mkrawiec allergic inflammation in preschool-toddler wheezing...asthma predictive index – h/o ≥4...
TRANSCRIPT
![Page 1: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/1.jpg)
Allergic Inflammation in Infant/Preschool Wheezing
Marzena E. Krawiec M.D.
Associate Professor of Pediatrics
Section Head Pulmonary Medicine
![Page 2: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/2.jpg)
Disclosures
� Speaker’s Bureau: Aerocrine
![Page 3: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/3.jpg)
KEY OBJECTIVES:� Review the unique characteristics of infancy and the
infant airway predisposing to wheezing
� Review the phenotypic presentations of early childhood wheezing
� Recognize the importance of atopy and early infection in the development of persistent wheezing
� Identify biomarkers which may distinguish transient from persistent wheezing children
![Page 4: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/4.jpg)
The Nature of the Beast� Most common chronic illness in childhood
– 87% had unscheduled physician visits in – the year prior to hospitalization
� #1 chronic illness causing school absences– 3X the school absences of children without asthma
� 78% of parents report a negativeimpact on the entire family– 40% of patients have sleep disturbance – 1-2 nights/week– 36% of parents reported missing work
due to their child’s asthma in the prior year
![Page 5: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/5.jpg)
Hospitalizations Due to Asthma in Children
0
10
20
30
40
50
60
70
1980-81 85-86 90-91 95-96 98-99
0-4 y 5-10 y 11-17 y
Hos
pita
lizat
ion
Rat
e(p
er 1
0 00
0)
Akinbami and Schoendorf. Pediatrics. 2002;110:315-22.
![Page 6: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/6.jpg)
![Page 7: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/7.jpg)
Pathophysiologic Properties Predisposing Infants and Young Children to Wheeze
1. ⇓⇓⇓⇓ Bronchial smooth muscle content2. Hyperplasia of bronchial mucous glands3. ⇓⇓⇓⇓ radius of conducting airways 4. ⇑⇑⇑⇑ peripheral airway resistance due to ⇓⇓⇓⇓ size5. ⇑⇑⇑⇑ Chest wall compliance6. Diaphragm
- Horizontal insertion of the diaphragm to the rib ca ge- ⇓⇓⇓⇓ number of fatigue-resistant skeletal muscle fibers
7. Deficient collateral ventilation
![Page 8: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/8.jpg)
Bronchoconstriction
Before 10 Minutes After Allergen Challenge
![Page 9: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/9.jpg)
Airway Mucosal Edema
![Page 10: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/10.jpg)
Inflammation
Airway Remodeling
Expiration
Volume
Inspiration
Flow
Expiration
Volume
Inspiration
Flow
![Page 11: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/11.jpg)
Medication Use and Asthma Severity
61%
75%80%78%
70%
40%
10%16% 18% 20%
18% 15%
0%
25%
50%
75%
100%
Mild
Intermittent
Mild Persistant Moderate
Persistent
Severe
Persistent
All Persistent Total
% o
f Patients
Quick-Relief Medication Inhaled Corticosteriods
Asthma in America Survey
![Page 12: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/12.jpg)
![Page 13: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/13.jpg)
The Natural History of Asthma
Allergens
Family hx asthma Passive smoke exposure
Atopic disease
Genetic Factors (Atopy)
Viruses
Wheezing
This image cannot currently be displayed.
Inflammation and RemodelingInflammation and Remodeling
ASTHMA
Persistent asthma & irreversibly reduced FEV 1
![Page 14: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/14.jpg)
Longitudinal Evaluation of Lung Function in Wheezing Infants
Martinez FD et al. NEJM 332:133, 1995
![Page 15: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/15.jpg)
Infant Wheezing: Phenotypes
• Distinguishing factors:
–Atopy– Airway Hyperresponsiveness– Lung Function
![Page 16: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/16.jpg)
Asthma Predictive Index
–H/o ≥≥≥≥ 4 wheezing episodes in the past year (at least one must be MD diagnosed)
PLUS– One major criteria or -Two minor criteria
• Parent with asthma ���� Food sensitivity• Atopic dermatitis ���� Peripheral eosinophilia ( ≥≥≥≥4%) • Aeroallergen ���� Wheezing not related to
sensitivity infection
If +, then 65% likelihood of developing clinical asthmaIf -, then 95% likelihood of not developing clinical asthma
Modified from: Castro-Rodriguez, AJRRCM, 2000.
