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Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
Asthma phenotypes in young children
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Asthma phenotypes in young children

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Asthma phenotypes in young children …

Asthma phenotypes in young children

Presented by Jaichat Mekaroonkamol, MD.

April11, 2014

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  • 1. Asthma Phenotypes Jaichat Mekaroonkamol, MD. In young children
  • 2. ©2014 MFMER | slide-3 1970’s 1980’s 1990’s present Bronchospasm Bronchospasm + Inflammation Bronchospasm + Inflammation + Remodeling T cell Eosinophil Th-2 IL-5 / IL-13 Th17 Dendritic cells CHEST 2013; 144(3):1026–1032. Asthma Timelines
  • 3. ©2014 MFMER | slide-4 Our understanding of asthma continues to increase overtime Bronchoconstriction Airway Hyperesponsiveness Inflammation and remodeling Phenotypes and genetics
  • 4. What Is a “Phenotype” Henderson J et al. Arch Dis Child. 2009 • Phenotype: Any observable characteristic of an individual that is influenced by genetic and environmental factors • Clinical relevance: May reflect causal pathways specific to subgroups of patients with asthma, may lead to improved management and Help to predict prognosis
  • 5. Natural history and Pathophysiology Inception • Genetics • Allergens • Infections Progression • Inflammation • Bronchospasm • Remodeling Exacerbations • Lung functions Stanley J. Szefler. J Allergy Clin Immunol 2014;133:3-13.)
  • 6. Clinical relevance Diagnosis Management Prognosis
  • 7. Diagnosing Asthma GINA 2011 Clinical features • Nocturnal • Exercise • Go to the Chest Pulmonary Function test • Spirometer: FEV1 • Peak Expiratory Flow:PEF Probability Confirm DX
  • 8. • Asthma, which typically begins in childhood and occurs throughout life • Major burden from asthma that persists into adult life • Many different „„phenotypes‟‟ that are associated with variable disease courses. Presentation of asthma Stanley J. Szefler. J Allergy Clin Immunol 2014;133:3-13.)
  • 9. Presentation of asthma
  • 10. Presentation of asthma Does my child have asthma?
  • 11. Key symptom indicators Middleton ed 8th .
  • 12. Not all wheeze is asthma
  • 13. Martinez FD, et al. N Engl J Med 1995
  • 14. Wheezing phenotypes Renato T Stein. Thorax 1997;52:946-52. • Newborn infants between May 1980 and October 1984 • A total of 1246 children were initially enrolled • 11 years follow up Tucson study
  • 15. Wheezing phenotypes No wheezing in first 6 years of birth 51.5% Renato T Stein. Thorax 1997;52:946-52.
  • 16. Wheezing phenotypes Renato T Stein. Thorax 1997;52:946-52.
  • 17. Wheezing phenotypes J Henderson. Thorax 2008;63:974–980 • Birth to 7 years from 6265 children • Longitudinal birth cohort • the ALSPAC study • 14,541 pregnant women AVON study
  • 18. Wheezing phenotypes J Henderson. Thorax 2008;63:974–980
  • 19. Wheezing phenotypes TUCSON study, 1997 • Never(51%) • Transient early wheezers (20%) •Wheezed first 3 years •Resolved by 6 years • Persistent wheezers(14%) •Wheezed first 3 years •Still present at 6 years •Late-onset wheezers(15%) •Wheezed after 3 years of age •Still wheeze at 6 years AVON study, 2001 •Never(51%) • Transient (16%) • Persistent (7%) • Intermediate(3%) •Late-onset (15%) • Prolonged early(9%)
  • 20. Wheezing phenotypes AVON study, 2001 •Never(51%) • Transient (16%) • Persistent (7%) • Intermediate(3%) •Late-onset (15%) • Prolonged early(9%) TUCSON study, 1997 • Never(51%) • Transient early wheezers (20%) •Wheezed first 3 years •Resolved by 6 years • Persistent wheezers(14%) •Wheezed first 3 years •Still present at 6 years •Late-onset wheezers(15%) •Wheezed after 3 years of age •Still wheeze at 6 years
  • 21. • Recurrent bronchial obstruction (rBO) defined as recurrent (at least two episodes) doctor- diagnosed wheeze • Asthma from 2–10 years and 10–16 years, defined as at least two episodes of doctor-diagnosed asthma,symptoms and medication use, Eur Respir J 2013; 41: 838–845
  • 22. Asthma diagnosis and relapse rate Eur Respir J 2013; 41: 838–845 1/3 9%
  • 23. Wheezing phenotypes Basic of classification Examples of clinical features Symptoms • Age at onset • Natural history/disease course • Severity Triggers • Viruses • Exercise • Allergens AAIAT Annual Meeting 2014 Common clinical elements that define phenotypes in pediatric asthma
  • 24. Trigger-Based Pediatric Phenotypes Virus-induced asthma Exercise-induced asthma Allergen-induced asthma Stanley J. Szefler. J Allergy Clin Immunol 2014;133:3-13.)
