asthmatic child hesi case study

Nursing Case Study for Pediatric Asthma

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Anthony is a 6-yr-old male patient brought to the pediatric ER with a history of asthma since he came home from the NICU as an infant. He lives with his parents, Bob and Josh, who adopted him after fostering him from age 4 months. They have tried the usual nebulizer treatments but Anthony is not responding as usual, so they brought him for evaluation.

Initial assessment in triage reveals both inspiratory and expiratory wheezes, dyspnea, tachypnea, diaphoresis, and retractions.

BP 70/40 mmHg SpO2 93% on room air HR 131 bpm RR 32bpm at rest Temp 38.3°C

What physiologic issue is Anthony suffering from based on the assessment findings?

• Respiratory distress is evidenced by both vital signs and physical assessment findings. His RR and HR are high. He is also sweating and having retractions which may indicate he is working hard to try to establish oxygen exchange.

What signs and symptoms might occur that would show worsening of his condition?

• Skin color changes (i.e. blue or bluish around the mouth or even inside the mouth, blue nail beds, gray or pale compared to usual)
• Grunting on exhalation (this indicates the body is trying to keep air in the lungs)
• Stridor (this is heard in the upper airway and can be an ominous sign)
• Changes in the level of consciousness (becoming lethargic or drowsy)

Anthony is pale but not gray. His lips do indicate a very faint bluish tinge. He can speak but it appears difficult.

What medications might the nurse expect the provider to order?

• Short-acting beta-agonists (SABAs)
• Racemic albuterol – A racemic mixture of albuterol (salbutamol) is the primary SABA used for quick relief of acute asthma symptoms and exacerbations.
• Levalbuterol – Levalbuterol (Levosalbutamol), the R-enantiomer, is the active isomer of racemic albuterol that confers the bronchodilator effects. Levalbuterol is approved in the United States for the treatment of bronchospasm in children ≥4 years of age via hydrofluoroalkane (HFA) metered-dose inhaler (MDI) and ≥6 years of age via solution for nebulizer

What side effects might occur from the medications ordered?

• “The most common side effects are tremor, increased heart rate, and palpitations” Anthony may report feeling jittery due to the activation of beta receptors.

After administration of racemic albuterol, Anthony now has a RR of 22 and O2 saturation of 95% on room air. However, the provider decides to admit him to the inpatient pediatric observation unit. His parents ask if there are ways to keep him from continually being admitted to the hospital.

What are some education topics to bring up to Anthony’s parents?

• Controlling asthma triggers — The factors that set off or worsen asthma symptoms are called “triggers.” Identifying and avoiding asthma triggers is essential to keeping symptoms under control. Common asthma triggers generally fall into several categories:
• Allergens (including dust mites, pollen, mold, cockroaches, mice, cats, and dogs)
• Respiratory infections, such as the common cold or the flu
• Irritants (such as tobacco smoke, chemicals, and strong odors or fumes)
• Exercise or other physical activity

What does the nurse understand about this medication?

• Systemic corticosteroids are an essential treatment option for many disease states, especially asthma. These medications reduce the length and severity of asthma exacerbations and reduce the need for hospitalization or ED visits. It is important for asthma patients to receive prednisolone as soon as possible after the onset of symptoms that are bronchodilator-unresponsive to attain these benefits.
• Although usually prescribed for a 5- to 7-day period, oral corticosteroids are not without adverse effects. The most common adverse effects are the same for the majority of oral corticosteroids and include increased appetite, weight gain, flushed face.
• Increased risk of infections, especially with common bacterial, viral and fungal microorganisms. Thinning bones (osteoporosis) and fractures happen over time, be mindful this may cause problems in an energetic child. Suppressed adrenal gland hormone production may result in a variety of signs and symptoms, including severe fatigue, loss of appetite, nausea and muscle weakness.

Anthony sleeps during the night shift and the next day, his pediatrician makes rounds and discusses a change in the severity rating of Anthony’s asthma.

What does the nurse know about asthma severity and how it is determined?

• Asthma severity is the intrinsic intensity of the disease. Assessment of asthma severity is made on the basis of components of current impairment and future risk. The severity is determined by the most severe category measured

Bob and Josh are interested in meeting with respiratory therapy for assistance with inhalers. They say that Anthony has trouble using inhaler devices.

Inviting respiratory therapy to provide parent teaching is an example of what? How can this department help the family?

• Interdisciplinary team collaboration.
• Teaching about medications, proper inhaler (or other equipment) use, thorough explanation of peak expiratory flow (PEF) measuring, ways to help control RR.

After lunch, Anthony is ready to be discharged. His parents verbalize gratitude to the staff and thank the team for helping with education.

What can the nurse help Bob and Josh start to establish to try to help them with Anthony’s condition?

• Setting goals and planning. Preparing for an action plan (“Asthma ‘action plan’ is a form or document that your child’s provider can help you put together; it includes instructions about how to monitor symptoms and what to do when they happen. Asthma action plans are available for children up to five years old, for children five years and older and adults and for school. An action plan can tell you when to add or increase medications, when to call your child’s provider, and when to get immediate emergency help. This can help you know what to do in the event of an asthma attack. Different people can have different action plans, and your child’s action plan will likely change over time.”) 

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This nursing case study course is designed to help nursing students build critical thinking.  Each case study was written by experienced nurses with first hand knowledge of the “real-world” disease process.  To help you increase your nursing clinical judgement (critical thinking), each unfolding nursing case study includes answers laid out by Blooms Taxonomy  to help you see that you are progressing to clinical analysis.We encourage you to read the case study and really through the “critical thinking checks” as this is where the real learning occurs.  If you get tripped up by a specific question, no worries, just dig into an associated lesson on the topic and reinforce your understanding.  In the end, that is what nursing case studies are all about – growing in your clinical judgement.

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Case 1 diagnosis: allergy bullying, clinical pearls.

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Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation

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Lopamudra Das, Michelle GK Ward, Case 1: A 12-year-old girl with food allergies and an acute asthma exacerbation, Paediatrics & Child Health , Volume 19, Issue 2, February 2014, Pages 69–70, https://doi.org/10.1093/pch/19.2.69

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A 12-year-old girl with a history of asthma presented to the emergency department with a three-day history of increased work of breathing, cough and wheezing. She reported no clear trigger for her respiratory symptoms, although she had noted some symptoms of a mild upper respiratory tract infection. With this episode, the patient had been using a short-acting bronchodilator more frequently than she had in the past, without the expected resolution of symptoms.

On the day of presentation, the patient awoke feeling ‘suffocated’ and her mother noted her lips to be blue. In the emergency department, her oxygen saturation was 85% and her respiratory rate was 40 breaths/min. She had significantly increased work of breathing and poor air entry bilaterally to both lung bases, with wheezing in the upper lung zones. She was treated with salbutamol/ipratropium and received intravenous steroids and magnesium sulfate. Her chest x-ray showed hyperinflation and no focal findings.

Her medical history revealed that she was followed by a respirologist for her asthma, had good medication adherence and had not experienced a significant exacerbation for six months. She also had a history of wheezing, dyspnea and pruritis with exposure to peanuts, chickpeas and lentils; she had been prescribed an injectible epinephrine device for this. However, her device had expired at the time of presentation. In the past, her wheezing episodes had been seasonal and related to exposure to grass and pollens; this presentation occurred during the winter. Further history revealed the probable cause of her presentation.

Although reluctant to disclose the information, our patient later revealed that she had been experiencing significant bullying at school, which was primarily related to her food allergies. Three days before her admission, classmates had smeared peanut butter on one of her schoolbooks. She developed pruritis immediately after opening the book and she started wheezing and coughing later that day. This event followed several months of being taunted with peanut products at school. The patient was experiencing low mood and reported new symptoms of anxiety related to school. The review of systems was otherwise negative, with no substance use.

The patient's asthma exacerbation resolved with conventional asthma treatment. Her pulmonary function tests were nonconcerning (forced expiratory volume in 1 s 94% and 99% of predicted) after her recovery. The trigger for her asthma exacerbation was likely multifactorial, related to exposure to the food allergen as well as the upper respiratory infection. A psychologist was consulted to assess the symptoms of anxiety and depression that had occurred as a result of the bullying. During the hospitalization, the medical team contacted the patient's school to provide education on allergy bullying, treatment of severe allergic reactions and its potential for life-threatening reactions with exposure to allergens. The medical team also recommended community resources for further education of students and staff about allergy bullying and its prevention.

Allergy bullying is a form of bullying with potentially severe medical outcomes. In recent years, it has gained increasing notoriety in schools and in the media. Population-based studies have shown that 20% to 35% of children with allergies experience bullying. In many cases (31% in one recent study [ 1 ]), this bullying is related directly to the food allergy. From a medical perspective, there are little published data regarding allergy bullying, and many health care providers may not be aware of the issue.

Allergy bullying can include teasing a child about their allergy, throwing food at a child, or even forcing them to touch or eat allergenic foods. Most episodes of allergy bullying occur at school, and can include episodes perpetrated by teachers and/or staff ( 2 ).

Allergy bullying can lead to allergic reactions, which may be mild or severe (eg, urticaria, wheezing, anaphylaxis), but may also lead to negative emotional consequences (sadness, depression) ( 2 ) and an overall decrease in quality of life measures ( 1 ). Adolescents commonly resist using medical devices, such as injectible epinephrine devices, and bullying may be a contributing factor for this ( 3 ). Attempting to conceal symptoms in a bullying situation may place children at risk for a worse outcome.

