Predictors of Symptoms Are Different From Predictors of Severe Exacerbations From Asthma in Children

Background: Asthma therapy is typically prescribed and titrated based on patient or parent self-report of symptoms. No longitudinal studies have assessed the relationship between symptoms and severe asthma exacerbations in children. The goal of our study was (1) to assess the association of asthma symptoms with severe asthma exacerbations and (2) to compare predictors of persistent asthma symptoms and predictors of severe asthma exacerbations. Methods: The Childhood Asthma Management Program was a multicenter clinical trial of 1,041 children randomized to receive budesonide, nedocromil, or placebo (as-needed beta-agonist). We conducted a post hoc analysis of diary cards that were completed by subjects on a daily basis to categorize subjects as having persistent vs intermittent symptoms. We defined a severe asthma exacerbation as an episode requiring >= 3 days use of oral corticosteroids, hospitalization, or ED visit due to asthma based on self-report at study visits every 4 months. Results: While accounting for longitudinal measures, having persistent symptoms from asthma was significantly associated with having severe asthma exacerbations. Predictors of having persistent symptoms compared with intermittent symptoms included not being treated with inhaled corticosteroids, lower FEV1/FVC ratio, and a lower natural logarithm of provocative concentration of methacholine producing a 20% decline in FEV1 (InPC20). Predictors of having one or more severe asthma exacerbations included younger age, history of hospitalization or ED visit in the prior year, >= 3 days use of oral corticosteroids in the prior 3 months, lower FEV1/FVC ratio, lower InPC20, and higher logarithm to the base 10 eosinophil count; treatment with inhaled corticosterolds was predictive of having no severe asthma exacerbations. Conclusions: Patients with persistent symptoms from asthma were more likely to experience severe asthma exacerbations. Nevertheless, demographic and laboratory predictors of having persistent symptoms are different from predictors of severe asthma exacerbations. Although symptoms and exacerbations are closely related, their predictors are different. The current focus of the National Asthma Education and Prevention Program guidelines on the two separate domains of asthma control, impairment and risk, are supported by our analysis. CHEST 2011; 140(1):100-107