Submitted Successfully!
To reward your contribution, here is a gift for you: A free trial for our video production service.
Thank you for your contribution! You can also upload a video entry or images related to this topic.
Version Summary Created by Modification Content Size Created at Operation
1 + 1678 word(s) 1678 2020-12-18 08:33:14 |
2 I deleted the initial "note". -28 word(s) 1650 2020-12-20 18:57:17 | |
3 format change -639 word(s) 1011 2020-12-21 05:25:49 |

Video Upload Options

Do you have a full video?

Confirm

Are you sure to Delete?
Cite
If you have any further questions, please contact Encyclopedia Editorial Office.
Porcaro, F.; Ullmann, N.; Allegorico, A.; Di Marco, A.; Cutrera, R. Difficult Asthma in Children. Encyclopedia. Available online: https://encyclopedia.pub/entry/3697 (accessed on 21 June 2024).
Porcaro F, Ullmann N, Allegorico A, Di Marco A, Cutrera R. Difficult Asthma in Children. Encyclopedia. Available at: https://encyclopedia.pub/entry/3697. Accessed June 21, 2024.
Porcaro, Federica, Nicola Ullmann, Annalisa Allegorico, Antonio Di Marco, Renato Cutrera. "Difficult Asthma in Children" Encyclopedia, https://encyclopedia.pub/entry/3697 (accessed June 21, 2024).
Porcaro, F., Ullmann, N., Allegorico, A., Di Marco, A., & Cutrera, R. (2020, December 20). Difficult Asthma in Children. In Encyclopedia. https://encyclopedia.pub/entry/3697
Porcaro, Federica, et al. "Difficult Asthma in Children." Encyclopedia. Web. 20 December, 2020.
Difficult Asthma in Children
Edit

Difficult asthma is asthma that is uncontrolled despite GINA step 4 and 5 (medium or high dose ICS with a second controller; maintenance of oral corticosteroids), or that requires such treatment to maintain good symptoms control and reduce the risk of exacerbations.

asthma difficult asthma children

1. Introduction

Once a diagnosis of difficult asthma has been confirmed, all possible risk factors or comorbidities need to be considered in patients with persistent symptoms despite standard treatment[1][2]. Periodical and careful assessments carried out by the specialist and by the family pediatrician can help identify potentially modifiable factors responsible for poorly controlled asthma. Indeed, poor symptom control is a consequence of modifiable factors that need to be carefully assessed, such as (1) nonadherence to medication or inadequate inhalation technique, (2) persistent environmental exposures, (3) comorbidities, and (4) psychosocial factors.

2. Adherence to Medication

Good adherence is most commonly defined as taking between 70–80% of prescribed treatment[3]. Suboptimal adherence to ICS leads to poor asthma control, severe asthma attacks, and frequent use of healthcare resources[4]. Although it is known that half of difficult-to-treat patients have poor adherence to prescribed medication or improperly use the suggested devices[5][6], clinicians are not used to always check adherence and inhaler technique at the time of patient’s evaluation[7]. Explaining and showing the spacer’s correct use is the most effective model to improve the inhaler technique and asthma control[8][9].

Several measurement tools, both subjective and objective, have been developed to assess adherence in adults and children with asthma[10] (Table 1). Unfortunately, each of these measures has limitations, such as the unavailability of self-report adherence questionnaires validated for the pediatric population, the often poor availability of electronic monitoring devices (EMD), the high production costs, the ability of patient/parent to manipulate the data, and the ability of EMD to measure inhalation and inhaler technique[10].

Table 1. Tools for monitoring the adherence to prescribed treatment.

Measurement Tools of Treatment Adherence

Subjective

Physician assessment of adherence

Self-report questionnaires

·                     Morisky scale

·                     Medication adherence report scale

Objective

Drug levels

Exhaled nitric oxide

Prescription data

Weighing inhaler canisters

Dose counters

Directly observed therapy

Nurse home visits

Electronic monitoring devices

Integrating digital technologies

3. Environmental Exposures

3.1. Tobacco Smoke

It is known that exposure to environmental tobacco smoke increases pediatric asthma severity[11] and, in particular, increases resistance to steroids[12]. Therefore, the assessment of passive and/or active smoke exposure is mandatory for all children with difficult asthma. As parents and patients (especially if teenagers) can deny the exposure to tobacco smoke, levels of salivary or urinary cotinine can be used to determine actual exposure[13].

3.2. Air Pollution

There is increasing evidence of the association between air pollution and asthma exacerbations as well as new onset of asthma in children. Air pollution is a mixture of particles and gases emitted from several sources or generated in the atmosphere through chemical reactions (fine particles < 2.5 µm in diameter, nitrogen dioxide, and ozone). All these elements can cause oxidative stress into the airways, leading to inflammation and remodeling, especially in asthmatic children[14].

