Asthma Control Questionnaires
Longitudinal TRACK scores were available for 10 TA-B-BAL patients. The
analysis included questionnaires within a 2-year period before and after
the combined procedure. A paired t-test revealed a clinically
significant improvement in TRACK score (>10 points change)
between the pre-procedure and post-procedure visit (p=<0.001)
in all 10 subjects, with a mean difference of 40.0 points. Four patients
(40%) reported TRACK scores of > 80 indicating asthma
control at the post-procedure visit.
Longitudinal TRACK scores were available for 12 patients in the control
group. Eight patients (66% of the control group) achieved a clinically
significant improvement in TRACK score between the baseline and follow
up visit, the overall group mean difference of 25.4 points was
significant (p=0.001). Five patients (42%) reported TRACK scores of
> 80 indicating asthma control at the follow-up time point
(Figure 5 ).
Discussion
This case-control study evaluated the effect of a TA-B-BAL procedure in
a cohort of preschool children with asthma. This is the first study to
report the beneficial effect of a combined TA-B-BAL procedure in a
preschool age sample using multiple outcome measures. The available
literature of TA in asthma is limited to children with mean age greater
than 6 years, studies that examine the impact of adenotonsillectomy
only, or the use of less robust asthma control measures.
There are several studies that have examined the impact of
adenotonsillectomy only for asthma management. Adenotonsillectomy has
been shown to improve asthma symptoms 9,13 and asthma
control questionnaire scores (ACT and CACT)11,13,25,26, reduce the rate of exacerbations and
emergency department visits 5,11,13,25,26, and
decrease the requirement for asthma medication for maintenance and acute
exacerbations 8,9,11-13,25,26. In the present study,
patients in the TA-B-BAL group were referred to the clinic on higher
doses of ICS compared to the asthmatic controls. Despite these higher
doses of ICS, there was little improvement in symptoms noted at the
medical follow-up visit, leading to a referral to the otolaryngology
service for the combined procedure (TA-B-BAL). This contrasts to the
asthma control group who achieved greater symptom control at the
follow-up visit and at the same ICS dose. Notably, post TA-B-BAL,
patienyd in this group were able to achieve the same level of control as
those medically managed but at a lower ICS dose.
The vast majority of the studies exploring adenotonsillectomy in
pediatric asthma patients included children with a mean age greater than
6 years 5,8,11,13,25,26. The mean age of the cohort of
patients in the present study was notably lower at 3.19 ± 1.13 years.
Interestingly, Koenigs and colleagues noted that younger children were
more likely to demonstrate a post-surgical improvement in asthma control25. This was attributed to a number of factors
including a higher relative degree of airway obstruction and
susceptibility to viral infection in the younger age groups27.
Asthma is a heterogenous syndrome, particularly in preschool children.
This study and others show that management of upper airway conditions
can improve asthma symptom control in a select group of patients5,8,9. From a physiological perspective, this may be
explained by the united airway hypothesis 16.
This hypothesis suggests that the inflammatory processes from infection
in the lower airways may lead to inflammation and proliferation of the
lymphadenoid tissues and tonsillar lymphocytes in the upper airway andvice versa 14,16. Levin and colleagues noted an
improvement in markers of airway inflammation (decrease in circulating
chitinase activity) in asthmatics who underwent adenotonsillectomy13. Alternatively, in preschool children, the
pathophysiologic cause of the symptoms may be due to the upper
respiratory obstruction mimicking symptoms of asthma. Further studies
are needed in this age group to objectively measure airway
hyper-responsiveness to further elucidate the underlying
pathophysiology.
Asthmatic patients are at an increased risk of respiratory complications
following a general anesthetic and surgery 28. Formal
pulmonary evaluation and optimization prior to surgery should be
achieved in all asthmatic patients 29. Nonetheless,
airway interventions can be performed safely in preschool wheeze. In a
series of 93 children, Busino and colleagues reported no significant
difference in the length of hospital stay between asthmatic and
non-asthmatic children undergoing adenotonsillectomy11. The safety of bronchoscopy and BAL procedures in
patients with asthma has also been evaluated and is associated with a
very low incidence of major complications (<2%)30-32. In the present study, only 1 patient
experienced respiratory difficulty and pneumonia requiring admission
post-operatively. This patient fully recovered without further
complication.
BAL procedures are important for the identification of viral and
bacterial colonization or infection and for cytology to identify an
increase in cells associated with inflammation 30,33.
In line with conditional recommendations put forth by the American
Thoracic Society, B and BAL can minimize unecessary antibiotic therapy
and ineffective medications by providing accurate culture and cytology
data, and identification of anatomical abnormalities17. Viral infections cause approximately 85% of
severe asthma exacerbations in children by increasing the production of
pro-inflammatory cytokines and chemokines, leading to airway
inflammation 6,31. Furthermore, colonization of the
hypopharyngeal region with Streptococcus pneumonia ,Haemophilus influenza and Moraxella catarrhalis has been
associated with acute severe exacerbations and hospitalizations for
wheeze 6. Eller and colleagues reported that patients
with controlled severe asthma had high eosinophil counts in sputum
compared to patients with severe, therapy-resistant asthma34. Patients with severe asthma resistant to
corticosteroid treatment also have increased neutrophil counts in
peripheral blood and BAL specimens 34,35. In the
present study, Moraxella catarrhalis was identified in 11
patients, Streptococcus pneumoniae was identified in 4 patients,
and enterovirus/rhinovirus species were isolated in 4 patients. Five
patients exhibited neutrophilia (>15%) and 2 patients
exhibited eosinophilia (>3%).
This study has demonstrated that a combined TA-B-BAL procedure can be
performed in a cohort of preschool age patients with severe asthma or
wheeze. The intervention alleviated symptoms of upper airway
obstruction, identified microbiological and cytological characteristics
of the lower airways, and ultimately improved measures of asthma
control.