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Prepared for your next patient.

Pediatric Asthma
Evaluation &
Management

Bradley E. Chipps, MD, FAAP

Capital Allergy & Respiratory
Disease Center
Sacramento, CA
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Disclaimers
Statements and opinions expressed are those of the authors
and not necessarily those of the American Academy of
Pediatrics.

Mead Johnson sponsors programs such as this to give

healthcare professionals access to scientific and educational
information provided by experts. The presenter has complete
and independent control over the planning and content of the
presentation, and is not receiving any compensation from Mead
Johnson for this presentation. The presenters comments and
opinions are not necessarily those of Mead Johnson.In the event
that the presentation contains statements about uses of drugs
that are not within the drugs' approved indications,Mead
Johnson does not promote the use of any drug for indications
outside the FDA-approved product label.
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Definition of Asthma
A chronic inflammatory disease of the airways
with the following clinical features:
Episodic and/or chronic symptoms of airway
obstruction
Bronchial hyperresponsiveness to triggers
Evidence of at least partial reversibility of the
airway obstruction
Alternative diagnoses are excluded
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Diagnosis
1. History
2. Pulmonary function tests (PFTs)
3. Challenge studies
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WheezingAsthma?
Wheezing with upper respiratory infections
is very common in small children, but:
Many of these children will not develop
asthma.
Asthma medications may benefit patients who
wheeze whether or not they have asthma.

All that wheezes is not

asthma.
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CoughAsthma?
Consider asthma in children with:
Recurrent episodes of cough with or without
wheezing
Nocturnal awakening because of cough
Cough that is associated with exercise/play
Cough without wheeze is often not asthma

Cough may be the only

symptom
present in patients with
asthma.
Goldsobel AB, Chipps BE. Cough in the pediatric population. J Pediatr. 2010;156(3):352358
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Asthma Predictive Index

Identify high risk children (2 and 3 years
of age):
4 wheezing episodes in the past year
(at least one must be MD diagnosed)

One major PLUS Two minor

criterion OR criteria
Parent with asthma Food sensitivity
Atopic dermatitis Peripheral
Aero-allergen eosinophilia
sensitivity (4%)
children with recurrent wheezing. Am J Respir Crit Care Med. 2000;162(4 Wheezing not
Modified from: Castro-Rodriguez JA, Holberg CJ, Wright AL, et al. A clinical index to define risk of asthma in young
Pt 1):14031406

related to
infection
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Objective Evaluation of Asthma

Physical examination
Pulmonary function
Bronchoprovocation
Validated control tools
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Defining Asthma Severity and

Control
1) 04 years
2) 511 years
3) 12 years and older
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How Can Asthma Control Be Measured?

Inflammation? Lung
Daytime
function?
Direct or indirect? symptom
s?
Utilization
of Nighttime
healthcare awakening
resources? Asthma s?
Use of
Function Control quick
al relief
status? inhaler
and/or
Missed work Patient self- nebulizer?
and/or report of
school?
Asthma control control?
test is a trademark of QualityMetric Incorporated.
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Asthma Control Cannot be Assessed

35 at a Single Time Point
30
% of Patients

25

20

15

10

0
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15-19 20-24 25+

Number of Changes Over

Approximately one-third of Weeks 112 and pediatric subjects had 15 or more
both adult
changes in their asthma severity classification based upon peak expiratory flow
Chipps BE, Span JD, Sorkness CA, et al. Variability in asthma severity in pediatric subjects with asthma previously
(PEF)
receiving short-acting beta2-agonists. during
J Pediatr. the 12-week studies.
2006;148(4):517521; Calhoun WJ, Sutton LB, Emmett A, et al.
Asthma variability in patients previously treated with beta2-agonists alone. J Allergy Clin Immunol.
2003;112(6):10881094
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Classifying Asthma Severity and

Initiating
Treatment in Children 0 to 4 Years of Age

Adapted from: National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the
Diagnosis and Management of Asthma. US Department of Health and Human Services. Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed July 5, 2012
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Assessing Asthma Control and Adjusting

Therapy in Children 0 to 4 Years of Age

Adapted from: National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the
Diagnosis and Management of Asthma. US Department of Health and Human Services. Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed July 5, 2012
Test for Respiratory and Asthma
TM

Control in Kids (TRACK)

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Stepwise Approach for Managing Asthma

in Children 0 to 4 Years of Age

Adapted from: National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the
Diagnosis and Management of Asthma. US Department of Health and Human Services. Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed July 5, 2012
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Classifying Asthma Severity and Initiating

