|Year : 2016 | Volume
| Issue : 1 | Page : 124-127
Evaluation of symptoms & spirometry in children treated for asthma
Shobi Anandi, Milind S Tullu, Keya Lahiri
Department of Pediatrics, Seth G.S. Medical College & KEM Hospital, Mumbai, India
|Date of Submission||17-Oct-2013|
|Date of Web Publication||3-Nov-2016|
Milind S Tullu
"Sankalp Siddhi", Block No.1, Ground Floor, Kher Nagar, Service Road, Bandra (East), Mumbai 400 051, Maharashtra
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Background & objectives: Spirometry plays an important role in the assessment and long term monitoring of patients with asthma. Difficulty in performing spirometry in children has resulted in a paucity of Indian studies using spirometry regularly for research in the paediatric population. This study was undertaken to assess the clinical improvement and changes in spirometric measurements with treatment in children with newly diagnosed asthma and to compare the changes in the symptom score and spirometric measurements.
Methods: This prospective study included 32 children between 6 to 12 yr of age (enrolled over a period of one year with follow up of six months) who were newly diagnosed as cases of asthma on the basis of symptoms and medical history. Baseline symptom score and spirometric measurements were determined at the first visit. The children were treated and followed up at six weeks, three and six months of initiating treatment. Symptom score and spirometric measurements were repeated at every visit.
Results: Significant improvement in symptom score was evident at six weeks of therapy ( P<0.05) while the lung function parameters FEV 1 (forced expiratory volume in 1 second) and FVC (forced vital capacity) showed significant improvement at three months of therapy. Peak expiratory flow rate (PEFR) was found to improve at six months. There was a positive linear correlation between the changes in symptom score and FEV 1, FVC and PEFR with treatment.
Interpretation & conclusions: Symptomatic improvement became apparent before the improvement in spirometric parameters in children with asthma (after treatment initiation).
Keywords: Airways - asthma - children - GINA guidelines - paediatric - pulmonary functions - spirometry - symptom score
|How to cite this article:|
Anandi S, Tullu MS, Lahiri K. Evaluation of symptoms & spirometry in children treated for asthma. Indian J Med Res 2016;144:124-7
Asthma is a chronic inflammatory disease of airways characterized by bronchial hyper-responsiveness and reversible airway obstruction  . Pulmonary function tests, mainly spirometry are gold standard tools for objective evaluation in childhood asthma  . Spirometry determines the degree of airway obstruction and its response to treatment.  However, most asthmatic children, independent of the disease severity, have been found to have normal forced expiratory volume (FEV) values especially when asymptomatic , . Hence, the role of pulmonary function tests in short and long term evaluations of childhood asthma remains controversial. Also, reliable spirometric measurements depend on the patient's ability to perform a forceful expiratory maneuver which is difficult in young children. Hence, the clinical picture in terms of signs and symptoms is also of paramount significance  . The lung function measurements give information about the patients' physiology in an objective way, whereas symptoms give more information about how the disease is affecting the patient  . Though it is known that with treatment there is improvement in both symptoms and lung function measures, the levels of improvement in each of the parameters are not yet clear. This emphasizes the need for further studies to determine how spirometric measures and the clinical features improve with treatment. Hence we undertook this study to determine the clinical improvement and the changes in the spirometric measurements with treatment in newly diagnosed cases of asthma in children and to compare the change in the symptom score and spirometric measurements.