  • 25. Virus-induced asthma • Most common presentation of asthma in early life • 90% of children younger than 3 years with acute wheezing • HRV • RSV • Influenza virus • Metapneumovirus Stanley J. Szefler. J Allergy Clin Immunol 2014;133:3-13.)
  • 26. Virus-induced asthma M.L. Garcı´a-Garcı´a, PhD. Pediatric Pulmonology 45:585–591 (2010)
  • 27. Virus-induced asthma M.L. Garcı´a-Garcı´a, PhD. Pediatric Pulmonology 45:585–591 (2010)
  • 28. Virus-induced asthma M.L. Garcı´a-Garcı´a, PhD. Pediatric Pulmonology 45:585–591 (2010)
  • 29. Virus-induced asthma: RSV Stéphane A. Régnier, Pediatr Infect Dis J 2013;32: 820–826.
  • 30. Virus-induced asthma: RSV Stéphane A. Régnier, Pediatr Infect Dis J 2013;32: 820–826.
  • 31. Virus-induced asthma: HRV Daniel J. Jackson, Am J Respir Crit Care Med, 2008 *P , 0.05 vs. Neither +P , 0.05 vs. RSV only COAST study 259 child followed prospectively from birth
  • 32. Virus-induced asthma: HRV Tuomas Jartti & Matti Korppi, Pediatr Allergy Immunol 2011; 22: 350–355.
  • 33. Virus-induced asthma: HRV YoshimichiOkayama, Frontiers in Microbiology, 2013
  • 34. Virus-induced asthma: HRV • Airway edema • Hypersecretion • Bronchospasm YoshimichiOkayama, Frontiers in Microbiology, 2013
  • 35. Viral infection and Atopic Development Renato T Stein, Lancet 1999; 354: 541–45
  • 36. Viral infection and Atopic Development Serum IgE SPT Renato T Stein, Lancet 1999; 354: 541–45
  • 37. Viral infection and Atopic Development Jartti T, Kuusipalo H, Pediatr Allergy Immunol 2010; 21: 1008–1014 62% 12% 15% Rhino virus RSV Entero virus Boca virus Other virus ≥ 2 virus No virus Sensitization 32% 9% 0%Atopic eczema • Aeroallergen sensitization (respectively; 4.18; 2.00, 8.72) • Food allergen sensitization (respectively2.02; 1.08, 3.78)
  • 38. Virus-induced asthma The risk of asthma after viral LRI is increased in the presence of allergic sensitization in early life and if the infection is more severe Atopy-associated mechanisms also appear to be involved in viral-induced acute exacerbations of asthma Peter D. Sly, J Allergy Clin Immunol 2010; 125:1202-5
  • 39. Trigger-Based Pediatric Phenotypes Virus-induced asthma Exercise-induced asthma Allergen-induced asthma Stanley J. Szefler. J Allergy Clin Immunol 2014;133:3-13.)
  • 40. Exercise -induced asthma • Exercise: a common trigger of symptoms – Affects up to 90% of children with asthma – May occur with other triggers • Loss of water and heat from airway appears to initiate pathologic/proinflammatory response to exercise. •Cysteinyl leukotrienes and other eicosanoids from mast cells and eosinophils perpetuate the underlying inflammatory processes Mayoclinic, 2011
  • 41. Exercise -induced asthma Inflammation and irritation of airways Broncho constriction Overcooling of airways Dry of airways Mechanic irritation of airways Mayoclinic, 2011
  • 42. Exercise -induced asthma Typical pattern of EIA. • Patients often experience improvement in lung function during exercise. • Exercise-induced asthma does not fully manifest until after exercise Expert Rev Clin Immunol, 2009
  • 43. Exercise -induced asthma Duke University Health System
  • 44. Trigger-Based Pediatric Phenotypes Virus-induced asthma Exercise-induced asthma Allergen-induced asthma Stanley J. Szefler. J Allergy Clin Immunol 2014;133:3-13.)
