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Objective monitoring tools for improved management of childhood asthma

Respiratory Research volume 25, Article number: 194 (2024) Cite this article

Abstract

Asthma is a common chronic disease amongst children. Epidemiological studies showed that the mortality rate of asthma in children is still high worldwide. Asthma control is therefore essential to minimize asthma exacerbations, which can be fatal if the condition is poorly controlled. Frequent monitoring could help to detect asthma progression and ensure treatment effectiveness. Although subjective asthma monitoring tools are available, the results vary as they rely on patients’ self-perception. Emerging evidence suggests several objective tools could have the potential for monitoring purposes. However, there is no consensus to standardise the use of objective monitoring tools. In this review, we start with the prevalence and severity of childhood asthma worldwide. Then, we detail the latest available objective monitoring tools, focusing on their effectiveness in paediatric asthma management. Publications of spirometry, fractional exhaled nitric oxide (FeNO), hyperresponsiveness tests and electronic monitoring devices (EMDs) between 2016 and 2023 were included. The potential advantages and limitations of each tool were also discussed. Overall, this review provides a summary for researchers dedicated to further improving objective paediatric asthma monitoring and provides insights for clinicians to incorporate different objective monitoring tools in clinical practices.

Introduction

Asthma, one of the most common chronic diseases in children and adolescents [1], is a chronic inflammatory disease with narrowing and inflammation of the small airways in the lungs [2]. It is a non-communicable disease associated with airway hyperresponsiveness to direct or indirect stimuli, such as exercise, exposure to allergens or irritants, change in weather or viral respiratory infection [2]. Symptoms usually begin in preschool age, including recurrent episodes of wheezing, cough, chest tightness, shortness of breath, and difficulty breathing [3]. The symptoms may vary in intensity over time but may also be persistent [3]. Therefore, controlling asthma in children is paramount to ensure their quality of life and wellness [4, 5].

Previous studies showed that poorly controlled and severe persistent asthma could be associated with growth retardation [6] and chronic obstructive pulmonary disease in adulthood [7]. Worryingly, the number of deaths due to childhood asthma worldwide was estimated at 12.9 thousand in 2019 [8]. Therefore, it is essential to ensure that children with active asthma, particularly those with severe asthma symptoms, can be effectively identified and monitored frequently to detect asthma progression and ensure the effectiveness of asthma treatment [9]. However, there are still some unmet needs in asthma control as the rate of admission to the emergency department (ED) and uncontrolled asthma remain high [10,11,12]. A study from Netherlands estimated that children with a family history of asthma had two-fold higher risk of having uncontrolled asthma [13]. Environmental risk factors including air pollutants nitrogen dioxide (NO2), particulate matter with a diameter of 10 microns or less (PM10), poor housing condition consists of allergens dust mites or mold are associated with an increased risk of asthma exacerbation and admission to emergency department (ED), particularly in Asia countries [14, 15]. Besides, excessive use of short-acting beta-agonists (SABA) could occur because parents may misunderstand that SABA can control asthma, despite it can only provide quick relief of symptoms but not modify the underlying inflammatory process [16]. Regular monitoring of asthma control may help to identify children at risk of morbidity and mortality. However, the subjective monitoring tools strongly rely on patients’ or their caregivers’ perceptions, while psychological factors may influence their symptom perception, resulting in variation in results and unrealistic reflection of the patient’s actual clinical status [17].

Recently, multiple clinical studies demonstrated the effectiveness of using subjective monitoring tools in conjunction with objective monitoring tools to assess asthma control, such as spirometry (e.g. forced expiration volume in one second, FEV1 and forced vital volume, FVC), fractional exhaled nitric oxide (FeNO), bronchial hyperresponsiveness tests [18, 19]. Guidelines have also been updated and recommended that objective monitoring tools, such as spirometry and FeNO measurements, may be used in conjunction to guide asthma preventive treatment in children [20]. However, no gold standard is available, and the tools used in clinical settings differ between guidelines. Therefore, this review aims to summarise the existing objective monitoring tools and their effectiveness in paediatric asthma management.

Prevalence of asthma in children

The prevalence of childhood asthma in different regions is shown in Table 1 [21,22,23,24,25,26,27,28,29,30]. According to the United States (US) National Health Interview Survey 2020, the prevalence was 9.4%, which accounted for about six million children [21]. The United Kingdom (UK) also estimated the prevalence of childhood asthma at around 9%, with one million children receiving asthma treatment [23]. Meanwhile, in the Asia-Pacific region, asthma was more common in developed cities and countries, the prevalence ranged from 2% in China [25] to 10% in Australia [26]. In China, densely populated areas had a higher prevalence rate due to the ongoing urbanisation [25, 31].

When stratifying the prevalence to age and sex, older children and males tend to have a higher prevalence rate. Children aged 10–19 years had a 8.9% higher prevalence rate than children aged 1–9 years in Canada [22]. In Singapore, the prevalence of asthma in children aged 12 to 15 years was 9% higher than in children aged 6–7 years [30]. In addition, the prevalence of asthma in males was 1.9% and 1.6% higher than in females in the US and Australia, respectively [21, 32].

