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Abstract
The transition from paediatric care to adult care is often difficult, especially in children with chronic diseases like asthma. A significant number of children reach remission throughout puberty; consequently, they are not tracked down for subsequent follow-ups and are not included in transition programmes to adult care. This case report focuses on a young adult with asthma that began in childhood and went into remission during adolescence, only to experience a recurrence when the patient was a young adult. Due to failing to complete the transition process into adult care services, she had poor adherence to therapy and asthma control.
Adherence and asthma control significantly improved after a multidisciplinary approach in an adult care setting. In conclusion, appropriate transition and a multidisciplinary approach are critical for the effective management of asthma in young adults.
- healthcare improvement and patient safety
- asthma
- respiratory system
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Background
The underlying mechanisms in asthma are still unknown. However, genetic vulnerability, respiratory infections, environmental exposures (farmyard environment, air pollution, tobacco smoke exposure), increased infant weight gain, preterm birth, the lung and gut microbiome all play a role in the development and pathogenesis of childhood asthma.1 Additionally, growing evidence indicates that severely sensitised children,2 3 sensitised early in life,4 5 or sensitised to several allergens and animal allergens have a significantly increased chance of developing asthma.4 6–8
Unlike most chronic diseases that progress over time, asthma, particularly in children, can persist but also resolve or manifest as a cycle of remissions and relapses. The majority of patients with asthma can anticipate having periods of active disease interspersed with years of not requiring medical attention and likely being in remission.9 Remission is likely in males and those with milder disease, less atopic sensitisation, a lower degree of airway hyper-responsiveness, and no concomitant allergic disease. On the other hand, persistence is associated with allergy sensitisation, increased frequency and intensity of symptoms, poor lung function and increased airway hyper-responsiveness.10
Asthma diagnosed in elementary school has a remission rate of about 20%,11 12 with 38% of children relapsing and 18% persisting into early adulthood.12 When children are followed for an extended period, the prevalence of complete remission of childhood asthma drops to 7% at age 25 and 10% at age 49, indicating that this is a rare occurrence and that individuals in asthma remission may relapse later in life.13 For this group of patients, the gap in physician claims can range from 5 to 9 years in a quarter of cases, while 5% of patients can be symptom-free for up to 15 years.9 Throughout adolescence, children who achieve remission rarely attend follow-up appointments and do not transition to adult care until they relapse and experience acute asthma attacks.
Adolescence begins around the age of 12, and the neurobiological changes that occur during this period can last into early adulthood.14 The most significant changes in the brain are those related to reward and risk processing, self-regulation and the influence of peers on decision-making. These neurologic alterations often impair decision-making and may impair medical decision-making depending on the circumstances. Adolescents may be unable to take self-management responsibilities, resulting in inadequate treatment adherence and other negative consequences.15 Additionally, as adolescents reach the age of 18, they are forced to transition from paediatric to adult medical facilities, resulting in feelings of loss and fear of the unknown,16 leading to missed appointments and poor asthma control.17 This is particularly important because childhood-onset adult asthma is characterised by chronic airway inflammation and structural remodelling, which lead to irreversible lung function loss in adulthood.18 19
Case presentation
The patient is a female Caucasian. In her middle childhood years, she was diagnosed with allergic rhinitis and asthma with an allergy to house dust mites (HDMs). According to her, she was prescribed allergy pills, an intranasal spray, and an inhaler, which she used from autumn to spring. Typically, she was off therapy for the summer. She had no recollection of her last consultation with a paediatrician, as she had been feeling well for an extended period and did not require previously recommended therapy. Her first encounter with adult care was in her late adolescence, when she was taken to the Emergency Room for an acute asthma attack caused by a respiratory infection. In the ER, she was treated with a parenteral corticosteroid, an inhaled short-acting beta-agonist (SABA) and an antibiotic. Additionally, she has been prescribed a metered-dosage inhaler (MDI) containing a moderate dose of inhaled corticosteroids (ICS) and long-acting beta-agonist (LABA). She continued to use her recommended inhaler for 3 months until discontinuing it in May due to improved health.
In October, she experienced an asthma attack once more. As a result, her general practitioner (GP) treated her with parenteral corticosteroids four times, the last time 2 weeks before her November appointment with an adult allergist. She did not bring any previous medical records to her appointment and could not recall the names of drugs she was using in childhood. The patient reported that she was born preterm but was otherwise healthy. She was a student, sharing a house with her parents and a dog. Her family had a history of atopy but not asthma. She complained of nasal congestion, postnasal drip, productive cough with whitish sputum and shortness of breath, particularly in the morning. The Asthma Control Test (ACT) score was nine (red zone for asthma). She was taking intranasal corticosteroid spray, peroral antihistamine (AH) and SABA as needed. The patient had nasal congestion, a chronically irritated pharynx and a prolonged expiratory sound with wheezing on physical examination.
