Severe Asthma

Severe Asthma in Children

School-age children who are having symptoms despite prescribed therapy of >800 microgm/d of total dose of inhalers (budesonide or equivalent) and have undergone trial of an additional controllers medicines (at least 2 of 3 of other ) are labelled as Problematic Severe Asthma.
Child can either daily symptoms or frequent attacks requiring admissions despite treatment. Many of such children would have problems or medically called as obstruction in their pulmonary function tests.

How do we handle such children who just do not seem to respond to the usual medicines?

The reasons for a poor control of asthma will have to be identified step-wise.

  • The common reasons are: wrong diagnosis (may be having some other diagnosis, NOT ASTHMA), problems with the dose and delivery of the medicine, incorrect technique of inhalers,  associated problems like a sinusitis, allergic nose, etc.
  • The evaluation would start with a detailed case history and examining the child. The child might also need a few basic investigations like a Lung Function Test, X-rays of the chest, sinuses, neck, etc.
  • In “My Experience” most children would settle down with appropriate management of the things mentioned above.

What are the conditions other asthma which can present similarly?

There are a few conditions which should be considered in children who present with similar problems but are not responding to the usual treatment. These are described below. Some might need further investigations.

Differential diagnosisClinical pointersInvestigations
Chronic suppurative lung disease and BronchiectasisChildren would have recurrent episodes for wet cough (cough with phlem), wet cough lasting for >6 months, clubbing. There can be associated wheezing with these episodes.Usually clinical diagnosis, HRCT Chest Normal
TuberculosisProlonged fever, weight loss, loss of appetite, contact with TB caseMantoux test, gastric aspirates for testing, chest x ray
Chronic rhino-sinusitisThese children would have signs of post nasal drip and chronic pharyngeal congestion.Sinus xray, CT useful but required only in resistant cases for surgical intervention
Bronchiolitis OblitecransUsually post infectious are viral bronchiolitis, persistent wheezing lasting for >60 daysPulmonary functions tests suggestive of non reversible severe obstruction, HRCT pattern of mosaic perfusion, lung biopsy in atypical cases
Primary ciliary dyskinesiaFeatures of CSLD/bronchiectasis, rhinitis since birth, chronic otitis, situs inversusCiliary motility and ultrastructural studies
Cystic fibrosisFeatures of CSLD/bronchiectasis, malabsobtion, failure to thriveSweat chloride, mutation analysis
Tropical Pulmonary EosinophiliaLiving in an endemic area. High AEC >3000/micL. Reticulonodular infiltrates on Chest XrayUsually clinical and response to DEC.
Allergic BronchopulmonaryAspergillosisAsthma getting uncontrolled. High IgE >1000 micL. Fleeting infiltrates.Aspergillus specific IgE and IgG.Would there be a group of children with asthma (who do not have any alternative diagnosis) and still do not respond to the usual medicines?

Would there be a group of children with asthma (who do not have any alternative diagnosis) and still do not respond to the usual medicines?
This is very rare but does happen. These children might be offered other treatment like anti-allergic medicines (Omalizumab), cyclosporin etc.