Treatment in Children 5 to 11 Years of Age
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Assessing Asthma Control and Adjusting

Therapy in Children 5 to 11 Years of Age
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Childhood Asthma Control Test

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Stepwise Approach for Managing Asthma

in Children 5 to 11 Years of Age

Adapted from: National Asthma Education and Prevention Program. Expert Panel Report 3 (EPR-3): Guidelines for the
Diagnosis and
Management of Asthma. US Department of Health and Human Services. Available at:
http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.pdf. Accessed July 5, 2012
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Classifying Asthma Severity and Initiating

Treatment in Youth 12 Years of Age and
Adults
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Assessing Asthma Control in Children

12 Years of Age and Adults
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Asthma Control Test (ACT)

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Stepwise Approach for Managing Asthma

in Children 12 Years of Age and Adults
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Infants and Young Children

When to Start Controllers
>3 episodes of wheezing in the last year, and
Parental history of asthma or physician diagnosis
of eczema
Or 2 of the following:
Physician diagnosis of allergic rhinitis, wheezing apart
from colds, peripheral eosinophilia
Courses of oral steroids more often than every 6
weeks
Symptoms >2 times per week, nocturnal symptoms
>2 times per month
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Step-down Therapy
Step down once control is achieved:
After 23 months
25% reduction over 23 months

Follow-up monitoring:
Every 16 months
Assess symptoms.
Review medication use.
Objective monitoring (PEF or spirometry)
Review medication.
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Step-up Therapy
Indications: Symptoms, need for quick-
relief medication, exercise intolerance,
decreased lung function
May need a short course of oral steroids.
Continue to monitor.
Follow and reassess every 16 months
Step down when appropriate.
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Phenotypic Expressions of Childhood

Wheezing Disorders
1. Viral induced wheezing
2. Severe intermittent wheezing
3. Exercise bronchospasm/asthma
4. Persistent asthma
5. Severe asthma
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Viral Induced Wheezing

1. Triggered by viral infections
2. Non-atopic
3. Remission in childhood
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Infants
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Intermittent Inhaled Corticosteroids (ICS)

in Infants with Episodic Wheezing
Single randomized double-blind study
N=411 infants with a 3-day history of wheezing
Infants treated with budesonide 400 g/d or
placebo for 2 weeks
Primary outcome variables were:
Number of symptom free days
Number of days free from rescue medication use
Number of episodes
Number of treatments with open label
budesonide
Bigaard H, Hermansen MN, Loland L, et al. Intermittent inhaled corticosteroids in infants with episodic
wheezing. N Eng J Med. 2006;354(19):19982005
 Intermittent ICS in Infants:
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Withdrawal Due to Persistent Wheezing

50
Percentage of Children Withdrawn
Because of Persistent Wheezing 40

30
Budesonide

20
Placebo

10 P=0.41

0
0 100 200 300 400 500 600 700 800 900
Days after Randomization
No. at Risk

Budesonide 149 115 78 27

Placebo 145 114 92 27

Progression from episodic to persistent wheezing. Results were not

significant.
Bigaard H, Hermansen MN, Loland L, et al. Intermittent inhaled corticosteroids in infants with episodic wheezing. N Eng J Med.
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Role of Viral Infections

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Rhinovirus (RV) Wheezing versus

Respiratory Syncytial Virus (RSV)
Wheezing in
First 3 Years of Life and Asthma at 6
Years of Age

Jackson DJ, Gangnon RE, Evans MD, et al. Wheezing rhinovirus

illnesses in early life predict asthma development in high-risk
children. Am J Respir Crit Care Med. 2008; 178(7):667672
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Forced Expiratory Volume in 1 Second

(FEV1)
Percent Predicted
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RV Infections and the Development of

Asthma
RV infections can produce more than upper
airway illnesses during infancy.
Children who develop asthma by 6 years of
age have a significantly increased burden of
viral wheezing illnesses in early life.
Pulmonary function abnormalities at 6 years
of age are most significantly associated with
early childhood wheezing illnesses due to RV
(not RSV).
Of all outpatient wheezing viral illnesses in
early life, those due to RV are most
significant.
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Oral Prednisolone for Preschool Children

with Acute Virus-induced Wheezing
Randomized, double-blind, placebo-controlled trial comparing a 5-day
course of oral prednisolone (10 mg daily for children 1024 months and 20
mg daily for older children) versus placebo in 700 children between the
ages of 10 and 60 months.