| Material & Methods|| |
The present study was a prospective observational study initiated after the approval of the protocol and the study design by the Institutional Ethics Committee, and conducted at the Paediatric Chest Clinic at KEM Hospital, a tertiary care referral hospital in Mumbai, Maharashtra, India. The study included children between 6 and 12 yr of age who consecutively presented at this clinic over a period of one year (January to December 2010) with signs and symptoms suggestive of asthma (newly diagnosed) and who were able to perform spirometry. Patients who were treated elsewhere, on long term oral steroids, those who could not perform spirometry or refused to give consent were excluded. A total of 37 patients were identified and five were lost to follow up. Only 32 patients were followed up for a period of six months. Written informed consent of the parent/guardian and assent of children above seven years of age were obtained. The children were assessed and classified according to severity of the symptoms as per the Global Initiative for Asthma (GINA) guidelines 2009  . The baseline symptom score and spirometric measurements were done. Spirometric readings were obtained on a portable standardized spirometer (spirolab III, MIR, Italy). The symptom score was determined by using the Childhood Asthma Control Test: C-ACT  . This test consists of seven questions related to the last four weeks, of which four are to be answered by the child and three by the parents. The total score can range from 0-27. The C-ACT is a validated test to assess asthma control and identify children with inadequately controlled asthma  . The children were started on treatment according to GINA guidelines  . Metered dose inhaler or rotahaler was used to deliver beta 2 agonists and steroids. The drugs were stepped up/down as required according to the guidelines. The parents were educated about the disease and treatment, the symptoms and signs of acute exacerbation and the importance of avoiding triggering factors. They were trained to use the inhalation devices and the technique was checked at every visit to ensure adequate drug delivery. Regular visits were ensured by giving the date for the next visit and patients who did not turn up on the day of the scheduled visit were reminded telephonically. Thus follow up and treatment compliance was ensured. The children were followed up at six weeks, three and six months of treatment and assessed clinically in terms of symptom score. Spirometric measurements were performed at every visit. The tests were not applied during an acute exacerbation. Spirometry was performed when the patient was not on bronchodilators.
The following lung function parameters were monitored during the study period: FEV 1 (forced expiratory volume in 1 second), FVC (forced vital capacity), FEV 1 /FVC ratio, and PEFR (peak expiratory flow rate).
Statistical analysis: The data were tested for normality using D'Agostino-Pearson omnibus normality test  and were found to be not normally distributed. The data were analyzed using the 'Wilcoxon signed Rank sum test for the symptom score and paired t test for the lung function parameters. The symptom score and each of the lung function parameters were compared and Pearsons correlation factor was calculated.
| Results & Discussion|| |
The mean age of the patients was 8.72 ± 1.95 yr; 20 (62.5%) were males and 12 (37.5%) were females. The male: female ratio was 1.67:1. The height was 125.50 ± 12.23 cm, and the weight was 22.19 ± 6.7 kg. Twenty seven patients belonged to mild persistent type and five were of moderate persistent type of asthma. The mean symptom score, FEV 1, FVC, FEV 1 /FVC and PEFR values at each visit and the improvement in the various parameters when compared to baseline are shown in [Table 1]. Significant improvement in the symptom score was evident at six weeks of therapy while the lung function parameters, FEV 1 and FVC showed significant improvement at three months. PEFR was found to show improvement at six months. FEV1/ FVC did not show significant improvement during the study period. [Table 2] shows improvement in the various parameters during follow up when compared to the previous visit. Improvement was noticed in all the spirometric parameters at six months follow up. There was a positive linear correlation between the changes in symptom score and FEV 1, FVC and PEFR (r=0.91, P<0.001; r=0.93, P<0.001; and r=0.88, P<0.001, respectively).
|Table 1. Mean symptom score, and lung function parameters at baseline and upto six months of follow up |
Click here to view
|Table 2. Improvement in symptom score and lung function parameters at follow up when compared to previous visit |
Click here to view
Asthma control and severity have been conventionally assessed using several indices which have included symptoms, level of treatment and lung function , . It is apparent that no single measure of disease control can encompass all the clinical problems in asthma  . It is also known that patients with similar levels of lung function may experience a wide range of severity and morbidity  . Thus, there is always a risk of underdiagnosis or overdiagnosis of asthma if only the spirometric measurements (FEV 1 ) were taken into account since majority of children irrespective of the severity of asthma tend to have a normal FEV 1 when asymptomatic , . Stout et al reported that one third of the children with asthma were reclassified into a more severe asthma category when pulmonary functions were taken into consideration in addition to symptom frequency. Measurements of pulmonary functions require a high degree of patient's cooperation and the readings reflect a onetime measurement of the child's status and so are probably of questionable value ,, . Serial follow ups and monitoring of the lung function measures are more reliable than a single reading which usually does not convey much meaning  . This highlights the need to use multiple parameters in assessing children with asthma  . Our study showed that with appropriate treatment and regular follow up, there was a significant improvement in both the symptom score and the lung function measures. The improvement was initially apparent in the symptom score of the patient.
