Related Experiment Videos
Difficult asthma
1Department of Pediatrics, Sir Ganga Ram Hospital, New Rajinder Nagar, New Delhi. chughk@bol.net.in
Insights
Difficult asthma in children requires a thorough investigation for alternative diagnoses and treatment failures. Optimizing inhaled steroids and considering steroid-sparing agents are key, with specialist care for severe or resistant cases.
Area of Science:
- Pediatric Pulmonology
- Allergy and Immunology
Background:
- Asthma uncontrolled despite guideline-based therapy is termed difficult-to-manage asthma.
- Several phenotypes exist, but alternative diagnoses must be ruled out first.
Purpose of the Study:
- To outline the diagnostic approach and management strategies for difficult-to-manage asthma in children.
- To emphasize the importance of identifying underlying causes and optimizing treatment.
Main Methods:
- Review of diagnostic considerations including alternative diagnoses (e.g., cystic fibrosis, foreign body aspiration).
- Analysis of treatment failure causes (e.g., noncompliance, incorrect inhaler technique, steroid resistance).
- Discussion of pharmacological management including inhaled corticosteroids, steroid-sparing agents, and advanced therapies.
Main Results:
- A systematic approach is crucial to identify underlying conditions mimicking difficult asthma.
- Optimizing inhaled steroid therapy and adding steroid-sparing agents (e.g., long-acting beta-2 agonists, leukotriene inhibitors) control most cases.
- A small subset requires continuous oral steroids or specialized management at centers with access to experimental drugs.
Conclusions:
- Thorough evaluation for alternative diagnoses and contributing factors is essential for children with difficult asthma.
- Most cases can be managed with optimized inhaled steroids and steroid-sparing agents.
- Specialized centers are necessary for managing steroid-resistant or severe cases requiring advanced therapies.
Abstract:
Children with asthma who are not well controlled in spite of optimum therapy outlined in Asthma Management Guidelines are said to have 'difficult-to manage asthma' or 'difficult asthma'. Several phenotypes of this subset of asthma have been described. However, before any child is labeled as difficult asthma a thorough search for an alternative diagnosis should be made. Thus, one should look for recurrent aspiration pneumonia, tuberculosis, foreign body aspiration, tracheomalacia, bronchomalacia, cystic fibrosis etc. Causes of treatment failure range from unidentified exacerbating factors, noncompliance, inappropriate inhalers and spacers and true steroid dependence or resistance. Economics of the treatment and social beliefs should also be taken into consideration at the time of finalizing the management plan. Management involves recognizing and correcting the above factors. However, steroids form the main pillar of treatment. Majority of the patients can be controlled by optimizing inhaled steroid therapy and possibly adding steroid sparing agents. Thus, long acting bata-2 agonists, long acting theophyllines and leukotriene inhibiters may be useful. A few children will require continuous oral steroid therapy and an occasional one may be actually steroid steroid resistant. Such children are best managed at asthma specialist centers where experimental drugs like, methotrexate cyclosporin or IVIG may be tried on an individual basis under close monitoring.