Recognition of the peripheral airway impairment phenotype in children with well-controlled asthma

Peripheral airway impairment, although frequently unrecognized, is a risk factor for poor asthma control, loss of control, increased exacerbations, airway hyperresponsiveness, and loss of lung function with age, even in patients with well-controlled asthma.

To determine the presence of peripheral airway impairment by impulse oscillometry and forced expiratory flow between 25% and 75% (FEF_25%-75%) in children whose asthma is well controlled by National Asthma Education and Prevention Program (NAEPP) guidelines.

In this retrospective, cross-sectional analysis, outcomes were evaluated across 192 encounters in 139 patients with moderate to severe asthma, ages 4-18 years. Receiver operator characteristic curves were created and oscillometry thresholds determined by maximizing the sum of sensitivity and specificity to identify those whose condition is not well controlled. Impairment was then identified for those whose condition was well controlled when these age-dependent oscillometry thresholds were met for each IOS measure or FEF_25%-75% < 65% of predicted.

Reactance at 5 Hz (X5) appeared most robust to identify peripheral airway impairment. In 96 well-controlled asthma encounters, impairment was identified by X5 in approximately 20% and 45% for those younger than 12 years and adolescents, respectively, compared with a maximum of 10% with FEF_25%-75% in the adolescent cohort (P < .05).

We conclude that peripheral airway impairment, determined by oscillometry, is common in patients with well-controlled asthma across age cohorts. X5 with optimal cut points ≤ -3.8, ≤ -2.5, and ≤ -1.5 cmH₂O/L/s for ages 4-7, 8-11, and >12 years, provides the clinician with a practical tool to identify the presence of the peripheral airway impairment phenotype that is consistently superior to FEF_25%-75%. This recognition, if confirmed, may reduce the risk of asthma-associated consequences with earlier and more targeted therapy.