sign101

A small prospective observational study in 40 children suggested that serial measurements
of FENO and/or sputum eosinophilia may guide step down of inhaled corticosteroids (ICS). 844
Another small study of 40 children showed that a rising FENO predicted relapse after cessation
of ICS . 840 The number of children involved in these step-down and cessation studies is small
and the results should be interpreted with some caution until replicated in larger datasets.
A better understanding of the natural variability of biomarkers independent of asthma is required
and studies are needed to establish whether subgroups of patients can be identified in which
biomarker guided management is effective. Table 8 summarises the methodology, measurement
characteristics and interpretation of some of the validated tools used to assess symptoms and
other aspects of asthma.
Clinical issues
When assessing asthma control a general question, such as “how is your asthma today?”, is likely
to yield a non-specific answer; “I am ok”. Using closed questions, such as “do you use your
blue inhaler every day?”, is likely to yield more useful information. As in any chronic disease
of childhood, it is good practice to monitor growth at least annually in children diagnosed with
asthma.
; When assessing asthma control use closed questions.
; Growth (height and weight centile) should be monitored at least anually in children with
asthma.
; Practitioners should be aware that the best predictor of future exacerbations is current
control.
2.6.2 MONITORING ASTHMA IN ADULTS
In the majority of patients with asthma symptom-based monitoring is adequate. Patients achieving
control of symptoms with treatment have a low risk for exacerbations. 107 Patients with poor
lung function and with a history of exacerbations in the previous year may be at greater risk of
future exacerbations for a given level of symptoms.
; Closer monitoring of individuals with poor lung function and with a history of
exacerbations in the previous year should be considered.
In two small studies in a hospital based population, one of which only included patients
with severe and difficult asthma, a management strategy that controlled eosinophilic
airway inflammation resulted in less exacerbations. 84-86 A strategy which controlled airways
responsiveness resulted in a much higher dosage of inhaled corticosteroids and slightly less
exacerbations. 108 More research is needed before these strategies can be recommended for
widespread use.
Table 8 summarises the methodology, measurement characteristics and interpretation of some
of the validated tools used to assess symptoms and other aspects of asthma. Some measures
provide information about future risk and potential corticosteroid responsiveness (ie sputum
eosinophil count, airway responsiveness and FENO) rather than immediate clinical control. Risk
reduction, eg minimising future adverse outcomes such as exacerbations is an important goal
of asthma management. Some patients have an accelerated decline in lung function in terms of
FEv ; risk factors and treatment strategies for these patients are poorly defined. Further research
1
in this area is an important priority.
; When assessing asthma control in adults use specific questions, such as “how many
days a week do you use your blue inhaler?”.
2 diAGnosis
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