No difference in 7-day symptom scores, albuterol use, or readmission

Panickar J, Lakhanpaul
Primarily non-atopic and 60%M, Lambert
first PC, et al.
time Oral prednisolone for
wheezers
preschool children with acute virus-induced wheezing. N Engl J
Med. 2009;360(4):329338
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Severe Intermittent
Wheezing
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Acute Intermittent Management

Strategies (AIMS)Primary
Hypothesis
In young children with recurrent severe
wheezing, intervention with an ICS or
leukotriene receptor antagonist (LTRA) at the
onset of respiratory tract illness (RTI)-
associated symptoms will increase the
proportion of episode-free days over a 12-
month period compared with conventional
therapy.*
*Conventional therapyinhaled bronchodilator followed by the sequential
addition of systemic
corticosteroids
 Preschool Children TM

with Moderate-to-Severe Intermittent

Acute IntermittentWheezing
Management Strategies (AIMS)
Study Overview
At first sign of RTI symptoms x 7 days

Budesonide 1 mg bid+ Placebo LTRA + -agonist

Run in Randomization Montelukast 4 mg daily + Placebo ICS + -agonist

Placebo LTRA + Placebo ICS + -agonist

Randomized, multicenter, double-blind, placebo-controlled 1 year trial

238 children, 1259 months, with recurrent episodes of intermittent
wheezing
2 episodes in the previous year
2 urgent care visits, 2 oral steroid courses, or 1 of each
Primary outcome = episode free days
Secondary outcomes = symptoms scores during illnesses and oral
corticosteroids
Bacharier (OCS)
LB, Phillips BR, Zeiger RS, et use
al. Episodic use of an inhaled corticosteroid or leukotriene receptor antagonist in
preschool children with moderate-to-severe intermittent wheezing. J Allergy Clin Immunol. 2008;122(6):11271135
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1 OutcomeMean Proportion of
Episode Free Days

Proportion of episode free days adjusted for age group, API status, center
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Maintenance versus Intermittent

Inhaled
Steroids in Wheezing Toddlers
1. 12 month(MIST) Study
R, DB, active control: 278
children
(1253 months)
2. 4 episodes of wheezing last year:
Positive mAPI
1 episode: OCS, emergency
department, urgent care or
hospital
3. Primary outcome: Exacerbation with
OCS
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Run-in: 2
Treatment Phase: 52 weeks
weeks
Randomized Nightly, During
except RTIs only
Pbo run-in Treatment Group during RTI for 7 days
nightly + Daily low dose 0.5 mg PM Pbo AM
budesonide
Albuterol 0.5 mg
PRN PM
Intermittent high Pbo PM 1.0 mg
dose budesonide AM

1.0 mg
PM
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MIST Study
1. Exacerbations 0.95/patient year; p=0.6
2. Similar time to first exacerbation; p=0.87
3. No difference in treatment failures or
episode free days
4. Height=0.26 cm average difference;
weight=0.16 Kg average difference
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Diagnosis of Exercise-
induced Bronchospasm
(EIB) / Exercise-induced
Asthma (EIA)
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EIA TherapyGeneral Principles

EIA may reflect suboptimally controlled
asthma, which may require adjustment of
overall therapy of asthma.
Goal: Facilitate normal activity levels,
including competitive sports.
Individualize therapy.
Child needs to understand and be a
partner in therapy.
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Diagnosis of EIB
Normal PFT at rest
No other stimulus for bronchospasm
Most common in allergic rhinitis patients
Dx: 10% decrease FEV1 after 8 minutes of
exercise at 90% maximum predicted
heart rate
Rx: B-agonist before exercise, LTRA daily
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Diagnosis of EIA
Normal or obstructive PFT at rest
Patient has other stimuli for asthma
symptoms.
Patient has both inflammatory and
bronchospasm component.
Dx: Same criteria
Rx: ICS, LTRA, ICS/long-acting beta
antagonist (LABA) daily, B-agonist before
exercise
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Persistent Asthma
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Multicentre Allergy Study (MAS)

1. Birth cohort: 1314
13-year follow up: 441 (33.6% all visits)
No wheeze 1st year: 315 (74%)
2. Early wheezers: 126
No wheeze (413 years): 79 (68%)
Initial wheeze: 43 (34%)
Persistent wheeze: 4 (3%)
3. Wheeze 36 years: 40 (13%)
4. Wheeze 613 years: 42 (13%)
Matricardi PM, Illi S, Grber C, et al. Wheezing in childhood: incidence, longitudinal patterns and factors
predicting persistence. Eur Respir J. 2008;32(3):585392
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The Prevalence of Wheezing Varies