Physicians can play a key role in detecting allergy bullying and its health consequences. In many cases, children have not discussed this issue with their parents ( 1 ). Given the prevalence of bullying, its potential to lead to severe harm, including death, and the lack of awareness of this issue, clinicians should specifically ask about bullying in all children and teens with allergies. Physicians can also work with families and schools to support these children, educate their peers and school staff, and help prevent negative health outcomes from allergy bullying.

Online resources

www.anaphylaxis.ca − A national charity that aims to inform, support, educate and advocate for the needs of individuals and families living with anaphylaxis, and to support and participate in research. This website includes education modules for schools and links to local support groups throughout Canada.

www.whyriskit.ca/pages/en/live/bullying.php − A website for teenagers with food allergies; includes a segment that addresses food bullying.

www.foodallergy.org − Contains numerous resources for children and their families, including a significant discussion on bullying and ways to prevent it.

Allergy bullying is common but is often unrecognized as a factor in clinical presentations of allergic reactions.

Physicians should make a point of asking about bullying in patients with allergies and become familiar with resources for dealing with allergy bullying.

Physicians can play roles as advocates, educators and collaborators with the school system to help make the school environment safer for children with allergies who may be at risk for allergy bullying.

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• Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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• Published: 21 February 2018

Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment

• Virginia Mirra 1 ,
• Silvia Montella 1 &
• Francesca Santamaria 1  

BMC Pediatrics volume  18 , Article number:  73 ( 2018 ) Cite this article

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The primary goal of asthma management is to achieve disease control for reducing the risk of future exacerbations and progressive loss of lung function. Asthma not responding to treatment may result in significant morbidity. In many children with uncontrolled symptoms, the diagnosis of asthma may be wrong or adherence to treatment may be poor. It is then crucial to distinguish these cases from the truly “severe therapy-resistant” asthmatics by a proper filtering process. Herein we report on four cases diagnosed as difficult asthma, detail the workup that resulted in the ultimate diagnosis, and provide the process that led to the prescription of omalizumab.

Case presentation

All children had been initially referred because of asthma not responding to long-term treatment with high-dose inhaled steroids, long-acting β 2 -agonists and leukotriene receptor antagonists. Definitive diagnosis was severe asthma. Three out four patients were treated with omalizumab, which improved asthma control and patients’ quality of life. We reviewed the current literature on the diagnostic approach to the disease and on the comorbidities associated with difficult asthma and presented the perspectives on omalizumab treatment in children and adolescents. Based on the evidence from the literature review, we also proposed an algorithm for the diagnosis of pediatric difficult-to-treat and severe asthma.

Conclusions

The management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma. The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism in the management of children and adolescents with atopic severe asthma.

Peer Review reports

Children with poor asthma control have an increased risk of severe exacerbations and progressive loss of lung function, which results in the relevant use of health resources and impaired quality of life (QoL) [ 1 ]. Therefore, the primary goal of asthma management at all ages is to achieve disease control [ 2 , 3 , 4 ].

According to recent international guidelines, patients with uncontrolled asthma require a prolonged maintenance treatment with high-dose inhaled corticosteroids (ICS) in association with a long-acting β 2 -agonist (LABA) plus oral leukotriene receptor antagonist (LTRA) (Table  1 ) [ 5 ].

Nevertheless, in the presence of persistent lack of control, reversible factors such as adherence to treatment or inhalation technique should be first checked for, and diseases that can masquerade as asthma should be promptly excluded. Finally, additional strategies, in particular anti-immunoglobulin E (anti-IgE) treatment (omalizumab), are suggested for patients with moderate or severe allergic asthma that remains uncontrolled in Step 4 [ 5 ].

Herein, we reviewed the demographics, clinical presentation and treatment of four patients with uncontrolled severe asthma from our institution in order to explain why we decided to prescribe omalizumab. We also provided a review of the current literature that focuses on recent advances in the diagnosis of pediatric difficult asthma and the associated comorbidities, and summarizes the perspectives on anti-IgE treatment in children and adolescents.

Case presentations

Table  2 summarizes the clinical characteristics and the triggers/comorbidities of the cases at referral to our Institution. Unfortunately, data on psychological factors, sleep apnea, and hyperventilation syndrome were not available in any case. Clinical, lung function and airway inflammation findings at baseline and after 12 months of follow-up are reported in Table  3 . In the description of our cases, we used the terminology recommended by the ERS/ATS guidelines on severe asthma [ 6 ].

A full-term male had severe preschool wheezing and, since age 3, recurrent, severe asthma exacerbations with frequent hospital admissions. At age 11, severe asthma was diagnosed. Sensitization to multiple inhalant allergens (i.e., house dust mites, dog dander, Graminaceae pollen mix, and Parietaria judaica ) and high serum IgE levels (1548 KU/l) were found. Body mass index (BMI) was within normal range. Combined treatment with increasing doses of ICS (fluticasone, up to 1000 μg/day) in association with LABA (salmeterol, 100 μg/day) plus LTRA (montelukast, 5 mg/day) has been administered over 2 years. Nevertheless, persistent symptoms and monthly hospital admissions due to asthma exacerbations despite correct inhaler technique and good adherence were reported. Parents refused to perform any test to exclude gastroesophageal reflux (GER) as comorbidity [ 6 ]. However, an ex-juvantibus 2-month-course with omeprazole was added to asthma treatment [ 7 ], but poor control persisted. Anterior rhinoscopy revealed rhinosinusitis that was treated with nasal steroids for six months [ 8 ], but asthma symptoms were unmodified. Treatment with omalizumab was added at age 12. Reduced hospital admissions for asthma exacerbations, no further need for systemic steroids, and improved QoL score (from 2.0 up to 6.7 out of a maximum of 7 points) were documented over the following months. Unfortunately, after one year of treatment, adherence to omalizumab decreased because of family complaints, and eventually parents withdrew their informed consent and discontinued omalizumab. Currently, by age 17, treatment includes inhaled salmeterol/fluticasone (100 μg/500 μg∙day -1 , respectively) plus oral montelukast (10 mg/day). Satisfactory symptom control is reported, with no asthma exacerbations.

A full-term male, who had a recurrent severe preschool wheezing, at 6 years of age developed exercise-induced asthma. At age 10, severe asthma was diagnosed. High serum IgE levels (1300 KU/l) and skin prick tests positive to house dust mites were found. Despite a 3-year treatment with progressively increasing doses of inhaled fluticasone (up to 1000 μg/day) combined with salmeterol (100 μg/day) and oral montelukast (5 mg/day), monthly hospital admissions with systemic steroids use were reported. At age 13, a 24-h esophageal impedance/pH study demonstrated the presence of acid and non-acid GER [ 7 ]. Esomeprazole was added to asthma medications, but with an incomplete clinical benefit for respiratory symptoms. Esomeprazole was withdrawn after 3 months, and parents refused to re-test for GER. As respiratory symptoms persisted uncontrolled despite treatment, severe asthma was definitively diagnosed [ 6 ]. BMI was within the normal range and anterior rhinoscopy excluded rhinosinusitis. Inhaler technique and adherence were good; thus we considered the anti-IgE treatment option [ 9 ]. Subcutaneous omalizumab was started, with fast improvement of both symptoms and QoL score (from 3.9 up to 6.5). Seventeen months later, the dose of ICS had been gradually tapered and oral montelukast definitely discontinued. Currently, at age 14, treatment includes the combined administration of bimonthly subcutaneous omalizumab and of daily inhaled salmeterol/fluticasone (50 μg/100 μg∙day - 1 , respectively). Asthma control is satisfactory and no side effects are reported. Omalizumab has been continuously administered for 2.6 years and is still ongoing.

A full-term male had severe preschool wheezing and, since age 3, recurrent, severe asthma exacerbations with acute respiratory failure that frequently required intensive care unit (ICU) admission. At age 6, sensitization to multiple perennial inhalant (i.e., house dust mites, dog and cat danders, Alternaria alternata , Graminaceae pollen mix, Artemisia vulgaris , Parietaria judaica , and Olea europaea pollen) and food allergens (i.e., egg, milk, and peanut) was diagnosed. Serum IgE levels were 2219 KU/l. Weight and height were appropriate for age and sex. The patient has been treated over 3 years with a combined scheme of high-dose inhaled fluticasone (up to 1000 μg/day) plus salmeterol (100 μg/day) and oral montelukast (5 mg/day), with correct inhaler technique and good adherence. Despite this, monthly hospital admissions with systemic steroids use were recorded. Rhinosinusitis and GER were excluded on the basis of appropriate testing; thus treatment with omalizumab was started when the patient was 9 years old. At age 11, adherence to treatment is satisfactory, with no side effects. More importantly, reduced hospital admissions for asthma exacerbations, no further need for systemic steroids, and improved QoL score (from 6.4 to 6.8) were reported. Finally, progressive step-down of anti-asthma treatment was started, and at present (by 11.5 years) inhaled fluticasone (200 μg/day) plus bimonthly subcutaneous omalizumab provide good control of symptoms. Omalizumab has been continuously administered for 2.6 years and is still ongoing.

A full-term male had severe preschool wheezing and, since age 4, recurrent, severe asthma exacerbations with frequent hospital admissions. At age 8, multiple perennial inhalants and food sensitization (i.e., house dust mites, dog dander, Graminaceae pollen mix, Olea europaea pollen, tomatoes, beans, shrimps, and peas) and high serum IgE levels (1166 KU/l) were found. The patient has been treated over 5 years with inhaled fluticasone (up to 1000 μg/day) in association with salmeterol (100 μg/day) and oral montelukast (5 mg/day). Despite this, monthly hospital admissions with systemic steroids need were recorded. After checking the inhaler technique and adherence to treatment, comorbidities including obesity, rhinosinusitis and GER were excluded. Omalizumab was proposed, but parents refused it. By 13.6 years, despite a treatment including the association of inhaled salmeterol/fluticasone (100 μg/1000 μg∙day − 1 , respectively) plus oral montelukast (10 mg/day), monthly exacerbations requiring systemic steroids are reported.

