For predicting uncontrolled asthma, score cut-off points of 19 were used for C-ACT and ACT. The ACQ-6 is well validated for assessing asthma control among patients older than 6 years.24 Items ask about nighttime awakenings, morning symptoms, activity limitations, breathlessness, wheezing and short-acting bronchodilator use.
Asthma control refers to the degree to which the manifestations of asthma are minimized by therapeutic interventions and the goals of therapy are met. Although assessment of asthma severity is used to guide initiation of therapy, monitoring of asthma control helps determine whether therapy should be maintained or adjusted. The nuances of estimation of asthma control include understanding concepts of current impairment and future risk and incorporating their measurement into clinical practice.
Therefore, the accompanying guardian may not have sufficient information to accurately complete asthma control questionnaires. At present, there are no validated alternatives to assess asthma control in children of 4–11 years of age in the absence of the parent or caregiver. Asthma diaries could serve as an alternative, especially if administered as a web-based diary.11,12 However, use of asthma diaries among younger patients in the absence of parents has not been demonstrated. Successful asthma management includes appropriate grading of disease control (see Table 47-3 ). Asthma severity, or the intrinsic intensity of the disease, should be distinguished from asthma control.
After finishing the questions for a single day, results were submitted. Children with asthma, treated in the outpatient clinics of four general hospitals and two university hospitals, were eligible for this study.
Nevertheless, some asthma specialists have adopted the use of FENO as an adjunct ambulatory clinical tool for measuring airway inflammation and serial monitoring asthma control in individual patients with difficult-to-control asthma. Spirometry, by itself, is not useful in establishing the diagnosis of asthma because airflow limitation may be mild or absent, particularly in children.
Similarly, a Swedish study has shown that the nasal, eye and lower airway symptoms of patients with allergic rhinitis and asthma were lower in the group using SMS reminders and e-diaries, when compared to controls following usual care  . Additionally, email or SMS and social media websites have been shown to be very useful tools to facilitate communication between medical staff and asthma patients  .
Several tools are useful in detecting uncontrolled asthma in children. The aim of this study was to compare Global Initiative for Asthma (GINA) guidelines with the Childhood Asthma Control Test (C-ACT) and the Asthma Control Test (ACT) in detecting uncontrolled asthma in children.
During the study period, no medication changes or exacerbations occurred in the study population. Children who failed to fill in their diaries did not differ in baseline characteristics from participants. The ASUI is a 10-item questionnaire, with a 2-week recall period, designed to assess the frequency and severity of four asthma symptoms (cough, wheeze, dyspnoea and awakening at night) and side effects of asthma medications.25 The scores range from 0 to 1 with higher scores indicating fewer asthma symptoms.
Familiarity with the properties, application, and relative value of these measures will enable health care providers to choose the optimal set of measures that will adhere to national standards of care and ensure delivery of high-quality care customized to their patients. The web-based diary card was filled in once a day, in the afternoon or evening, during four consecutive weeks and was based on GINA criteria (table 1) .
Overall, 17% (13 out of 78) in the younger age group and 33% (19 out of 57) in the older age group had uncontrolled asthma corresponding to a C-ACT or ACT score ≤19. Table 3 shows ACT and C-ACT outcomes in relation to asthma control according to GINA criteria. Out of 173 children included in the study, 145 children filled in the diary cards.
Patients should start treatment at the step most appropriate to the initial severity grading (or control level for those already receiving treatment) of their asthma. Not all of these instruments include a measure of lung function. They are being promoted for use not only in research but for patient care as well, even in the primary care setting. Some, suitable for self assessments by patients, are available in many languages, on the Internet, and in paper form and may be completed by patients prior to, or during, consultations with their health care provider.
Key questions focusing on the past 4 weeks are asked to determine asthma control. Each question offers several answers, which are scored on a scale of 0 to 5. The questionnaire for children 4-11 includes a section for the child to complete and a section for the parent to complete. Patients whose combined score is 19 or less are deemed to have asthma that is not well controlled and are advised to talk to their healthcare provider about their asthma.
The ACT is a patient-completed questionnaire and consists of five items evaluating the preceding 4 weeks (limitation of activities, shortness of breath, awakenings at night, use of reliever medication and patient's perception of asthma control) [12, 13]. Each question has five response options, resulting in scores of 1–5. The sum of all scores yields the total ACT score, ranging from 5 (poorest asthma control) to 25 (optimal asthma control). It has been validated from the age of 12 yrs and a score ≤19 indicates poorly controlled asthma.
The simplest and by far most diffused tool is the SMS. Randomized controlled studies have proven that SMS alerts are not only well accepted by patients, but also improve adherence to medication and the objectively recorded asthma control test score (ACT). These studies suggested that an SMS service might be more effective than conventional telephone-call management  . It may also improve the perceived control of asthma and quality of life  , as well as adherence to treatment  . Our group demonstrated a higher adherence to ICS (mometasone) treatment among 30 German children with seasonal allergic rhinitis, compared to 31 controls receiving usual care, as they could record their symptoms and medication on a eHealth platform (electronic diary) and received SMS alerts (Fig. 18.2 )  .
