Covar Ronina A, Szefler Stanley J, Zeiger Robert S, Sorkness Christine A, Moss Mark, Mauger David T, Boehmer Susan J, Strunk Robert C, Martinez Fernando D, Taussig Lynn M
Department of Pediatrics, National Jewish Medical and Research Center and University of Colorado Health Sciences Center, Denver, Colo.
Department of Pediatrics, National Jewish Medical and Research Center and University of Colorado Health Sciences Center, Denver, Colo.
J Allergy Clin Immunol. 2008 Oct;122(4):741-747.e4. doi: 10.1016/j.jaci.2008.08.021.
Asthma exacerbations are a common cause of critical illness in children.
To determine factors associated with exacerbations in children with persistent asthma.
Regression modeling was used to identify historical, phenotypic, treatment, and time-dependent factors associated with the occurrence of exacerbations, defined by need for oral corticosteroids or emergency or hospital care in the 48-week Pediatric Asthma Controller Trial study. Children age 6 to 14 years with mild-to-moderate persistent asthma were randomized to receive either fluticasone propionate 100 microg twice daily (FP monotherapy), combination fluticasone 100 microg AM and salmeterol twice daily, or montelukast 5 mg once daily.
Of the 285 participants randomized, 48% had 231 exacerbations. Using a multivariate analysis, which included numerous demographic, pulmonary, and inflammatory parameters, only a history of an asthma exacerbation requiring a systemic corticosteroid in the past year (odds ratio [OR], 2.10; P < .001) was associated with a subsequent exacerbation during the trial. During the trial, treatment with montelukast versus FP monotherapy (OR, 2.00; P = .005), season (spring, fall, or winter vs summer; P < or = .001), and average seasonal 5% reduction in AM peak expiratory flow (OR, 1.21; P = .01) were each associated with exacerbations. Changes in worsening of symptoms, beta-agonist use, and low peak expiratory flow track together before an exacerbation, but have poor positive predictive value of exacerbation.
Children with mild-to-moderate persistent asthma with previous exacerbations are more likely to have a repeat exacerbation despite controller treatment. Inhaled corticosteroids are superior to montelukast at modifying the exacerbation risk. Available physiologic measures and biomarkers and diary card tracking are not reliable predictors of asthma exacerbations.
哮喘急性发作是儿童危重症的常见病因。
确定持续性哮喘儿童急性发作的相关因素。
在一项为期48周的儿童哮喘控制试验研究中，采用回归模型来识别与急性发作相关的既往史、表型、治疗及时间依赖性因素，急性发作定义为需要口服糖皮质激素或急诊或住院治疗。将6至14岁的轻至中度持续性哮喘儿童随机分组，分别接受每日两次100微克丙酸氟替卡松（氟替卡松单药治疗）、每日上午100微克氟替卡松联合每日两次沙美特罗或每日一次5毫克孟鲁司特治疗。
在随机分组的285名参与者中，48%的人出现了231次急性发作。采用多变量分析，纳入了众多人口统计学、肺部及炎症参数，结果显示仅过去一年有因哮喘急性发作而使用全身糖皮质激素的病史（比值比[OR]，2.10；P <.001）与试验期间随后的急性发作相关。在试验期间，孟鲁司特治疗与氟替卡松单药治疗相比（OR，2.00；P =.005）、季节（春季、秋季或冬季与夏季相比；P ≤.001）以及上午呼气峰值流速平均季节性降低5%（OR，1.21；P =.01）均与急性发作相关。在急性发作前，症状恶化、β受体激动剂使用及呼气峰值流速降低的变化是同步的，但对急性发作的阳性预测价值较差。
既往有急性发作史的轻至中度持续性哮喘儿童，尽管接受了控制治疗，仍更有可能再次急性发作。在改变急性发作风险方面，吸入性糖皮质激素优于孟鲁司特。现有的生理指标、生物标志物及日记卡记录均不是哮喘急性发作的可靠预测指标。