Table 1 The prevalence of childhood asthma in different regions
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Severity of asthma in children

While the prevalence of childhood asthma varied among countries, the data suggested that asthma management is suboptimal in many of them, even in developed countries (Table 2) [21, 23, 28, 33,34,35,36]. In the US, nearly 3 million children had one or more attacks in a year [21]. A similar situation was found in Canada, where 65% of asthmatic children had 1–3 asthma episodes in a year [33]. In the UK, nearly half had an attack in the previous year [23]. A European cohort study showed that the severe asthma exacerbation (SAE) rates were the highest in children with severe asthma [34]. In the Asia-Pacific region, 2.1% of children in Hong Kong had an asthmatic attack ≥ 1 time per month [28]. In China, there were 87.7% and 10.1% of children suffered 1–5 and 6–10 attacks per year respectively [35].

Table 2 The severity of childhood asthma in different regions
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Uncontrolled asthma not only contribute to asthma attacks but also cause frequent visits to the emergency department (ED) and hospitalisation (Table 3) [22, 23, 36,37,38,39,40]. There were 16.6% and 12.5% of children admitted to ED per year in the US and Canada, respectively [21, 22]. In the UK, nearly half of the children aged 0–18 admitted to the hospital for asthma reported having an asthma attack in the past year [23]. The hospitalisation rate decreased by 5% in the United States between 2003 and 2013, in which more younger children (aged 0–4 years old) were admitted to the hospital due to asthma attacks than among those aged 12–17 years [37]. In China, the hospitalisation rate ranged from 16 to 47% [36, 38]. The rate increased slightly in Hong Kong and Singapore between 1996 and 2008 [40]. The asthma control tends to be suboptimal in the Asia-Pacific region because of infrequent monitoring, and the rate of using regular inhaled corticosteroids (ICS) was low [10].

Table 3 The hospitalisation rate of childhood asthma in different regions
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Objective tools in paediatric asthma monitoring

Search strategy

The literature search was conducted in two databases, PubMed and Web of Sciences, in July 2023. The search focused on original studies published in English from Jan 2016 to Jun 2023 with available full-text. The following combinations of keywords were used: (“paediatric” OR “children” AND “spirometry” AND “efficacy”); (“paediatric” OR “children” AND “asthma monitoring” AND “FeNO” OR “Fractional Exhaled Nitric Oxide” AND “efficacy”); (“paediatric” OR “children” AND “corticosteroid treatment” AND “FeNO” OR “Fractional Exhaled Nitric Oxide” AND “efficacy”); (“paediatric” OR “children” AND “therapy adherence monitoring” AND “FeNO” OR “Fractional Exhaled Nitric Oxide” AND “efficacy”); (“paediatric” OR “children” AND “guide therapy” AND “FeNO” OR “Fractional Exhaled Nitric Oxide” AND “efficacy”); (“paediatric” OR “children” AND “hyperresponsiveness” OR “bronchial challenge test” OR “bronchial provocation test” OR “Mannitol” OR “exercise” OR “histamine” OR “methacholine” AND “efficacy”); (“paediatric” OR “children” AND “wearable device”); (“paediatric” OR “children” AND “asthma electronic monitoring” AND “efficacy”). The studies were included if they fulfilled the following criteria: children aged ≤ 18 years old and  evaluating the effectiveness in asthma monitoring. Literature reviews, case reports, and studies evaluating the accuracy of objective asthma monitoring tools in comparison with subjective assessments were excluded.

Spirometry

Four studies were included, the number of recruited participants ranged from 26 to 612, and the minimum age was 5 years old (Table 4) [41,42,43,44]. The measurement frequency ranged from twice daily to every 3 months [41, 43, 44]. Two studies specified that spirometry was conducted according to the American Thoracic Society and European Respiratory Society (ATS/ERS) guidelines [42, 43].

Performing spirometry at each follow-up can help in paediatric asthma monitoring as it can detect the changes in FEV1 and FVC after treatment initiation [44]. FEV1 value is an independent risk factor for asthma exacerbations, asthmatic children with FEV1 value < 60% could have a double risk of asthma exacerbations [45]. Furthermore, spirometry can identify children with airway obstruction but with fewer symptoms [46]. A cohort study showed that spirometry detected 54% of abnormal results in children who reported good asthma symptom control [42]. This highlights the need to use spirometry to assess asthma control as the severity of asthma may be under-recognised [42]. Suboptimal control of asthma may occur if clinicians evaluate and manage children’s condition only based on symptoms [42].

One study in France recruited participants to conduct spirometry with a portable spirometer at home to monitor their asthma [41]. About 73% of participants reported that the device was acceptable [41]. The mean FEV1 did not differ significantly, but it detected a significant decrease (> 40%) in FEV1 variability and peak expiratory flow (PEF) variability [41]. Participants could be more familiar with the procedures for performing spirometry upon frequent monitoring. Conducting spirometry at home regularly could help to detect the changes in lung function earlier than children who only have spirometry during follow-up in clinics. It may help to provide a clear lung function profile, serving as a guide for clinicians’ judgment. Frequent monitoring may be feasible as parents were generally satisfied with this approach [41].