Discussion and conclusions

Most children and adolescents with asthma respond well to inhaled short-acting beta 2 -agonists (SABA) on demand if symptoms are intermittent, or to low dose controller drugs plus as-needed SABA if the risk of exacerbations increases [ 1 ]. Nevertheless, a proportion of patients is referred to specialists because this strategy is not working and asthma is persistently uncontrolled [ 4 ]. For these children, assessment is primarily aimed at investigating the reasons for poor control. Indeed, when the child is initially referred, before the label of “severe, therapy-resistant asthma” (i.e., not responding to treatment even when factors as exposure to allergens and tobacco smoke have been considered) is assigned, three main categories need to be identified: 1) “not asthma at all”, in which response to treatment is suboptimal because the diagnosis is wrong; 2) “asthma plus ”, when asthma is mild but exacerbated by one or more comorbidities; and 3) “difficult-to-treat asthma”, when asthma is uncontrolled because of potentially reversible factors [ 10 ].

The reported cases highlight some aspects of the disease process that may expand the diagnosis and improve patients’ care. At our institution, the severe asthma program includes a multidisciplinary approach with consultations by gastroenterologists as well as ear, nose and throat experts. Recently, sleep medicine experts joined this multidisciplinary team; thus, unfortunately, sleep-disordered breathing (SDB) could not be excluded at the time of our patients’ assessment. Inhalation technique is periodically evaluated by nurses or doctors in each patient. Unfortunately, in Italy an individual prescription database is not available and thus we cannot assess patients’ use of medication. In two cases, the filtering process eventually identified GER and rhinosinusitis, but poor control of asthma persisted even after comorbidities were treated. In all subjects, inhaler skills, treatment adherence, and environmental exposure to indoor/outdoor allergens as well as to second- and third-hand smoke were excluded as cause of lack of control. Eventually, three out of four patients started anti-IgE treatment; asthma control was obtained and maintenance drugs were progressively reduced. In the case that refused omalizumab therapy, pulmonary function, clinical features and controller treatment including high-dose ICS were unchanged.

Previous studies have highlighted an association between increasing asthma severity in children and reduced QoL [ 11 , 12 , 13 ]. Uncontrolled asthma symptoms not only affect children physically, but can impair them socially, emotionally, and educationally [ 13 ]. In line with previous observations, 3 out 4 of our cases had poor QoL, assessed by a standardized questionnaire [ 14 ]. It is well known that improving QoL in difficult asthma is not an easy task, despite a variety of treatments aimed at achieving control [ 12 ], and much more remains to be done to address the problem. Nevertheless, 2 of our 3 cases showed a remarkable improvement of QoL after one year of treatment with omalizumab.

Reduction in forced expiratory volume in the first second (FEV 1 ) is often used to define childhood asthma severity in treatment guidelines and clinical studies [ 5 , 11 , 15 ]. Nevertheless, children with severe asthma often have a normal FEV 1 that does not improve after bronchodilators, indicating that spirometry may be a poor predictor of asthma severity in childhood [ 6 , 16 , 17 ]. Actually, children with a normal FEV 1 , both before and after β 2 -agonist, may show a bronchodilator response in terms of forced expiratory flow between 25% and 75% (FEF 25–75 ) [ 18 ]. However, the utility of FEF 25–75 in the assessment or treatment of severe asthma is currently unknown. Interestingly, all the reported cases showed normal or slightly reduced values of FEV 1 but severe impairment of FEF 25–75 . Two cases showed a bronchodilator response in terms of FEV 1 (subjects 3 and 4), while 3 patients had a significant increase of FEF 25–75 (cases 1, 3 and 4). Unfortunately, we could not provide the results of bronchodilator response during or after the treatment with omalizumab in any case.

Available literature on the diagnostic approach to difficult asthma in children offers a number of reviews which basically summarize the steps needed to fill the gap between a generic diagnosis of “difficult asthma” and more specific labels (i.e., “severe” asthma, “difficult-to-treat” asthma, or even different diagnoses) [ 3 , 5 , 6 , 8 , 10 , 19 , 20 , 21 ]. So far, few original articles and case reports have been published, probably due to the peculiarity of the issue, which makes retrospective discussion of cases easier than the design of a prospective clinical study [ 4 , 22 , 23 , 24 , 25 , 26 ]. Available knowledge mainly derives from the experience of specialized centers.

The evaluation of a child referred for uncontrolled asthma should start with a careful history focused on typical respiratory symptoms and on the definition of possible triggers. In the “severe asthma” process, it is crucial for clinicians to maintain a high degree of skepticism about the ultimate diagnosis, particularly in the presence of relevant discrepancies between history, physical features and lung function, as many conditions may be misdiagnosed as asthma. In order to simplify this process, herein we propose an algorithm for the diagnosis of difficult-to-treat and severe asthma (Fig.  1 ). Confirmation of the diagnosis through a detailed clinical and laboratory re-evaluation is important because in 12–50% of cases assumed to have severe asthma this might not be the correct diagnosis [ 10 ]. Several documents have indicated the main steps of the process that should be followed in children with uncontrolled asthma [ 3 , 8 , 10 ]. The translation of these procedures into real life practice may deeply change from one subject to another due to the variability of individual patients’ history and clinical features, which will often lead the diagnostic investigations towards the most likely reason for uncontrolled asthma. For children with apparently severe asthma, the first step is to confirm the diagnosis and, before proceeding to broader investigations, to verify that the poor control is not simply determined by poor adherence to treatment, inadequate inhaler skills and/or environmental exposure to triggers. A nurse-led assessment, including a home visit, despite not being applicable in all settings, may be useful for identifying potentially modifiable factors in uncontrolled pediatric asthma [ 27 ].

A practical algorithm for the diagnosis of difficult-to-treat and severe asthma. ICS, inhaled corticosteroids; OCS, oral corticosteroids

A number of comorbidities have been increasingly recognized as factors that may impact asthma clinical expression and control in childhood [ 10 , 28 ]. Children with uncontrolled disease should be investigated for GER, rhinosinusitis, dysfunctional breathing and/or vocal cord dysfunction, obstructive sleep apnea, obesity, psychological factors, smoke exposure, hormonal influences, and ongoing drugs [ 3 , 6 , 8 , 20 ]. Indeed, the exact role played by comorbidities in pediatric asthma control is still debated [ 28 ]. The most impressive example is GER. Several pediatric documents recommend assessing for GER because reflux may be a contributing factor to problematic or difficult asthma [ 7 , 29 ]. Nevertheless, GER treatment might not be effective for severe asthma [ 30 , 31 ], as confirmed by current cases 1 and 2. There is an established evidence that chronic rhinosinusitis is associated with more severe asthma in children [ 32 , 33 , 34 ]. Therefore, examination of upper airways and ad hoc treatment if rhinosinusitis is evident are recommended in children with severe asthma [ 3 , 8 , 35 ]. However, intranasal steroids for rhinitis resulted in a small reduction of asthma risk in school-aged children [ 36 ], and actual placebo-controlled studies on the effect of treatment of rhinosinusitis on asthma control in children are lacking [ 10 , 37 ].

Dysfunctional breathing, including hyperventilation and vocal cord dysfunction, is associated with poorer asthma control in children [ 8 , 10 , 38 , 39 ]. Unfortunately, there is scarce literature on the effect of its treatment on the control of severe asthma in children [ 40 ]. SDB ranging from primary snoring to obstructive sleep apnea syndrome is very common in children [ 41 ], and an increased prevalence of SDB together with increasing asthma severity has been reported [ 42 ]. Interestingly, GER may also be worsened by recurrent episodes of upper airway obstruction associated with SDB, and this may further trigger bronchial obstruction. Asthma guidelines recommend the assessment of SDB through nocturnal polysomnography in poorly controlled asthmatics, particularly if they are also obese [ 5 ]. There are no studies examining whether pediatric asthma improves after SDB has been treated, for example, with nasal steroids, adenotonsillectomy, continuous positive airway pressure or weight reduction if the child is also obese [ 43 ]. The parallel increase in obesity and asthma suggests that the two conditions are linked and that they can aggravate each other [ 44 , 45 ], even though the exact mechanisms that underlie this association remain unclear [ 46 ]. Indeed, other coexisting comorbidities such as SDB or GER may play a confounding role in the development of the interactions between obesity and the airways [ 47 , 48 ]. Obesity is associated with increased markers of inflammation in serum and adipose tissue and yet decreased airway inflammation in obese people with asthma [ 49 ]. Several interventions, including behavioral and weight reduction programs or bariatric surgery, may result in improved asthma control, quality of life and lung function in adult obese asthmatics [ 50 ]. Although reports of adolescent bariatric surgery demonstrate a significant body weight decrease, this approach is not widely available and there are no published reports on its effect on pediatric severe asthma control [ 51 ]. Finally, although it is still unclear whether food allergy is causative or shares a common pathway with difficult asthma, it might explain the loss of asthma control at least in some children and thus be considered as a comorbid condition [ 10 , 16 , 52 ].

In conclusion, establishing the impact of comorbidities on asthma control may be cumbersome, and an ex-juvantibus treatment is sometimes necessary to assess their role. Comorbid conditions can also worsen each other, and symptoms arising from some of them may mimic asthma [ 6 ]. Although the ability to improve pediatric severe asthma by treating comorbidities remains unconfirmed, they should be treated appropriately [ 9 ].