  • 45. Allergens -induced asthma Kerstin Gerhold, AACI 2007
  • 46. Lancet, 2006; 368: 763–70 • The German Multicentre Allergy Study followed 1314 children from birth to 13 years of age • 90% of children with wheeze but no atopy lost their symptoms at school age and retained normal lung function at puberty. • Sensitisation to perennial allergens (eg, house dust mite, cat and dog hair) developing in the first 3 years of life was associated with a loss of lung function at school age
  • 47. ≤3 yr ≤5 yr The chronic course of asthma characterised by airway hyper- responsiveness and impairment of lung function at school age is determined by continuing allergic airway inflammation beginning in the first 3 years of life. on lung function at age 7 years Lancet, 2006; 368: 763–70
  • 48. Allergens -induced asthma CACI 2010; 23:180-182
  • 49. Allergens -induced asthma Daniel J. Stoltz, Clin Exp Allergy, 2014 AR
  • 50. Allergens -induced asthma • Sensitization to perennial allergens was more strongly associated with asthma risk • cat, dog, cockroach, D.p., D.f., Alternaria alternata • sensitization to seasonal allergens was more closely associated with rhinitis risk. • ragweed, silver birch, timothy grass Daniel J. Stoltz, Clin Exp Allergy, 2014
  • 51. Allergens -induced asthma Daniel J. Stoltz, Clin Exp Allergy, 2014
  • 52. Allergens -induced asthma Dog exposure at birth was associated with a reduced risk of asthma, regardless of dog sensitization status during the first 6 years of life (p = 0.05). Daniel J. Stoltz, Clin Exp Allergy, 2014
  • 53. Wheezing phenotypes Brand, Eur Respir J, 2008
  • 54. Wheezing phenotypes Brand, Eur Respir J, 2008
  • 55. A Schultz, Acta Pædiatrica 2010 • 132, 2–6 year old • doctor diagnosed asthma and on maintenance inhaled steroids (fluticasone) • followed up at three-monthly intervals for a year • Initial (retrospective) classification • EVW/MTW in the past year • Re-classification
  • 56. The retrospectively determined phenotype was independent of gender, atopy, smokers in the home and maternal smoking during pregnancy (all p values>0.05) A Schultz, Acta Pædiatrica 2010
  • 57. Phenotypic classification - remained the same in 50(45.9%) - altered in 59 (54.1%) - similar number of children EVW to MTW/ no wheeze The prospectively determined phenotype was independent of gender, atopy, smokers in the home and maternal smoking during pregnancy (all p values>0.05) A Schultz, Acta Pædiatrica 2010
  • 58. • History from parents of preschool children with recurrent wheeze may be insufficient to provide a reliable classification of wheezing phenotype as EVW or MTW • Atopy, family history of atopy and gender were not helpful in predicting whether the phenotype would be stable or variable A Schultz, Acta Pædiatrica 2010
  • 59. Asthma Predictive Tools JOSÉ A. CASTRO-RODRÍGUEZ, Am J Respir Crit Care Med. 2000
  • 60. Asthma Predictive Tools JOSÉ A. CASTRO-RODRÍGUEZ, Am J Respir Crit Care Med. 2000
  • 61. Asthma Predictive Tools Anina M. Pescatore, J Allergy Clin Immunol , 2014; 133:111-8
  • 62. Asthma Predictive Tools Classic API • Sensitivity 63.2%, Specificity 70.4%, PPV 59.7%, NPV 73.4% Allergy 2013; 68: 531-8 Anina M. Pescatore, J Allergy Clin Immunol , 2014; 133:111-8
  • 63. Clinical relevance Diagnosis Management Prognosis
  • 64. Management PRACTALL, 2008; 63: 5–34
  • 65. Episodic viral wheeze Systemic Steroid Inhaled corticosteroid: ICS Leukotriene receptor antagonist: LTRA
  • 66. Pediatr Allergy Immunol 2013; 24: 237–243.
  • 67.  Risk of recurrent wheezing • prednisolone (bold line) • placebo  7-yr follow-up Risk of recurrent wheezing Pediatr Allergy Immunol 2013; 24: 237–243.
  • 68. Risk of recurrent wheezing hazard ratio 2.33; 95% CI 1.11–4.90 Pediatr Allergy Immunol 2013; 24: 237–243.
  • 69. Risk of recurrent wheezing hazard ratio 3.54; 95% CI 1.51–8.30 Pediatr Allergy Immunol 2013; 24: 237–243.
