Robin J. Green

Guideline for the management of chronic asthma in children -2009 update

OBJECTIVE To revise the guideline for the diagnosis and management of chronic asthma in children in view of the following considerations: the existing South African Childhood Asthma Working Group (SACAWG) guideline was produced 10 years ago; diagnosis of asthma in young children remains a challenge; evidence-based treatment is the new paradigm; new treatment approaches to achieving and maintaining control; therapeutic roles of several medications have evolved; more studies and data on treatment in young children; new medications and formulations; a change of emphasis in assessing asthma control to guide treatment changes. The main aim of the guideline is to promote a better standard of treatment based on understanding of the pathophysiology and pharmacotherapy of asthma, and encouraging uniformity in asthma management. EVIDENCE A detailed literature review by a working group of clinicians from relevant disciplines. The strategies recommended are classified according to the evidence category in Appendix B, and denoted as Evidence A, B, C and D. RECOMMENDATIONS These include an appropriate diagnostic approach, environmental control measures, treatment options, definition of asthma control, and strategies to achieve control. ENDORSEMENT The guideline document was endorsed by the South African Thoracic Society (SATS), the National Asthma Education Programme (NAEP), the South African Paediatric Association (SAPA) and the South African Academy of Family Practice.

Disagreement Among Common Measures of Asthma Control in Children

BACKGROUND Asthma is a worldwide problem. It cannot be prevented or cured, but it is possible, at least in principle, to control asthma with modern management. Control usually is assessed by history of symptoms, physical examination, and measurement of lung function. A practical problem is that these measures of control may not be in agreement. The aim of this study was to describe agreement among different measures of asthma control in children. METHODS A prospective sequential sample of children aged 4 to 11 years with atopic asthma attending a routine follow-up evaluation were studied. Patients were assessed with the following four steps: (1) fraction of exhaled nitric oxide (FENO), (2) spirometry, (3) Childhood Asthma Control Test (cACT), and (4) conventional clinical assessment by a pediatrician. The outcome for each test was coded as controlled or uncontrolled asthma. Agreement among measures was examined by cross-tabulation and κ statistics. RESULTS Eighty children were enrolled, and nine were excluded. Mean FENO in pediatrician-judged uncontrolled asthma was double that of controlled asthma (37 parts per billion vs 15 parts per billion, P < .005). There was disagreement among measures of control. Spirometric indices revealed some correlation, but of the unrelated comparisons, those that agreed with each other most often (69%) were clinical assessment by the pediatrician and the cACT. Worst agreement was noted for FENO and cACT (49.3%). CONCLUSION Overall, different measures to assess control of asthma showed a lack of agreement for all comparisons in this study.

HIV-related bronchiectasis in children : an emerging spectre in high tuberculosis burden areas

BACKGROUND Human immunodeficiency virus (HIV) infected children have an eleven-fold risk of acute lower respiratory tract infection. This places HIV-infected children at risk of airway destruction and bronchiectasis. OBJECTIVE To study predisposing factors for the development of bronchiectasis in a developing world setting. METHODS Children with HIV-related bronchiectasis aged 6-14 years were enrolled. Data were collected on demographics, induced sputum for tuberculosis, respiratory viruses (respiratory syncytial virus), influenza A and B, parainfluenza 1-3, adenovirus and cytomegalovirus), bacteriology and cytokines. Spirometry was performed. Blood samples were obtained for HIV staging, immunoglobulins, immunoCAP®-specific immunoglobulin E (IgE) for common foods and aeroallergens and cytokines. RESULTS In all, 35 patients were enrolled in the study. Of 161 sputum samples, the predominant organisms cultured were Haemophilus influenzae and parainfluenzae (49%). The median forced expiratory volume in 1 second of all patients was 53%. Interleukin-8 was the predominant cytokine in sputum and serum. The median IgE level was 770 kU/l; however, this did not seem to be related to atopy; 36% were exposed to environmental tobacco smoke, with no correlation between exposure and CD4 count. CONCLUSION Children with HIV-related bronchiectasis are diagnosed after the age of 6 years and suffer significant morbidity. Immune stimulation mechanisms in these children are intact despite the level of immunosuppression.

