Post on 06-Jan-2016
description
Asthma from childhood to adulthood
Ernst Eber
Respiratory and Allergic
Disease Division, Paediatric
Department, Medical University
of Graz, Austria
300 million people suffer from asthma worldwide
No data available
Prevalence of asthma
ISAAC Lancet 1998
Martinez FD Pediatr Pulmonol 1997 based on: N Engl J Med 1995
Wheezing in preschool children
Martinez FD Pediatr Pulmonol 1997 based on: N Engl J Med 1995
Wheezing in preschool children
Wheezing in preschool children
Landau LI Pediatr Pulmonol 1996
• Different phenotypes of childhood
asthma
- Virus associated wheeze
- Post-bronchiolitis wheeze
- Atopy associated wheeze
• Asthma in more than 50% begins <3
years
Asthma is not one disease
„... there is a belief among general
practitioners and paediatricians that
children grow out of asthma.“
Issues in Adolescent Asthma.Thorax 1996; 51 (Supplement 1)
Childhood asthma
„... it is often not the asthma that is
outgrown but the paediatrician.“
Outcome of asthma and wheezing in the first 6 years of life
Morgan WJ et al. Am J Respir Crit Care Med 2005
Outcome of asthma and wheezing in the first 6 years of life
Morgan WJ et al. Am J Respir Crit Care Med 2005
Outcome of asthma and wheezing in the first 6 years of life
Morgan WJ et al. Am J Respir Crit Care Med 2005
Outcome of asthma and wheezing in the first 6 years of life
Morgan WJ et al. Am J Respir Crit Care Med 2005
„... our study strongly suggests that
both lung function characteristics in
early infancy and events occurring
during the first 6 years of life
determine the expression of asthma
and the level of lung function that
will be achieved during childhood
and into early adult life.“
The Melbourne Asthma Study: 1964-1999
Phelan PD et al. J Allergy Clin Immunol 2002
• 1964: Children at age 7 yrs with a history
of wheezing randomly selected; further
group selected from the same birth cohort
at age 10
• Subjects followed prospectively at 7-yr
intervals; last review 1999 (average age
42 yrs)
• 87% of the original cohort participated in
the 1999 review
The Melbourne Asthma Study: 1964-1999
Oswald H et al. Pediatr Pulmonol 1997
The Melbourne Asthma Study: 1964-1999
Phelan PD et al. J Allergy Clin Immunol 2002
• The majority of children who had only a few
episodes of wheezing associated with symptoms
of a respiratory infection had a benign course,
with many ceasing to wheeze by adult life. Most
who continued with symptoms into adult life were
little troubled by them.
• Children with asthma mostly continued with
significant wheezing into adult life, and the more
troubled they were in childhood, the more likely
symptoms continued.
The Melbourne Asthma Study: 1964-1999
Phelan PD et al. J Allergy Clin Immunol 2002
• There was a loss in lung function by the age of 14
years in those with severe asthma, the loss did
not progress in adult life.
• There was no significant loss of lung function in
those with milder symptoms.
A longitudinal, population-based cohort study of childhood asthma followed to
adulthood
Sears MR et al. N Engl J Med 2003
14.5%
15.0%12.4%9.5%21.2%27.4%
A longitudinal, population-based cohort study of childhood asthma followed to
adulthood
Sears MR et al. N Engl J Med 2003
A longitudinal, population-based cohort study of childhood asthma followed to
adulthood
Sears MR et al. N Engl J Med 2003
• More than 1 in 4 children had wheezing that
persisted from childhood to adulthood or that
relapsed after remission.
• The factors predicting persistence or relapse were
sensitization to HDM, AHR, female sex, smoking,
and early age at onset.
• These findings, together with persistently low lung
function, suggest that outcomes in adult asthma
may be determined primarily in early childhood.
A clinical index to define risk of asthma in young children with recurrent wheezing
Castro-Rodriguez JA et al. Am J Respir Crit Care Med 2000
A clinical index to define risk of asthma in young children with recurrent wheezing
Castro-Rodriguez JA et al. Am J Respir Crit Care Med 2000
Risk factors for onset of asthma
A 12-year prospective follow-up study
Porsbjerg C et al. Chest 2006
The presence of AHR and concomitant atopic
manifestations in childhood increase the risk
of developing asthma in adulthood, and
should be recognized as markers of
prognostic significance, whereas the absence
of these manifestations predicts a very low
risk of future asthma.
Asthma from childhood to adulthood
Airway inflammation and airway remodelling
are present in children and adolescents with
clinical remission of their asthma.
(Eosinophils, T cells, mast cells and IL-5 in bronchial
biopsy tissue; eosinophils in BALF; eosinophils, ECP,
TNF-α and GM-CSF in induced sputum; FeNO; BR to
AMP and MCh)
van den Toorn et al. Am J Respir Crit Care Med 2000 & 2001; Warke et al. Eur Respir J 2002; Obase et al. Allergy 2003
Childhood factors associated with asthma remission after 30 years follow up
Vonk JM et al. Thorax 2004
Cohort of 119 allergic asthmatic children
visit 1: 5-14 yrs, visit 2: 21-33 yrs, visit 3: 32-42 yrs
Clinical remission: no asthma symptoms, no use
of ICS
Complete remission: no asthma symptoms, no use
of ICS, normal lung function, no BHR
Childhood factors associated with asthma remission after 30 years follow up
Vonk JM et al. Thorax 2004
Complete remission at visit 3: 22%
Clinical remission at visit 3:30%
Both complete and clinical remission were
associated with a higher lung function level in
childhood and a higher subsequent increase in
FEV1.
Asthma from childhood to adulthood
Summary I
In the vast majority of cases asthma has its
onset in childhood.
In a proportion of asthmatic children,
asthma remits in adolescence or early
adulthood and the severity of asthma tracks
significantly with age.
Asthma from childhood to adulthood
Summary II
Complete remission of childhood asthma
may be the exception rather than the rule.
Patients with asthma in clinical
remission should be monitored with
periodic assessment of lung function,
bronchial responsiveness, and other
markers of inflammation.
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