Advances in the pathogenesis and personalised treatment of paediatric asthma

Abstract

The diversity of pathology of severe paediatric asthma demonstrates that the one-size-fits-all approach characterising many guidelines is inappropriate. The term "asthma" is best used to describe a clinical syndrome of wheeze, chest tightness, breathlessness, and sometimes cough, making no assumptions about underlying pathology. Before personalising treatment, it is essential to make the diagnosis correctly and optimise basic management. Clinicians must determine exactly what type of asthma each child has. We are moving from describing symptom patterns in preschool wheeze to describing multiple underlying phenotypes with implications for targeting treatment. Many new treatment options are available for school age asthma, including biological medicines targeting type 2 inflammation, but a paucity of options are available for non-type 2 disease. The traditional reliever treatment, shortacting β2 agonists, is being replaced by combination inhalers containing inhaled corticosteroids and fast, longacting β2 agonists to treat the underlying inflammation in even mild asthma and reduce the risk of asthma attacks. However, much decision making is still based on adult data extrapolated to children. Better inclusion of children in future research studies is essential, if children are to benefit from these new advances in asthma treatment.

Keywords: asthma; pediatrics.

Figure 1

Stepwise protocol for assessment and management of children with severe asthma. BDR=bronchodilator reversibility; DOT=directly observed treatment; FeNO=fractional exhaled nitric oxide; ICS=inhaled corticosteroids; MART=maintenance and reliever treatment

Figure 2

Overview of a proposed approach for the non-acute assessment and management of wheeze in children of preschool age. HDU=high dependency unit; ICS=inhaled corticosteroids; PICU=paediatric intensive care unit; SABA=shortacting β2 agonist

Figure 3

Phenotype guided assessment and management of severe recurrent wheeze in children of preschool age. Overview of proposed pathological phenotype approach using objective measurements to guide directed management

Figure 4

Licensed biological medicine treatments for severe asthma in children. Summary of prescribing indications for biological medicine treatments licensed in the UK as an additional treatment for children with severe treatment resistant asthma. No evidence or guidance currently exists on which biological medicine should be prescribed if a child is eligible for treatment with more than one biological medicine treatment. IgE=immunoglobulin E; FeNO=fractional exhaled nitric oxide; IL4Rα=interleukin 4 receptor; IL5=interleukin 5; ppb=parts per billion; SPT=skin prick test