How to manage uncontrolled asthma and its causes

Susan Laubach, MD, FAAP

David N. Cornfield, MD

In the United States, 8.4% of children have asthma. Among this cohort, 5% have asthma that is classified as severe and poorly controlled despite adherence to standard treatments. However, a much larger proportion of children with asthma report frequent symptoms that are difficult to control. The highest rates of uncontrolled asthma occur in black children (63%), young children aged 0 to 4 years (59%), and girls (53%). A number of factors can affect asthma control in these children and make it difficult to control.

To help pediatricians and front-line healthcare providers recognize and diagnose difficult-to-control asthma in children, Susan S. Laubach, MD, FAAP, associate clinical professor of Pediatrics, University of California San Diego, and director, Allergy Clinic, Rady Children’s Hospital, San Diego, California, provided an overview of factors that make asthma difficult to control and key questions that should be asked to identify these factors to make the diagnosis during a session at the American Academy of Pediatrics (AAP) 2019 National Conference and Exhibition in New Orleans, Louisiana, titled “Breathe easy: Diagnosis and management of difficult-to-control asthma” on Sunday, October 27, 2019.

These key questions include: 1) Is this really asthma?; 2) Are the treatments working?; 3) Are there unrecognized triggers?; and 4) Are there comorbidities? For each question, Laubach used a case study to illustrate how clinicians should approach a child with difficult-to-control asthma to ensure optimal management.

Laubach discussed a personalized asthma management approach taken from the 2019 Global Strategy for Asthma Management and Prevention (GINA) Report that is based on a strategy of assessing, adjusting, and reviewing symptoms and risks of severe asthma to confirm the diagnosis and implement interventions. As the first step, assessing requires confirming a diagnosis if necessary; identifying symptom control and modifiable risk factors as well as comorbidities; inhaler technique and adherence; and understanding patient goals. Adjusting includes treatment of modifiable risk factors and comorbidities; managing with nonpharmaceutical strategies; educating the patients; and use of asthma medications. Reviewing focuses on reviewing the response to treatments including symptoms, exacerbations, adverse effects, lung function, and patient satisfaction.

In addition to a review of the recommended step-up treatments used to control asthma symptoms, Laubach listed other factors that contribute to making asthma difficult to control. Many of these factors, she emphasized, are modifiable. She urged clinicians to consider “other diagnoses in the differential diagnosis of a child who coughs and wheezes; adhering to the treatment guidelines to make sure the correct medications and doses are being used for a child’s level of severity; checking inhaler technique; addressing parental concerns about adverse effects of medications; assessing for environmental triggers (such as allergies, tobacco, smoke exposure, and pollution); comorbidities (such as obesity, reflux, and sinus disease); and age-specific concerns (especially in adolescence).”

Laubach ended her talk with a brief description of new biologic therapies available for older children and adults.

Overall, Laubach emphasized the need for pediatricians to look for factors underlying difficult-to-control asthma and getting help as needed. “When asthma is difficult to control, consider the underlying factors and consider consulting allergy or pulmonary specialists,” she said.

COMMENTARY

Asthma remains the cause of substantial morbidity and even mortality in children and young adults. Discerning the relative degree of disease severity can be challenging. Although severe, difficult-to-control asthma is distributed asymmetrically across sex (female predominance), socioeconomic strata (uninsured), and race (black children), and children are afflicted irrespective of geography, wealth, or race.

On Sunday, October 27, 2019, Susan S. Laubach MD, associate clinical professor, University of California San Diego, and director, Allergy Clinic, Rady Children’s Hospital, San Diego, California, provided an overview of factors that make asthma difficult to control during a session titled “Breathe easy: Diagnosis and management of difficult-to-control asthma.”

Several aspects of the presentation and difficult-to-control asthma merit comment. First, difficult-to-control asthma may derive from a cause that is addressable. Undertaking a careful history that includes environmental exposures (pollutants, volatile chemicals, dust mites), living situation (smokers, pets, heat source), as well as allergic and family history can inform both diagnosis and treatment. Prolonged exposure to an inflammatory stimulus can lead to chronic inflammation and poorly controlled asthma.

Second, clinicians managing children with difficult-to-control asthma should ensure both compliance and the diagnosis. From a compliance perspective, patients may be in possession of the correct medication, but they are delivering it incorrectly. Review of delivery techniques and capacity for the patient and family to comply with the medications as prescribed is essential. Moreover, considering the difficult-to-control asthma patient from a comprehensive perspective is important as highly labile asthma may result from a cause such as aspiration, allergy, or reflux.

The significance of the difficult-to-control asthma patient is amplified further by the changes unfolding in our environment. With global warming and increasing levels of particulate matter in the air, especially in developing countries and inner cities, there is reason to believe that the prevalence of difficult-to-control asthma will be increasing. Further, the advent of increasingly specific therapeutic tools, more precise and more personal, will allow for the delivery of more bespoke care than ever before. Thus, being able to achieve a highly defined, “thin” phenotype will enable clinicians to mitigate the clinical harm associated with difficult-to-control asthma by providing therapies that address the underlying cause.

David N. Cornfield, MD, is the Anne T. and Robert M. Bass Professor in Pulmonary Medicine, and director, Center for Excellence in Pulmonary Biology, Department of Pediatrics and (by courtesy) Surgery, Stanford University School of Medicine, Stanford, California.