A Practical Approach to Severe Asthma in Children

Abstract

Severe asthma accounts for only a small proportion of the children with asthma but a disproportionately high amount of resource utilization and morbidity. It is a heterogeneous entity and requires a step-wise, evidence-based approach to evaluation and management by pediatric subspecialists. The first step is to confirm the diagnosis by eliciting confirmatory history and objective evidence of asthma and excluding possible masquerading diagnoses. The next step is to differentiate difficult-to-treat asthma, asthma that can be controlled with appropriate management, from asthma that requires the highest level of therapy to maintain control or remains uncontrolled despite management optimization. Evaluation of difficult-to-treat asthma includes an assessment of medication delivery, the home environment, and, if possible, the school and other frequented locations, the psychosocial situation, and comorbid conditions. Once identified, aggressive management of issues related to poor adherence and drug delivery, remediation of environmental triggers, and treatment of comorbid conditions is necessary to characterize the degree of control that can be achieved with standard therapies. For the small proportion of patients whose disease remains poorly controlled with these interventions, the clinician may assess steroid responsiveness and determine the inflammatory pattern and eligibility for biologic therapies. Management of severe asthma refractory to traditional therapies involves considering the various biologic and other newly approved treatments as well as emerging therapies based on the individual patient characteristics.

Asthma in Children and Adults – What are The Differences and What Can They Tell us About Asthma?

“…It is important to differentiate between severe therapy-resistant asthma and difficult-to-treat asthma due to comorbidities Difficult to treat asthma is a much more common reason for persistent symptoms and exacerbations and can be managed if comorbidities, such as allergic rhinitis and chronic exposure to asthma triggers, are directly targeted. Home visiting programs and assessment of the school environment are important features of the evaluation for children with concern for chronic exposure to asthma triggers (50)(51)(52). Children with persistent symptoms and exacerbations despite correct inhaler technique and good medical adherence to standard asthma therapy (steroid-resistant or therapy resistant asthma) should be referred to an asthma specialist to consider more potent biologic therapies such as anti-IgE, anti-IL-5, or anti-IL-13 therapies and further evaluation (47).…”

New Drugs for Pediatric Asthma

“…Although an official document and a recent pragmatic review do not recommend the routine use of macrolides for children with severe asthma (9, 64), they may be useful for reducing daily oral steroid administration and improving FEV 1 (65), and, for this reason, can be proposed as ex-juvantibus trial in children with neutrophilic asthma (66). In conclusion, further well-designed and large RCTs are warranted before routine use of macrolides is recommended or definitely condemned in pediatric severe asthma.…”

Measuring Airway Obstruction in Severe Asthma in Children

“…From a practical point of view, spirometry is useful in confirming the diagnosis of severe asthma in children and it should be always performed with the administration of a bronchodilator to detect airway obstruction and its reversibility. The aspect of the Flow-Volume inspiratory and expiratory loops can be also useful in the differential diagnosis of other causes of obstruction, intrathoracic or extrathoracic airway obstruction ( 17 ).…”