Pediatric Severe Asthma in the Era of Biologic Treatments.
Pediatric Severe Asthma in the Era of Biologic Treatments.
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生物治疗时代的小儿严重哮喘。
DOI：
10.1089/ped.2020.1249
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发表时间：
2020
期刊：
影响因子：
--
通讯作者：
Teague,WGerald
中科院分区：
文献类型：
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作者：
Teague,WGerald
儿童严重哮喘是一种复杂的综合征，具有显着的发病率和经济成本。受影响的儿童往往入学率低，每天睡眠质量差，运动能力下降。患有严重哮喘的儿童患肥胖及其并发症的风险较高，甚至由于身体状况不佳而导致的呼吸困难被误认为是哮喘控制不佳。 1 在冬季，患有严重哮喘的儿童经常会因每年的鼻病毒和流感季节而出现症状控制失误，并且因季节性病情加重而需要紧急护理和入住 ICU 的情况并不罕见。结果，护理人员经常中断工作安排，患有严重哮喘的儿童的兄弟姐妹也受到混乱的家庭环境的不利影响。患有严重哮喘的孩子的单亲父母必须让大家庭成员照顾孩子才能工作。哮喘药物的成本不断增加，以至于中等收入家庭面临着品牌计量吸入器的自付费用和与医疗保健相关的自付费用的挑战。健康的社会决定因素对于影响哮喘的结果至关重要，这是一个明显的事实，但医疗保健提供者、药品制造商、公共卫生官员和政府却严重低估了这一事实。制定严重哮喘治疗指南的驱动原则是认为它主要是一种 2 型介导的气道炎症疾病，如果管理得当，可以通过适当剂量的吸入皮质类固醇 (ICS) 联合长效支气管扩张剂来有效控制。我们在弗吉尼亚大学 (UVA) 的经验是，大多数接受详细研究的有问题的喘息/哮喘评估儿童并没有 2 型为主的肺部炎症（图 1）。 2 此外，我们一直在努力提供符合指南的药物。例如，在我们描述哮喘控制不佳的学龄儿童表型特征的文章的同行评审中，2-1 审稿人指出，样本中未接受高剂量 ICS/长效 β 受体激动剂 (LABA) 联合疗法的儿童比例相对较低。尽管付出了巨大的努力，我们仍无法让医疗补助管理式医疗组织和私人健康保险公司承担这些药物的费用！结果*，该报告中 40% 的儿童接受了隔日口服泼尼松治疗，与 ICS/LABA 吸入器的自付费用相比，这是一种实用的解决方案，成本低廉。矛盾的是，在哮喘药物治疗已经大大改善的时代，许多患者的哮喘症状控制却很差。 3
Pediatric severe asthma is a complex syndrome asso-ciated with significant morbidity and financial cost. Affected children often have poor school attendance, and day to day suffer with poor sleep quality, and reduced exercise performance. Children with severe asthma are at higher risk of obesity and its complications, to the extent that dyspnea due to deconditioning is mistaken for poor asthma control. 1 During winter, children with severe asthma frequently experience lapses in symptom control with the annual rhinovirus and flu seasons, and not uncommonly require acute care and ICU admissions for seasonal exacerbations. As a result, care providers often have interrupted employment schedules, and the siblings of children with severe asthma are adversely impacted by a chaotic home environment. Single parents of a child with severe asthma must involve extended family members to care for the child to work. Asthma medications have increased in cost, to the extent that middle-income families are challenged by the out-of-pocket costs of branded metered-dose inhalers and co-pays associated with health care. The social determinants of health are vitally important in affecting asthma outcomes, a glaring truth that has been grossly underestimated by health care providers, drug manufacturers, public health officials, and governments.The driving principle in the formulation of treatment guidelines for severe asthma is the view that it predominately is a disorder of type-2 mediated airways inflammation, which, if managed appropriately, is effectively controlled by appropriate dose inhaled corticosteroids (ICSs) combined with long-acting bronchodilators. Our experience at the University of Virginia (UVA) has been that most children evaluated for problematic wheeze/asthma who undergo detailed studies do not have type-2-predominant lung inflammation (Fig. 1). 2 Furthermore, we have struggled to provide medications that conform to the guidelines. For example, in peer review of our article describing the phenotypic characteristics of school-age children with poorly controlled asthma, 2 1 reviewer pointed out the relatively low proportion of children in the sample not treated with highdose ICS/long-acting beta agonist (LABA) combination therapies. Despite significant effort, we could not get Medicaid managed care organizations and private health insurers to cover the costs of these medications! As a result,* 40% of the children in that report were treated with alternate day oral prednisone, a practical solution that costs pennies compared with the out-of-pocket cost for an ICS/LABA inhaler. Paradoxically, in an era when the pharmacotherapy of asthma has greatly improved, asthma symptom control is poor in many patients. 3