Depending on Age and Atopic Status
P re va le n c e ( % )

80 A to p i c (n =9 4 )
N o n - a to p i c ( n = 5 9 )
70

60

50

40

30

20

10

0
1 2 3 4 5 6 7 8 9 10 11 12 13

A g e ( ye a r s )
Illi S, von Mutius E, Lau S, et al. Perennial allergen sensitisation early in life and chronic asthma in children: a
birth cohort study. Lancet. 2006;368(9537):763770
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Time of Sensitization and Degree of

Exposure to Indoor Allergens and Lung
Function Impairment at 7 Years of Age
1 20 1 15
1 15 1 10
p =0 .0 0 9 p =0 .0 0 3
1 10
1 05
1 05
1 00
1 00
95
95
90
90
85
85
80
80
75 75

70 70
0 0
N S S / L E S / HE N S S / LE S / HE N S S / L E S / HE N S S / L E S / HE

FE V 1 M E F50 FE V 1 M E F50
(% p red ) ( % p r ed ) (% p red ) ( % p r ed )

Illi S, von Mutius E, Lau S, et al. Perennial allergen sensitisation early in life and chronic asthma in children: a birth cohort
study. Lancet. 2006;368(9537):763770
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Melbourne Epidemiological Study

Phelan PD, Robertson CF, Olinsky A. The Melbourne Asthma Study: 1964-1999. J Allergy Clin Immunol.
2002;109(2):189194
 A Longitudinal, Population-based,
Cohort Study
TM

of Childhood Asthma Followed to

Adulthood

Sears MR, Greene JM, Willan AR, et al. A longitudinal population-based, cohort study of childhood asthma followed to
adulthood. N Engl J Med. 2003;349(15):14141422
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ICS Therapy in Preschool Children

Multicenter, double-blind, randomized placebo
controlled study designed to determine if ICS
therapy can modify the subsequent
development of asthma in high risk children
Children with a positive asthma predictive
index (23 years of age, N=285) treated with
either fluticasone 88 g BID or placebo for 2
years followed by a year of observation
Primary outcome variable: Proportion of
episode
Guilbert free
TW, Morgan WJ, Zeiger RS, days
et al. Long-term inhaled corticosteroids in preschool children at high risk for
asthma. N Engl J Med. 2006; 354(19):19851997
Fluticasone Had No Carryover Effect TM

During the Observation Period

p=0.006 p=0.78
Proportion of Episode-free Days 1.00

0.95 Fluticasone

Placebo
0.90

0.85

0.80

0.75
0.00
0 2 4 6 8 10 12 14 16 18 20 22 24 26 28 30 32 34 36
Months
Treatment Period Observation Period

The increase in symptom free days in the fluticasone cohort during the
treatment period was
lost in the 12 months subsequent during the observation period.
 TM

The Need for Oral Corticosteroids

All Children Children Not Receiving
Supplementary Medication
Observati
No Need for a First course

on
Treatme Observatio
of Prednisolone (% of

100 100
nt n
75 Fluticasone
75
children)

Placebo

50 50 Fluticasone
Placebo
25 25

0 0
0 6 12 18 24 30 36 0 24 26 28 30 32 34 36
Months Months
No. at Risk No. at Risk

Fluticasone 143 102 80 66 57 42 Fluticasone 132 88

Placebo 142 87 62 57 50 41 Placebo 130 85

 TM

The Need for Supplementary Controller

Meds:
Asthma-Controller Medication

No Difference at 36 months
No Need for Supplementary

100 100 Fluticasone Fluticasone

(% of children)

75 75
Placebo Placebo
50 50

25 25

0 0
0 6 12 18 24 30 36 0 24 26 28 30 32 34 36
Months No. at Risk
Months
No. at Risk
Fluticasone 132 111
Fluticasone 143 131 118 116 113 99

Placebo 130 105

Placebo 142 125 103 99 93 86

The fluticasone group had less of a need for supplementary medications

during the treatment period (p<0.01). By the end of the observation
period (36 months), the
groups were indistinguishable (P=0.99)
 TM

Changes in Height from Baseline and

Between Groups

Difference in Height Change

between Fluticasone and
Change in Height from

Placebo Groups (cm)