Table 4 Use of spirometry in paediatric asthma monitoring
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Fractional exhaled nitric oxide (FeNO)

FeNO is a biomarker of eosinophilic airway inflammation to predict children’s asthma conditions and assess the response to ICS therapy [47]. Its level is high in asthmatic patients with T2 inflammation due to the elevated inducible nitric oxide synthases (iNOS) [47]. FeNO is a simple and non-invasive test that measures nitric oxide levels when the patient breathes out [48]. However, it has limited feasibility in younger children because they are unable to exhale at a standard constant flow rate [47]. The success rate was found to be decreased by 60% for 4-year-old children vs. 10-year-old children [49].

The American Thoracic Society (ATS) provides detailed recommendations on interpreting FeNO measurements in children aged 5–12 [50]. A FeNO level lower than 20 parts per billion (ppb) indicates less likely to have benefits if the dose of ICS therapy is increased in children with asthma symptoms [50]. A FeNO level higher than 35 ppb indicates the likelihood of relapse following withdrawal of ICS therapy in asymptomatic patients with stable asthma [50]. It is also associated with an increased risk of asthma exacerbation. Intermediate FeNO values between 20 and 35 ppb are advised to be interpreted carefully with reference to the clinical context [50].

Recent studies evaluated the effectiveness of FeNO in asthma control, response and adherence to the treatment (Table 5) [51,52,53,54,55,56,57,58,59,60,61,62]. Paracha et al. indicated a single high FeNO value did not predict adherence to ICS. It should be used in combination with objective tools like spirometry and subjective tools for asthma symptoms to formulate effective management [62]. The role of FeNO in monitoring treatment response to ICS has also been explored, and the results varied. One randomised controlled trial (RCT) found that FeNO did not reduce the risk of asthma attacks compared to subjective monitoring tools [61]. Meanwhile, Fang et al. combined FeNO and spirometry to guide the ICS and showed a reduction in the risk of asthma attacks [58].

Regarding the effectiveness of asthma control, recent studies have shown inconsistent conclusions. In a study of 200 children, high FeNO levels correlated with increased symptom severity and poor asthma control [56]. Another study from Vietnam indicated low level of FeNO (< 20 ppb) was associated with a risk of uncontrolled asthma after followed up 3 months (odds ratio [OR] 1.7, 95% CI 0.8–3.3, p < 0.05) [54]. Interestingly, a combination of FeNO with impulse oscillometry (IOS) significantly increased the specificity for predicting uncontrolled asthma compared with FeNO alone (p < 0.01) [57]. However, one study showed no significant difference in FeNO to predict asthma attacks between the uncontrolled and controlled asthma groups in 3 to 6-year-old children [51].

Table 5 Use of FeNO tests in paediatric asthma monitoring
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Hyperresponsiveness tests

They are the objective tools to measure airway hyperresponsiveness by triggering bronchoconstriction either directly (inhalation of methacholine or histamine to act on the smooth muscle receptors) or indirectly (such as performing exercise or inhalation of adenosine, mannitol to stimulate the release of inflammatory mediators) [63]. Adenosine challenge test, exercise challenge test (ECT) and mannitol challenge test have been investigated in paediatric asthma control monitoring (Table 6) [64,65,66,67]. The recruited children were aged 2, 4 and 6 years old.

The adenosine challenge test stimulates inflammatory mediators’ release to induce smooth bronchial muscle contraction [63]. Solution with adenosine monophosphate (AMP) was administered by nebuliser up to 200 mg/mL. A positive test is classified as one or more of the following: [1] continuous wheeze detected using a stethoscope; [2] oxygen saturation drops at least 5% from baseline; and [3] an increase in the respiratory rate of 50% or more from baseline [64]. Two studies indicated that the test could monitor the children’s condition via the detection of inflammatory changes, guiding the clinician to step up or down the therapy to reduce the risk of asthma exacerbations [64, 65].

ECT induces airway narrowing by running on a treadmill, followed by spirometry to test the lung function [68]. Children with > 12% decrease in FEV1 value were considered to have a positive response [68]. ECT increased exercise-induced bronchoconstriction (EIB) detection rate in children with asthma [66]. In addition, mannitol dry powder (MDP) has been suggested as a potential objective monitoring tool to evaluate ICS therapy [67]. Up to a cumulative dose of 635 mg MDP is administered for the mannitol challenge test. A positive response is classified if the dose of MDP induces a 15% decrease in FEV1 (PD15) versus the baseline value or a 10% fall in FEV1 between two consecutive doses [69]. Alternatively, a negative response is defined when PD15 is not noted after the maximum cumulative dose [69]. Karantaglis et al. showed that the PD15 value increased significantly after the initiation of ICS treatment and decreased with the presence of nocturnal asthma symptoms [67]. While this study demonstrated the potential of MDP challenge test in guiding ICS therapy, the relatively small sample size (23 subjects) may be too few to extend the findings to general population of paediatric asthmatics. Also, there were 3 patients (13.4%) discontinued the test because of severe general discomfort and an urgent tendency to vomit [67]. Although these adverse events were consistent with the previous published studies [69], more research is required to demonstrate the safety profile of using MDP in paediatric asthma monitoring due to the small sample size. The repeated MDP inhalation and spirometry testing procedures could be a possible cause, particularly for younger children who often need more than one inhalation manoeuvres to administer the high dose MDP capsules (40 mg powder per capsule). Other easier lung function evaluation techniques, such as forced oscillation technique (FOT) and interrupter respiratory resistance (Rint), to couple with the MDP challenge test may be considered in future study [70].

