Small Airway Disease in Pediatric Asthma: the Who, What, When, Where, Why, and How to Remediate. A Review and Commentary
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Small Airway Disease in Pediatric Asthma: the Who, What, When, Where, Why, and How to Remediate. A Review and Commentary Russell J. Hopp 1
&
Mark C. Wilson 1 & M. Asghar Pasha 2
Accepted: 29 October 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Asthma affects all portions of the airways. Small airways, however, comprise a substantial component of the conducting lung air flow. In asthma, inflammatory processes can affect the whole respiratory tract, from central to peripheral/small airways. The emphasis in adult and pediatric respiratory disease clinics is to focus on large airway obstruction and reversibility. This information, although valuable, underemphasizes a large portion of the conduction airway of asthmatics. Standard descriptions of asthma management focus on a multiple medication approaches. We particularly focused on the management of asthma in the international guidelines for the Global Initiative for Asthma (GINA). Overall, however, minimal attention is placed on the small airway pool in asthma medical management. We took the opportunity to thoroughly review and present specific data from the adult asthma literature which supported the concept that small airway abnormalities may play a role in the pathogenesis and clinical expression of asthma. Based on the conclusions of the adult asthma literature, we here present a thorough review of the literature as it relates to small airway disease in children with asthma. We used, collectively, individual data sources of data to expand the information available from standard diagnostic techniques, especially spirometry, in the evaluation of small airway disease. As the pharmacological approaches to moderate to severe asthma are advancing rapidly into the realm of biologics, we sought to present potential pharmacological options for small airway dysfunction in pediatrics prior to biological modifier intervention. Keywords Asthma . Small airway . Small airway disease . Pediatrics . Children
Abbreviations SAD Small airway disease (dysfunction) GINA Global Initative for Asthma FeNO Fractional expired nitric oxide IOS Impulse oscillometry FVC Forced vital capacity FEV1 Forced expiratory flow at 1 sec FEF25-75 Forced expiratory flow at 25–75 of forced vital capacity FEF50 Forced expiratory flow at 50% of forced vital capacity R5-R20 Measurement of respiratory resistance between R5 and R20
AX RV TLC ICS (CalvNO) FEVz sRawz MMEFz AIT LABA LAMA ACT CASI
Area of reactance. X5: Represents the reactance throughout the respiratory system Residual volume Total lung capacity Inhaled corticosteroid Calculated alveolar nitric oxide Z score for FEV1 Z score for specific airway conductance Z score for mid-maximal expiratory flow Allergy immunotherapy Long-acting beta-agonist Long-acting muscarinic antagonist Asthma control test scores Composite asthma severity index
* Russell J. Hopp [email protected]
Introduction 1
2
Department of Pediatrics, University of Nebraska Medical Center and Children’s Hospital and Medical Center, O
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