Diagnosis and Management of Problematic Severe Asthma

Abstract

<p>This review will outline an evidence-based approach for diagnosing and managing children with problematic severe asthma (PSA). Children with PSA have uncontrolled asthma symptoms, despite maximal prescribed asthma treatment. These children have high morbidity and mortality and should be referred for specialist respiratory assessment and management. The first step in the assessment of a child with PSA is confirming the diagnosis of asthma using objective evidence. Following this, an assess- ment of inhaled corticosteroid adherence and a multi-disciplinary team approach is essential for separating difficult asthma (DA) from severe therapy resistant asthma (STRA). The majority of children have DA which entails uncontrolled asthma symp- toms due to underlying modifiable factors including poor treatment adherence, poor inhaler technique, exposure to environ- mental allergens, co-morbid conditions and psycho-social factors. Approximately 20% of children with PSA have STRA, and have persistent asthma symptoms despite good treatment adherence and correction of modifiable factors. Children with STRA typically have multiple and severe aeroallergen sensitization, eosinophilic airway inflammation and high fraction exhaled nitric oxide (FeNO). Further investigation of children with STRA includes an assessment of systemic steroid responsiveness, this is important for confirming the diagnosis of STRA and guiding the choice of additional treatment. Biologics are an add on (immune targeted) therapy for STRA. The current biologics used in children target the T2 helper (Th2) pathway mediating eosino- philic, allergic asthma.</p><p><strong>Conclusion. </strong>Future clinical trials of biologics in children will be essential to help identify childhood specific biomarkers and to decide which biologic is best for which individual child.</p>

Progress in diagnosis and treatment of difficult-to-treat asthma in children

“… 35 In fact, the vast majority of kids with STRA (85%) will test positive for one or more allergens, have very serious and intricate allergen sensitivity, and typically have more drastic disease states when there are also food allergies present. 36 , 37 Such children may require care that goes beyond standard treatment guidelines.…”

“…Previous research has discovered that up to 50% of children evaluated for problematic severe asthma have been misdiagnosed or have an affiliated diagnosis. 37 Additionally, 12–30% of non-asthmatic conditions were misdiagnosed as uncontrolled asthma. 21 , 54 …”

Asthma and Allergies: From Diagnosis-Based Approach towards Personalised Treatments

“…Asthma and allergic diseases are amongst the most common chronic disorders worldwide (1). The articles in this issue of the journal are describing various aspects related to this modern "epidemics", starting with a practical guidance on how to deal with patients with severe asthma (2,3), highlighting the advances related to virus-induced asthma exacerbations (4) and protective factors and mechanisms underpinning resistance to asthma (5,6), then moving on to a fascinating discussion on the importance of a healthy immune status and the development thereof (7). A particular emphasis has been given to the challenges facing the low-and middle-income countries (8,9).…”

“…These patients with modifiable risk factors comprise ~80% of patients with troublesome asthma. However, there remains ~20% of children with PSA who have a genuinely severe therapy resistant asthma (STRA), and have poor symptom control despite good treatment adherence and correction of modifiable factors (3). Further investigation of children with STRA should include an assessment of systemic steroid responsiveness (e.g.…”

“…by giving a single dose of intramuscular triamcinolone and measuring a change in asthma symptoms and objective markers such as lung function). This step is important for confirming the diagnosis of STRA, and guiding the choice of additional treatment with expensive biologics (3).…”