Many children with problematic severe asthma that does not respond to treatment have been given the wrong diagnosis or are not taking their medication correctly. Despite substantial advances in treatment strategies for patients with therapy-resistant asthma, the best approach is a thorough multidisciplinary assessment which should result in at least 50% of these children being successfully managed with standard therapies, according to a Review in this week's European Respiratory Society meeting special edition of The Lancet.
Current management strategies for severe asthma are based on very limited research and there are no randomised trials of treatment for therapy-resistant asthma in children.
Therefore, Andrew Bush and Sejal Saglani from Imperial College London and the Royal Brompton Harefield NHS Foundation Trust, UK, reviewed evidence from published papers on adults with severe asthma and children with mild-to-moderate asthma, as well as using data from their personal clinical practice, to produce recommendations for the management of severe asthma in children.
The studies reviewed showed that many cases of apparently treatment-resistant asthma occur because of poor management of the basics including adherence to treatment, inhaler technique, dose and frequency, and minimisation of exposure to environmental triggers such as allergens and smoke. Indeed, studies reported that less than half of children referred to specialist care with problematic severe asthma have true therapy-resistant asthma. The authors point out that tackling severe asthma will require a multidisciplinary effort to prevent misdiagnosis and improve management.
Firstly, they recommend a detailed re-evaluation to confirm the diagnosis and ensure that basic management strategies are being dealt with correctly. This should be followed by a multidisciplinary filtering process to examine whether the asthma is exacerbated by comorbidities (e.g. dysfunctional breathing, obesity, and food allergies); or whether a child has difficult asthma that improves when potentially reversible basics such as poor adherence to treatment are corrected; or they have true treatment-resistant asthma that is still symptomatic even when the basics have been addressed.
Once the basics are right, the authors suggest two stages of invasive investigations to re-assess symptoms, followed by the development of an individualised treatment plan tailored to clinical symptoms and the underlying pathophysiology.
The review also discusses the complexities involved in the treatment of severe, therapy-resistant asthma in children without an evidence base, and examines the available treatment options with licensed and unlicensed drugs and experimental therapy, based on the authors' personal practice.
The authors point out that future treatment options include promising therapies in adults, such as monoclonal antibody therapies and bronchial thermoplasty, for which data in children are required.
The Review concludes that: "Despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management in the foreseeable future."
Professor Andrew Bush, National Heart and Lung Institute, Imperial College London and the Royal Brompton Hospital, UK. Via
Shima Islam, Press Office, Royal Brompton Harefield NHS Foundation Trust. T) +44 (0) 207 351 8672 or +44 (0)7866 536 345 (mobile) E) S.Islam@rbht.nhs.uk
For full Review see: http://press.thelancet.com/asthchild.pdf
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Journal
The Lancet