Serial examinations of pulmonary function are an integral component of asthma monitoring. Effective asthma therapy should lead to an improvement in, and ideally normalization of, FEV1 and FEV1/FVC ratio.
One part is filled in by the child and consists of four questions on perception of asthma control, limitation of activities, coughing and awakenings at night. Each question has four response options. The second part is filled in by the parent or caregiver and consists of three questions (daytime complaints, daytime wheezing and awakenings at night) with six response options. The sum of all scores yields the C-ACT score, ranging from 0 (poorest asthma control) to 27 (optimal asthma control). A cut-off point ≤19 indicates uncontrolled asthma .
However, FEF25–75 is considered to be of secondary importance because it is not specific and is highly variable (effort dependent). A range of pediatric asthma quality-of-life instruments have been developed, encompassing the impact of asthma on children’s or their parents’ lives.23 The instruments have been validated but are time-intensive to fill out and are therefore not routinely used in clinical practice. Subjective measures of asthma control include (1) detailed history taking, (2) use of composite asthma control scores, and (3) quality-of-life measures (used mainly in research settings). Table 1–Control status according to Global Initiative for Asthma (GINA) guidelinesAccess to the web-based diary was granted by a personal account with username and password. After logging in to the secured Internet page, participants could answer the questions by clicking the appropriate box.
SMS can provide useful personalized feedback on medication adherence and may be used to adapt a possible intervention to each patient’s specific need, personal barriers to medication adherence and patterns of medication use  . Similarly, teen-agers with asthma had better disease self-management when supported by an SMS alert system  . It is believed that optimal history-taking from lower school-aged children (e.g., 5 to 12 years of age) should include input from both the parent and child. Children can accurately recognize asthma symptoms, their common triggers, and their impact on daily activities; although younger children may be unable to accurately quantify the frequency of their symptoms or place them in the context of time. In a study by Lara and colleagues assessing the validity of exercise-related symptom reporting by children with asthma compared with their parents, child-reported coughing and wheezing correlated with lung function changes and observed symptoms due to exercise; in contrast, parent-reported symptoms did not correlate.14 Guyatt and coworkers observed in children younger than 11 years of age that their symptom reports correlated strongly with changes in quality of life measures, whereas parents' ratings of asthma symptoms showed moderate correlations with FEV1 and asthma control, but not quality of life measures.15 Thus, clinicians are likely to obtain important and complementary information from children and their parents.
A therapeutic trial of regular controller therapy (for 1–3 months) may often be necessary to evaluate response and maintenance of control. Normal values for spirometry are well established and are based on height, age, sex, and race/ethnicity of the healthy US population. Spirometric measures are highly reproducible within testing sessions in approximately 75% of children older than 5 to 6 years of age. Guidance on performing spirometry in an office setting and coding for asthma visits have been described.30 The forced expiratory maneuver may be displayed as a flow-volume loop. Guidelines regarding interpretation of the primary measures (FEV1, FVC, and the FEV1/FVC ratio) are well outlined in the EPR3.1,31 Of note, most automatic interpretations of the spirometry report fail to comment on the FEV1/FVC ratio, an important parameter that, in children, is normally 85% predicted or greater.1 Forced expiratory flow between 25% and 75% of vital capacity (FEF25–75) may reflect obstructive changes that occur in the small airways of children with asthma.
Asthma control can be further classified as well controlled, not well controlled, and very poorly controlled as elegantly laid out in the National Heart, Lung and Blood Institute Expert Panel Report 3 (EPR3).1 Asthma can be considered not well controlled if symptoms are present more than 2 days a week or multiple times on 2 or fewer days per week; rescue bronchodilator medication is used more than 2 days per week; nighttime awakenings are 2 times a month or more; there is some limitation of work, school, or exercise; and the PEF/FEV1 is 60% to 80% of personal best/predicted, respectively. Asthma is classified as very poorly controlled if symptoms are present throughout the day; rescue bronchodilator medication is used several times per day; nighttime awakenings are more than 1 time a week; there is extreme limitation of work, school, or exercise; and the PEF/FEV1 is less than 60% of personal best/predicted, respectively. The main findings of this study are that the C-ACT questionnaire has good psychometric properties in a population of paediatric patients with poorly controlled asthma. The psychometric properties of a shortened version with only the responses of the child, the C-ACTc, although acceptable, are not as good.
The Asthma Control Test (ACT) for children 12 years of age and older, and the Childhood ACT for children 4 to 11 years of age, are two examples of self-administered questionnaires that have been developed and validated with the objective of identifying the most relevant questions (Table 58-3 ). In the development of both questionnaires, questions about all of the domains of asthma control were included, and key questions were selected via logistic regression analyses as predictors of asthma control.28,29 These two questionnaires are similar in that each question provides a score such that the sum of the scores constitutes the total test score, and lower scores indicate poorer control. Generally, a total score of 19 or less indicates inadequate control.
