Is there a “traffic light” in asthma management?

The theme of World Asthma Day 2021 is “Uncovering Misconceptions about Asthma”.
To call for action to address the prevalent ‘myths’ and ‘misconceptions’ about bronchial asthma (Asthma for short) that prevent people with asthma from benefiting best from major advances in asthma management 1.
In order to further improve the popularity of the asthma action plan and implementation, in April this year, the clinical application of Chinese children asthma action plan expert consensus “(hereinafter referred to as the” consensus “) 2, at the same time, Chinese children asthma action plan (CCAAP) on the basis of the 2017 version also be updated, in order to deliver asthma right concept, reduction and prevention of asthma,
Prevent asthma-related deaths and promote self-management in children with asthma.
Childhood asthma has its clinical characteristics
Asthma is a heterogeneous disease characterized by chronic airway inflammation and airway hyperresponsiveness, with recurrent wheezing, cough, shortness of breath and chest tightness as the main clinical manifestations. It often attacks or worsens at night and/or in the early morning.
Asthma is the most common chronic respiratory disease in childhood. In the past 30 years, the prevalence of asthma has been on the rise, which brings an increasingly heavy disease burden to individuals, families and society.
There are four clinical characteristics of childhood asthma 3:(1) It is often manifested as wheezing, cough, shortness of breath and chest tightness.
The inducement is diverse, has the characteristic of recurrent, seasonal and reversibility;
There is a time rule, often in the night and early morning, autumn and winter season or change seasons when the attack or aggravation;
Antiasthmatic drugs usually relieve symptoms.
(2) Most of the children had a history of other allergic diseases, or a family history of asthma and other diseases.
(3) Children with chronic duration and clinical remission may have no abnormal signs.
The most common signs of an asthma attack are prolonged expiratory phase and wheezing, but “silent lungs” may occur in an acute attack of extreme severity.
(4) Pulmonary function is characterized by variable restricted expiratory flow and increased airway reactivity.
The asthma control rate in China is less than 30%, so it is of great significance to promote CCAAP
It is estimated that the global mortality rate of children with asthma is 0 ~ 0.7/100,000. Research 5 shows that the mortality rate of children with asthma aged 0 ~ 19 in China is at a low level in the world, ranging from 0.023/100,000 to 0.046/100,000.
However, due to the large population base in China, the estimated number of asthma deaths in this age group is relatively high (70 to 148 deaths per year).
In 2017, a total of 3875 patients were included in the survey of the control level of outpatients with bronchial asthma in urban areas of 30 provinces and cities in China. According to the asthma control level classification defined by the Global Initiative for Asthma Prevention and Treatment (GINA), the results showed that the overall control rate of asthma in urban areas in China was 28.5%6.
Inadequate implementation of asthma action plan is one of the important risk factors for death caused by asthma. The asthma guidelines of all countries propose to provide each asthma patient with an individualized written asthma action plan 7.
Self-management level of asthma patients is an important link to achieve asthma control goals.
The management of childhood asthma in China has made great progress, but there is still poor control, and promoting the implementation and implementation of CCAAP is an important part of self-management education for asthma patients 6.
Fluticasone propionate suspension was added in the three zones of the new CCAAP
For many years, the prevention and treatment of childhood Asthma in China has always emphasized the education and self-management of children, and in the revision of Guidelines for the Diagnosis and Prevention of Childhood Bronchial Asthma in 2016, the application of Asthma Action Plan (AAP)2 in the management of children with Asthma was clearly proposed.
In 2017, the National Clinical Research Center for Respiratory Diseases and others formulated the China Children’s Asthma Action Plan (CCAAP) (2016 paper version), and developed and built the mobile version of AAP and mobile AAP asthma management platform 8 at that time.
This year, CCAAP(paper version) has been updated. Based on the experience in the use of the first version, the new version of CCAAP(paper version) has updated the content, added commonly used drugs and optimized the format.
Promoting the implementation of CCAAP can improve the self-management level of children with asthma in China, and provide an effective tool for self-management and education of children with asthma in China.
CCAAP adopts green, yellow and red traffic light modes to conduct self-management of asthma according to clinical symptoms of children’s asthma and monitoring results of maximum expiratory flow rate (PEF). At the same time, the sensitization of children’s personal allergenic factors and common triggers are marked, and the avoidance of triggers is emphasized as a non-drug intervention.
These individualized asthma management approaches help maximize the benefits of AAP 2.
The “green zone”, “yellow zone” and “red zone” in the new version of CCAAP(paper version) all add the “suspension for fluticasone propionate aerosol inhalation 0.5mg/2ml”, which just came into the market in 2018.
The management level of children varies with the division
The Expert Consensus on Clinical Application of the Action Plan for Chinese Children’s Asthma 2 specifies the management of each division, as shown in the table below.
Table 1 Management and follow-up by area AR: Allergic Rhinitis, SABA: Short-acting β2 agonist,
ICS: Inhaled glucocorticoids, LABA: Long-acting β2 receptor agonist
There are many kinds of control drugs and palliative drugs for children’s asthma. Consensus 2 also suggests the usage and dosage (see Table 2).
Table 2 Dosage forms, specifications and dosages of commonly used medicines for children. Preferred aerosol inhalation ICS — Suspensions for aerosol inhalation of fluticasone propionate (FPN)
As can be seen from the consensus, ICS is recommended for the treatment of childhood asthma.
The suspension for fluticasone propionate aerosol inhalation added in the “green zone”, “yellow zone” and “red zone” in the paper version of CCAAP has a variety of pharmacological advantages and is the optimal ICS for children.
A multicentre, randomized, double-blind, double-simulated, 7-day Chinese clinical study confirmed that FP aerosolized suspension was no less effective than oral hormones in treating acute asthma attacks in Chinese children.
A systematic review 10 included 10 RCT studies that showed systemic safety of FP to be superior to or equivalent to budesonide (BUD).
Fluticasone propionate is the latest generation of ICS molecules, with six pharmacological properties, which make it have three core advantages of strong efficacy, good safety data and economy, and is the preferred ICS for atomization inhalation.
This year, the Chinese Children’s Asthma Action Plan Clinical Application Expert Consensus was released, and CCAAP was also updated. It is expected that pediatricians, respiratory department and other physicians will continue to deepen the understanding of asthma, promote the implementation of CCAAP, improve the management level of children’s asthma, and achieve long-term control of asthma.

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