20 0
Baseline (cm)

15
-0.5
10
-1.0
5

0 -1.5
0 10 20 30 0 10 20 30
Months Month 1 4 8 12 16 20 24
28 32 36
81 7 00
1 01 01 01 01 001 .00
3
08
0. . 0 .0 0.0 0.0 . 0 . 0 0. 0 0 .0
0 0 < < <0 <0 <
P value
Change in height from baseline represented by the panel on the left. The difference
between
groups with associated p-values represented on the right. At the end of 24 months
the fluticasone group averaged 1.1 cm less than the placebo group. At the end of
the observation period
(36 months) the difference between groups was 0.7 cm.
 TM

Summary and Clinical Implications

Based on the results of the Prevention of
Early Asthma in Kids (PEAK) study:

ICS are effective in improving asthma-like

symptom burden, exacerbations, and lung
function in high risk toddlers.

Continuous ICS therapy for 2 years once

discontinued does not modify the natural
history of asthma in early childhood.
 TM

START
INHALED STEROID TREATMENT
AS REGULAR THERAPY
IN EARLY ASTHMA
The Worlds Largest Study
in Asthma Therapy
Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a
randomised, double-blind trial. Lancet. 2003;361(9363):10711076
 TM

Primary Study Objective and Primary

Variables
Examines effect of early intervention with ICS
on evolution of newly diagnosed asthma
Primary outcome:
Time to first severe asthma-related event (SARE)
during first 3 years of study
A severe event requiring hospitalization or
emergency treatment due to worsening of asthma
or death due to asthma
Secondary outcome:
Change in postbronchodilator FEV1
Intent to treat analysis
Pauwels RA, Busse WW, OByrne PM, et al. The inhaled Steroid Treatment as Regular Therapy in early asthma (START)
study: rationale and design. Control Clin Trials. 2001;22(4):405419
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Double-blind (Part A) and

Open-label (Part B) Design
Part A Pulmicort
Adults therapy
Pulmicort 400 g Part B: Open-label
once daily + usual
Children (610therapy
asthma y of age) Adults
Pulmicort 200 g once Pulmicort 400 g
daily once daily + usual
+ usual asthma therapy asthma therapy
Part A Reference Children (610 y of age)
therapy
Adults and Pulmicort 200 g once
Children daily
Placebo once daily + usual asthma
+ usual asthma therapy therapy

Year 0 1 2 3 4 5
Visit1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
16 17 18 19 20 21 22
 TM

Cumulative Probability Time to First SARE

44% (95% CI, 2955%) reduced risk of
first SARE*
0.10
Budesonide therapy
0.08 Reference therapy

0.06

0.04
0.02

0.00
0 1 2 3
*Hazard ratio = 0.56; P<.0001.
Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a
randomised, double-blind trial. Lancet. 2003;361(9363):10711076
 TM

Patients Requiring Additional

Corticosteroids*

*Inhaled, oral, or systemic

Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a
randomised, double-blind trial. Lancet. 2003;361(9363):10711076
 TM

Changes in Postbronchodilator FEV1

Over 3 Years

Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a
randomised, double-blind trial. Lancet. 2003;361(9363):10711076
 TM

Early Intervention with Budesonide in

Mild Persistent Asthma

Sullivan SD. Early intervention with budesonide in mild persistent

asthmathe START study. Presented at the European Respiratory
Society (ERS). Stockholm, Sweden, 2002
 TM

Early Intervention with Budesonide in

Mild Persistent Asthma
Budesonide therapy reduces the risk of a
severe asthma exacerbation by 44% in
patients with mild persistent asthma.
Daily treatment with low dose budesonide
decreases the need for oral corticosteroids
in mild persistent asthma.
Budesonide daily improves asthma control
More symptom free days
Less additional asthma medication
Pauwels RA, Pedersen S, Busse WW, et al. Early intervention with budesonide in mild persistent asthma: a randomised,
double-blind trial. Lancet. 2003;361(9363):10711076
 TM

BADGER Trial
 TM

BADGER Trial
1. 182 children (617 years of age),
uncontrolled asthma, FP 100 g BID,
triple crossover design,
16-week period
2. FP 250 g BID
FP 100 g + SALM 50 g BID
FP 100 g BID + MTL 5 or 10 mg daily
3. 3 outcomes
Exacerbations
Symptom free days
FEV1 (Pre)
Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving
inhaled corticosteroids. N Engl J Med. 2010;362:975985
 TM

