Update on the current methods for the diagnosis and treatment of severe childhood asthma

Abstract

The level of asthma control is the key outcome towards which asthma management is evaluated. The majority of children with asthma can obtain adequate control of symptoms through avoidance of triggering factors and/or with the help of low to moderate doses of current available medications. However, there is still a group of children with poor symptom control despite intensive treatment. The current review will provide an overview of a standardized approach to characterize this heterogeneous group of severely sick children. Factors that attenuate the effect of the prescribed treatment and make asthma difficult to treat are discussed. In addition, the usefulness of current methods of assessing asthma severity, pulmonary function, allergy and airway inflammation is also described. Finally, an overview of therapeutic options for children with severe asthma is provided.

Does allergy explain why some children have severe asthma?

“…60 A study by Roberts et al found children with acute life-threatening asthma requiring ventilation were much more likely to have clinical FA than those attending the emergency department with non-life-threatening exacerbations. 62 In other studies, multiple food allergies have been associated with STRA 16,60,62 It is not clear whether the observed relationship between STRA and FA is due solely to a shared stronger atopic tendency, or whether a causal pathophysiological link is responsible. 62 In other studies, multiple food allergies have been associated with STRA 16,60,62 It is not clear whether the observed relationship between STRA and FA is due solely to a shared stronger atopic tendency, or whether a causal pathophysiological link is responsible.…”

“…61 Additionally, a study of 201 children with asthma found peanut and milk allergy were independently associated with hospitalizations for asthma exacerbations. 62 In other studies, multiple food allergies have been associated with STRA 16,60,62 It is not clear whether the observed relationship between STRA and FA is due solely to a shared stronger atopic tendency, or whether a causal pathophysiological link is responsible. 63 Several mechanisms have been proposed for a causal link.…”

“…7 However, not all children adequately respond to Omalizumab. 14,16 • Mepolizumab, Reslizumab and Benralizumab are newer monoclonal antibodies targeting interleukin-5, but there is currently minimal data on their efficacy in paediatric STRA. [132][133][134][135][136][137] • Subcutaneous or sublingual immunotherapy to symptomatic aeroallergens may reduce asthma severity in children with mild-moderate asthma 72,138,139 but safety concerns surround the use of immunotherapy in STRA.…”

“…[4][5][6][7][8][9] These children have "severe therapy-resistant asthma" (STRA) (Box 1). 12 This involves confirming the diagnosis of asthma by demonstrating variable and reversible airflow obstruction, [13][14][15] ensuring adherence to treatment by checking general practitioner prescription records and that the appropriate inhalers are available on the home visit 2,16 and checking the child's inhaler technique. 5,7,11 It is imperative that children with difficult asthma undergo thorough assessment to identify and address modifiable factors before undergoing invasive investigations and further escalation of potentially harmful treatments for STRA.…”

“…5,7,11 It is imperative that children with difficult asthma undergo thorough assessment to identify and address modifiable factors before undergoing invasive investigations and further escalation of potentially harmful treatments for STRA. 12 This involves confirming the diagnosis of asthma by demonstrating variable and reversible airflow obstruction, [13][14][15] ensuring adherence to treatment by checking general practitioner prescription records and that the appropriate inhalers are available on the home visit 2,16 and checking the child's inhaler technique. 17 It is also necessary to minimize exposure to environmental allergens where possible, 2 avoid pollutants including cigarette smoke 13 and manage comorbidities including obesity, 9 dysfunctional breathing and vocal cord dysfunction, allergic rhinitis and food allergy.…”