3.3. Allergen Exposure

Children with poor asthma control despite proper treatment should be investigated for allergy sensitization[15]. Several studies reported the increased risk of asthma in children with a family history of atopy, early-onset atopic dermatitis, sensitization to egg or milk in the first years of life[16]. In addition, the poor control of asthma symptoms is directly correlated with both specific IgE levels and the number of sensitizations[15]. Consequently, it is essential that allergen exposure is minimized in all patients with difficult asthma before any drug escalation.

4. Comorbidities

Co-morbidities are important in the management of difficult asthma[17], as they may contribute to poor disease control, as well as mimicking asthma symptoms (Table 2). Researching and optimizing the management of these conditions also through a multidisciplinary team is mandatory in all asthmatic patients with poor symptom control [18].

Table 2. Asthma comorbidities.

Comorbidity

Diagnosis

Treatment

Rhinosinusitis/nasal polyposis

ENT evaluation

Sinus CT

Topic CS

Surgery

Allergic rhinoconjuctivitis

Anamnestic data

SPT test

Specific IgEs

Allergen avoidance

Topic CS

Antihistamines

Antileukotriene

Dysfunctional breathing

Anamnestic data

Nijmegen questionnaire

Breathing rehabilitation

Vocal cord dysfunction

ENT evaluation

Laryngoscopy

Speech retraining

Obesity

BMI

Diet

Obstructive sleep apnea

Anamnestic data

Polisomnography

Weight loss

Nocturnal CPAP

Gastroesophageal reflux

PPI trial

pH-impedance

PPI

Lifestyle changes

Bronchiectasis

Chest CT scan

Hypertonic solutions

Physiotherapy

Macrolide

Bronchopulmonary aspergillosis

Total IgE

IgE for Aspergillus Fumigatus IgG for Aspergillus Fumigatus

Chest CT scan

Prednisone

Voriconazole

 

5. Psychosocial Factors

Although the literature on psychiatric and behavioral disorders among children with asthma is conflicting, most research reported that children with asthma display more emotional and behavioral problems than their healthy peers[19].

Anxiety, depression, and symptoms of inattention, hyperactivity, and oppositional behaviors are often reported by patients and their parents. Children with asthma and internalizing disorders are at risk of having worse asthma control, increased use of rescue medications, more access to healthcare facilities for attacks, poorer pulmonary outcomes, and more missed school days[20][21][22]. Moreover, the caregivers of children with asthma can suffer too from chronicity, developing emotional difficulties that can interfere with the management of the young patient.

Questionnaires assessing the quality of life for both the child and family (Pediatric asthma quality of life questionnaire; PAQLQ)[23] as well as symptom control (Asthma control test; ACT)[24] are useful tools to estimate the severity and the impact of the disease on patient’s life. Consequently, psychosocial interventions, including educational programs, behavioral support, cognitive-behavioral therapy, and family interventions can be considered to reduce the psychological impact of the disease and to better control asthma symptoms.

6. Socioeconomic Factors

In addition, we must not forget that low socioeconomic status (low income, educational level, parents’ occupation) is often associated with poor asthma control (need for rescue therapy for asthma exacerbation, need for emergency health service visits, need for hospitalization for asthma exacerbation and fatal outcome)[25]. In these cases, the role of the family pediatrician becomes fundamental in identifying children vulnerable to asthma with a worse prognosis.

7. Conclusion

Poor controlled asthma represents a challenge for physicians; therefore, a multidisciplinary systematic assessment is warranted. Early identification of modifiable factors for children with difficult-to-treat asthma allows establishing better control of asthma without the need for further invasive investigations and treatment escalation. 