  • 70. J Pediatr 2003;143:725-30 Prednisolone 1-2 MKD 3-5 days in acute viral induced wheeze
  • 71. J Pediatr 2003;143:725-30
  • 72. Episodic viral wheeze Systemic Steroid Inhaled corticosteroid: ICS Leukotriene receptor antagonist: LTRA
  • 73. Inhaled corticosteroid: Continuous Pediatrics 2009;123:e519–e525
  • 74. N Engl J Med 2006;354:1985-97. PEAK study
  • 75. N Engl J Med 2006;354:1985-97. Fluticasone Placebo
  • 76. N Engl J Med 2006;354:1985-97.
  • 77. N Engl J Med 2006;354:1985-97.
  • 78. Inhaled corticosteroid: Continuous Pediatrics 2009;123:e519–e525
  • 79. • 12-week, multicenter, doubleblind, randomized, parallel-group study • 480 asthmatic infants and children (64% boys) • Ages 6 months to 8 years • Moderate persistent asthma. • Approximately 30% of children were previously on inhaled corticosteroids that were discontinued before the study. Pediatrics 1999; 103:414–421
  • 80. Inhaled corticosteroid: Continuous Pediatrics 2009;123:e519–e525
  • 81. Pediatric Pulmonology, 2004; 37:111–115 • Age less than 2 years • Asthmatic symptoms (3/3) • three or more episodes of wheeze • clinical improvement after bronchodilators • familial history of asthma OR any other clinical finding indicating atopy (e.g. AR or eczema) in first-degree relatives.
  • 82. N Engl J Med 2006; 354:1998-2005. • 411 infants enrolled and randomly 294 infants • Single-center, randomized, double-blind, prospective study of three years‟ Duration • Budesonide (Pulmicort, AstraZeneca), at a dose of 400 μg per day, or matching placebo was administered by pressurized metered-dose inhaler and a spacer for two weeks • Initiated after a three-day episode of wheezing
  • 83. N Engl J Med 2006; 354:1998-2005.
  • 84. early intervention with intermittent ICS therapy • no effect on the progression from episodic to persistent wheezing in young children • no short-term effect on wheezing N Engl J Med 2006; 354:1998-2005.
  • 85. finding that was unaffected by the presence or absence of atopic dermatitis N Engl J Med 2006; 354:1998-2005.
  • 86. N Engl J Med 2009; 360:339-53 • 129 childrens • 1 to 6 years of age • receive 750 μg of FP or placebo twice daily • beginning at the onset of an URI and continuing to 10 days • 6 to 12 months • ≥ 3 wheezing episodes in their lifetime, triggered by URI or • received at least one course of rescue systemic corticosteroids in the previous 6 months (or two in the preceding 12 months) or • Hospital admission
  • 87. N Engl J Med 2009; 360:339-53
  • 88. In preschool-age children with moderate-to-severe virus-induced wheezing, preemptive treatment with high-dose fluticasone as compared with placebo reduced the use of rescue oral corticosteroids Treatment with fluticasone was associated with a smaller gain in height and weight N Engl J Med 2009; 360:339-53
  • 89. Episodic viral wheeze Systemic Steroid Inhaled corticosteroid: ICS Leukotriene receptor antagonist: LTRA
  • 90. Pediatr Pulmonol. 2005; 40:285–291 P < 0.01 P < 0.05
  • 91. P < 0.001 P < 0.01 P < 0.01 P < 0.05 Family history of atopy/ asthma Patient history of eczema/ dry cough Pediatr Pulmonol. 2005; 40:285–291
  • 92. Leukotriene receptor antagonist: LTRA odds ratio 0.78 Post-bronchiolitis recurrent wheezing Wan-Sheng Peng. Pediatric Allergy and Immunology, 2014; 25: 143–150.