The vast majority of asthmatic children exhibit a mild or at most a moderate disease that can be fully controlled with low-to-medium dose ICS associated or not with other controllers [ 5 , 6 ]. However, a subset of asthmatics remains difficult-to-treat [ 5 , 6 ]. With the advent of biologics, these severe steroid-dependent asthmatics have alternative options for treatment, as steroid-related adverse events are common in severe asthma [ 53 ]. Omalizumab, an anti-IgE monoclonal antibody, is the only biologic therapy recommended in children with moderate-to-severe asthma by the recent guidelines [ 5 , 6 ]. In Italy, this treatment is fully covered by the National Health System. Therefore, there is no influence by any funding on treatment decisions. It was approved by the US (Food and Drug Administration) in 2003 and by the European Union (European Medicines Agency) in 2005 as an add-on treatment for patients aged > 12 years with severe persistent allergic asthma and who have a positive skin test or in-vitro reactivity to a perennial aeroallergen, FEV 1  < 80% predicted, frequent daytime symptoms or nighttime awakenings, and multiple documented severe asthma exacerbations despite daily ICS plus a LABA [ 54 , 55 ]. In 2009, it also received approval in Europe for treating patients aged 6–12 years. Figure  2 illustrates current indications for treatment with omalizumab in children and adolescents with severe asthma.

Indications for omalizumab in children and adolescents with severe asthma

IgE antibodies, Th 2 -derived cytokines and eosinophils play a major role in the development of chronic airway inflammation in asthmatic subjects [ 56 ]. Once released from plasma cells, IgE binds principally to the high-affinity IgE receptor (FcεRI) on mast cells, triggering different effector responses, including the release of mediators leading to allergic inflammatory reactions [ 56 ]. The activation of the allergic cascade by IgE, under constant allergen stimulation, leads to the establishment of chronic allergic inflammation in the airways of asthmatic patients, with IgE being a key element of the vicious circle that maintains it. Cytokines produced during the late phase and subsequent chronic inflammation stage have been directly associated with the induction of airway remodelling, indirectly implicating IgE in the process [ 56 ]. At present, omalizumab is the only commercially available recombinant humanized anti-IgE monoclonal antibody that specifically binds serum free IgE at its CH 3 domain, in the proximity of the binding site for FcεRI, thus preventing IgE from interacting with its receptor on mast cells, basophils, antigen-presenting cells and other inflammatory cells [ 57 ]. The rapid reduction of free IgE levels leads to a downregulation of the FcεRI expression on inflammatory cells and an interruption of the allergic cascade, which results in the reduction of peripheral and bronchial tissue eosinophilia and of levels of granulocyte macrophage colony stimulating factor, interleukin (IL)-2, IL-4, IL-5, and IL-13 [ 58 ]. Moreover, basophils have a relevant role in the initiation and progression of allergic inflammation, suggesting that they may represent a viable therapeutic target. Indeed, in children with severe asthma, it has been reported that omalizumab therapy is associated with a significant reduction in circulating basophil numbers, a finding that is concurrent with improved clinical outcomes [ 59 ]. This finding supports a mechanistic link between IgE levels and circulating basophil populations, and may provide new insights into one mechanism by which omalizumab improves asthma symptoms.

Several clinical controlled and real-life studies of adults with severe, inadequately controlled allergic asthma have demonstrated the efficacy and safety of omalizumab in reducing asthma-related symptoms, corticosteroid use, exacerbation rates, and healthcare resource utilization, and in improving QoL and lung function [ 60 , 61 , 62 , 63 ]. Fewer studies have been published in children. In two double-blind, randomized, placebo-controlled trials (RCTs) of children aged 6 to 12 years with moderate-to-severe allergic asthma, treatment with omalizumab reduced the requirement for ICS and protected against disease exacerbations, but there was little change in asthma symptom scores or spirometry [ 9 , 64 ]. These findings were confirmed and extended in older children [ 65 , 66 , 67 ].

The results of the ICATA study, a multicenter RCT of 419 inner-city children, adolescents and young adults with persistent allergic asthma, showed that, compared to placebo, omalizumab reduces the number of days with asthma symptoms and the proportion of participants with at least one exacerbation by approximately 25% and 19%, respectively ( p  < 0.001), thus reducing the need for asthmatic symptom controllers [ 68 ]. Another multicenter RCT of inner-city children and adolescents showed that the addition of omalizumab to ongoing guidelines-based care before patients return to school reduces fall asthma exacerbations (odds ratio, 0.48), particularly in subjects with a recent exacerbation [ 69 ]. Moreover, in a real-life study of 104 children and adolescents with severe allergic refractory asthma followed over 1 year, treatment with omalizumab resulted in good asthma control in 67% of the cases ( p  < 0.001), while FEV 1 improved by 4.9% ( p  = 0.02) and exacerbation rates and healthcare utilisation decreased approximately by 30% ( p  < 0.001) [ 70 ]. The same authors also showed that, after two years of treatment, exacerbation rate and healthcare utilisation were further decreased by 83% and 100%, respectively, while level of asthma control, steroid use and lung function remained unchanged [ 71 ].

A systematic review of pediatric RCTs pooled the data of 1381 children and adolescents with moderate-to-severe allergic asthma in order to establish the efficacy of omalizumab as an add-on therapy [ 72 ]. During the stable-steroid phase, omalizumab decreased the number of patients with at least one exacerbation (risk ratio, 0.69; p  < 0.001), the mean number of asthma exacerbations per patient (risk ratio, 0.35; p  < 0.001), and the asthma symptom score (mean difference, 0.12; p  = 0.005) when compared to placebo. During the steroid reduction phase, omalizumab further reduced the number of patients with at least one exacerbation (risk ratio, 0.48; p  < 0.001) and the mean number of asthma exacerbations per patient (mean difference, 0.12; p  < 0.05).

Given the cost of omalizumab, many authors have argued for the importance of identifying specific asthma populations who will have significant benefit from it [ 68 , 73 , 74 ]. In the ICATA study, baseline predictors of good response to treatment were sensitization and exposure to cockroach allergen, sensitization to house dust mite allergens, a serum IgE level of more than 100 IU per milliliter, a BMI of 25 or more, and a history of at least one unscheduled medical visit in the previous year [ 68 ].

Several studies have assessed the long-term safety of omalizumab in children and adults. A pooled analysis of 67 RCTs conducted over 2 decades on 4254 children and adults treated with omalizumab showed no association between omalizumab treatment and risk of malignancy [ 75 ]. In an RCT evaluating 225 school-aged children, omalizumab was well tolerated, there were no serious adverse events, and the frequency and types of all adverse events were similar to the placebo group [ 9 ]. These results have been further confirmed by a recent systematic review of RCTs that concluded that treatment with omalizumab does not result in increased risk of malignancy or hypersensitivity reactions [ 72 ].

While the rationale for long-term treatment with omalizumab is supported by pharmacokinetic-pharmacodynamic models [ 76 ], the duration of treatment is still under discussion. Results from published studies suggest that omalizumab should be continued for > 1 year [ 77 , 78 ]. In a retrospective study of adults and children with uncontrolled severe asthma treated with omalizumab, the response to treatment was ‘excellent’ in 52.5% of patients, particularly in the subgroup of children aged 6 to 11 years [ 77 ]. After the discontinuation of treatment, loss of asthma control was documented in 69.2% of the patients who had received omalizumab for < 1 year, 59.1% of the subjects treated for 1–2 years, and 46.1% of the cases treated for > 2 years. Time to loss of control was shorter in younger children and longer in patients with an ‘excellent’ response compared with patients with a ‘good’ response. No early loss of control (within 6 months) was observed among patients with > 3.5 years of continuous treatment with omalizumab. Finally, 20% of patients in whom omalizumab was re-prescribed because of loss of control did not respond to the treatment anymore [ 77 ]. Despite these encouraging findings, the impact of omalizumab on the natural history of severe asthma in children deserves to be further investigated by long-term studies that will also define the criteria and timing for discontinuing the treatment.

It is well known that asthma pharmacotherapy is effective in controlling symptoms and bronchial inflammation, but cannot affect the underlying immune response, thus leading to the possibility of symptom reappearance after its discontinuation [ 79 ]. In this scenario, allergen-specific immunotherapy (AIT) has been proposed as the only therapeutic method that can modulate the underlying immune pathophysiology in allergic asthma [ 80 ].

AIT is currently indicated in children and adults with mild-moderate allergic asthma that is completely or partially controlled by pharmacotherapy and with the evidence of a clear relationship between symptoms and exposure to a specific allergen [ 81 , 82 , 83 , 84 ]. However, according to recent guidelines, the efficacy of AIT in asthmatic subjects is limited, and its potential benefits must be weighed against the risk of side effects and the inconvenience and costs of the prolonged therapy [ 5 ]. Moreover, severe or uncontrolled asthma (regardless of its severity) is a major independent risk factor for non-fatal or even fatal adverse reactions, thus representing a contraindication for AIT [ 85 , 86 , 87 ]. Finally, children with severe asthma are often sensitized to multiple allergens, thus making AIT prescription even more complicated [ 88 ].

In subjects with uncontrolled and/or severe allergic asthma, a combination of omalizumab and AIT has been proposed [ 88 ]. Surprisingly, only a few studies have addressed this issue [ 89 , 90 , 91 , 92 ]. However, pre-treatment with omalizumab seems to improve the efficacy and tolerability of subcutaneous AIT in children and adults with severe allergic asthma both during omalizumab treatment and after its discontinuation [ 89 , 91 , 92 ]. Omalizumab has also been successfully used as a supplementary treatment to AIT in order to improve asthma control in children ≥6 years with severe persistent allergic asthma [ 90 ]. Given the scarcity of studies on AIT plus omalizumab in children with severe allergic asthma, further research is warranted to assess risks and benefits of the combined treatment.