Perceptions, impact and management of asthma in South Africa: a patient questionnaire study

INTRODUCTION A number of studies from around the world have indicated that asthma morbidity is still unacceptably high. In the AIRE study over one-third of children and half of the adults reported daytime symptoms at least once a week. This study was conducted to understand the impact (including the impact on health-related quality of life) of asthma on South African asthmatics. MATERIALS AND METHODS General Practitioners (GPs) and pharmacists in South Africa were randomly identified from the Medical Association database. These individuals were approached and asked to recruit asthmatic patients to complete a questionnaire. The questionnaire inquired about symptoms, quality of life, complications, trigger factors, associated allergic conditions, medication used, medication preference, medication adherence and concerns about the condition. RESULTS 3347 respondents returned their demographic data but only 710 met the criteria for analysis, ie. had asthma and were presently on controller medication. Symptom analysis revealed that 21.4% of respondents were coughing on most days, 25.6% were wheezing on most days, and 22.8% were experiencing night-time symptoms on most days. Symptoms were exacerbated by exercise in 56.9%, while nocturnal wakening due to asthma occurred in 36.9% more than four times per week. Only 35.1% of respondents had not missed school or work in the preceding year. 45.4% of individuals worry about side effects of asthma therapy. CONCLUSION This study indicates that there is under-treatment, inappropriate treatment and/or lack of patient education for asthma patients in South Africa. The data support the notion that poor therapy and/or poor patient adherence has an enormous impact on the health-related quality of life of South Africas asthmatics.

South African guideline for the diagnosis, management and prevention of acute viral bronchiolitis in children

ENDORSEMENT South African Thoracic Society, South African Society of Paediatric Infectious Diseases, United South African Neonatal Association. OBJECTIVE To develop and publish a guideline for doctors managing acute viral bronchiolitis, because this condition is extremely common in South Africa, it is responsible for significant morbidity in the population, and subsequently a great deal of patient and parental distress, and the disease is costly, since many children are unnecessarily subjected to investigations and treatment strategies that are of no proven benefit. The main aims of the guideline are to promote an improved standard of treatment based on understanding of the disease and its management, and to encourage cost-effective and appropriate management. EVIDENCE A detailed literature review was conducted and summarised into this document by a selected working group of paediatricians from around the country. Recommendations. These include the appropriate diagnostic and management strategies for acute viral bronchiolitis.

Outcome of human immunodeficiency virus–exposed and –infected children admitted to a pediatric intensive care unit for respiratory failure

Objective: Acute severe pneumonia with respiratory failure in human immunodeficiency virus-infected and -exposed infants carries a high mortality. Pneumocystis jiroveci is one cause, but other organisms have been suggested to play a role. Our objective is to describe the coinfections and treatment strategies in a cohort of human immunodeficiency virus-infected and -exposed infants with respiratory failure and acute respiratory distress syndrome, in an attempt to improve survival. Design: Prospective intervention study. Setting: Steve Biko Academic Hospital, Pretoria, South Africa. Patients: Human immunodeficiency virus–exposed infants with respiratory failure and acute respiratory distress syndrome were recruited into the study. Interventions: All infants were treated with routine therapy for Pneumocystis jiroveci and bacterial coinfection. However, in addition, all infants received ganciclovir from admission until the cytomegalovirus viral load result was demonstrated to be <log 4. Measurements: Routine investigations included human immunodeficiency virus polymerase chain reaction, cytomegalovirus viral load, blood culture, C-reactive protein, and white cell count. Tracheal aspirates for Pneumocystis jiroveci detection, bacterial culture, tuberculosis culture, and viral identification were performed. Main Results: Sixty-three patients met the recruitment criteria. The mortality rate was 30%. Pneumocystis jiroveci was positive in 33% of infants, while 38% had cytomegalovirus viral load ≥log 4. Only 7.9% of infants had a positive tuberculosis culture. Nineteen deaths occurred, 13 of which had a cytomegalovirus viral load ≥log 4. Bacterial coinfection and CD4 count were not predictors of mortality. Conclusions: A case fatality rate of 30% is achievable if severe pneumonia with respiratory failure and acute respiratory distress syndrome is managed with a combination of antibiotics and ventilation strategies. Cytomegalovirus infection appears to be associated with an increased risk of death in this syndrome. This may, however, be a marker of as yet undefined pathology.

