The obese asthmatic child: Management considerations − Rakyat Biologi

Studies in adults have evaluated asthma outcomes following weight-loss interventions [99-102]. The most consistent findings involve the improvement in breathlessness, exercise tolerance, asthma symptoms and lung volumes. It has been difficult to decipher improvements in general cardiorespiratory health and wellness following weight loss, from asthma-specific improvements. Though the impact of weight-loss in obese children with asthma has not been adequately studied, it is rationale to expect similar improvements in symptom control and lung volumes, and striving for a healthy weight should continue to be a primary goal. Exercise and other life-style intervention remains an important area of future research for obese children with asthma.

Current research does not support major deviations from current GINA and NHLBI EPR3 guidelines for the care of all asthmatics. However, volume of distribution and the metabolic/hormonal alterations associated with obesity may impact the pharmacokinetics and pharmacodynamics of therapeutic agents. Recent research may provide important guidance to the clinician for individual obese patients. Evidence suggests that obesity may blunt the response to inhaled corticosteroids [88, 91, 94] and low-dose theophylline [90]. Limited empirical data suggests that obese asthmatics may respond more favorably to montelukast with increasing BMI [94].

Since much of the impairment domain of asthma control involves subjective assessment and quality of life issues, attention to obesity-related sequelae that may interact with asthma symptoms remains critically important. Though empiric treatment for “silent” gastro-esophageal reflux so far does not seem warranted [103], some obese patients with gastro-esophageal reflux and cough may improve with anti-reflux medications. Clinicians should maintain a high-index of suspicion for certain common obesity-related comorbidities such as sleep-disordered breathing (especially those with snoring, sleep disturbance, or daytime behavior changes) and metabolic syndrome (especially among children with central obesity, acanthosis nigricans, cutaneous striae or recurrent need for oral corticosteroids).

The most universally effective management plan for obese children with persistent asthma continues to involve inhaled corticosteroids, weight-loss, daily exercise and repeated asthma education regarding inhaler technique and trigger avoidance. Response heterogeneity likely exists among obese asthmatics as it does among lean asthmatics. This means that a significant portion will respond best to ICS-LABA, a portion will respond best to ICS plus montelukast, and the remaining will respond best to a higher dose of ICS [104]. Because of the flat dose-response curve seen among obese asthmatics, initial step-up therapy for obese asthmatics with poor control with ICS + montelukast may be warranted. Regardless of the step-up therapy chosen, close follow-up is critically important to re-iterate proper inhaler techniques, weight-control, low-fat diet, daily exercise and monitoring of asthma symptoms and medication side-effects.