Children with severe asthma require a detailed and individualized approach including re-assessment for differential diagnoses, comorbidities and contributory factors, environmental triggers, lung function and inflammation, adherence and response to therapy, and QoL. Treatment of pediatric severe asthma still relies on the maximal optimal use of corticosteroids, bronchodilators and other controllers recommended for moderate-to-severe disease. However, the management of asthma is becoming much more patient-specific, as more and more is learned about the biology behind the development and progression of asthma.

In the current paper, we described the characteristics of four children with severe asthma in whom omalizumab was prescribed. A review of the relevant literature on the topic was also performed. Finally, we provided an algorithm for the diagnosis of difficult-to-treat and severe asthma in children and adolescents, based on the evidence from the literature review. As all algorithms, it is not meant to replace clinical judgment, but it should drive physicians to adopt a systematic approach towards difficult and severe asthma and provide a useful guide to the clinician.

The addition of omalizumab, the first targeted biological treatment approved for asthma, has led to renewed optimism of outcome improvements in patients with allergic severe asthma. As severe asthma is a heterogeneous condition consisting of different phenotypes, the future of asthma management will likely involve phenotypic and potentially even genotypic characterization in selected cases in order to determine appropriate therapy and thus to provide the highest possible benefit, especially if specific responder phenotypes can be identified and selected for this highly specific treatment.

Abbreviations

Anti-immunoglobulin E

Body mass index

IgE receptor

Forced expiratory flow between 25% and 75%

Forced expiratory volume in the first second

Gastroesophageal reflux

Inhaled corticosteroids

Intensive care unit

Interleukin

Long-acting β 2 -agonist

Oral leukotriene receptor antagonist

Quality of life

Randomized controlled trials

Short-acting β 2 -agonists

Sleep-disordered breathing

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The authors gratefully thank Dr. Marco Maglione for his contribution in the clinical assessment of the described cases. Medical writing assistance was provided by Stephen Walters on behalf of City Hills Proofreading.

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Mirra, V., Montella, S. & Santamaria, F. Pediatric severe asthma: a case series report and perspectives on anti-IgE treatment. BMC Pediatr 18 , 73 (2018). https://doi.org/10.1186/s12887-018-1019-9

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Impact of Nurse-Led Asthma Intervention on Child Health Outcomes: A Scoping Review

Zainab al kindi.

1 School of Nursing and Midwifery, Trinity College Dublin, Ireland

2 College of Nursing, Sultan Qaboos University, Muscat, Oman

Catherine McCabe

Margaret mccann.

Given the leading role school nurses occupy within the school setting, they are often the most suited health care professionals to lead asthma programs. However, most school-based asthma programs have been conducted by researchers outside the school setting. Thus, we aim to determine what is currently known about the type of school nurse-led asthma intervention programs and their impact on children’s asthma-related outcomes. This article describes published literature on school nurse-led asthma intervention programs for the school-aged population using Arksey and O’Malley’s scoping review framework. A search strategy was developed and implemented in six electronic databases from 1980 to 2020. Results showed that school nurse-led asthma programs were predominantly educational interventions. Yet given the positive outcomes of school nurse-led asthma interventions reported across the articles reviewed, it is important to emphasize the leadership role school nurses assume in asthma programs, to promote more positive asthma-related outcomes in school children.

Asthma is the most common chronic condition among children, with more than a million children in the United Kingdom ( Asthma UK, 2020 ) and more than 6 million children in the United States living with asthma ( Zahran et al., 2018 ). Despite health care advancement, asthma prevalence and exacerbation rates continue to persist among children ( Global Initiative for Asthma [GINA], 2019 ). Children with asthma are at risk of disability, emotional problems, and poor academic outcomes ( Cicutto et al., 2013 ; Nurmagambetov et al., 2018 ). For chronic conditions such as asthma, management is achieved through medical intervention combined with self-care. As asthma is a lifelong disease, there is a demand to prioritize self-management strategies to promote positive outcomes and prevent asthma exacerbation ( Isik et al., 2020 ).

The National Association of School Nurses (NASN) defines school nursing as a specialized public health nursing field that protects and promotes student health, enables normal development, and promotes academic success ( NASN, 2016 ). In the school setting, school nurses are key players in asthma management. This is because they spend more time in contact with children in comparison to all other health care professionals, allowing them to develop a thorough knowledge of each child’s condition and promote self-management strategies. Additionally, their advocacy role in children’s care places them in an ideal position to identify high-risk children with asthma, plan for interventions, and evaluate programs’ effectiveness. The GINA guidelines support the implementation of effective asthma management programs for school-aged children. These programs include preventive asthma care that supports and guides school nurses’ effort to deliver asthma interventions for school communities. Consequently, school nurses focus on preventive care rather than caring for children when they are experiencing an asthma exacerbation ( Halterman et al., 2018 ).

The impact of asthma intervention programs on children’s health outcomes using various interventions has been consistently reported in the literature ( Grover et al., 2016 ; Horner et al., 2016 ; Kintner et al., 2015 ; Payrovee et al., 2014 ; Suwannakeeree et al., 2016 ). These interventions were delivered by research teams and required additional resources, that is, manpower and materials that could affect the sustainability of the intervention in a real-world setting. Nonetheless, several researchers found a significant improvement in school children’s quality of life (QoL; Payrovee et al., 2014 ), asthma management and risk reduction behavior ( Kintner et al., 2015 ), and in self-management behavior, asthma control, and asthma knowledge ( Suwannakeeree et al., 2016 ) following asthma intervention programs. Furthermore, other studies investigating similar interventions found fewer emergency room (ER) visits, less hospital admissions, better medication compliance, enhanced QoL, and improved asthma management self-efficacy ( Grover et al., 2016 ; Horner et al., 2016 ).

Implementing school nurse-led asthma intervention programs outside of the hospital setting enables students with asthma to learn about their condition, develop asthma self-management skills, and reduce school absence and missed class time ( Isik et al., 2020 ; Yoder, 2019 ). However, school-based asthma interventions are often conducted by researchers outside the school setting ( Isik et al., 2019 ). Thus, school nurses need to be emphasized as leaders of asthma programs in a school setting and should instead conduct these interventions. To our knowledge, the literature regarding school nurse-led asthma interventions has not been systematically reviewed or synthesized. Although Isik et al. (2019) explored the effectiveness of school and community-based educational intervention programs for school-aged children and their parents, none of the studies included school nurse-led intervention programs. The current review differed because it included school-based programs that were led by the school nurse. Therefore, the objective of this scoping review was to examine and map out what is currently known about the impact that school nurse-led asthma intervention programs have on child health outcomes by including solely school-based programs that were led by school nurses. This scoping review did not include any of the studies in the review done by Isik et al. (2019) .

Scoping reviews aim to identify and map the existing evidence in a specific area of research. Furthermore, they have a broader question and aim to identify research gaps in existing literature ( Arksey & O’Malley, 2005 ). As such, a scoping review methodology was used in this article to answer the following question: What is the impact of school nurse-led asthma education programs on child health outcomes? Furthermore, the review had the following objectives:

• Describe the types of school nurse-led asthma intervention programs that have been reported for the school-aged population, their impact on children’s asthma-related outcomes, and the role of school nurses in each program.
• Identify the research gaps in existing literature concerning aspects of school nurse-led asthma intervention programs, particularly educational interventions.

Inclusion/Exclusion Criteria

The population, exposure, and outcomes framework was employed to guide the selection of included studies and can be seen in Table 1 ( Bettany-Saltikov, 2012 ).

PEO Framework.

Note . Exclusion criteria: Studies with asthma interventions who were not school nurse-led and studies outside the school setting were excluded. Case management and infection prevention studies were also excluded. PEO = population, exposure, and outcomes; ER = emergency room.

Search Strategy

Six electronic databases were searched: Cumulative Index of Nursing and Allied Health Literature (CINAHL), PsychINFO, MEDLINE, Educational Resources Information Centre (ERIC), EMBASE, and Applied Social Sciences Index and Abstracts (ASSIA). The search was limited to articles published in the English language. The reference lists of the retrieved articles were examined but the manual search did not uncover additional eligible studies. The search was carried out between June and August 2020.

Search terms related to “asthma,” “school,” and “nurses” were adapted to maximize results from each database. These terms were combined with the Boolean operator (AND). The search strategy was designed in the CINAHL database and translated to other databases (see Table 2 ).

Search Strategy Index Terms Used in Databases.

Study Selection and Data Extraction Process

The literature review search was conducted in consultation with the university librarian. Figure 1 shows the process of study selection according to the Preferred Reporting Items for Systematic Review and Meta-Analyses guidelines. As shown, the initial database screening, which was conducted by one of the authors, resulted in 2,117 papers; 647 duplicates were removed leaving 1,470 to screen. A three-step process was followed to assess the inclusion/exclusion of articles. In the first step, screening of the title and abstracts was performed by one author using Covidence software extraction 2.0 (Covidence GmbH, Australia). Following a review of titles and abstracts, 19 papers went forward for full-text review. On the second step, the other two authors independently reviewed the full text of the 19 articles to determine alignment with the inclusion criteria. Of these, 12 studies were excluded because they focused on school nurse case management ( N = 5) and were not a school nurse-led intervention ( N = 7). Overall, seven studies were included in the review. There were no disagreements between the evaluators when selecting and extracting the data. The third step was to review the bibliography of the identified articles; no additional articles were identified.