Although few studies investigated the effectiveness of hyperresponsiveness tests recently [62], the use of hyperresponsiveness tests in asthma monitoring is not common in clinical settings as the tests are required to be conducted in clinics that limit their feasibility [71]. Parents may feel hesitant to use the tests as they are aware of the occurrence of adverse effects after the use of pharmacological substances to trigger children’s bronchoconstriction [71]. In addition, the tests are not recommended in NICE and GINA guidelines. Particularly, the NICE guideline states that “do not use challenge testing to monitor asthma control” [72]. More research is required to demonstrate their clinical significance in asthma monitoring.

Table 6 Use of hyperresponsiveness tests in paediatric asthma monitoring
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Use of electronic monitoring devices (EMDs) in paediatric asthma

Four studies were included; the outcomes were mainly the effectiveness in asthma control and adherence to inhalation therapy (Table 7) [73,74,75,76]. EMDs have the potential to increase the adherence rate for patients who used pMDI and nebulizer [73, 75, 76]. A study recruited participants between 6 months and 3 years old children to use the EMDs combined with weekly feedback to parents [75]. Results showed a significant improvement in treatment compliance [75]. In addition, van der Kamp et al. combined a smart inhaler, a handheld spirometer and an electrocardiography device [74]. It detected nearly 90% of children with uncontrolled asthma conditions [74]. The use of EMDs may provide guidance to clinicians in assessing patients’ compliance and adherence, as it can collect objective data [77]. The sensor was connected to a nebuliser or inhaler to measure adherence [73, 75, 76]. The devices detected each time actuation and automatically sent reminders to inform healthcare professionals or caregivers via a smartphone app to alert them if any non-adherence occurred [73, 75, 76]. Two studies included clinical outcomes and showed no significant improvement in lowering the rate of asthma exacerbations [73, 76]. Vasbinder et al. also showed no significant in cost reduction of asthma exacerbations between intervention and control groups [76]. More studies are required to evaluate the clinical outcomes and whether the purchasing cost of EMDs can outweigh the direct and indirect cost of hospitalization or ED admission due to nonadherence.

Furthermore, several issues need to be considered before use. Firstly, more evidence is required to demonstrate the effectiveness regarding the validity and accuracy of the devices over a long-term period, as well as their generalisability to other inhalation devices. Secondly, the devices generally only record actuation but not the inhalation technique. Thirdly, the size and the design of the device could affect patients’ willingness to use it [77]. Fourthly, it could increase the workload of clinicians as they require extra time to examine the electronic monitoring data. Clarifying the responsibility in managing, interpreting and discussing data with patients is recommended [77].

Table 7 Use of EMDs in paediatric asthma monitoring
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Conclusion

Paediatric asthma outcomes can be severe and even fatal if not well controlled. Therefore, it is crucial to monitor asthma conditions to initiate appropriate management plans to reduce the risk of acute exacerbations. Although no standardised objective tools are available due to limited evidence demonstrating significant benefits in asthma monitoring, spirometry has been widely used to monitor lung function. However, patients who have normal lung function tests can still have the risk of asthma exacerbation. Findings suggest that FeNO may be effective in this condition as well as assessing the treatment responses. Hyperresponsiveness tests with indirect stimuli, such as MDP, have not been included in the NICE and GINA guidelines, but recent research demonstrates it may have potential benefit in asthma monitoring. In addition, some studies suggest that a combination of objective monitoring tools may be more effective in asthma monitoring.

Furthermore, paediatric asthma management has been extended from clinic to home-based settings by incorporating information technology. Although objective testing is scheduled regularly in current clinical practice, it can only be evaluated in clinical settings at infrequent intervals. EMDs send reminders via smartphone applications to users. They are convenient for patients to monitor at home and may help in the early detection of any abnormality in lung function, as well as increase treatment adherence. However, further research is recommended as limited research evaluates their validity and accuracy.

Data availability

No datasets were generated or analysed during the current study.

References

  1. Asher MI, Rutter CE, Bissell K, Chiang C-Y, El Sony A, Ellwood E, et al. Worldwide trends in the burden of asthma symptoms in school-aged children: global Asthma Network Phase I cross-sectional study. Lancet. 2021;398(10311):1569–80.

    Article  PubMed  PubMed Central  Google Scholar 

  2. Holgate ST. Innate and adaptive immune responses in asthma. Nat Med. 2012;18(5):673–83.

    Article  CAS  PubMed  Google Scholar 

  3. Holgate ST, Wenzel S, Postma DS, Weiss ST, Renz H, Sly PD. Asthma Nat Reviews Disease Primers. 2015;1(1):15025.

    Article  PubMed  Google Scholar 

  4. Everhart RS, Fiese BH. Asthma severity and child quality of life in pediatric asthma: a systematic review. Patient Educ Couns. 2009;75(2):162–8.

    Article  PubMed  Google Scholar 

  5. Beasley R, Ellwood P, Asher I. International patterns of the prevalence of pediatric asthma the ISAAC program. Pediatr Clin North Am. 2003;50(3):539–53.

    Article  PubMed  Google Scholar 

  6. O’Connell EJ. The burden of atopy and asthma in children. Allergy. 2004;59(Suppl 78):7–11.

    Article  PubMed  Google Scholar 

  7. Meghji J, Mortimer K, Agusti A, Allwood BW, Asher I, Bateman ED, et al. Improving lung health in low-income and middle-income countries: from challenges to solutions. Lancet. 2021;397(10277):928–40.

