Dysfunctional breathing impacts asthma control among children, adolescents
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Key takeaways:
- Older children and girls were more likely to have dysfunctional breathing.
- Dysfunctional breathing was correlated with poorer asthma control and greater use of beta 2 agonists.
Dysfunctional breathing was a frequent comorbidity among children and adolescents with asthma, with correlations with perceived poorer asthma control, according to a study published in Pediatric Allergy and Immunology.
Also, dysfunctional breathing (DB) was more common among adolescent girls and was associated with greater use of beta 2 agonists, Signe Vahlkvist, MD, PhD, department of pediatrics and adolescent medicine, Lillebaelt Hospital, University Hospital of Southern Denmark, and colleagues wrote.
The study involved 363 patients (median age, 13.8 years; 49% boys) aged 10 to 17 years attending a scheduled follow-up asthma visit at the Pediatric and Adolescent Outpatient Clinic of the University Hospital of Lillebaelt starting in February 2021 and running through 15 months.
The researchers administered the 16-item Nijmegen Questionnaire (NQ) to each patient, and 18% of them had scores of 23 or higher, indicating DB. Median scores included 9 for the non-DB group and 29 for the DB group (P < .001).
The DB group was older (median age, 15.6 vs. 13.7 years; P < .001) and had fewer boys (16% vs. 57%; P < .001) than the non-DB group.
BMI standard deviation scores (SDS) included 0.6 for the non-DB group and 0.3 for the DB group (P = .05). Also, the non-DB group had lower percentages of FEV1 (mean, 85.7 vs. 89.4; P < .05) as well as lower ratios of FEV1 to forced vital capacity (FVC; mean, 0.82 vs. 0.87; P < .05) than the DB group.
More patients in the non-DB group were sensitized to one or more aeroallergens as well. Both groups were equal in their inhaled corticosteroid (ICS) doses, usage of second controllers and nasal steroids, and compliance with ICS or ICS/long-acting beta agonist prescriptions.
Median Asthma Control Questionnaire (ACQ) scores included 2 for the DB group and 0.6 for the non-DB group (P < .001), and median beta 2 agonist use included two puffs a week for the DB group and none for the non-DB group (P < .001), predicting poorer perceived asthma control in the DB group, the researchers said.
Both groups had equal responses in FEV1 to beta 2 agonists and exercise challenges at the time of diagnosis, the researchers said, but the DB group had a higher median dose of mannitol used to provoke a 15% fall in FEV1 than the non-DB group (358.5 µg vs. 200 µg; P = .05). Additionally, 14% of the non-DB group and 35% of the DB group failed their exercise challenges (P < .05).
Significant variability in FEV1 ensured diagnosis during hospitalization for 29 of the 35 patients who were hospitalized and after hospitalization for four of these patients.
Based on these findings, the researchers said that older age, female sex, higher ACQ scores and higher FEV1 predicted DB, whereas BMI SDS had a negative correlation with DB.
Similarly, NQ scores, beta 2 agonist use, and BMI SDS predicted and had positive correlations with ACQ scores, indicating that higher NQ scores, higher BMI SDS and higher use of bronchial reliever medication predicted poorer asthma control per ACQ estimates.
Based on these findings, the researchers said that the DB group did not suffer from more severe asthma than the non-DB group. Also, the researchers hypothesized that the high degree of exercise intolerance among the DB group was not due to asthma.
DB was a contributor to poorer perceived asthma control, the researchers continued, high BMI SDS correlated with poor perceived asthma control, and low BMI SDS correlated with DB. Since the DB group was leaner and had poorer perceived asthma control, the researchers suggested, overweight and DB may be different factors for poor perceived asthma control.
DB was a frequent comorbidity of adolescent asthma and had a negative effect on perceived asthma control, the researchers said, suggesting that it may be a confounder of asthma symptoms and lead patients to believe their asthma control is worse than it really is.
The researchers encouraged physicians to routinely screen pediatric and adolescent patients for DB to avoid overtreatment and added that treatment options may be investigated in future studies.
Perspective
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Christopher O'Brien, MD, PhD, FCCP
The concept of difficult-to-treat asthma recognizes that a significant proportion of patients with asthma may have concomitant features such as DB that may underlie perceived poor asthma control but are unresponsive to traditional asthma therapeutics. Once identified, however, concurrent breathing retraining interventions that include biofeedback, vocal cord relaxation techniques and other nonpharmacologic measures can yield significant benefit in these patients. The study by Vahlkvist and colleagues, conducted in a large Danish pediatric clinic population, presents important data that builds on this concept and supports the finding of how surprisingly common DB may be, particularly in adolescent patients.
This cross-sectional study is a very nice example of how to effectively utilize a survey methodology in conjunction with a multicomponent database to provide actionable information and help inform important questions for further evaluation. In this case, multiple domains were used to characterize patient attributes and address potential confounders such as compliance in assessing several key questions related to dysfunctional breathing in the pediatric asthma population.
Importantly, patients with documented objective measures of asthma were surveyed with a significant proportion found to have concomitant DB and perceived poor asthma control. Interestingly, findings indicative of DB were more common in adolescents and in females, but were also present in a meaningful proportion of males as well. Supported by this study’s results, this may be particularly relevant for young patients with perceived poor asthma control characterized by recurrent symptoms and rescue beta-agonist use despite normal, or near normal, lung function on ICS-based/anti-inflammatory therapy.
Overall, these results reinforce the need to consider and manage co-occurring factors that may exacerbate or trigger asthma symptoms, such as allergic rhinitis, while also maintaining awareness and vigilance for comorbidities that may mimic asthma symptoms but are not generally responsive to bronchodilator and anti-inflammatory treatments.
As the authors suggest, routine screening for dysfunctional breathing in adolescent patients with difficult-to-treat asthma seems warranted, particularly as these patients may be at risk of overtreatment with both bronchodilator and anti-inflammatory therapies. Similarly, as the authors observe, in these patients who are often frustrated by poor response to escalating treatments, it may be both validating and a relief for them to recognize and address DB as a contributor to their symptoms.
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