Preferred Reporting Items for Systematic Review and Meta-Analyses flowchart.

Data from the included studies were extracted into an evidence table that included author, year, country, aim, design, population/sample, nature of the intervention, outcome assessed, results, and measurement tools (see Table 3 ).

Characteristics of the Included Studies.

Note . SN = school nurse; NA = not applicable; ER = emergency room. a Refer to level of evidence in Table 4 .

The purpose of this review was to identify the current evidence on the impact of school nurse-led asthma intervention programs. The school nurse’s role in the included studies varied between providing educational interventions for asthmatic children ( D. M. Carpenter et al., 2016 ; Isik et al., 2020 ; Persaud et al., 1996 ; Simoneau et al., 2020 ), supervising the administration of preventive asthma medication ( Harrington et al., 2018 ; Trivedi et al., 2018 ), and running a school asthma clinic ( Salisbury et al., 2002 ).

Study Characteristics

All included studies ( N = 7) discussed an asthma program led by a school nurse ( D. M. Carpenter et al., 2016 ; Harrington et al., 2018 ; Isik et al., 2020 ; Persaud et al., 1996 ; Salisbury et al., 2002 ; Simoneau et al., 2020 ; Trivedi et al., 2018 ). Furthermore, all reported at least one of the asthma health-related outcomes. The seven studies combined represented a total of 946 school-aged children and 15 school nurses. The sample size ranged from 25 to 490. The target population of the included studies was children alone ( D. M. Carpenter et al., 2016 ; Harrington et al., 2018 ; Isik et al., 2020 ; Salisbury et al., 2002 ; Trivedi et al., 2018 ), children with their parents ( Persaud et al., 1996 ), or children and school nurses (Simoneau et al., 2020). Notably, none of the studies included in this review indicated the qualification of the school nurses who led the interventions.

The intervention programs led by school nurses were conducted in the school setting. Six studies were conducted in the United States and one in the United Kingdom ( Salisbury et al., 2002 ). The research study designs used in the included studies were randomized controlled trials (RCTs; N = 4; Harrington et al., 2018 ; Isik et al., 2020 ; Persaud et al., 1996 ; Salisbury et al., 2002 ) or quasi-experimental designs ( N = 3; D. M. Carpenter et al., 2016 ; Simoneau et al., 2020 ; Trivedi et al., 2018 ). Table 4 shows the evidence level ( Melnyk & Fineout-Overholt, 2015 ). The discussion of studies in this review is grouped into the following categories: (1) school nurse asthma education intervention, (2) school nurse supervised asthma therapy, (3) school nurse asthma clinic, and (4) asthma health-related outcomes.

Melnyk Levels of Evidence.

School Nurse Asthma Education Intervention

Four studies evaluated school nurse-led asthma education programs with two being RCTs ( Isik et al., 2020 ; Persaud et al., 1996 ) and two quasi-experimental studies ( D. M. Carpenter et al., 2016 ; Simoneau et al., 2020 ). The format of the education programs varied to include structured educational sessions ( Isik et al., 2020 ; Persaud et al., 1996 ; Simoneau et al., 2020 ) and a tailored video program ( D. M. Carpenter et al., 2016 ). The asthma education session led by school nurses was delivered to a group of participants in a face-to-face setting (group format) in two studies ( D. M. Carpenter et al., 2016 ; Isik et al., 2020 ; Simoneau et al., 2020 ) and a one-on-one session (individual format) in two studies ( Persaud et al., 1996 ; Simoneau et al., 2020 ).

The participating school nurses in Persaud et al.’s (1996) study attended a 4-hr training session to improve their knowledge and skills before they delivered the education session to children. They received a theoretical session covering asthma pathophysiology, management strategy, and medication use. School nurses also received a practical demonstration on peak flow monitoring, inhaled medication, and the use of spacer devices. They were also introduced to the following educational strategies: how to communicate with the child, conduct interviews and role-plays, and provide positive reinforcement. Following the 4-hr training session, school nurses provided a weekly one-on-one, 20-min session for each child for 8 weeks. Children were taught asthma self-management principles and peak flow monitoring. Before the education sessions and following the consent process, children were randomly assigned to the intervention group ( N = 18) and the control group ( N = 18). Both groups had a preintervention appointment where they received a physical examination and pulmonary function test by a pediatrician. However, the intervention group received education sessions by the school nurse, while the control group received no education. There were two data collection points, at baseline and immediately following the 8-week session.

Similarly, D. M. Carpenter et al. (2016) provided a validated training program to school nurses before these school nurses delivered the education sessions to school children. However, D. M. Carpenter et al.’s (2016) study focused on the inhaler technique. School nurses watched a demonstration video on inhaler use by three children. Then, they viewed 18 incorrect inhaler techniques and used a certified respiratory therapist checklist to score each technique; thereafter, they received feedback on each video. After the training, school nurses recruited a convenience sample of seven asthmatic children (four elementary, two middle school, and one high school). Children demonstrated their inhaler technique and school nurses evaluated the demonstration using a checklist score. The children’s demonstrations were video-recorded and entered into a tailored video software program. Children then viewed a correct inhaler technique by one of the video characters of their choice (there were six characters with different genders and ethnicities). The children then watched their 1–2-min tailored video with systematic feedback on each step demonstrated. In addition, children were praised for each correct step with positive statements. One month later, school nurses asked children to demonstrate the inhaler technique and evaluated them by using the same validated checklist to score their technique. This was the only follow-up point after the intervention.

Simoneau and colleagues (2020) investigated the effectiveness of a five-element school nurse-led asthma management program in providing asthma care and reducing school absenteeism. In this study, the school nurse-led asthma intervention extended beyond a structured education program. Researchers trained 28 school nurses on five program elements (asthma risk assessment, control, education, medication, and communication) with the medical care provider. Once trained, school nurses conducted the five-element program in their school setting. They continued to enroll students throughout the two academic years (2015–2016 to 2016–2017). An area of concern in this study is that school nurses could choose elements to deliver based on a needs assessment of each student with asthma. This led to the limited implementation of specific elements such as communication with primary care providers where school nurses communicate concerns or ask questions to the child’s primary care provider. The most utilized element was the inhaler technique task. There were 102 students with asthma who completed two inhaler technique assessments over the 2 academic years: one at baseline and one at the end of the academic year.

Isik et al. (2020) investigated the effectiveness of a theoretically based school nurse-led asthma intervention on symptoms, asthma self-management with peak flow meter (PFM) usage, daily activities, and school absenteeism among elementary school children aged 7–12 years. Participants were randomly assigned to receive a school nurse-led asthma intervention (treatment N = 37) or usual care (control N = 36). The intervention group received a school nurse-led asthma group session over 6 weeks. Topics covered were (1) pathophysiology, (2) PFM, (3) symptom identification and asthma action plans, (4) medication and delivery devices, (5) triggers identification and prevention as well as breathing exercises, and (6) individualized discussion and self-management strategies. To improve class interaction, researchers utilized hands-on practice, problem-based learning, case studies, storytelling, role-plays, and class discussions. The treatment group received a PFM with a personal peak flowchart and a spacer. The control group received usual care, which refers to receiving their medication according to the action plan prescribed by the child’s doctor. Data collection took place three times: at baseline, 6 weeks, and 12 weeks.

School Nurse-Supervised Asthma Therapy

Two studies examined school nurse-supervised asthma therapy ( Harrington et al., 2018 ; Trivedi et al., 2018 ). In an RCT, Harrington et al. (2018) assessed school nurses’ administration of asthma therapy to students with persistent asthma ( N = 21) and its impact on asthma-related health outcomes. The school nurse administered a daily dose of the inhaled corticosteroids (ICS) every morning at school to those assigned to the intervention group ( n = 18). The clinician prescribed administration of ICS at home every evening of a school day, and every morning and evening during holidays. Parents did home medication administration. For the control group ( n = 25), the ICS doses were prescribed to be administered daily by parents at home every morning and evening for the 2-month study period. There were two data collection points: at baseline and 60 days after enrolment. Structured telephone follow-up interviews were conducted with parents to assess ICS doses and parental reported asthma symptoms and disability during the study period.

Similarly, Trivedi et al. (2018) investigated the outcome of health care utilization after a school nurse-supervised asthma intervention that included daily directly observed ICS medication administration. The difference in this study is that the school nurse administered both the morning (at 8:00 a.m.) and evening doses (at 2:00 p.m.) at school. There were 84 enrolled children with asthma. As part of the program, school nurses provided training to participants on the correct inhaler and spacer techniques, but there was no reporting on how often instructions were given or how often these skills were followed up on. There was a retrospective assessment of asthma-related ER visits, asthma-related hospital admissions, and school absenteeism 1 year before enrolment and 1 year after enrolment.

School Nurse Asthma Clinic

Salisbury et al. (2002) conducted an RCT of a nurse-run asthma clinic in four secondary schools. Asthmatic adolescents at these schools were randomly assigned to receive a review of their asthma status at school (school clinic group) or in general practice (GP; practice care group). The nurse-run asthma clinic took place weekly in each of the four schools. The school clinic group received the same care as the practice care group; however, the discussion was tailored to the needs and interests of adolescents. Follow-up was done at the school asthma clinic 1 month and 6 months after the initial assessment. Students in the control group were invited by their practice to attend an asthma review that could be provided by a practice nurse or a doctor, according to the usual practice.

Asthma-Related Health Outcomes

The focus of this scoping review is to discuss the available evidence in relation to the impact of school nurse-led asthma programs on children’s health-related outcomes. The measurement of different outcomes varied and was complex due to the incomplete data reported by some papers. The outcomes reported included: medication use, inhaler technique, and PFM use, symptoms, school absence, QoL, health care utilization, and asthma knowledge.

