Robinson_Headshot Dr Paul Robinson

Kids Research Institute

Clinical Associate Professor Dr Paul Robinson is a clinician researcher within the University of Sydney’s Discipline of Paediatrics and Child Health and is a Respiratory Paediatrician at The Children’s Hospital at Westmead. He is an established member of The Children’s Chest Research Centre within Kids Research, the research division of the Sydney Children’s Hospital Network.

His work targets early detection and improved monitoring of paediatric lung disease through the development and translation into clinical practice of novel peripheral airway function tests. These tests are highly feasible throughout the paediatric age range (including infants and pre-schoolers). The “peripheral airways” these tools probe may be small in size but account for a vast amount of the total lung volume (almost 95%).

Conventional lung function techniques fail to assess these smaller airways, leading many people to previously view them as existing within a “silent lung zone” where disease could develop undetected. The importance of these smaller airways in disease emergence and progression has already been confirmed in important diseases, such as Cystic Fibrosis, Asthma, and COPD and is being established in other settings, such as post lung and/or bone marrow transplantation.

A/Prof Robinson’s research focuses on two particular peripheral airway function techniques, Multiple breath washout (MBW) and Oscillometry (previously known as the Forced Oscillation technique, FOT). He leads international MBW standardisation work to ensure testing is not only performed correctly, but efficiently and with equipment that accurately reflects what is happening in the lungs. Ongoing local research is funded by both national and international grants through strong national and international collaborative networks established with leading researchers. Incorporation of advanced imaging techniques, using both CT and MRI, allow structure-function relationships in early disease to be better defined and understood. “Having managed these children for many years, and seen how established lung disease can be before our previous techniques detected impairment, this work is critical to improve long term outcomes by detecting and intervening at an earlier stage” he says “In established disease, targeting this lung region using these tools also offers exciting potential to achieve better disease stability”.

Why was funding this research important?

Maintaining good asthma control is only achieved by a minority of children with persistent asthma, and poor asthma control is a well recognised risk factor for poor asthma outcomes including ongoing asthma exacerbations and asthma death. Monitoring asthma control in children presents several challenges. The current best option for lung function monitoring – peak flow – is challenging to perform consistently (as it is effort dependent) and insensitive to the changes that occur with exacerbations and poor asthma control. As a result, we remain reliant on symptom reporting, medication diaries and questionnaires, all of which are susceptible to poor symptom perception and poor recall, by both the child and the parents. This lack of an objective and sensitive tool limits the ability of parents and clinicians to make the right management decisions.

Oscillometry (previously known as the Forced Oscillation technique, FOT) is an effort-independent, easy-to-perform novel lung function test that provides information on respiratory system mechanics (e.g., how narrow the airways are and stiff the lungs are). It is performed during relaxed tidal breathing and has shown good feasibility down to the pre-school age ranges. Oscillometry has exciting potential as a home-based, parent-supervised tool to not only monitor paediatric asthma severity and control, but also help detect or predict asthma exacerbations at an earlier stage.

What did the researchers do?

The researchers aimed to document the feasibility of oscillometry as an at home monitoring tool and its ability to provide early insight into when an exacerbation is about to happen. They recruited 27 children aged eight to 18 years of age, with persistent asthma and a history of at least two exacerbations in the past year, and seven healthy controls.

Participants underwent a four-month monitoring period, using oscillometry in their home on a daily basis, under the supervision of their parents. Participants also completed the Asthma Control Questionnaire at weekly intervals, quality of life at monthly intervals, and a daily record of respiratory symptoms and reliever use. Following the four-month monitoring period, participants were followed for the remainder of the year to determine whether oscillometry during the monitoring period predicted long term asthma control.

What was the outcome?

The data collected in this study proved all the study hypotheses. The team have shown that home based oscillometry monitoring is not only highly feasible, but the results obtained during non-exacerbation periods contain information about the level of asthma control and the number of exacerbations experienced by the child. In addition, the results suggested that oscillometry can provide an early signal of loss of asthma control. These findings confirm the exciting potential of this approach to improve future asthma outcomes.

Related Publications and Presentations

1. Wong A, Hardaker K, Field P, Huvanandana J, King GG, Reddel H, Selvadurai H, Thamrin C, Robinson PDHome-based forced oscillation technique day-to-day variability during pediatric asthma exacerbations. AJRCCM 2019;119(9):1556-60.

Asthma Australia, Dr Paul Robinson and the research team from the Children’s Hospital at Westmead and The Woolcock Medical Research Institute, wish to pass on their heartfelt thanks to the Ross Trust for their support of the 2017-2019 project which will provide exciting insight into how asthma monitoring in children with ongoing asthma issues can be improved.

What’s next?

Thanks to a donation from The Neil and Norma Hill Foundation, the team are undertaking further research to investigate whether the ability to predict loss of asthma control is a reproducible finding. They will examine this by monitoring children at risk of loss of asthma control. They will recruit children with asthma with good control, who are eligible to step-down their asthma preventer treatment. We know that approximately 1/3 of those children will lose good control when they step down their medication.

The project aims to determine

  1. a) whether oscillometry day-to-day variability consistently increases with a loss of asthma control,
  2. b) whether this change occurs before asthma symptoms and/or exacerbation occurs, and
  3. c) define the values of variability at which we should act with a treatment change in future studies.

This will build on the results of the previous study to provide a better more sensitive tool for asthma.

“This project fulfils a vital next step in our efforts to provide a sensitive easy-to-perform tool for home-based monitoring. It will allow us to define whether a reliable early signal is seen with oscillometry indicating loss of asthma control and impending asthma exacerbation. Defining this signal will then allow us to design the future studies to show the utility of this monitoring approach on important asthma outcomes.

This funding is vital and without it this proposed study would not be possible. It will provide key funds to support the research staff working on this project. We are incredibly grateful to the Hill Foundation for their generous support.”

Dr Paul Robinson