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The silent zone of paediatric asthma: integrating small airway dysfunction assessment into clinical practice
Cristiana Indolfi1, Angela Klain1, Giulio Dinardo1
1Department of Woman, Child and of General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy.
Insights
Small airway dysfunction (SAD) is a key factor in pediatric asthma, often missed by standard tests. Early detection and management of SAD in children are crucial for better asthma control.
Area of Science:
- Pediatric Pulmonology
- Respiratory Medicine
- Asthma Research
Background:
- Small airway dysfunction (SAD) is increasingly recognized in pediatric asthma.
- Peripheral airway abnormalities can precede spirometric changes and impact disease control.
- Current asthma evaluations may not adequately detect early peripheral airway disease.
Purpose of the Study:
- To review current evidence on assessing and understanding the clinical implications of SAD in children.
- To highlight the role of SAD in pediatric asthma management.
- To identify gaps in current knowledge and clinical practice.
Main Methods:
- Narrative review of studies from PubMed/MEDLINE and the Cochrane Library.
- Evaluation of various assessment methods for small airway function in children.
- Analysis of clinical implications and management strategies for SAD.
Main Results:
- Spirometry has limited sensitivity for early peripheral airway disease in children.
- Impulse oscillometry is a practical, effort-independent method for assessing distal airway mechanics, especially in preschoolers.
- Complementary methods include body plethysmography, nitrogen washout, HRCT, and biomarkers (FeNO, nitric oxide, VOCs).
Conclusions:
- A multimodal, clinically integrated approach is recommended when symptoms and spirometry results are inconsistent.
- Standardized pediatric reference values are needed for SAD assessment tools.
- Further research, including cost-effectiveness analyses and randomized trials, is required for routine clinical guideline implementation.
Abstract:
Small airway dysfunction (SAD) is increasingly recognised as a clinically relevant component of paediatric asthma because peripheral airway abnormalities may precede spirometric impairment and contribute to poor disease control despite preserved FEV1. This narrative review summarises current evidence on the assessment and clinical implications of SAD in children, based on studies identified through PubMed/MEDLINE and the Cochrane Library. Spirometry remains the cornerstone of asthma evaluation but has limited sensitivity for early peripheral airway disease. Impulse oscillometry provides the most practical effort-independent assessment of distal airway mechanics, particularly in preschool children, while body plethysmography, multiple-breath nitrogen washout, high-resolution computed tomography, and inflammatory biomarkers including FeNO, alveolar nitric oxide, and volatile organic compounds offer complementary information in selected settings. Current evidence supports a multimodal and clinically integrated approach when symptoms and spirometry are discordant. However, standardised paediatric reference values, cost-effectiveness analyses, and randomised trials demonstrating improved outcomes with SAD-guided management are required before routine implementation in clinical guidelines.
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