    Article  PubMed  Google Scholar 

  8. Zhang D, Zheng J. The Burden of Childhood Asthma by Age Group, 1990–2019: a systematic analysis of global burden of disease 2019 data. Front Pediatr. 2022;10:823399.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Mariëlle WP, Eugenio B, Paul LPB, Kai-Håkon C, Ernst E, Thomas F, et al. Monitoring asthma in children. Eur Respir J. 2015;45(4):906.

    Article  Google Scholar 

  10. Wong GWK, Kwon N, Hong JG, Hsu J-Y, Gunasekera KD. Pediatric Asthma control in Asia: phase 2 of the Asthma insights and reality in Asia-Pacific (AIRIAP 2) survey. Allergy. 2013;68(4):524–30.

    Article  CAS  PubMed  Google Scholar 

  11. Wang H-C, Djajalaksana S, Sharma L, Theerakittikul T, Lim HF, Yoo KH, et al. Evaluation of short-acting Beta-2-agonist prescriptions and associated clinical outcomes: findings from the SABA use IN Asthma (SABINA) study in Asia. World Allergy Organ J. 2023;16(10):100823.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  12. Nwaru BI, Ekström M, Hasvold P, Wiklund F, Telg G, Janson C. Overuse of short-acting β(2)-agonists in asthma is associated with increased risk of exacerbation and mortality: a nationwide cohort study of the global SABINA programme. Eur Respir J. 2020;55(4).

  13. Kansen HM, Le TM, Uiterwaal C, van Ewijk BE, Balemans W, Gorissen D, et al. Prevalence and predictors of uncontrolled asthma in children referred for Asthma and Other Atopic diseases. J Asthma Allergy. 2020;13:67–75.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  14. Achakulwisut P, Brauer M, Hystad P, Anenberg SC. Global, national, and urban burdens of paediatric asthma incidence attributable to ambient NO < sub > 2 pollution: estimates from global datasets. Lancet Planet Health. 2019;3(4):e166–78.

    Article  PubMed  Google Scholar 

  15. Sio YY, Chew FT. Risk factors of asthma in the Asian population: a systematic review and meta-analysis. J Physiol Anthropol. 2021;40(1):22.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Butz AM, Ogborn J, Mudd S, Ballreich J, Tsoukleris M, Kub J, et al. Factors associated with high short-acting β2-agonist use in urban children with asthma. Ann Allergy Asthma Immunol. 2015;114(5):385–92.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  17. Rietveld S. Symptom perception in asthma: a multidisciplinary review. J Asthma. 1998;35(2):137–46.

    Article  CAS  PubMed  Google Scholar 

  18. Alexander M, Kai-Hakon C, Peter DS, Eugenio B, Giorgio P, Ian P, et al. Monitoring asthma in childhood: lung function, bronchial responsiveness and inflammation. Eur Respiratory Rev. 2015;24(136):204.

    Article  Google Scholar 

  19. Buzoianu E, Moiceanu M, Plesca DA. Asthma Control Assessment in Children: correlation between Asthma Control Test and Peak Expiratory Flow. Maedica (Bucur). 2014;9(4):338–43.

    PubMed  Google Scholar 

  20. Fielding S, Pijnenburg M, de Jongste JC, Pike KC, Roberts G, Petsky H, et al. Change in FEV(1) and feno measurements as predictors of future asthma outcomes in children. Chest. 2019;155(2):331–41.

    Article  PubMed  Google Scholar 

  21. Prevention CfDCa. 2020 Interview Survey (NHIS) Data. https://www.cdc.gov/asthma/nhis/2020/table2-1.htm 2020 [.

  22. Canada PHAo. Asthma and Chronic Obstructive Pulmonary Disease (COPD) in Canada. 2018. https://www.canada.ca/content/dam/phac-aspc/documents/services/publications/diseases-conditions/asthma-chronic-obstructive-pulmonary-disease-canada-2018/pub-eng.pdf 2018 [.

  23. NHS. Childhood Asthma [fact sheet]. https://www.england.nhs.uk/childhood-asthma/#main-content. 2018 [.

  24. Selroos O, Kupczyk M, Kuna P, Łacwik P, Bousquet J, Brennan D, et al. National and regional asthma programmes in Europe. Eur Respir Rev. 2015;24(137):474–83.

    Article  PubMed  PubMed Central  Google Scholar 

  25. Li X, Song P, Zhu Y, Lei H, Chan KY, Campbell H, et al. The disease burden of childhood asthma in China: a systematic review and meta-analysis. J Glob Health. 2020;10(1):010801.

    Article  PubMed  PubMed Central  Google Scholar 

  26. Welfare AIH. Australia’s children, Asthma prevalence among children. https://www.aihw.gov.au/getmedia/6af928d6-692e-4449-b915-cf2ca946982f/aihw-cws-69-print-report.pdf.aspx?inline=true.

  27. Lee SL, Wong W, Lau YL. Increasing prevalence of allergic rhinitis but not asthma among children in Hong Kong from 1995 to 2001 (phase 3 International Study of Asthma and allergies in Childhood). Pediatr Allergy Immunol. 2004;15(1):72–8.

