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Original Research: ASTHMA |

Predictors of Symptoms Are Different From Predictors of Severe Exacerbations From Asthma in ChildrenPredictors of Asthma Symptoms and Exacerbations

Ann Chen Wu, MD, MPH; Kelan Tantisira, MD, MPH; Lingling Li, PhD; Brooke Schuemann, BS; Scott T. Weiss, MD; Anne L. Fuhlbrigge, MD; for the Childhood Asthma Management Program Research Group
Author and Funding Information

From the Center for Child Health Care Studies (Drs Wu and Li), Department of Population Medicine, Harvard Pilgrim Health Care Institute and Harvard Medical School; the Department of Pediatrics (Dr Wu), Children’s Hospital; Harvard Medical School (Drs Wu, Tantisira, Li, Weiss, and Fuhlbrigge); the Channing Laboratory (Drs Tantisira, Weiss, and Fuhlbrigge and Ms Schuemann) and the Center for Genomic Medicine (Drs Tantisira and Weiss), Department of Medicine, Brigham and Women’s Hospital, Boston, MA.

Correspondence to: Ann Wu, MD, MPH, Department of Population Medicine, 133 Brookline Ave, 6th Floor, Boston, MA 02215-5301; e-mail: ann.wu@childrens.harvard.edu


A complete list of participants is located in e-Appendix 1.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


© 2011 American College of Chest Physicians


Chest. 2011;140(1):100-107. doi:10.1378/chest.10-2794
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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 β-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 (lnPC20). 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 lnPC20, and higher logarithm to the base 10 eosinophil count; treatment with inhaled corticosteroids 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.


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