References

  1. Adams, A.; Saglani, S. Difficult-to-Treat Asthma in Childhood. Drugs 2013, 15, 171–179.
  2. Licari, A.; Brambilla, I.; Marseglia, A.; De Filippo, M.; Paganelli, V.; Marseglia, G.L. Difficult vs. Severe Asthma: Definition and Limits of Asthma Control in the Pediatric Population. Pediatr. 2018, 6, 170.
  3. Jochmann, A.; Artusio, L.; Jamalzadeh, A.; Nagakumar, P.; Delgado-Eckert, E.; Saglani, S.; Bush, A.; Frey, U.; Fleming, L. Electronic monitoring of adherence to inhaled corticosteroids: an essential tool in identifying severe asthma in children. Respir. J. 2017, 50, 1700910.
  4. Williams, L.K.; Peterson, E.L.; Wells, K.; Ahmedani, B.K.; Kumar, R.; Burchard, E.G.; Chowdhry, V.K.; Favro, D.; Lanfear, D.E.; Pladevall, M. Quantifying the proportion of severe asthma exacerbations attributable to inhaled corticosteroid nonadherence. Allergy Clin. Immunol. 2011, 128, 1185–1191 e2.
  5. Lee, J.W.; Tay, T.R.; Radhakrishna, N.; Hore-Lacy, F.; Mackay, A.; Hoy, R.; Dabscheck, E.; O’Hehir, R.; Hew, M. Nonadherence in the era of severe asthma biologics and thermoplasty. Respir. J. 2018, 51, 1701836.
  6. Bracken, M.; Fleming, L.; Hall, P.; Van Stiphout, N.; Bossley, C.; Biggart, E.; Wilson, N.M.; Bush, A. The importance of nurse-led home visits in the assessment of children with problematic asthma. Dis. Child. 2009, 94, 780–784.
  7. Von Bülow, A.; Backer, V.; Bodtger, U.; Søes-Petersen, N.U.; Assing, K.D.; Skjold, T.; Porsbjerg, C. The level of diagnostic assessment in severe asthma: A nationwide real-life study. Med. 2017, 124, 21–29.
  8. Hoch, H.E.; Kattan, M.; Szefler, S.J. Challenges in managing difficult‐to‐treat asthma in children: Stop, look, and listen. Pulmonol. 2019, 55, 791–794.
  9. Hew, M.; Menzies-Gow, A.; Hull, J.H.; Fleming, L.; Porsbjerg, C.; Brinke, A.T.; Allen, D.; Gore, R.; Tay, T.R. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. Allergy Clin. Immunol. Pr. 2020, 8, 2222–2233.
  10. Pearce, C.J.; Fleming, L. Adherence to medication in children and adolescents with asthma: methods for monitoring and intervention. Rev. Clin. Immunol. 2018, 14, 1055–1063.
  11. Hatoun, J.; Davis-Plourde, K.; Penti, B.; Cabral, H.J.; Kazis, L. Tobacco Control Laws and Pediatric Asthma. 2018, 141, S130–S136.
  12. Kobayashi, Y.; Bossley, C.; Gupta, A.; Akashi, K.; Tsartsali, L.; Mercado, N.; Mercado, N.; Barnes, P.J.; Bush, Andrew.; Ito, K. Passive smoking impairs histone deacetylase-2 in children with severe asthma. Chest 2014, 145, 305–312.
  13. Oddoze, C.; Dubus, J.C.; Badier, M.; Thirion, X.; Pauli, A.M.; Pastor, J; Bruguerolle, B. Urinary cotinine and exposure to parental smoking in a population of children with asthma. Clin Chem. 1999, 45, 505–509.
  14. Vardoulakis, S.; Osborne, N. Air pollution and asthma. Dis. Child. 2018, 103, 813–814.
  15. Arasi, S.; Porcaro, F.; Cutrera, R.; Fiocchi, A.G. Severe Asthma and Allergy: A Pediatric Perspective. Front Pediatr. 2019, 7, 28.
  16. Amat, F.; Soria, A.; Tallon, P.; Bourgoin-Heck, M.; Lambert, N.; Deschildre, A.; Just, J. New insights into the phenotypes of atopic dermatitis linked with allergies and asthma in children: An overview. Exp. Allergy 2018, 48, 919–934.
  17. Ullmann, N.; Mirra, V.; Di Marco, A.; Pavone, M.; Porcaro, F.; Negro, V.; Onofri, A.; Cutrera, R. Asthma: Differential Diagnosis and Comorbidities. Pediatr. 2018, 6, 276.
  18. Porsbjerg, C.; Menzies-Gow, A. Co-morbidities in severe asthma: Clinical impact and management. 2017, 22, 651–661.
  19. Booster, G.D.; Oland, A.A.; Bender, B.G. Psychosocial Factors in Severe Pediatric Asthma. Immunol. Allergy Clin. North Am. 2016, 36, 449–460.
  20. Richardson, L.P.; Lozano, P.; Russo, J.; McCauley, E.; Bush, T.; Katon, W. Asthma Symptom Burden: Relationship to Asthma Severity and Anxiety and Depression Symptoms. Pediatr. 2006, 118, 1042–1051.
  21. Bender, B.G.; Zhang, L. Negative affect, medication adherence, and asthma control in children. J. Allergy Clin. Immunol. 2008, 122, 490–495.
  22. Feldman, J.M.; Steinberg, D.; Kutner, H.; Eisenberg, N.; Hottinger, K.; Sidora-Arcoleo, K.; Warman, K.; Serebrisky, D. Perception of Pulmonary Function and Asthma Control: The Differential Role of Child Versus Caregiver Anxiety and Depression. J. Pediatr. Psychol. 2013, 38, 1091–1100.
  23. Juniper, E.F.; Guyatt, G.H.; Feeny, D.H.; Ferrie, P.J.; Griffith, L.E.; Townsend, M. Measuring quality of life in children with asthma. Qual. Life Res. 1996, 5, 35–46.
  24. Juniper, E.F.; Gruffydd-Jones, K.; Ward, S.; Svensson, K. Asthma Control Questionnaire in children: validation, measurement properties, interpretation. Eur. Respir. J. 2010, 36, 1410–1416.
  25. Cope, S.F.; Ungar, W.J.; Glazier, R.H. Socioeconomic factors and asthma control in children. Pulmonol. 2008, 43, 745–752.
More
Information
Subjects: Pediatrics
Contributors MDPI registered users' name will be linked to their SciProfiles pages. To register with us, please refer to https://encyclopedia.pub/register : , , , ,
View Times: 502
Revisions: 3 times (View History)
Update Date: 23 Feb 2021
1000/1000
Video Production Service