Severe and Difficult-to-Treat Asthma in Children

Severe and Difficult-to-Treat Asthma in Children Posted By:

Among children with asthma, approximately 5% have severe disease. The American Thoracic Society (ATS) criteria for severe asthma in children includes treatment with high-dose inhaled corticosteroids plus use—or failed trial—of long-acting beta-2 agonists, leukotriene receptor antagonists, or low-dose theophylline. The asthma must also be considered "uncontrolled," for which the ATS requires at least one of the following factors: poor symptom control (Asthma Control Test [ACT] score <20), frequent severe asthma attacks (defined as ≥2 courses of systemic corticosteroids in the previous year), ≥1 serious attacks (leading to hospitalization, ICU stay, or mechanical ventilation), presence of airflow limitation (FEV1 <80% predicted), or persistent airflow limitation despite treatment with systemic steroids or a short-acting beta-2 agonist.

Difficult-to-control or treatment-resistant asthma is not the same as severe asthma, and affects fewer children than severe asthma. This may be considered in pediatric patients who meet some or all of the above criteria for severe asthma. Since difficult-to-treat asthma is rare in children, other comorbid conditions or asthma "mimickers" need to be considered in the differential diagnosis. These comorbid conditions include, but are not limited to: larygnotracheobronchomalacia, laryngotracheobronchitis, exercise-induced laryngeal obstruction, vocal cord dysfunction or paralysis, foreign body aspiration, tracheoesophageal fistula, toxic inhalation, GERD, underlying causes of bronchiectasis (eg, cystic fibrosis, bronchopulmonary mycoses), primary ciliary dyskinesia, interstitial lung disease, eosinophilic pneumonia or other eosinophilic lung conditions, tuberculosis, pneumonia, or vasculitis.

For proper evaluation and management, timely referral to pediatric allergist or pulmonologist is essential for pediatric patients with severe asthma and suspected difficult-to-control or treatment-resistant asthma. First, a thorough history and physical exam will be obtained. In addition to the clinical history, exposure to environmental factors must be considered, including tobacco smoke; air pollution; or environmental allergens such as dust mites, animal dander, or cockroach dander. Reducing exposure to relevant sensitized aeroallergens and tobacco/vape smoke is crucial in management.

After a thorough history and physical exam, further diagnostic studies including pre- and post-bronchodilator spirometry and fractional exhaled nitric oxide (FeNO) testing must be obtained. Skin prick testing or serum-specific immunoglobulin (Ig) E testing to aeroallergens should also be obtained to evaluate for allergic triggers to asthma. If the diagnosis is not confirmed after this testing, then other etiologies, as mentioned above, must be considered. Additional testing may be necessary, including exercise challenge, chest radiography or CT, bronchoscopy, induced sputum testing, or testing for corticosteroid responsiveness. If other comorbid conditions are suspected, referral to specialists such as dietitians, endocrinologists, speech therapists, sleep medicine specialists, or otolaryngologists is necessary.

In addition to the above, providers seeing patients with severe asthma should also consider screening for depression and anxiety, as they are highly associated. To optimize care, providers or clinic staff should also discuss barriers such as financial difficulties, access to medication refills, or transportation with patients and caregivers, especially if there is concern patients are not taking medications as prescribed or not attending routine follow-up visits. Medication adherence is key and should be stressed to families, and education on how to properly use inhaled medications should be reviewed at every office visit.

By being aware of the potential comorbid conditions associated with asthma, asthma "mimickers," criteria for diagnosis of severe asthma, and the need for timely referrals, providers can ensure children with severe or difficult-to-treat asthma get the proper and thorough evaluation they need.

  • Bush A, et al. Difficult-to-treat asthma management in school-age children. J Allergy Clin Immunol Pract. 2022;10:359.


Filed under: Pulmonary Medicine , Allergy/Immunology

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