Medication use

Three studies evaluated medication usage among asthmatics in a school setting after a school nurse-led asthma program ( Harrington et al., 2018 ; Salisbury et al., 2002 ; Trivedi et al., 2018 ). Trivedi et al. (2018) found a significant decline in the number of asthma rescue medication (beta agonist) refills between the pre-and postintervention periods ( p < .001). Harrington et al. (2018) reported similar significant findings as the intervention group received 91.7% of the expected morning dose of ICS at school by the school nurse (that is more than the hypothesized percentage of 80%). Contrastingly, Salisbury et al. (2002) reported no significant differences in the number of adolescents prescribed ICS ( p = .89) or daily ICS use ( p = .60) following the implementation of a school nurse-led asthma program.

Inhaler technique and PFM use

Two studies assessed the inhaler technique among students with asthma ( D. M. Carpenter et al., 2016 ; Salisbury et al., 2002 ). D. M. Carpenter et al. (2016) evaluated a school nurse-led tailored video intervention to improve inhaler techniques among asthmatic children. The number of correct steps increased significantly from baseline after watching the video ( p = .03). Carpenter and colleagues reported that the steps children most commonly missed were exhaling normally before taking a deep breath, shaking their inhaler four to six times, and holding their breath for 10 s after inhaling the medicine. In this study, children significantly sustained inhaler technique at the 1-month follow-up. Likewise, adolescents with asthma in the intervention group demonstrated higher inhaler scores ( p < .001) than their peers randomized to the control group in the study by Salisbury et al. (2002) .

There was a lack of PFM assessment in the included studies with only two studies highlighting this outcome ( Persaud et al., 1996 ; Salisbury et al., 2002 ). Persaud et al. (1996) did not assess changes in PFM reading; however, they reported that knowing the baseline PFM reading facilitated decision making by school nurses on when to seek medical help or when to advise the child to use an inhaler. Salisbury et al. (2002) assessed PFM readings before and after the intervention, reporting no differences in PFM reading ( p = .36) between the groups.

Two studies assessed the impact of school nurse-led asthma programs on symptom frequency ( Isik et al., 2020 ; Salisbury et al., 2002 ). While Salisbury et al. (2002) reported no differences in the level of symptoms ( p = .42) for the intervention group (adolescents) attending a school nurse asthma clinic, Isik et al. (2020) reported a statically significant difference in asthma symptoms among the treatment group after a theoretically based school nurse-led asthma intervention ( p < .001).

School absence

The outcome of school absenteeism was measured using school records or self-reported data in six of the included studies ( Harrington et al., 2018 ; Isik et al., 2020 ; Persaud et al., 1996 ; Salisbury et al., 2002 ; Simoneau et al., 2020 ; Trivedi et al., 2018 ). Overall, these studies reported a reduction in the number of missed school days among school-aged children after the school nurse-led intervention. Persaud et al. (1996) reported that 5 months following an asthma education program delivered by school nurses, there was a decline in the number of missed school days, but there was no significant difference between the intervention and the control group (6.4 and 7.6 days, respectively). The same result was supported by Salisbury et al. (2002) and Trivedi et al. (2018) who also reported a nonsignificant decline in asthma-related school absence between students in the treatment and control group.

Simoneau et al. (2020) reported that students with asthma who engaged in a school nurse-led asthma program (easy breathing for schools) had a 25% reduction in their absenteeism rate compared to students without asthma who did not engage. This translated into three to four gained school days annually. Similarly, Isik et al. (2020) reported that school absence decline was not statically significantly different between groups ( p = .179), yet the treatment group missed fewer school days.

In our review, three studies examined QoL as an outcome ( Harrington et al., 2018 ; Persaud et al., 1996 ; Salisbury et al., 2002 ). Salisbury et al. (2002) assessed the differences in QoL among asthmatic adolescents assigned to the school clinic or GP care. There was no significant difference in the QoL score among the groups ( p = .63).

The study by Persaud et al. (1996) assessed child health locus of control using an instrument that measured children’s perception of the extent to which their health was primarily affected by their action versus outside forces. This study also assessed children’s feelings about themselves using an asthma attitude survey. While differences existed between the intervention and control group, these were not significant and would require a larger sample to approach significance.

Harrington et al. (2018) assessed multiple measures of QoL in terms of functional limitation, family adjustment, and medical interference. There were significantly less functional limitations ( p = .04), required adjustment to family life ( p = .03), and sleep loss due to asthma ( p = .04) after the school nurse-supervised asthma therapy. Overall, there was a statistically significant difference in QoL in the treatment group compared to the control group ( p < .001).

Health care utilization

The impact of school nurse-led asthma programs on health care use includes ER visits, unscheduled visits to physicians, and/or hospitalization. Out of the seven included studies, three studies explored the impact of a nurse-led asthma program on the number of ER visits ( Harrington et al., 2018 ; Persaud et al., 1996 ; Trivedi et al., 2018 ). Persaud et al. (1996) reported that the percentage of students who attended the ER due to an exacerbation of their asthma was significantly higher in the control group (50% N = 9) than the intervention group (22%, p ≤ .05). When the age of onset was controlled, however, the association between the number of ER visits per child and the educational intervention was not statistically significant.

Trivedi et al. (2018) also found a significant reduction in asthma-related health care utilization in a recent study. The authors reported a decrease in asthma-related ER visits and asthma-related hospitalization over a 1-year follow-up period after enrolment in a school nurse supervised asthma therapy. The ER visits declined 37.5% from the preintervention mean of 0.8 to a postintervention mean of 0.3 visits ( p < .001). Asthma-related hospital admission showed a significant decline as well from a preintervention mean of 0.3 admissions to a postintervention mean of 0 admissions ( p < .001). Contrastingly, Harrington et al. (2018) reported no difference in unscheduled ER visits or hospitalization as the school nurse-supervised asthma therapy was administered over 60 days.

Asthma knowledge among children and their parents

Only two studies in this review assessed the knowledge of children after an asthma program was delivered by a school nurse ( Persaud et al., 1996 ; Salisbury et al., 2002 ). Persaud et al. (1996) found that there was no statistically significant difference in the knowledge score among children ( p = .9) and their parents ( p = .54) after program implementation. This was the only study that addressed parent’s knowledge alongside children’s knowledge. In contrast, Salisbury et al. (2002) found that asthmatic students attending school clinics (treatment group) had a greater knowledge of asthma compared to students in the practice care group (control group; p = .001).

As has been illustrated, nurses play a leading role in the school setting, placing them in an optimal position to lead programs in asthma management. However, most school-based asthma programs were conducted by researchers outside the school setting; thus, highlighting a gap in the literature. We, therefore, aimed to determine what is currently known about the type of school nurse-led asthma intervention programs and their impact on children’s asthma-related outcomes by conducting a scoping review.

Types of School Nurse-Led Intervention Programs and Their Outcomes

Our scoping review found that school nurse-led asthma programs had a positive impact on children’s asthma health-related outcomes, which include medication use, reduction in school absenteeism, reduction in health care utilization, improved asthma knowledge, and QoL. The review findings are consistent with previous non-nurse-led intervention studies, which found that school-based asthma programs improved health outcomes and prevented complications ( Horner et al., 2016 ; Rasberry et al., 2014 ; Suwannakeeree et al., 2016 ). However, not all of the interventions contributed to significant results. Indeed, there was a mix of statistically significant and nonsignificant findings. For example, only one study reported a significant reduction in asthma symptoms following the intervention ( Isik et al., 2020 ), and one study found a significant difference in QoL postintervention ( Harrington et al., 2018 ).

The review highlighted a positive impact on medication adherence and, therefore, symptom frequency among children. This positive impact was not significantly prominent among adolescents in Salisbury et al.’s (2002) study. This could be due to adolescents’ reluctance to go to the GP as recommended by the school nurse who advised participants who needed drug changes or delivery devices to contact their GP. The results in this study corroborate Persaud et al.’s (1996) findings of younger children being more vulnerable to visit the ER due to their asthmatic symptoms and are more likely to benefit from school nurse-led asthma programs; thus, indicating the significance of preventive health earlier in life. Ismaila et al. (2013) who systematically reviewed asthma burden in Canada emphasized this trend. They reported that rates of health care utilization outcomes (ER visits, hospitalization, and physician visits) are higher among children with asthma <18 years old.

The frequency and accuracy of medication administration through medication delivery devices to either prevent symptoms or for quick episode relief are important indicators of asthma management. The review reported a weakening of inhaler technique skills as early as 1 month after receiving education on best practice inhaler technique skills. This illustrates how improper inhaler technique is a major problem among asthmatic children ( Román-Rodríguez et al., 2019 ). Suwannakeeree et al. (2016) made this point and noticed that the rate of ICS use among children with asthma at 6 months after the intervention was fewer than at 3 months after the intervention. While GINA guidelines recommended that inhaler technique should be assessed at every visit, this is challenging. One way of improving the inhaler technique is through systematic-standardized teaching by health care providers ( Simoneau et al., 2020 ). As seen in this review, the studies varied regarding the number of follow-ups conducted, that is, some studies collected data in two separate occasions (one follow-up), while other collected data in three separate occasions (two follow-ups). School nurses are in the best position to conduct periodic skill assessment to prevent skill deterioration and promote the sustainability of learning.