Primary Predictors of a Differential

Response to Step-up Therapy

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving inhaled
corticosteroids. N Engl J Med. 2010;362:975985
 TM

Primary Predictors of a Differential

Response to Step-up Therapy

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving inhaled
corticosteroids. N Engl J Med. 2010;362:975985
 TM

Secondary Predictors of a Differential

Response to Step-up Therapy

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children
with uncontrolled asthma receiving inhaled corticosteroids. N Engl J Med.
2010;362:975985
 TM

Enrollment, Outcomes, and Schedule

of Evaluations

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled asthma receiving inhaled
corticosteroids. N Engl J Med. 2010;362:975985
 TM

Pairwise Comparisons

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled
asthma receiving inhaled corticosteroids. N Engl J Med. 2010;362:975985
 TM

Probability of Best Response

Lemanske RF, Mauger DT, Sorkness CA, et al. Step-up therapy for children with uncontrolled
asthma receiving inhaled corticosteroids. N Engl J Med. 2010;362:975985
 TM

Severe Asthma
 TM

Severe Asthma
Refractory
Difficult to control asthma
Uncontrolled asthma refractory to
conventional treatment
Frequent exacerbations
? Distinct phenotype or subgroup
 TM

Reasons for Failure to Achieve

Control
Compliance
Asthma heterogeneity
Wrong diagnosis
Wrong target
Failure to deliver drug to the target site
 TM

Demographic and clinical

characteristics of children
and adolescents with severe or
difficult-to-treat asthma
 TM

TENOR Study Design

3-year, multi-center, observational study
Patients continued to receive medications
and treatments administered for their
asthma as indicated by their physician.
4,756 patients enrolled between January
and October 2001
6 years of age or older
283 sites across the US
Dolan CM, Fraher KE, Bleecker ER, et al. Design and baseline characteristics of The Epidemiology and Natural
History of Asthma: Outcomes and Treatment Regimens (TENOR) study: a large cohort of patients with severe or
difficult-to-treat asthma. Ann Allergy Asthma Immunol. 2004; 92(1):3239
 TM

Objectives
Primary objective
Describe the natural history of patients
considered by physicians to have severe
or difficult-to-treat asthma.
Secondary objectives
Examine relationship between features of
asthma, treatments, and outcomes.
Observe frequency of comorbid
conditions.
Examine the relationship between
immunoglobulin and disease.
 TM

Methods
Cross-sectional baseline data analyzed
TENOR patients between 6 and 17 years of age
included (N=1,261)
Patients categorized into 4 age groups by
gender: Males Females Total
Age group (N=791) (N=470) (N=1,261)
(years) n (%) n (%) n (%)
6-8 145 (18) 88 (19) 233 (18)
9-11 282 (36) 120 (26) 402 (32)
12-14 240 (30) 171 (36) 411 (33)
15-17 124 (16) 91 (19) 215 (17)
Chipps BE, Szefler SJ, Simons FE, et al. Demographic and clinical characteristics of children and adolescents with
severe or difficult-to-treat asthma.
J Allergy Clin Immunol. 2007;119(5):11561163
 TM

Spirometry by Age and Gender

Chipps BE, Szefler SJ, Simons FE, et al. Demographic and clinical
characteristics of children and adolescents with severe or
difficult-to-treat asthma. J Allergy Clin Immunol.
2007;119(5):11561163
 TM

Medication Use by Age

*Based on test for linear trend, a statistically significant age trend (P <.05) was seen for methylxanthines and long-a
Chipps BE, Szefler SJ, Simons FE, et al. Demographic and clinical
characteristics of children and adolescents with severe or
difficult-to-treat asthma. J Allergy Clin Immunol.
2007;119(5):11561163
 TM

Healthcare Utilization by Long-term

Controller Use:
611 and 1217 Years of Age

Chipps BE, Szefler SJ, Simons FE, et al. Demographic and clinical
characteristics of children and adolescents with severe or
difficult-to-treat asthma. J Allergy Clin Immunol.
2007;119(5):11561163
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SummaryPredicting Persistence of
Wheezing
1. Family history of asthma
2. Recurrent lower airway symptoms in infancy
3. Absence of nasal symptoms at 1 year
4. Atopic sensitization before 4 years and early
exposure
5. Eczema
6. Exposure to ETS
7. Females
8. Acetaminophen ?
9. Vitamin D ?
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Thank You
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