Difficult asthma: Pearls and pitfalls

S1C – Pre-School Wheeze/Asthma in Children
DIFFICULT ASTHMA: PEARLS AND PITFALLS

Andrew Bush
Imperial College and Royal Brompton Hospital, London, United Kingdom

Most children with asthma have excellent outcomes if they use low dose inhaled steroids (ICS) correctly and regularly, sometimes with the addition of long-acting β-2 agonists. If the child is not responding, the wrong thing to do is uncritically add more treatments, especially biologicals (which are only rarely needed). Instead, a detailed, protocolised investigation to determine why the child is not responding, including ensuring the child actually has asthma. This should focus on basic management steps (e.g. adherence, the environment, psychosocial aspects) and co-morbidities (especially obesity and dysfunctional breathing). Beyond guidelines therapy, especially biologicals, should only be prescribed after a detailed review. Options for biologicals in children aged 6 and over are omalizumab (binds IgE), mepolizumab (binds circulating interleukin (IL)-5 and dupilumab (blocks the IL4/IL13 receptor, all of which are treatments for severe Type 2 inflammatory asthma. Tezepelumab also treats non-Type 2 asthma but is only licensed for children aged 12 years and over. Before treatment, it is essential to determine what type of severe asthma the child has. Finally, asthma attacks must be treated as a serious red-flag. The strongest predictor of another attack is a previous attack, and so a detailed review is mandatory after an attack. This should include determining what went wrong, and if necessary, developing a new asthma plan. An asthma attack is an acute sign of suboptimal management of a chronic disease