 71% (spontaneous resolution) but relapsed in 28% of the children who later responded to ICS treatment again (asthma). Aeroallergen sensitization (relative risk, 2.86; 95% CI, 1.17-6.99) and previous history of chronic cough (relative risk, 2.68; 95% CI, 1.10-6.49) increased the risk of asthma. Cough duration, the cough score, the family history of asthma, and serum eosinophilia were not found discriminative for the final diagnosis. There were no differences among children who eventually developed asthma and responded to either the 2-week or 8-week trial in terms of the study parameters. Conclusions Chronic NIC does not recur in the majority of children. Initial response to the ICS trial may be misleading but the trial may be preferred for children who have atopic sensitization, a previous history of chronic cough, or both .
To cite this article: Arga M, Bakirtas A, Catal F, Derinoz O, Harmanci K, Razi CH, Ergöcen S, Demirsoy MS, Turktas I. Training of trainers on epinephrine autoinjector use. Pediatric Allergy ...Immunology 2011; 22: 590–593.
The majority of physicians do not know how to use epinephrine autoinjectors. This displays that current education of physicians on anaphylaxis is inadequate for a thorough practice. We hypothesize that a theoretical lecture together with a practical session on epinephrine autoinjector use will improve its proper use by physicians. Residents, specialists, and consultants from General Pediatrics excluding allergists and allergy fellows were included in this study. All physicians were given an eight‐item questionnaire followed by a practical session scoring and timing ability to use epinephrine autoinjector trainer. This ensued with one‐to‐one hands‐on training on correct autoinjector use. Finally, a joint theoretical lecture on anaphylaxis including re‐demonstration of epinephrine autoinjector use was given. All physicians were scored a second time on use of epinephrine autoinjector 6 months later. One hundred fifty‐one of 196 participants completed all steps of the study in four tertiary hospitals. Correct use of epinephrine autoinjector improved from 23.3% to 74.2%, mean score from 3.49 ± 1.14 to 4.66 ± 0.65, need for prospectus from 91.4% to 29.1%, and mean time to administer autoinjector from 28.01 ± 6.22 s to 19.62 ± 5.01 s (p < 0.001 for each). The rate of most common mistakes during autoinjector use decreased but the ranking did not change. An integrated theoretical and practical education increased correct of epinephrine autoinjector use by physicians. Ongoing mistakes despite this education may be related with its design.
Background
No information exists on how the knowledge or the practice of pediatricians regarding anaphylaxis episodes vary with episode severity. The aim of this study was to assess and compare ...pediatrician knowledge on the management of mild and severe anaphylaxis using clinical scenarios and to determine factors that affect their decisions.
Methods
A questionnaire consisting of eight questions on the diagnosis and management of anaphylaxis was distributed at two national congresses. A uniform answer box including possible response choices was given below each question, and respondents were asked to check the answers that they thought appropriate. The management of mild and severe anaphylaxis was examined using two clinical case scenarios involving initial treatment, monitoring, and discharge recommendations.
Results
Four hundred and ten questionnaires were analyzed. The percentage of pediatricians who correctly answered all questions on the management of mild and severe anaphylaxis scenarios was 11.3% and 3.2%, respectively. Pediatricians did significantly better with initial treatment, but they were less knowledgeable with respect to observation time and discharge criteria in the mild anaphylaxis case scenario compared with the severe one (both P < 0.001). Multiple logistic regression analysis identified only working in an emergency department or intensive care unit as significantly predicting correct diagnosis of anaphylaxis among pediatricians (P = 0.01, 95% confidence interval: 0.11–0.57). No pediatrician‐related factors predicted physician knowledge on the management of anaphylaxis.
Conclusions
Pediatricians have difficulty with different steps in managing mild and severe anaphylaxis. Their deficiencies in management may result in failure to prevent recurrences of mild anaphylaxis and may increase mortality in severe anaphylaxis.
...although scientific evidence is the backbone of clinical practice, we should act prudently and should not rush to put it into regular practice before additional multicenter studies with strict ...patient selection criteria confirm the same results, immunopathogenic mechanisms are explained, and the long-term effects of this treatment on the immune system are clarified.
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