Severe asthma in children - differential diagnosis and management

Author: V. Dimov, M.D., Allergist/Immunologist and Assistant Professor at University of Chicago
Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at NSU

Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children (JACI, 2011).

Severe asthma - differential diagnosis and management (click to enlarge the image). Related: Common Asthma-related Comorbidities. Medscape, 2011, (figure).

If asthma treatment is not working, check DAT:

- Diagnosis - not asthma at all (VCD, CF, FBA), asthma plus AR, GERD
- Adherence - compliance with medication - 24% of asthma exacerbations are attributable to ICS medication nonadherence ( Poor adherence to asthma medications (less than 80%) was seen in 75% of children (JACI, 2011).
- Technique - NEB, HFA with spacer, DPI, etc.

3 C's of care - communication, continuity, concordance (finding common ground) are critical for asthma management (

Children who are referred to specialist care with asthma that does not respond to treatment (problematic severe asthma) are a heterogeneous group.

In many children with severe asthma, the diagnosis is wrong or adherence to treatment is poor. Therefore, the first step is a detailed diagnostic assessment to exclude an alternative diagnosis (“not asthma at all”), followed by a multidisciplinary approach to exclude comorbidities (“asthma plus”) and to assess whether the child has difficult asthma (improves when the basic management needs, such as adherence and inhaler technique, are corrected) or true, therapy-resistant asthma (still symptomatic even when the basic management needs are resolved). In particular, environmental causes of secondary steroid resistance should be identified.

Licensed therapeutic approaches include:

- high-dose inhaled steroids and LABA
- Symbicort maintenance and reliever (SMART) regimen (with budesonide and formoterol fumarate)- anti-IgE therapy

Unlicensed treatments include methotrexate, azathioprine, ciclosporin, and subcutaneous terbutaline infusions.

Pediatric data are needed on cytokine-specific monoclonal antibody therapies and bronchial thermoplasty.

Asthma Inhalers (click to enlarge the image).

Inhaled corticosteroid (ICS)

Relative binding affinity for glucocorticoid receptor (GR): mometasone > fluticasone > budesonide > triamcinolone.

Relative anti-inflammatory potency: mometasone = fluticasone > budesonide = beclomethasone > triamcinolone.


Management of severe asthma in children. Prof Andrew Bush MD, Sejal Saglani MD. The Lancet, Volume 376, Issue 9743, Pages 814 - 825, 4 September 2010.

Evidence-based asthma management in children — what’s new? MJA 2011; 194 (8): 383-384.
One in 20 children has severe asthma that doesn't respond to standard therapies.

An approach to recalcitrant, severe asthma - AAAAI Ask the Expert, 2011.

Common Asthma-related Comorbidities. Medscape, 2011, (figure) and

24% of asthma exacerbations are attributable to ICS medication nonadherence (

Single inhaler therapy in asthma (SMART) linked to poor day-to-day control of symptoms and increasing inflammation. Clin Exp Allergy. 2012 Jan 18.


Published: 09/03/2010
Updated: 03/08/2013

1 comment: said...

Comments from Twitter:

@allergydoc4kidz poor compliance remains the biggest barrier

@DrVes Yes, that's the red box in the diagram

@allergydoc4kidz yup, but it always bears repeating, so many unnecessary tests and tx changes when a call to a pharmacy would be more informative

@DrVes Yes, also observing the inhaler technique: - Asthma video: "Are you using your inhaler right?" - "Do I look like an idiot?!"