    Article  PubMed  Google Scholar 

  28. Wong GW, Leung TF, Ko FW, Lee KK, Lam P, Hui DS, et al. Declining asthma prevalence in Hong Kong Chinese schoolchildren. Clin Exp Allergy. 2004;34(10):1550–5.

    Article  CAS  PubMed  Google Scholar 

  29. Kong TUoH. Survey findings on prevalence of allergic diseases among Hong Kong primary and secondary schoolchildren. https://www.hku.hk/press/press-releases/detail/23934.html 2022 [.

  30. Wang XS, Tan TN, Shek LP, Chng SY, Hia CP, Ong NB, et al. The prevalence of asthma and allergies in Singapore; data from two ISAAC surveys seven years apart. Arch Dis Child. 2004;89(5):423–6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Song WJ, Wong GWK. Changing trends and challenges in the management of asthma in Asia. J Allergy Clin Immunol. 2017;140(5):1272–4.

    Article  PubMed  Google Scholar 

  32. Statistics ABo. Asthma, 2020-21 financial year. https://www.abs.gov.au/statistics/health/health-conditions-and-risks/asthma/latest-release 2021.

  33. Lawson JA, Brozek G, Shpakou A, Fedortsiv O, Vlaski E, Beridze V, et al. An international comparison of asthma, wheeze, and breathing medication use among children. Respir Med. 2017;133:22–8.

    Article  PubMed  Google Scholar 

  34. Engelkes M, Baan EJ, de Ridder MAJ, Svensson E, Prieto-Alhambra D, Lapi F, et al. Incidence, risk factors and re-exacerbation rate of severe asthma exacerbations in a multinational, multidatabase pediatric cohort study. Pediatr Allergy Immunol. 2020;31(5):496–505.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Zhang J, Dai J, Yan L, Fu W, Yi J, Chen Y, et al. Air pollutants, Climate, and the prevalence of Pediatric Asthma in Urban areas of China. Biomed Res Int. 2016;2016:2935163.

    PubMed  PubMed Central  Google Scholar 

  36. Sha L, Liu C, Shao M, Chen Y. [Ten years comparison of diagnosis and treatment of asthma in urban children in China]. Zhonghua Er Ke Za Zhi. 2016;54(3):182–6.

    PubMed  Google Scholar 

  37. Zahran HSBC, Damon SA, Garbe PL, Breysse PN. Vital signs: Asthma in Children — United States, 2001–2016. MMWR Morb Mortal Wkly Rep. 2018;67:149–55.

    Article  PubMed  PubMed Central  Google Scholar 

  38. Zhao J, He Q, Zhang G, Chen Q, Bai J, Huang Y, et al. Status of asthma control in children and the effect of parents’ knowledge, attitude, and practice (KAP) in China: a multicenter study. Ann Allergy Asthma Immunol. 2012;109(3):190–4.

    Article  PubMed  Google Scholar 

  39. Database NHM, Asthma. https://www.aihw.gov.au/getmedia/3678077a-5aee-4ca2-8b2a-7bdfe47f4bc8/Asthma-2020.xls.aspx.

  40. Chua KL, Ma S, Prescott S, Ho MH, Ng DK, Lee BW. Trends in childhood asthma hospitalisation in three Asia Pacific countries. J Paediatr Child Health. 2011;47(10):723–7.

    Article  PubMed  Google Scholar 

  41. Fossati A, Challier C, Dalhoumi AA, Rose J, Robinson A, Perisson C et al. Telehome monitoring of symptoms and lung function in children with asthma. Healthc (Basel). 2022;10(6).

  42. Lo DK, Beardsmore CS, Roland D, Richardson M, Yang Y, Danvers L, et al. Lung function and asthma control in school-age children managed in UK primary care: a cohort study. Thorax. 2020;75(2):101–7.

    Article  PubMed  Google Scholar 

  43. Kang MG, Yoon SA, Sim JH, Woo SI. Fractional exhaled nitric oxide and forced expiratory volume in 1 second/forced vital capacity have predictive value of asthma exacerbation in Korean school children. Asia Pac Allergy. 2020;10(1):e7.

    Article  PubMed  PubMed Central  Google Scholar 

  44. Anandi S, Tullu MS, Lahiri K. Evaluation of symptoms & spirometry in children treated for asthma. Indian J Med Res. 2016;144(1):124–7.

    Article  PubMed  PubMed Central  Google Scholar 

  45. Fuhlbrigge AL, Kitch BT, Paltiel AD, Kuntz KM, Neumann PJ, Dockery DW, et al. FEV(1) is associated with risk of asthma attacks in a pediatric population. J Allergy Clin Immunol. 2001;107(1):61–7.

    Article  CAS  PubMed  Google Scholar 

  46. Rietveld S, Everaerd W. Perceptions of asthma by adolescents at home. Chest. 2000;117(2):434–9.

    Article  CAS  PubMed  Google Scholar 

  47. Pijnenburg MW. The role of FeNO in Predicting Asthma. Front Pead. 2019;7.

  48. Hoggins R, Velpula M, Woodward S, Tighe MP. How to use the fractional exhaled nitric oxide test. Arch Dis Child Educ Pract Ed. 2022;107(2):133–40.

