Preschool Recurrent Wheezing and Asthma

This is Twitter summary from the 2018 WSAAI meeting. This summary was compiled from the tweets posted by @MatthewBowdish, an allergist/immunologist, who attended the 2018 Western Society of Allergy, Asthma and Immunology (WSAAI) meeting. The tweets were labeled #WSAAI. The text was edited and modified by me.

Leonard Bacharier presented on Management of Preschool Recurrent Wheezing and Asthma.

One of the big challenges for pediatricians has been determining which preschool kids who wheeze go on to develop asthma and who don't.

Estimated prevalence of wheezing identified by latent class analysis:

Modified Asthma Predictive Index (API) (click to enlarge the image).

mAPI: High risk children ages 2-3 include 4 wheezing episodes in the past year PLUS one major criterion (pt w/MD asthma, MD atopic derm, aeroallergen sensitivity) OR two minor criteria (food sens, peripheral eos >4%, non-infectious wheeze).

Stepwise pharmacologic approach for children younger than 5yo with wheezing:

Reviewing results of Individualized therapy for asthma in toddlers (INFANT) study - Fitzpatrick AM et al JACI 2016;138:1608. Differential response between at least two treatments was observed in 75% of children. Take-homes from INFANT: 1) In kids w/aeroallergen sensitivity or eosinophilia, start ICS first. In kids who are not sensitized to aeroallergens or without eosinophilia, you can choose any of the treatments (ICS, prn daily ICS or daily LTRA).

Subgroup analysis of kids w/intermittent asthma or viral-triggered wheezing showed reduced risk of exacerbation w/preemptive high-dose intermittent ICS compared w/placebo (Kaiser SV, Pediatr 2016;137.

Azithro started at the earliest signs of RTIs was effective in reducing the risk of experiencing episodes of severe lower respiratory tract illness. (JAMA 2015;314(19):2034). There was no difference in response by API status, and azithro was well-tolerated with low rates of adverse effects.

Putting these together in an approach that we may be able to use in the clinic:

Research also suggests that if a child does not respond to a given controller, explore other Step 2 therapies before moving on to Step 3 therapies.

Summary slide:

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