Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
H. Makrinioti and V. Fainardi contributed equally to the manuscript.
Eur Respir J. 2024 Sep 5;64(3). doi: 10.1183/13993003.00624-2024. Print 2024 Sep.
Since the publication of the European Respiratory Society (ERS) task force reports on the management of preschool wheezing in 2008 and 2014, a large body of evidence has accumulated suggesting that the clinical phenotypes that were proposed (episodic (viral) wheezing and multiple-trigger wheezing) do not relate to underlying airway pathology and may not help determine response to treatment. Specifically, using clinical phenotypes alone may no longer be appropriate, and new approaches that can be used to inform clinical care are needed for future research. This ERS task force reviewed the literature published after 2008 related to preschool wheezing and has suggested that the criteria used to define wheezing disorders in preschool children should include age of diagnosis (0 to <6 years), confirmation of wheezing on at least one occasion, and more than one episode of wheezing ever. Furthermore, diagnosis and management may be improved by identifying treatable traits, including inflammatory biomarkers (blood eosinophils, aeroallergen sensitisation) associated with type-2 immunity and differential response to inhaled corticosteroids, lung function parameters and airway infection. However, more comprehensive use of biomarkers/treatable traits in predicting the response to treatment requires prospective validation. There is evidence that specific genetic traits may help guide management, but these must be adequately tested. In addition, the task force identified an absence of caregiver-reported outcomes, caregiver/self-management options and features that should prompt specialist referral for this age group. Priorities for future research include a focus on identifying 1) mechanisms driving preschool wheezing; 2) biomarkers of treatable traits and efficacy of interventions in those without allergic sensitisation/eosinophilia; 3) the need to include both objective outcomes and caregiver-reported outcomes in clinical trials; 4) the need for a suitable action plan for children with preschool wheezing; and 5) a definition of severe/difficult-to-treat preschool wheezing.
自 2008 年和 2014 年欧洲呼吸学会(ERS)工作组发布有关学龄前喘息管理的报告以来,大量证据表明,所提出的临床表型(发作性(病毒)喘息和多触发喘息)与潜在的气道病理学无关,可能无法帮助确定治疗反应。具体来说,仅使用临床表型可能不再合适,需要新的方法来为未来的研究提供临床护理信息。该 ERS 工作组审查了 2008 年后发表的与学龄前喘息相关的文献,并建议用于定义学龄前儿童喘息障碍的标准应包括诊断年龄(0 至<6 岁)、至少一次确认喘息,以及曾经有过一次以上喘息发作。此外,通过确定可治疗的特征,包括与 2 型免疫相关的炎症生物标志物(血液嗜酸性粒细胞、过敏原致敏)和对吸入性皮质类固醇的不同反应、肺功能参数和气道感染,可改善诊断和管理。然而,更全面地使用生物标志物/可治疗特征来预测治疗反应需要前瞻性验证。有证据表明,特定的遗传特征可能有助于指导管理,但这些特征必须经过充分的测试。此外,该工作组确定缺乏针对该年龄组的照顾者报告的结果、照顾者/自我管理选择以及应提示专科转诊的特征。未来研究的重点包括:1)确定驱动学龄前喘息的机制;2)可治疗特征的生物标志物和无过敏致敏/嗜酸性粒细胞增多患者干预措施的疗效;3)在临床试验中需要同时包括客观结果和照顾者报告的结果;4)需要为患有学龄前喘息的儿童制定合适的行动计划;5)定义严重/难以治疗的学龄前喘息。