    PubMed  Google Scholar 

  49. Buchvald F, Baraldi E, Carraro S, Gaston B, De Jongste J, Pijnenburg MW, et al. Measurements of exhaled nitric oxide in healthy subjects age 4 to 17 years. J Allergy Clin Immunol. 2005;115(6):1130–6.

    Article  CAS  PubMed  Google Scholar 

  50. Dweik RA, Boggs PB, Erzurum SC, Irvin CG, Leigh MW, Lundberg JO, et al. An official ATS clinical practice guideline: interpretation of exhaled nitric oxide levels (FENO) for clinical applications. Am J Respir Crit Care Med. 2011;184(5):602–15.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  51. Zheng S, Hu Y, Chen Z, Wang M, Liao W. Predicting Asthma exacerbation by impulse oscillometry evaluation of small airway function and fractional exhaled nitric oxide in preschool children. Pediatr Pulmonol. 2020;55(7):1601–7.

    Article  PubMed  Google Scholar 

  52. Kim JK, Jung JY, Kim H, Eom SY, Hahn YS. Combined use of fractional exhaled nitric oxide and bronchodilator response in predicting future loss of asthma control among children with atopic asthma. Respirology. 2017;22(3):466–72.

    Article  PubMed  Google Scholar 

  53. Xepapadaki P, Korovessi P, Bachert C, Finotto S, Jartti T, Lakoumentas J et al. Evolution of Airway Inflammation in preschoolers with asthma-results of a two-year longitudinal study. J Clin Med. 2020;9(1).

  54. Ngo-Minh X, Tang-Thi-Thao T, Doan-Thi-Quynh N, Craig TJ, Duong-Quy S. Study of the role of exhaled nitric oxide (NO) in predicting controlled or uncontrolled asthma in asthmatic children. Multidiscip Respir Med. 2020;15(1):656.

    PubMed  PubMed Central  Google Scholar 

  55. Songnuy T, Petchuay P, Chutiyon W, Nurak A. Correlation between fractional exhaled nitric oxide level and clinical outcomes among childhood asthmatic patients: community hospital-based perspective. Heliyon. 2021;7(5):e06925.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  56. Diamant N, Amirav I, Armoni-Domany K, Sadot E, Shapira U, Cahal M, et al. High fractional exhaled nitric oxide levels in asthma patients: does size matter? Pediatr Pulmonol. 2021;56(6):1449–54.

    Article  PubMed  Google Scholar 

  57. Lin LM, Chang YJ, Yang KD, Lin CH, Chien JW, Kao JK, et al. Small Airway Dysfunction measured by Impulse Oscillometry and Fractional exhaled nitric oxide is Associated with Asthma Control in Children. Front Pediatr. 2022;10:877681.

    Article  PubMed  PubMed Central  Google Scholar 

  58. Fang C, Yang LJ, Chen XJ, Li DM, Li DX, Liang LT et al. A clinical investigation into the usefulness of fractional exhaled nitric oxide in guiding glucocorticoid therapy in children with bronchial asthma. J Physiol Pharmacol. 2022;73(4).

  59. Morphew T, Shin HW, Marchese S, Pires-Barracosa N, Galant SP. Phenotypes favoring fractional exhaled nitric oxide discordance vs guideline-based uncontrolled asthma. Ann Allergy Asthma Immunol. 2019;123(2):193–200.

    Article  CAS  PubMed  Google Scholar 

  60. Dinh-Thi-Dieu H, Vo-Thi-Kim A, Tran-Van H, Tang-Thi-Thao T, Duong-Quy S. Study of the beneficial role of exhaled nitric oxide in combination with GINA guidelines for titration of inhaled corticosteroids in children with asthma. J Breath Res. 2020;14(2):026014.

    Article  CAS  PubMed  Google Scholar 

  61. Turner S, Cotton S, Wood J, Bell V, Raja E-A, Scott NW, et al. Reducing asthma attacks in children using exhaled nitric oxide (RAACENO) as a biomarker to inform treatment strategy: a multicentre, parallel, randomised, controlled, phase 3 trial. Lancet Respiratory Med. 2022;10(6):584–92.

    Article  CAS  Google Scholar 

  62. Paracha R, Lo DKH, Montgomery U, Ryan L, Varakantam V, Gaillard EA. Asthma medication adherence and exacerbations and lung function in children managed in Leicester primary care. NPJ Prim Care Respir Med. 2023;33(1):12.

    Article  PubMed  PubMed Central  Google Scholar 

  63. Chapman DG, Irvin CG. Mechanisms of airway hyper-responsiveness in asthma: the past, present and yet to come. Clin Exp Allergy. 2015;45(4):706–19.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  64. Levin G, Rottensctreich A, Picard E, Avital A, Springer C, Cohen S. The correlation of adenosine challenge test results with subsequent clinical course among young children with suspected asthma: a retrospective cohort study. Pediatr Pulmonol. 2019;54(7):1087–92.

    Article  PubMed  Google Scholar 

  65. Levin G, Cohen S, Springer C, Avital A, Picard E, Rottensctreich A. Factors Associated with positive Adenosine Challenge Test in Young Children with suspected asthma. Pediatr Allergy Immunol Pulmonol. 2019;32(3):103–8.