Investigations
The results of blood diagnostic tests are summarised in table 1. The skin prick test for HDM, ragweed and dog dander were positive. Specific immunoglobulin E (sIgE) was positive for HDM in class V and ragweed in class II but was negative for a dog or cat dander. Spirometry revealed moderate obstruction, a significant bronchodilatory response with complete reversibility of obstruction (figure 1A). Tests also showed elevated values of eosinophils in blood and sputum, important for asthma phenotyping and assessment of response to inhaled corticosteroids.
The results of the blood diagnostic tests performed during the initial visit to adult care
Spirometry results from the adolescent female patient during her initial visit to adult care revealed a moderate obstruction with a significant bronchodilator response and complete reversibility (A) and normal spirometry results at the follow-up visit following 4 weeks of treatment with a metered-dose inhaler containing an inhaled corticosteroid and long-acting beta-agonist (B). FEF25%, forced expiratory flow at 25% of FVC; FEF50%, forced expiratory flow at 50% of FVC; FEF75%, forced expiratory flow at 75% of FVC; FEV1, forced expiratory volume in one second; FVC, forced vital capacity; FEV/FVC, ratio; PEF, peak expiratory flow.
Differential diagnosis
Based on her history, clinical examination and evaluation results, the patient was diagnosed with perennial allergic rhinitis and eosinophilic allergic asthma with HDM allergy. Due to the absence of clinical symptoms associated with exposure to these allergens, the skin prick test and sIgE to ragweed and dog were interpreted as a sensitisation.
Treatment
After a lengthy discussion regarding her disease and the importance of drug adherence and regular follow-up, the patient was advised to use an MDI containing moderate doses of ICS and LABA via a spacer. Additionally, she was encouraged to continue using INC spray and an AH and was instructed on how to minimise her exposure to HDM. The patient participated in the pulmonary rehabilitation programme, including education about their disease, treatment options, proper breathing and inhaler technique and the personal asthma action plan.
Outcome and follow-up
On the follow-up visit, she was feeling well and had a normal pulmonary function test (figure 1B) and an ACT score of 24 (green zone). She was encouraged to use the mobile asthma app to remind herself to take her medication and bring her inhaler to sessions to have her technique checked. She now attends routine follow-ups and maintains a high adherence and control of her asthma.
Discussion
The European Academy of Allergy and Clinical Immunology (EAACI) published guidelines on the effective transition of adolescents and young adults (AYA) with allergy and asthma in 2020, emphasising patients aged 11–25.20 The guideline defines transition as the process by which AYA develops the knowledge, skills and confidence necessary to function independently, competently and expertly as adult patients. The guidelines emphasise the critical significance of initiating the transition early (between the ages of 11 and 13 years).20 However, the guidelines are only applicable to children under the care of a paediatrician or GP on a routine basis.
The reported case represents a sizeable proportion of the AYA seen in our adult outpatient allergy/pulmonology clinic. Frequently, these individuals are diagnosed and treated by paediatricians during childhood but experience remission during adolescence. As a result, they do not receive routine follow-up care and cannot transition to adult healthcare adequately. Adult allergists and pulmonologists often initially encounter these patients in the ER during an acute asthma attack episode. Additionally, they are often seen in routine outpatient care following a series of acute asthma attacks treated with parenteral corticosteroid due to non-compliance with inhaler medication. They often do not bring earlier medical records to their initial visit and can not recollect the names of previous therapies or allergens to which they are allergic. They are accustomed to being looked after by their parents and lack the ability to handle themselves. According to a recent EAACI survey, this is likely why many clinicians have difficulty treating AYA.21
Parents of preadolescent children with asthma should be aware of the chronic nature of the disease, the possibility of relapse and the need to transition into adult care, even among those who maintain remission throughout puberty. If this does not occur in a timely manner, physicians working in adult care services should approach them, ensuring illness comprehension, actively checking adherence and emphasising the consequences of their disease. Additionally, EAACI guidelines advocate simplifying pharmaceutical regimes, utilising reminders and recruiting peers, friends and family members to aid disease management.20
Learning points
Asthma is a chronic disease with remission and relapse periods.
All patients with asthma and their parents should be aware of the chronic nature of the disease and the possibility of relapse.
Successful transition from paediatric to adult care leads to good adherence and asthma control.
Adolescents and young adults are a unique population that typically needs specialised medical care and attention.
This case report highlights the need for electronic medical records and lifetime continuity of care.
Patient’s perspective
For a long time, I felt good, and I thought my asthma was gone. I was so surprised when I started to feel like I did when I was a kid. I didn't know who to call or where to go for help because I was too old to go to my paediatrician and didn't know who to call for adult care. So, I went to the ER to get help. Also, I didn't know that I should always take the drugs my doctor gave me.
When I finally saw an adult allergist, I was so glad that someone could tell me what was wrong and how to treat it. Now I know why I need therapy and how to do it.
Ethics statements
Patient consent for publication
References
Footnotes
Contributors VVL is the first and corresponding author. IM and AMS reviewed the case and helped with writing.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Case reports provide a valuable learning resource for the scientific community and can indicate areas of interest for future research. They should not be used in isolation to guide treatment choices or public health policy.
Competing interests None declared.
Provenance and peer review Not commissioned; externally peer reviewed.