![Page 17: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/17.jpg)
Source: Joseph Spahn, MD, National Health, Denver, Colorado.
Eczema at 2 years of age
![Page 18: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/18.jpg)
Source: Joseph Spahn, MD, National Jewish Health, Denver, Colorado.
Child with chronic cough With Positive Skin Test Reactions to
Common Aeroallergens
![Page 19: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/19.jpg)
Infantile Wheeze - AHR
• Infants are born with highly responsive airways becoming less so with age– Factors such as parental smoking, respiratory
illness and/or allergen exposure predispose infants to airway narrowing and potential decline in lung function.
– These factors may interfere with the natural decline in airway hyperresponsiveness with age progression.
![Page 20: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/20.jpg)
Transient Early Wheezing• Characterized by recurrent episodes of wheezing
in the first year of life – Resolution of symptoms between ages 3-5 years 1
• Most prevalent form of early wheezing– Almost 60% of subjects who wheezed in TCRS had reso lution
of their symptoms by age 6 1
• No significant relationship to atopy1,2
1Martinez FD, et al. N Engl J Med 1995; 332: 133-8.
2Kurukulaaratchy RJ, et al. Clin Exp Allergy 2003; 3 3: 573-78.
![Page 21: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/21.jpg)
Transient Wheezers
• Risk factors:– Maternal smoking during pregnancy
• Only significant variable associated in TCRS (OR 2. 2 [95% CI 1.3-3.7])1
• Italian Studies of Respiratory Disorders in Childho od and the Environment (SIDRIA; OR 1.46 [95% CI 1.26-1.69]) 2
• Swedish BAMSE cohort (4089 infants); OR 2.1 [95% CI 1.2-3.7]3
– Lower level of lung function in infancy before any respiratory infections 4
1Stein RT, et al. Am J Epidemiol 1999; 149: 1030-7.
2Rusconi F, et al. Am J Respir Crit Care Med 1999; 160: 1617-22.
3Lannero E et al. Respir Res 2006; 7:3.
4Martinez FD, et al. N Engl J Med 1995; 332: 133-8.
![Page 22: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/22.jpg)
![Page 23: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/23.jpg)
Perennial Allergen Sensitization Early in Life & Chronic Asthma In Children
� German Multicenter Allergy Study (MAS) birth cohort of 1314 children followed from birth to 13 yrs
� Sensitization measured at 1,2,3,5,6,7, &10 yrs; � Allergen exposure at 6 &18 mo, 3, 4, 5 yrs;� Lung function at 7, 10, 13 yrs.
� Results:– 90% with recurrent wheeze but not atopic had lost t heir symptoms
at school age and had normal lung function at 13yrs– 56% atopic wheezers had active asthma at 13 yrs.– Sensitization to indoor allergens ≤ 3 yrs associated with impaired
lung function
Illi et al., Lancet 2006; 368:763-70.
![Page 24: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/24.jpg)
Time of Sensitization and Degree of Exposure Determines Degree of Lung
Function Impairment at 7 yrs
100
95
90
8580
75
700
105
110
115
FEV1 (% pred)
MEF50 (% pred)
NS S/LES/HE NS S/LES/HE
100959085
8075700
105110115120
p=0.009 p=0.003
FEV1 (% pred)
MEF50 (% pred)
NS S/LE S/HE NS S/LE S/HE
Illi et al., Lancet 2006; 368:763-70.
![Page 25: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/25.jpg)
![Page 26: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/26.jpg)
Asthma Histopathology in
Children
• Lung biopsies from 2 children with asthma in remission compared to 2 children dying in status
– Similar: Goblet cell hyperplasia, mucus plugging, collagen deposition
– Different: In status, larger numbers of submucosaleosinophils and more extensive denudation of the epithelium
Cutz E et al. Histopathology 2:407, 1978
![Page 27: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/27.jpg)
Bronchial Biopsy From Subjects With and Without Asthma
Normal Asthma
JM4
![Page 28: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/28.jpg)
Slide 27
JM4 Add EM slide of patient with asthmaJonathan Malka, 5/9/2009
![Page 29: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/29.jpg)
The Epithelium and Pediatric Asthma
• Bronchial specimens post mortem or by bronchoscopy and biopsy in children 5-15 years– 7 nonasthmatics– 7 moderate asthmatics– 9 severe asthmatic
Federov IA et al. Thorax 2005; 60:389-394.
