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Published on: November 4, 2010
How to Choose the Correct Drug in Severe Pediatric Asthma
Andrew Bush1,2,3
1National Heart and Lung Institute, Imperial College, London, United Kingdom.
Insights
When children with severe asthma don't respond to treatment, a thorough assessment is crucial. Personalized treatment strategies, including biologics and targeted therapies, are essential for managing difficult-to-treat asthma in children.
Area of Science:
- Pediatric Pulmonology
- Allergy and Immunology
- Respiratory Medicine
Background:
- Severe asthma in children often requires reassessment when initial treatments fail.
- Identifying alternative diagnoses, comorbidities, or environmental factors is critical for effective management.
- Current treatment protocols vary significantly across different age groups, from school-aged children to infants.
Purpose of the Study:
- To review current approaches for diagnosing and managing severe pediatric asthma.
- To highlight the need for personalized treatment strategies based on individual patient profiles.
- To identify gaps in pediatric asthma research and advocate for evidence-based therapeutic decisions.
Main Methods:
- Review of clinical guidelines and existing literature on pediatric asthma management.
- Analysis of diagnostic protocols for school-aged children and preschool children.
- Discussion of treatment options including inhaled corticosteroids (ICSs), single maintenance and reliever treatment (SMART), and biological therapies.
- Examination of the role of biomarkers and endotypes in guiding treatment.
Main Results:
- Protocolized assessment is recommended for school-aged children with refractory asthma.
- SMART inhaler therapy can benefit children with non-adherence.
- Biologicals like omalizumab and mepolizumab are options for steroid-resistant Type 2 inflammation, though pediatric data for mepolizumab is limited.
- Aeroallergen sensitization and eosinophil counts aid targeted ICS use in preschool asthma.
- Chronic airway infection may benefit from targeted antibiotics in preschool wheeze.
- Asthma in the first year of life lacks Type 2 inflammation, limiting evidence-based recommendations beyond avoiding ICSs.
Conclusions:
- Personalized treatment approaches are vital for severe pediatric asthma.
- There is an urgent need for more pediatric-specific research, objective biomarkers, and endotype-based therapies.
- Addressing the lack of pediatric data is crucial for making evidence-based therapeutic decisions.
Abstract:
When a child with severe asthma (asthma defined clinically for the purposes of this review as wheeze, breathlessness, and chest tightness sometimes with cough) does not respond to treatment, it is important to be sure that an alternative or additional diagnosis is not being missed. In school age children, the next step is a detailed protocolized assessment to determine the nature of the problem, whether within the airway or related to co-morbidities or social/environmental factors, in order to personalize the treatment. For example, those with refractory difficult asthma due to persistent non-adherence may benefit from using budesonide and formoterol combined in a single inhaler [single maintenance and reliever treatment (SMART)] as both a reliever and preventer. For those with steroid-resistant Type 2 airway inflammation, the use of biologicals such as omalizumab and mepolizumab should be considered, but for mepolizumab at least, there is a paucity of pediatric data. Protocols are less well developed in preschool asthma, where steroid insensitive disease is much more common, but the use of two simple measurements, aeroallergen sensitization, and peripheral blood eosinophil count, allows the targeted use of inhaled corticosteroids (ICSs). There is also increasing evidence that chronic airway infection may be important in preschool wheeze, increasing the possibility that targeted antibiotics may be beneficial. Asthma in the first year of life is not driven by Type 2 inflammation, so beyond avoiding prescribing ICSs, no evidence based recommendations can be made. In the future, we urgently need to develop objective biomarkers, especially of risk, so that treatment can be targeted effectively; we need to address the scandal of the lack of data in children compared with adults, precluding making evidence-based therapeutic decisions and move from guiding treatment by phenotypes, which will change as the environment changes, to endotype based therapy.
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