As asthma is strongly linked to school absenteeism, studies supported school nurses’ role in reducing school absence among students with chronic conditions ( Johnson et al., 2019 ; Moricca et al., 2013 ; Rodriguez et al., 2013 ). The American Academy of Pediatrics Council recommended establishing a relationship with school nurses to improve chronic condition management ( Council on School Health, 2016 ). This is because school nurses play a proactive role in preventing school absence among younger children with asthma. In line with this, our review stressed the essential role the school nurse plays in preventing school absence among students with asthma. Despite reporting nonsignificant findings due to the small sample size, short assessment period, and variation in absence recording, the five included studies that investigated school absence reported a trend in the declining number of missed school days after the school nurse-led intervention, regardless of the intervention type. Furthermore, an important point to consider when assessing the asthma burden on school absence is the consideration of students’ and parents’ reports, as well as school health records ( Johnson et al., 2019 ).

Addressing asthma knowledge among children and their parents is an important determining factor of asthma management. Our results demonstrated that educating parents and children was a major component of school nurse-led asthma interventions. The National Heart, Lung, and Blood Institute highlights the importance of involving children and their parents in asthma management ( National Institutes of Health, 2012 ; van Bragt et al., 2015 ). However, in this review, only two studies examined asthma knowledge outcomes, one among children only and one among children and their parents. Despite being nonsignificant, the parent knowledge score showed an improvement ( Persaud et al., 1996 ). Several school-based non-nurse-led asthma education programs addressed asthma knowledge among children and their parents ( Grover et al., 2016 ; Horner et al., 2016 ; Kintner et al., 2015 ; Payrovee et al., 2014 ; Suwannakeeree et al., 2016 ). These studies showed improved knowledge scores postintervention. Agusala et al. (2018) recommended involving parents in asthma programs and indicated that parents reported increased knowledge in managing asthma symptoms and triggers. It is, therefore, clear that parents’ education was also associated with a reduction in health care utilization ( Agusala et al., 2018 ). It is important to note that asthma knowledge can be improved through educational programs; however, knowledge improvement does not necessarily reflect an improvement in care practice.

It could be argued from our review that the consistency and sustainability of the intervention is a challenge. Trivedi et al. (2018) reported that relying on the school infrastructure and the existing school nurse service promoted the sustainability and reproducibility of the intervention. However, it should be noted that school nursing services are not available across the globe. This requires asthma intervention programs to be developed for school personnel such as schoolteachers. A systematic review by Coelho et al. (2016) emphasized such a trend by highlighting that asthma educational activities should include the whole school community. Hence, students, teachers, and school staff can recognize disease symptoms and management strategies ( Coelho et al., 2016 ). While schoolteachers play an essential role in implementing school policies, the literature showed that their asthma knowledge was suboptimal ( Lucas et al., 2012 ; Rodríguez Fernández-Oliva et al., 2010 ). To address such issues, some asthma education programs were developed for teachers in England, Italy, and the United States ( Brooten et al., 2008 ; Goei et al., 2010 ; McWhirter et al., 2008 ). Also, a review by Al Aloola et al. (2014) discussed this point and reported that relying on nonhealth care personnel, such schoolteachers, to deliver asthma interventions may seem more sustainable; however, teachers’ limited time and training on asthma education could represent a challenge ( Al Aloola et al., 2014 ). Similarly, Suwannakeeree et al. (2016) included five teachers in an asthma training program and supported that enhanced asthma knowledge among teachers provided them with an awareness of the child’s condition and enabled them to support children to manage their asthma symptoms.

Our review highlighted supervised asthma medication administration in school settings as a form of a school nurse-led asthma intervention. Salazar et al. (2018) emphasized that school-supervised asthma therapy improves asthma outcomes. Although successfully implemented, they suggested that medication administration by school nurses causes an uncompensated workload for school nurses ( Salazar et al., 2018 ). Schools with limited nursing services can establish a system to maintain the administration of preventive asthma medications as seen in Halterman et al.’s (2018) study, where an asthma care coordinator who received additional asthma training was appointed to assist the school nurse in communicating with the physician, families, and school. This role promotes a therapeutic relationship between the school nurse and schoolchildren; thus, facilitating ongoing monitoring and education. An additional strategy that may help to reduce school nurse workload while implementing such programs is the electronic linkage between the hospital health record and school electronic health record, so that the school nurse is aware of any change in the treatment plan.

School-Based Intervention Versus Nurse-Led Intervention

Many studies described school-based interventions targeting children, and these interventions showed improvement in asthma outcomes ( Cicutto et al., 2013 ; Grover et al., 2016 ; Payrovee et al., 2014 ; Perry et al., 2018 ; Szefler et al., 2018 ). However, these programs are sometimes short-term, delivered by research teams, or require additional resources such as manpower or materials that could affect the sustainability of the intervention. Asthma intervention programs should be developed in schools to sensitize the school and community to self-management practice in the long run ( Coelho et al., 2016 ). To enable practice sustainability and maintain asthma self-management skills, school nurses need to be involved in planning, implementing, evaluating, and leading the intervention ( L. Carpenter et al., 2013 ; Isik et al., 2020 ). School nurses are leaders in the development of programs, policies, and procedures provided to students in the school system ( NASN, 2016 ). Therefore, at the policy development and implementation level, school nurses act as change agents to promote the concept of self-management of chronic conditions such as asthma. Accordingly, school nurse-led programs are of particular importance to achieve sustainable evidence-based practice nursing care by creating a linkage between schools, hospitals, and home ( L. Carpenter et al., 2013 ). As studies in this review did not elaborate on school nurses’ extent of involvement in intervention design, further research is needed to compare child health outcomes when asthma interventions are developed by school nurses versus implemented or led by school nurses.

School Nurses’ Training Needs

The NASN framework for 21st Century School Nursing Practice includes leadership as one of the domains. Through school nurse-led interventions, school nurses contribute to the health and well-being of the students ( Hoekstra et al., 2016 ) as well as to their academic development ( Yoder, 2019 ). For school nurses to lead asthma interventions, there is a demand to assess their training needs to strengthen their competency. Ongoing education for school nurses based on a theoretical framework is recommended. Yet there is a dearth of qualitative studies that identify the training needs of school nurses in competency-based education programs ( Shin & Roh, 2020 ).

In summary, different school nurse-led asthma interventions carried out in schools can improve child health outcomes. Training of school nurses specifically support positive practice sustainability at a reduced cost ( L. Carpenter et al., 2013 )

Overall, this scoping review found that school nurse-led asthma intervention programs had a positive impact on children’s asthma-related outcomes. Several limitations identified in this review should be considered when planning a school nurse-led asthma program in the future. First, the included studies did not explore the effect a school nurse-led asthma program had on several other outcomes such as the number of exacerbations and asthma severity. Second, the dearth of evaluation strategies of school nurse-led programs requires investigation. It is not possible to draw a firm conclusion on the impact of a school nurse-led asthma program without an in-depth evaluation of such outcomes and a longer follow-up period of each outcome. Third, the wide variations in sample size, measurement tools, and the nature of school nurse-led asthma programs in the studies reviewed require a more rigorous type of research designed to better illustrate how nurse-led asthma programs are beneficial in reducing asthma-related outcomes. Most interventions included in our review were short-term, individual programs that lasted 1 year or consisted of four or less sessions. This reduced the impact of school nurse-led interventions or limited the opportunity to reinforce the instructions. Finally, the sustainability of interventions is influenced by the degree to which school nursing services are available, as the partnership between the clinical system (clinical setting) and the public system (school setting) promotes long-term asthma outcomes sustainability. Thus, the school nurse, as a member of an interprofessional team, can act as a linkage between the health sector and the educational sector. This provides an important insight that should be further explored in future research. Taken together, the findings highlighted in this review provide important practical implications in terms of ensuring the effectiveness of school nurse-led intervention programs addressing asthma among school-aged children. Thus, these insights can guide the future development and implementation of such programs, led by nurses, which will ensure positive asthma-related outcomes.

Author Biographies

Zainab AL Kindi , RN, MSN, PhD, is a candidate at School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Catherine McCabe , RN, MSN, PhD, is an associate professor at School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Margaret McCann , RN, MSN, PhD, is an assistant professor at School of Nursing and Midwifery, Trinity College Dublin, Ireland.

Author Contributions: Zainab Al kindi contributed to the conception and design of the paper, analysis, and interpretation of the data, drafting and revising the final version of the manuscript to be published, and agreed to be accountable for all aspects of the work. Catherine McCabe contributed to the conception and design of the paper, analysis, and interpretation of the data, drafting and revising the final version of the manuscript to be published, and agreed to be accountable for all aspects of the work. Margaret McCann contributed to the conception and design of the paper, analysis, and interpretation of the data, drafting and revising the final version of the manuscript to be published, and agreed to be accountable for all aspects of the work.

Declaration of Conflicting Interests: The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding: The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iD: Zainab Al Kindi, RN, MSN, PhD https://orcid.org/0000-0002-7028-4606

Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the  National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

• Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
• Methacholine challenge: PC 20 : 1.0 mg/mL
• Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

• Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
• Sinus CT: Mild mucosal thickening
• Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
• Immunoglobulin E (IgE): 25 IU/mL
• Allergy-skin test: Positive for dust, trees
• Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

• Esophagram/barium swallow: Negative
• Esophageal manometry: Negative
• Esophageal impedance: Within normal limits
• ECG: Within normal limits
• Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2  One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2  The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5  Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2  A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty  Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was  the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10  In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10  Shortly after the AIR trial, the  Research in Severe Asthma (RISA) trial  was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11  In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11  Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2  trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6  Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6  In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6  Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both  the AIR  and  the AIR-2  trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12  Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12  This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7  This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

• 1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
• 2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
• 3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
• 4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
• 5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
• 6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
• 7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
• 8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
• 10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
• 11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
• 12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

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