    Article  PubMed  PubMed Central  Google Scholar 

  66. Lammers N, van Hoesel MHT, Kamphuis M, Brusse-Keizer M, van der Palen J, Visser R, et al. Assessing Exercise-Induced Bronchoconstriction in Children; the need for testing. Front Pediatr. 2019;7:157.

    Article  PubMed  PubMed Central  Google Scholar 

  67. Karantaglis N, Kirvassilis F, Hatziagorou E, Gkantaras A, Kontouli K, Tsanakas J et al. Mannitol Challenge to assess therapy response in Asthmatic children: an interventional cohort study. Child (Basel). 2023;10(5).

  68. Anderson SD, Kippelen P. Assessment of EIB: what you need to know to optimize test results. Immunol Allergy Clin North Am. 2013;33(3):363–80. viii.

    Article  PubMed  Google Scholar 

  69. Sverrild A, Porsbjerg C, Backer V. The use of inhaled mannitol in the diagnosis and management of asthma. Expert Opin Pharmacother. 2012;13(1):115–23.

    Article  CAS  PubMed  Google Scholar 

  70. Afaf SA, Shannon JS, Stephen MS, Graham LH. The safety and feasibility of the inhaled mannitol challenge test in young children. Eur Respir J. 2013;42(5):1420.

    Article  Google Scholar 

  71. Law KW, Ng KK, Yuen KN, Ho CS. Detecting asthma and bronchial hyperresponsiveness in children. Hong Kong Med J. 2000;6(1):99–104.

    CAS  PubMed  Google Scholar 

  72. (NICE) NIfHaCE. Asthma: diagnosis, monitoring and chronic asthma management. https://www.nice.org.uk/guidance/ng80/chapter/Recommendations#monitoring-asthma-control. 2021 [.

  73. Gupta RS, Fierstein JL, Boon KL, Kanaley MK, Bozen A, Kan K, et al. Sensor-based electronic monitoring for Asthma: a Randomized Controlled Trial. Pediatrics. 2021;147(1):e20201330.

    Article  PubMed  Google Scholar 

  74. van der Kamp MR, Klaver EC, Thio BJ, Driessen JMM, de Jongh FHC, Tabak M, et al. WEARCON: wearable home monitoring in children with asthma reveals a strong association with hospital based assessment of asthma control. BMC Med Inf Decis Mak. 2020;20(1):192.

    Article  Google Scholar 

  75. Chen J, Xu J, Zhao L, Zhang J, Yin Y, Zhang F. The effect of electronic monitoring combined with weekly feedback and reminders on adherence to inhaled corticosteroids in infants and younger children with asthma: a randomized controlled trial. Allergy Asthma Clin Immunol. 2020;16:68.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  76. Vasbinder EC, Goossens LM, Rutten-van Mölken MP, de Winter BC, van Dijk L, Vulto AG, et al. e-Monitoring of Asthma Therapy to improve compliance in children (e-MATIC): a randomised controlled trial. Eur Respir J. 2016;48(3):758–67.

    Article  PubMed  Google Scholar 

  77. Howard S, Lang A, Sharples S, Shaw D. What are the pros and cons of electronically monitoring inhaler use in asthma? A multistakeholder perspective. BMJ Open Respir Res. 2016;3(1):e000159.

    Article  PubMed  PubMed Central  Google Scholar 

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Acknowledgements

This work was financially supported by the Health and Medical Research Fund, Research Fellowship Scheme, Food and Health Bureau, Hong Kong SAR Government (grant no. 04180037).

Funding

This work was financially supported by the Health and Medical Research Fund, Research Fellowship Scheme, Food and Health Bureau, Hong Kong SAR Government (grant no. 04180037).

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Authors and Affiliations

  1. School of Pharmacy, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China

    Phillip L.W. Au-Doung, Jason C.H. Chan, Oliver Y.H. Kui, Marco K.Y. Ho, Yin Ting Cheung & Sharon S.Y. Leung

  2. Department of Pharmaceutics, UCL School of Pharmacy, University College London, London, WC1N 1AX, UK

    Jenny K.W. Lam

  3. Sydney Pharmacy School, University of Sydney, Sydney, NSW, Australia

    Hak-Kim Chan

  4. Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia

    John Brannan

  5. Department of Paediatrics, Prince of Wales Hospital, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong SAR, China

    Kate C.C. Chan & Albert M. Li

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  1. Phillip L.W. Au-Doung
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Contributions

S.S.Y.L. conceptualization, supervision and funding acquisition. P.L.W. A., J.C.H.C. and O.Y.H.K. wrote the main manuscript text. M.K.Y.H prepared Tables 1, 2 and 3. Y.T.C., J.K.W.L., H.K.C., J.B., K.C.C.C., A.M.L. and S.S.Y.L. reviewed the manuscript.

Corresponding author

Correspondence to Sharon S.Y. Leung.

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Conflict of interest

No known conflict of interest exists between any author and supplier used in this study. Dr. Chan HK and Brannan J received royalty from the sale of Aridol/Osmohale.

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Au-Doung, P.L., Chan, J.C., Kui, O.Y. et al. Objective monitoring tools for improved management of childhood asthma. Respir Res 25, 194 (2024). https://0-doi-org.brum.beds.ac.uk/10.1186/s12931-024-02817-y

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Respiratory Research

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