Symptomatic treatment of upper respiratory tract symptoms in children

Abstract Most upper respiratory tract infections are viral and treatment of a viral URTI is symptomatic. Today, with the emergence of antimicrobial resitance, antibiotics must be thought of as contra-indicated. Acute bacterial sinusitis may complicate a viral URTI. All special investigations for diagnosing acute sinusitis are unhelpful. Treatment of pain and fever are usually the only nonspecific measures that help. Antimicrobial treatment has become a mainstay of acute sinusitis but there are studies suggesting that antibiotics do not alter the course of the disease. Since hearing loss is a risk of untreated and severe acute otitis media, this conditionis usually treated with antibiotics. However, a recent Cochrane Review has concluded that the number of patients needed to treat with antibiotics for a benefit is 15. The picture of itching, sneezing and profuse rhinorrhoea are classic of early allergic rhinitis but with time, and especially in perennial allergic rhinitis, nasal obstruction is a prominent symptom. It is the pathology which gives rise to both the classic facial appearance of patients (especially children) with perennial allergic rhinitis and the many complications. The most effective therapy of allergic rhino-sinusitis (as the disease should correctly be called) involves the topical nasal steroids.

Allergic rhinitis in South Africa: 2012 guidelines.

Background. Allergic rhinitis (AR) is an important disease in South Africa. The South African Allergic Rhinitis Working Group (SAARWG) has published previous guidelines for AR diagnosis and management. Areas of concern have arisen that require additional information, including the management of AR in infancy, appropriate and inappropriate allergy testing, cost of AR management, diagnosis and distinguishing the condition from sinusitis, use of over-the-counter medications, and the concept of the ‘united airway’. Recommendations. Clinicians should consider the possibility of AR in infants with recurrent nasal symptoms. Allergy testing should be used wisely and based on local allergens. Total IgE testing is not routinely required to prove allergy. Acute and chronic sinusitis should be considered in conjunction with AR; treatment of rhinitis will improve these conditions. Over-the-counter medications should be used sparingly and with caution. Concern for long-term use of topical decongestants must be noted. Asthma should always be considered in AR diagnosis. Immunotherapy is available in SA and may be extremely useful in selected AR patients. Conclusion. The SAARWG proposed an algorithm for the diagnosis and management of rhinitis in South Africa. AR is common, important and troubling to patients; therefore, every effort should be made to target therapy correctly. Patient education is important in the management of AR.

The Role of Macrolides in Childhood Non-Cystic Fibrosis-Related Bronchiectasis

Non-cystic fibrosis-related bronchiectasis is a chronic inflammatory lung disease, which is regarded as an “orphan” lung disease, with little research devoted to the study of this condition. Bronchiectasis results in impaired quality of life and mortality if left untreated. The tools available in the armamentarium for the management of bronchiectasis entail antibiotic therapy traditionally used to treat exacerbations, stratagems to improve mucociliary clearance, and avoidance of toxins. Macrolides have been known for the last two decades to have not only anti-bacterial effects but immunomodulatory properties as well. In cystic fibrosis, the use of macrolides is well documented in subjects colonized with Pseudomonas aeruginosa, to improve quality of life and lung function. There is currently emerging evidence to suggest the benefit of macrolides in subjects not colonized with Pseudomonas aeruginosa. This beneficial effect has been less explored in the context of bronchiectasis from other causes. The purpose of this paper is to review the current literature on the use of macrolides in non-cystic fibrosis related bronchiectasis in paediatrics.

Atopy in HIV-infected children in Pretoria

INTRODUCTION The development or aggravation of a pre-existing atopic state in patients with human immunodeficiency virus (HIV) has not been thoroughly investigated in South Africa. HIV-infected adults have been shown to have a higher prevalence of atopy in some international studies, but this has not been documented in children. METHODS A prospective convenience sample of 50 children aged between 3 months and 12 years attending the Tshwane District Hospital Paediatric HIV Clinic in Pretoria was recruited. Their personal and family histories of atopy, World Health Organization (WHO) HIV clinical staging and Centers for Disease Control (CDC) immunological staging with CD4 counts were documented. An age- and sex-matched control group of 50 HIV-negative children was included. Skin prick tests (SPTs) to identify common aeroallergens were conducted on all patients. RESULTS One hundred children were enrolled, with 50 in each group. Ten per cent of the HIV-infected patients compared with 16% of controls had positive SPTs to aeroallergens. A higher percentage of the HIV-infected patients had chronic rhinitis and eczema (60% and 68%, respectively). There was no relationship between CD4 count and positive SPTs (p = 0.61), mean log CD4 count and presence of reported asthma (p = 0.71), and CD4 count and presence of reported dermatitis (p = 0.84). The CD4 count was not statistically different between children with and without a family history of atopy (p = 0.68). CONCLUSION It appears that the stage of HIV disease does not influence the development or expression of allergy. There is a high prevalence of dermatitis and chronic rhinitis in HIV-infected children, probably not atopic in origin.