In summary, we showed that among asthma patients aged 6–11 years, the C-ACT has good psychometric properties and a shortened version with only the responses of the child, the C-ACTc is promising but needs additional study before it can be used in scientific research and daily practice. We also estimated the MID for the C-ACT and C-ACTc in our study population to be 2 points and 1 point, respectively. Remember, your child's asthma may change over time. Be sure to have your child take this test periodically, and work closely with your child's healthcare provider to monitor your child's level of asthma symptom control.
At baseline, 51% of study participants reported using combination inhaled corticosteroid/long-acting β2 treatment within the past 6 months and 74% reported use of systemic corticosteroids for asthma within the past year. Your child's asthma symptoms may not be as well controlled as they could be. Answers to these questions are not saved on asthma. Only you will have access to your answers. If you wish, you canprint the testand fill it out along with your child.
Almost all children were treated with inhaled corticosteroids. Children, and parents of children in the younger age group (4–11 yrs), had to be able to speak the Dutch language and have Internet access at home. Children with lung diseases other than asthma were excluded from the study. This prospective study is the extension of a study validating a web-based version of the C-ACT and ACT .
As children with missing weeks were probably misclassified and overrated in their control status (in case missing weeks were uncontrolled weeks), in this study we might even have overestimated the sensitivity. This low sensitivity is remarkable and suggests that overestimation of asthma control by patients and/or their parents is considerable, as mentioned in previous publications [6–8, 10, 21]. The C-ACT consists of seven items, addresses the previous 4 weeks and is divided into two parts .
In this prospective study, we compared the results of the C-ACT and ACT with GINA criteria in predicting uncontrolled asthma. We found a good predictive value of both the C-ACT and the ACT for detecting uncontrolled asthma compared with GINA guidelines. Overall control status in this group of children, using questionnaires to determine the level of control, was acceptable. However, when GINA criteria were used to assess asthma control, a large proportion of children had uncontrolled asthma in ≥1 out of 4 weeks (71 (51%) out of 139 patients) when symptoms were scored. This high percentage of children with at least 1 week of uncontrolled asthma might possibly be explained by intercurrent infections, in particular as children were included during winter and spring and the majority had uncontrolled asthma in only 1 or 2 weeks.
Generally, values of 0.70–0.95 are considered acceptable; however, the observed lower α could be because of the shorter number of questions in the C-ACTc. At a group level, both questionnaires distinguished between patients with poor control versus those with good asthma control. We also found that for both the C-ACT and C-ACTc, ICCs improve over time which suggests that there may be a learning curve for the children. However, this does not affect the interpretation of the psychometric properties as both questionnaires showed responsiveness to changes in asthma control. One of the main goals of asthma therapy is to achieve and maintain good asthma control.1 Asthma control is best assessed using patient-reported outcomes.2 Unfortunately, there are a few validated instruments for use in paediatric populations.
The 3 parent-reported items are scored on a 6-point numeric scale from 0 to 5, with higher numbers indicating better asthma control. Parents are asked about daytime symptoms, wheeze, and nighttime awakenings. The adult items are based on a recall period of 4 weeks.
Data from 161 study participants aged 6–11 years from the SARCA trial were included (Table 1 ). The mean age of these participants was 9 years (s.d., 1.6). A majority were male (63%) and black (50%). Twenty-eight per cent and 18% of the participants were white and Hispanic, respectively.
A judicious combination of measures from each category may be needed to optimally assess asthma control. Control status in any week was assessed according to GINA criteria. An overall score was determined after 4 weeks, being the worst score of control status in any week. 5 completed diary days in 1 week was considered the minimum to include the week’s data in the final assessment of asthma control. 145 children with asthma filled in a web-based daily diary card for 4 weeks on symptoms, use of rescue medication and limitations of activities, followed by either the C-ACT or ACT.
Patients may have relatively mild asthma that is poorly controlled due to multiple factors, such as inadequate treatment, impaired adherence, or excessive exposure to allergens or irritants. Once appropriate medical and environmental measures are instituted, the asthma may become “mild” in terms of absence of symptoms and normalization of pulmonary function while taking low doses of a controller medication.
The ACQ-6 has a recall period of one week. The scores range from 0 to 6, and higher scores indicate worse control. The C-ACTc is comprised of only the original 4 child-reported items.
Surprisingly, rescue medication was not used as often as the amount of days with complaints. The C-ACT is a seven-item questionnaire that was developed and validated to assess asthma control among children 4–11 years old.4 Four questions are answered by the child and three by the parent or caregiver. The four child-reported items are scored on a 4-point numeric scale from 0 to 3 with higher numbers indicating better asthma control. One question asks, ‘How is your asthma today.’ The remaining 3 ask about activity limitation, cough and nighttime awakenings without a clear recall period.