Difficult to Control Asthma in Children

Louise Fleminga,b; Nicola Wilsonb; Andrew Busha,b


Curr Opin Allergy Clin Immunol. 2007;7(2):190-195. 

In This Article

Abstract and Introduction

Purpose of review: The management of children with difficult asthma requires a systematic approach. These children are prescribed high doses of inhaled or oral corticosteroids and a balance must be struck between therapeutic efficacy and side effects. It is important to ensure the diagnosis is correct and that the reasons for poor control in a given child are characterized so that treatment can be targeted for maximal effect.
Recent findings: Recent data have demonstrated the correlation between invasive and noninvasive measurement of airway eosinophils. Noninvasive markers of inflammation can be used to determine phenotype and there is increasing evidence on the utility of repeated measures to monitor control and treatment effects. Side effects of high-dose corticosteroids remain a concern. The emergence of new therapies may be of benefit. These are often expensive, however, and have the potential for major side effects. Adherence remains a significant obstacle to the effective management of difficult asthma.
Summary: Children with difficult asthma are a heterogeneous group. Characterization and monitoring of these children can be enhanced by measurements of noninvasive markers of inflammation. Further evaluation of new and phenotype-specific treatments for children with difficult asthma need to be evaluated in prospective randomized controlled trials.

Difficult asthma is defined as that which is poorly controlled (chronic symptoms, episodic exacerbations, continued requirement for short-acting ß agonists) despite a daily dose of at least 800 µg budesonide or equivalent for 6 months or longer.[1] The majority of children with asthma will have their symptoms controlled with occasional bronchodilator use or low-dose inhaled corticosteroids (ICSs). For those children who remain uncontrolled despite being prescribed high doses of conventional therapy, careful evaluation is needed. Despite the simple definition of difficult asthma the multiplicity of causes make this far from simple to manage. Children with difficult asthma are a heterogeneous group, in terms of contributing factors and in underlying pathology. The diagnosis of asthma itself may be incorrect; there may be aggravating factors such as ongoing allergen presence or additional diagnoses; psychosocial factors may have a role to play, or prescribed medication may simply not be taken. Once all these issues have been addressed there will be a group of children with severe asthma who remain symptomatic despite conventional therapy. Investigation of the underlying pathophysiology reveals different pathological phenotypes, as determined by the presence and type of inflammation (eosinophilic versus neutrophilic), steroid responsiveness and airway reactivity. Such distinctions are important to make so that therapy can be targeted to the individual and the side effects of ineffective treatments avoided. The emergence of novel therapies aimed at particular subgroups of patients with asthma makes the pathological classification of the child with difficult asthma ever more important.

The approach has been summarized in three key steps outlined by the American Thoracic Society workshop on refractory asthma:[2] confirm the diagnosis of asthma; evaluate and treat confounding or exacerbating factors; optimize 'standard' asthma pharmacotherapy. In order to address these issues the management of children with difficult asthma requires a structured and methodical approach.


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