Single inhaler maintenance and reliever therapy in pediatric asthma

Purpose of review Asthma affects more than 25 million people worldwide and continues to grow in prevalence. According to a center for disease control and prevention (CDC) report, the total annual cost of asthma in the United States between 2008 and 2013, including medical care, absenteeism, and mortality, was $81.9 billion. Although the National Institute of Health guidelines recommend fixed inhaled corticosteroid (ICS) dosing, the 2008–2010 Medical Expenditure Panel Survey showed that asthma is still poorly controlled. Single inhaler maintenance and reliever therapy (SMART) offers a possible alternative management plan. This is a review of SMART vs. current treatment guidelines. Recent findings SMART addresses variable inflammation with symptom-driven dosing of ICS. It relies on a combination inhaler that has a long-acting β-agonist, which has an immediate onset of action to provide quick relief, in combination with an ICS. Recent studies show that SMART decreases the frequency and severity of asthma exacerbations when compared to fixed ICS dosing. In addition, intermittent use of ICS gave a reduced effect on growth and permitted a lower total amount of ICS to be delivered. Summary SMART appears to outperform treatment that is based on current guidelines in the United States. As inhalers capable of being used for SMART are already approved, what is needed is Food and Drug Administration approval of the SMART strategy. Correspondence to Jay M. Portnoy, MD, Section of Allergy, Asthma and Immunology, Children's Mercy Hospital, 2401 Gillham Road, Kansas City, MO 64108, USA. Tel: +1 816 960-8885; fax: +1 816 960-8888; e-mail: jportnoy@cmh.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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Phenotypes of wheezing and asthma in preschool children

Purpose of review The purpose of this review is to provide an overview of the identified phenotypes of preschool wheezing. Recent findings Early life wheezing patterns have been described in multiple populations, with several commonalities found between cohorts. Early life environmental exposures have been found to be differentially associated with preschool wheezing phenotypes and their future trajectories. These include allergen and microbe exposure, environmental tobacco smoke exposure, and maternal stress and depression. Elevated IgE in early life may also influence future asthma risk. Summary Preschool wheezing phenotypes are heterogeneous and complex, with trajectories that are related to factors including environmental exposures. More research is needed to characterize these relationships, hopefully leading to targeted prevention strategies. Correspondence to Leonard B. Bacharier, MD, Campus Box 8116, 660 S. Euclid Ave., St. Louis, MO 63110, USA. Tel: +1 314 454 2694; e-mail: Bacharier_l@wustl.edu Copyright © 2019 Wolters Kluwer Health, Inc. All rights reserved.

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Patient Phenotyping in OSA

Abstract

Purpose of Review

OSA treatment paradigms are evolving from a "one treatment for all" philosophy to personalised therapeutic options based on anatomical and physiological phenotypes. Understanding these different phenotypes will become vital for clinicians as OSA testing and treatment become more targeted.

Recent Findings

Phenotyping of the pharynx and upper airway is vital to inform anatomical treatment options such as surgery and mandibular advancement splints. Manipulated CPAP testing allows determination of traits such as arousal threshold, muscular responsiveness and ventilatory control. Targeted therapies of each of these physiological traits have shown promise in selected patients in the research context.

Summary

Current treatment paradigms are based on anatomical therapies (CPAP, MAS, surgery); the limitations of which may be particularly evident in patients with physiological contributors to their OSA. Physiological phenotyping is an area of ongoing research into non-anatomical traits which contribute to airway obstruction.

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