Management of severe asthma in children

Bush, Andrew; Saglani, Sejal

doi:10.1016/s0140-6736(10)61054-9

Cited by 220Asthma and respiratory diseasesOccupational exposure and asthmaChronic Obstructive Pulmonary Disease (COPD) Research

Management of severe asthma in children

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Bush, Andrew, Saglani, Sejal·2010·The Lancet

DOI 10.1016/s0140-6736(10)61054-9PMC PMC3471126

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Abstract

Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group, with substantial morbidity. The evidence base for management is sparse, and is mostly based on data from studies in children with mild and moderate asthma and on extrapolation of data from studies in adults with severe asthma. In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. The first step is a detailed diagnostic assessment to exclude an alternative diagnosis ("not asthma at all"), followed by a multidisciplinary approach to exclude comorbidities ("asthma plus") and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified. An individualised treatment plan should be devised depending on the clinical and pathophysiological characterisation. Licensed therapeutic approaches include high-dose inhaled steroids, the Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate), and anti-IgE therapy. Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions. Paediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty. However, despite the interest in innovative approaches, getting the basics right in children with apparently severe asthma will remain the foundation of management for the foreseeable future.

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The limitation of the use of maximum treatment is that there may be different reasons for poor asthma control among patients on maximum treatment, such as wrong diagnosis, non-adherence with medication, or therapy-resistant disease.
“The limitation of the use of “maximum treatment” is that there may be different reasons for poor asthma control among patients on “maximum treatment,” such as the wrong diagnosis (46), non-adherence with medication (50), or therapy-resistant disease (48).”
From Epidemiology of Asthma in Children and Adults (2019) · cites this paper as [48]

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[118]Adams NP Bestall JC Jones P Lasserson TJ Griffiths B Cates CJ Fluticasone at different doses for chronic asthma in adults and children Cochrane Database Syst Rev 2008 4 CD003534 18843646 PMC6984662

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Authors: Bush, A., & Saglani, S.
Affiliations: Royal Brompton Hospital (GB)
Corresponding author: Bush, Andrew
ORCID: Bush, Andrew
Saglani, Sejal
Venue: The Lancet
Publisher: Elsevier BV
Published: 2010-09
Volume: 376
Issue: 9743
Pages: 814-825
ISSN: 0099-5355 (ISSN-L)
0140-6736
DOI: 10.1016/s0140-6736(10)61054-9
PMC: PMC3471126
OpenAlex: W2137995619
Cited by: 220
References: 192
Citations by year: 2026: 3 · 2025: 2 · 2024: 2 · 2023: 6 · 2022: 10 · 2021: 9 · 2020: 12 · 2019: 21 · 2018: 18 · 2017: 25 · 2016: 12 · 2015: 11 · 2014: 12 · 2013: 21 · 2012: 28
FWCI: 2.44
Type: journal article
Language: en
Open access: green
www.ncbi.nlm.nih.gov
Licence: www.elsevier.com/tdm/userlicense/1.0/ (tdm)
Locations: The Lancet (publishedVersion)
PubMed (publishedVersion)
Europe PMC (PubMed Central) (acceptedVersion)
PubMed Central (acceptedVersion)
Funders: Wellcome Trust (083586)
National Institute for Health and Care Research (NF-SI-0508-10212)
Topics: Health Sciences › Medicine › Physiology › Asthma and respiratory diseases
Health Sciences › Medicine › Public Health, Environmental and Occupational Health › Occupational exposure and asthma
Health Sciences › Medicine › Pulmonary and Respiratory Medicine › Chronic Obstructive Pulmonary Disease (COPD) Research
Keywords: severe asthma, childhood asthma, treatment-resistant asthma, steroid resistance, inhaler technique, medication adherence, asthma comorbidity, difficult-to-treat asthma, high-dose inhaled corticosteroids, budesonide/formoterol, anti-IgE therapy, methotrexate, cyclosporine, bronchial thermoplasty, asthma diagnosis
MeSH terms: Formoterol Fumarate, Budesonide, Formoterol Fumarate Drug Combination, Administration, Inhalation, Adrenal Cortex Hormones, Allergens, Asthma, Azathioprine, Bronchial Provocation Tests, Bronchodilator Agents, Child, Clinical Trials as Topic, Drug Combinations, Drug Therapy, Combination, Eosinophils, Ethanolamines, House Calls, Humans, Immunoglobulin E, Methotrexate, Risk Factors, Severity of Illness Index, Spirometry, Terbutaline, Tobacco Smoke Pollution, Tomography, X-Ray Computed, Comorbidity, Cyclosporine, Treatment Outcome, Drug Resistance, Multiple, Anti-Asthmatic Agents, Budesonide, Interdisciplinary Communication, Off-Label Use

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