![Page 30: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/30.jpg)
Bronchsocopy and
Bronchoalveolar Lavage
NS
p<0.01
Stevenson EC et al. Clin.Exp.Allergy 27:1027, 1997
![Page 31: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/31.jpg)
Saline Antigen
BAL Cells 48 h After Allergen Challenge
Laboratory of Drs. Jarjour and Kelly.
![Page 32: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/32.jpg)
Inflammation in Wheezing Infants
• Infants and children < 60 mos with prolonged wheezing (> 2 mos within a 6 month period) not responding to conventional therapy– Exclusion:
• Acutely wheezing• > 450 µg/day of ICS• receiving antibiotics, oral steroids, or LTRAs within 1 mo of
evaluation
• BAL of right middle lobe• Data on patients with + bacterial cultures or
elevated LI was not included in the final analyses
Krawiec M et al. AJRCCM 163:1343, 2001
![Page 33: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/33.jpg)
0
4
8
12
LYMPH EPIWC NC WC NC
p=0.007
p=0.03
Cel
ls x
10
4 /m
l
WC NCPMN
p=0.02
BAL Cells in Wheezing Children (WC) Compared to Normal Controls (NC)
Krawiec ME; AJRCCM 163:1338, 2001
![Page 34: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/34.jpg)
p=0.01
p=0.02 p=0.023
p=0.015
CFA CC CW0
5
10
15
20p=0.004
p=0.004
p=0.001
p=0.007
CFA CC CW0
40
10
30
20
50
60
70
8090
Childhood Asthma is Characterized by AW Eosinophilia while Infantile Wheezing
Characterized by AW Neutrophilia
BALPMNs
(%)
BALEOS(%)
Marguet; AJRCCM 159:1553, 1999
![Page 35: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/35.jpg)
Sputum
Wilson N et al. Thorax 2000;55:768-774 .
60 asthmatic children27 NC
![Page 36: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/36.jpg)
Niox MINO®
Fractional Exhaled Nitric Oxide
![Page 37: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/37.jpg)
What is exhaled nitric oxide also known as the fractional exhaled nitric oxide (FeNO)?
� Bronchial epithelium produces NO and its fraction in exhaled air – elevated in atopic asthma – a biomarker of eosinophilic allergic airway– FeNO is a biomarker which reacts rapidly in response to
treatment or worsening of the disease
� Normal levels have now been established for children (20-25 ppb). – <20 ppb – unlikely to benefit from ICS therapy– 20-35ppb – may respond; evaluate in clinical context– >35 ppb – likely to response from ICS therapy
![Page 38: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/38.jpg)
• intermittent wheezing not described
Berry 2005, Payne 2001, Lex 2006, van den Toorn 2001
Why is knowing the exhaled NO helpful in allergic asthma?
� Measuring FeNO helps:– Identify steroid-responsive inflammation– Predicts and assess the ptient’s response to ICS
anti-inflammatory therapy– May help optimize the dosage of ICS treatment– May help to predict loss of control and possible
relapse therefore improving asthma outcomes– Helpful in monitoring compliance to ICS
![Page 39: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/39.jpg)
eNO as a Predictor of Asthma Exacerbation in Young Children during ICS Reduction
Zacharasiewicz A et al. AJRCCM 2005;171:1077-1082.
N=4030 tolerated 1 dose reduction12 weaned off6 loss of asthma control
![Page 40: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/40.jpg)
eNO Off-Line Tidal Breathing Collection System
![Page 41: MKrawiec Allergic Inflammation in Preschool-Toddler Wheezing...Asthma Predictive Index – H/o ≥4 wheezing episodes in the past year (at least one must be MD diagnosed) PLUS –](https://reader030.vdocuments.mx/reader030/viewer/2022040319/5e3fb6c472e5e40dd1602024/html5/thumbnails/41.jpg)
Life would be infinitely happier if we could only be born at the age of eighty and gradually approach eighteen………
Mark Twain