In a study on asthmatic children, where the improvement in symptom score at 2, 4 and 8 wk of starting treatment was determined, the mean symptom score showed a significant change from 57.80 to 49.5 at two weeks, 37.74 and 27.80 at four and eight weeks, respectively (P<0.01)  . There was a significant improvement in FEV 1 , FVC and PEFR at the same time, showing that improvement in both symptom score and lung function measures  . Another study showed that at the end of three months treatment, there was a significant improvement in the symptom score (8.35±0.67 vs 1.76±0.27, P<0.001) . Improvement was also noticed in the lung function parameters- FEV 1 (68.25±2.83 to 76.28±2.47, P<0.002) and PEFR (63.95±3.13 to 75.68±3.66, P<0.001)  . Zhang et al showed that perception of symptomatic improvement by both parents and children correlated weakly with the changes in pulmonary function parameters during the study period. This was attributed to the fact that the lung function measures represented the pulmonary functional status at the moment of visit while the symptom score reflected the improvement over a period of time  . Planned education interventions reduce the symptom frequency and duration and the need for oral steroid burst therapy  . Also, with proper education and follow up, children were found to take their medications more regularly  .
The improvement was initially evident in the symptom score as early as the six weeks of treatment while the improvement in the lung functions was noticed at three months. It indicates that the subjective improvement precedes improvement in objective parameters. So the symptom score, the FEV 1 , FVC and PEFR are all good indicators of response to treatment in asthma. In addition to drug therapy, the role of psychosocial and other environmental factors like avoidance of triggers in the control of asthma cannot be underestimated. The small sample size and the shorter duration of follow up were the main limitations of this study. A long term follow up of the patients would yield valuable information regarding the trends in both symptom score and lung function measures.
| Acknowledgment|| |
The authors thank Dr Sandhya Kamath - Dean of Seth G.S. Medical College and K.E.M. Hospital, for granting permission to publish this manuscript. The authors also thank GlaxoSmithKline Pharmaceuticals Ltd. (GSK) (copyright holder for the Childhood Asthma Control Test) for granting permission to use the Childhood Asthma Control Test in the study. The childhood asthma control test was created for use only on children between the ages of 4 and 11.
Conflicts of Interest : None.
| References|| |
Bateman ED, Hurd SS, Barnes PJ, Bosquet J, Drazen JM, FitzGerald M, et al
. Global strategy for asthma management and prevention: GINA executive summary. Eur Respir J
Spahn JD, Cherniack R, Paull K, Gelfand EW. Is forced expiratory volume in one second the best measure of severity in childhood asthma? Am J Respir Crit Care Med
Pierce R. Spirometry: an essential clinical measurement. Aust Fam Physician
The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in childen with asthma. N Engl J Med
Bacharier LB, Strunk RC, Mauger D, White D, Lemanske RF Jr, Sorkness CA. Classifying asthma severity in children: mismatch between symptoms, medication use, and lung function. Am J Respir Crit Care Med
Expert Panel Report 3 National Heart, Lung and Blood Institute Guidelines for the diagnosis and management of asthma. Available from: http://www.nhlbi.gov.
, accessed on August 16, 2009.
Global strategy for asthma management and prevention. Available from: http://www.ginasthma.org.
, accessed on August 16, 2009.
Liu AH, Zeiger R, Sorkness C, Mahr T, Ostrom N, Burgess S, et al.
Development and cross-sectional validation of the Childhood Asthma Control Test. J Allergy Clin Immunol
Ghasemi A, Zahediasl S. Normality tests for statistical analysis: A guide for non-statisticians. Int J Endocrinol Metab
Stout JW, Visness CM, Enright P, Lamm C, Shapiro G, Gan VN, et al
. Classification of asthma severity in children: the contribution of pulmonary function testing. Arch Pediatr Adolesc Med
Zhang L, Avila L, Leyraud L, Grassi S, Raquel T, Bonfanti T, et al
. Accuracy of parental and child's report of changes in symptoms of childhood asthma. Indian Pediatr
Singh M, Mathew JL, Malhi P, Srinivas BR, Kumar L. Comparison of improvement in quality of life score with objective parameters of pulmonary function in Indian asthmatic children receiving inhaled corticosteroid therapy. Indian Pediatr
Boskabady MH, Fasihfar M, Maemoori GA. Correlation between symptom score, wheeze, reversibility of pulmonary function tests and treatment response in asthma. Iran J Allergy Asthma Immunol
Lozano P, Finkelstein JA, Carey VJ, Wagner EH, Inui TS, Fuhlbrigge AL, et al
. A multisite randomized trial of the effects of physician education and organizational change in chronic-asthma care: health outcomes of the Pediatric Asthma Care Patient Outcomes Research Team II Study. Arch Pediatr Adolesc Med
[Table 1], [Table 2]