  • 93. Leonard B. Bacharier, J Allergy Clin Immunol. 2008 • Randomized, double-blind placebo-controlled • Twelve-month trial • 238 children • Aged 12-59 months • Moderate-severe intermittent wheezing • Received 7-days: early in respiratory tract illnesses • budesonide inhalation suspension (1mg twice daily) • montelukast (4mg daily) • placebos
  • 94. p=0.66 Exacerbation in 12 months Leonard B. Bacharier, J Allergy Clin Immunol. 2008
  • 95. Leonard B. Bacharier, J Allergy Clin Immunol. 2008
  • 96. Clinical relevance Diagnosis Management Prognosis
  • 97. Avon study (ALSPAC) J Henderson, Thorax 2008;63:974–980 • wheezing after 18 months (not three years) of age was more strongly associated with the development of asthma and atopy
  • 98. Avon study (ALSPAC) • Lung function is more impaired in children with prolong early, intermediate-onset and persistent wheezing • Airway hyperresponsiveness was greatest in the intermediate and late-onset phenotypes J Henderson, Thorax 2008;63:974–980
  • 99. Avon study (ALSPAC) • Lung function is more impaired in children with prolong early, intermediate-onset and persistent wheezing • Airway hyperresponsiveness was greatest in the intermediate and late-onset phenotypes J Henderson, Thorax 2008;63:974–980
  • 100. Tucson study Debra A. Stern, Lancet, 2008
  • 101. Tucson study Age at diagnosis was linearly associated with FEV1/FVC ratio at age 22 Debra A. Stern, Lancet, 2008
  • 102. Tucson study • ¼ of active asthma at age 22 were newly diagnosed • 71% females Asthma remittance by age 22 was higher among males Debra A. Stern, Lancet, 2008
  • 103. Tucson study M-OR multinomial odds ratio (estimated using multinomial logistic regression) with all risk factors listed in the table included in the model with the no asthma group as the reference group. Models were additionally adjusted for ethnicity, sex and current smoking at age 22 Debra A. Stern, Lancet, 2008
  • 104. Tucson study M-OR multinomial odds ratio (estimated using multinomial logistic regression) with all risk factors listed in the table included in the model with the no asthma group as the reference group. Models were additionally adjusted for ethnicity, sex and current smoking at age 22 Debra A. Stern, Lancet, 2008
  • 105. Tucson study F/U at age 22 years: risk for chronic asthma • Persistent wheezing in early life • Asthma at age 6 years • Sensitization to Alternaria sp • Low lung function at 6 years • Bronchial hyperresponsiveness to cold dry air at age 6 years Debra A. Stern, Lancet, 2008
  • 106. Thorax, 2010; 65:1045e1052
  • 107. Thorax, 2010; 65:1045e1052
  • 108. Thorax, 2010; 65:1045e1052
  • 109. Allergic rhinoconjunctivitis p<0.01 p<0.001 Thorax, 2010; 65:1045e1052
  • 110. Positive Phadiatop test p<0.001 Thorax, 2010; 65:1045e1052
  • 111. Persistent/ relapsing wheeze associated with early allergic sensitisation predominated in the RSV cohort compared with controls Thorax, 2010; 65:1045e1052
  • 112. Spirometric function was reduced in subjects with RSV with or without current asthma Thorax, 2010
  • 113. Thorax, 2010 Small airway dysfunction (LCI) is related to current asthma and airway inflammation but not to RSV bronchiolitis
  • 114. J Allergy Clin Immunol 2012; 130:103-10 Trousseau study Cross sectional analysis Less than 36 months of age with recurrent wheezing
  • 115. Trousseau study Cross sectional analysis Less than 36 months of age with recurrent wheezing • 59.3% • mild disease • triggered by viral upper respiratory infections (URIs) J Allergy Clin Immunol 2012; 130:103-10
  • 116. Trousseau study Cross sectional analysis Less than 36 months of age with recurrent wheezing • 28.5% • Moderate to severe disease • Need high doses of ICS • Parents with asthma • Girls • Abnormal CXR J Allergy Clin Immunol 2012; 130:103-10
  • 117. Trousseau study Cross sectional analysis Less than 36 months of age with recurrent wheezing • 12.2% • Multiple wheezing triggers (eg, URIs, exercise, cold air) • Boys • Atopy J Allergy Clin Immunol 2012; 130:103-10
  • 118. Trousseau study J Allergy Clin Immunol 2012; 130:103-10
  • 119. Trousseau study J Allergy Clin Immunol 2012; 130:103-10
  • 120. Trousseau study 83% 76% 90% J Allergy Clin Immunol 2012; 130:103-10
  • 121. J Allergy Clin Immunol, 2014
  • 122. Take Home Message • Asthma phenotypes may reflect causal pathways specific to subgroups of patients with asthma, may lead to improved management and help to predict prognosis • Several early-childhood wheezing phenotypes have been described based upon the natural history and associated risk factors • Asthma predictive tools were low sensitivity but high NPV • Management of viral induced wheeze in young children was controversy • Lung function is more impaired in children with persistent wheezing
  • 123. THANKS!

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