A Guide to Monitoring and Achieving Asthma Control in Children Younger Than 5 Years

Figure 5

WHAT IS THE TEST FOR RESPIRATORY AND ASTHMA CONTROL IN KIDS (TRACK^TM)?
Recently, TRACK (Figure 5) was developed and validated for caregivers of children younger than 5 years with 2 or more episodes of respiratory symptoms (eg, cough, wheeze, shortness of breath) that lasted 24 hours or more and with either physician-diagnosed asthma or bronchodilator use.⁷ In contrast to other validated tools, the TRACK tool encompasses both the risk and impairment domains of respiratory control consistent with current guidelines. ^6,7 This tool helps to identify the children with chronic respiratory symptoms consistent with asthma symptoms who would likely be classified as having uncontrolled asthma by an HCP.

The TRACK tool was specifically designed for preschool-aged children through a qualitative and quantitative research process.⁷ Interviews were conducted with pediatric asthma specialists, pediatricians, and caregivers of young children with recurrent respiratory problems or asthma. On the basis of their feedback, a set of possible test questions about the frequency and severity of respiratory symptoms, the effect of these symptoms on the child's life, and health care utilization was developed. The final TRACK tool comprises 5 questions that best discriminate between the guidelines-based controlled and uncontrolled asthma ratings and that have the greatest predictive value.

The TRACK tool includes 4 impairment questions: 3 about the frequency of respiratory symptoms, activity limitations, and nighttime awakenings in the past 4 weeks, and 1 about rescue medication use in the past 3 months.⁷ It also includes 1 riskrelated question about OCS use in the previous year. Each question is scored from 0 to 20 points, for a total score between 0 and 100 points. Higher scores indicate better respiratory control. A TRACK score lower than 80 suggests uncontrolled asthma and may be an indication that HCPs need to provide further evaluation and possibly adjust treatment plans. A TRACK score of 80 or more suggests that the child's breathing problems are controlled.

The TRACK instrument is not a diagnostic tool but is a brief, caregiver- completed, standardized instrument that is easily administered and scored and can be used for collecting basic information about respiratory and asthma control.⁷ It increases caregiver and HCP awareness of potential respiratory control problems in young children. However, the role of TRACK in clinical practice and research has not yet clearly been established. An ongoing study is under way to validate the TRACK tool in test-retest situations to determine its use at follow-up clinical visits. Caregivers should base the answers of all 5 TRACK questions on their own interpretation and not seek the opinion of an HCP while answering the questions. In addition, caregivers may be able to complete TRACK either in the waiting room or examination room, although check-in time is ideal. Caregivers also may access the tool online (www.asthmatracktest.com) and complete it at home. The completion of TRACK before seeing the HCP allows for more in-depth and focused caregiver-provider discussions. The TRACK score can help to facilitate dialogue between the caregiver and the HCP to identify strategies to better manage the child's respiratory symptoms.

HCPs should not depend solely on a caregiver's assessment of the child's asthma control because families may be accustomed to their children's asthma symptoms and report good control even for very symptomatic children.⁴⁴ In addition to considering the caregiver's assessment of asthma control, the clinician's assessment of asthma control should be obtained through the patient's medical history. Questions should focus on the child's signs and symptoms of asthma, level of activity, and exacerbation history.⁶ Table 5 provides sample questions for HCPs to assess and monitor asthma control.⁶ In addition, the HCP should review the child's TRACK score and help the caregiver interpret the score, allowing for a specific discussion of the child's level of respiratory and asthma control based on the guidelines (Figure 4).

The child's quality of life and satisfaction with treatment should also be reviewed. HCPs should also be aware of some of the external factors that can affect asthma control. A cross-sectional study of 362 children aged 5 to 12 years with asthma who had experienced an acute exacerbation in the past year assessed demographic, family, and pediatric practice characteristics as predictors of asthma control.⁴⁵ Factors associated with poor asthma control were Medicaid insurance, full-time or part-time maternal employment, and the presence of another family member in the home with asthma. The authors suggested that economic factors and a caregiver's job responsibilities may interfere with the caregiver's knowledge of the child's adherence to medication and level of asthma control. Although extrapolation to preschool- aged children cannot be made directly, the study suggests that the social history may affect asthma control.