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.