Management of preschool recurrent wheezing and asthma: a phenotype-based approach

Abstract

Purpose of review: The purpose of this review is to summarize the recent evidence on the management of preschool children with wheezing and asthma, and to propose a phenotype-based approach to the management of these children.

Recent findings: Recent studies have begun to identify populations of preschool children that are likely to benefit from inhaled corticosteroids (ICS) therapy and defined ICS regimens: daily ICS in preschool children with persistent asthma, and pre-emptive high-dose intermittent ICS among preschool children with intermittent disease reduce the risk of exacerbation. In addition, among preschool children with mild persistent asthma, the presence of aeroallergen sensitivity and/or blood eosinophil counts of 300/μL or greater are predictors of good response to daily ICS therapy. Other studies identified intermittent azithromycin as a therapy to prevent, and potentially to treat, acute exacerbations.The uncertainty of the role of oral corticosteroids (OCS) as a therapy for acute exacerbations continues, as a recent meta-analysis showed that OCS did not prevent hospitalizations or urgent visits, and did not reduce the need for additional courses of OCS. Whereas previous epidemiologic studies suggested acetaminophen may increase risk of exacerbations, a clinical trial clearly demonstrated acetaminophen use, compared to ibuprofen use,does not increase exacerbation risk among preschool children with mild-persistent asthma.

Summary: Recent studies have shown potential for phenotypic-driven therapies for the management of preschool children with asthma. Targeting airway bacteria has emerged as a promising therapeutic approach, but its effect on antibiotic resistance still needs to be investigated. Finally, more studies are required to evaluate if oral corticosteroids provide any benefits for acute episodic wheeze.

Figure 1

Phenotype-driven approach to the management of preschool children with asthma. ICS: Inhaled corticosteroids; LTRA: Leukotriene receptor antagonist; LRTI: Lower respiratory tract illness; mAPI: modified-asthma-predictive-index. * If no response to intermittent azithromycin therapy, then consider preemptive high-dose intermittent inhaled-corticosteroids therapy.