Asthma Severe

Question 1

What percentage of pediatric asthma is likely accounted for by refractory asthma?

Answer 1

Less than 5%

Question 2

Define severe asthma.

Answer 2

Patient requires treatment with guideline-suggested medications for GINA steps 4–5 asthma for the previous year OR systemic corticosteroids for ≥50% of the previous year OR remains ‘uncontrolled’ despite this therapy OR controlled asthma that worsens on tapering of high doses of ICS or systemic CS.

Question 3

What is defined as uncontrolled asthma?

Answer 3

One or more of the following: poor symptom control, frequent severe exacerbations, serious exacerbations, airflow limitation.

Question 4

What does poor symptom control consist of?

Answer 4

ACQ consistently >1.5, ACT <20

Question 5

How is frequent severe exacerbation defined?

Answer 5

Two or more bursts of systemic corticosteroids (>3 days each) in the previous year.

Question 6

What constitutes a serious exacerbation?

Answer 6

At least one hospitalization, ICU stay, or mechanical ventilation in the previous year.

Question 7

What airflow limitation indicates uncontrolled asthma?

Answer 7

FEV1 <80% predicted after withholding bronchodilators.

Question 8

What is fixed airflow limitation?

Answer 8

FEV1 <80% predicted despite a trial of systemic steroids and acute administration of SABA.

Question 9

What are the three types of severe asthma defined by WHO?

Answer 9

• Untreated
• Difficult-to-treat
• Treatment-resistant

Question 10

List the domains of asthma severity used to define risk.

Answer 10

• Level of prescribed treatment
• Level of baseline asthma control
• Level of underlying airway eosinophilia
• Burden and nature of exacerbations
• Risk of future complications

Question 11

What should the initial assessment of problematic severe asthma focus on?

Answer 11

Extra-pulmonary disease and environmental/lifestyle factors.

Question 12

What is the significance of normal spirometry in children with severe asthma?

Answer 12

Normal spirometry does not exclude severe asthma.

Question 13

What does a methacholine challenge test assess?

Answer 13

Airway hyperresponsiveness.

Question 14

What is fractional exhaled nitric oxide (FeNO) used for?

Answer 14

Diagnostic tool for asthma.

Question 15

True or False: A low FeNO50 excludes asthma.

Answer 15

False

Question 16

What are red flags in the differential diagnosis of problematic severe asthma?

Answer 16

• Neonatal onset of symptoms
• Chronic productive cough for more than 8 weeks
• Evidence of systemic disease

Question 17

How can obesity affect asthma?

Answer 17

It may cause breathlessness and wheeze without evidence of asthma, and can be associated with steroid resistance.

Question 18

What is the relationship between gastroesophageal reflux and asthma?

Answer 18

Reflux can cause symptoms that mimic or coexist with asthma.

Question 19

How should food allergy be documented?

Answer 19

With a double-blind challenge unless there is overwhelming evidence for the diagnosis.

Question 20

What is the role of psychosocial morbidity in asthma?

Answer 20

Acute and chronic stress may trigger asthma exacerbations.

Question 21

What is the purpose of a hospital admission for assessment in asthma?

Answer 21

To evaluate symptoms and manage treatment under supervision.

Question 22

What are the components of airway disease in severe asthma?

Answer 22

• Airway inflammation
• Airway infection
• Airway obstruction
• Mucus production
• Eosinophilia
• Neutrophilia

Question 23

What is the protocol for invasive investigation of severe, therapy-resistant asthma?

Answer 23

Assess symptoms, spirometry, and perform bronchoscopy with BAL and biopsy.

Question 24

What cytokines are implicated in pediatric severe, therapy-resistant asthma?

Answer 24

• GRO (CXCL1)
• RANTES (CCL5)
• IL-12
• IFN-γ
• IL-10

Question 25

What is a characteristic of induced sputum in severe asthma?

Answer 25

Eosinophil dominated.

Question 26

Fill in the blank: A cough in severe asthma is a _______ phenomenon.

Answer 26

secondary

Question 27

What cytokines best discriminate between severe, therapy-resistant asthma and mild-moderate disease?

Answer 27

GRO (CXCL1), RANTES (CCL5), IL-12, IFN-γ, IL-10 ## Footnote These cytokines play a significant role in distinguishing between different asthma severities.

Question 28

Is pediatric severe, therapy-resistant asthma a TH1- or TH2-driven disease?

Answer 28

Neither ## Footnote This indicates a different underlying mechanism compared to typical TH1 or TH2 asthma.

Question 29

Which epithelial-derived cytokines may be implicated in pediatric severe asthma?

Answer 29

IL-25, IL-33, TSLP ## Footnote These cytokines are thought to play a role in the pathogenesis of severe asthma.

Question 30

What is the role of IL-33 in pediatric severe asthma?

Answer 30

Steroid resistant and promotes collagen synthesis from fibroblasts ## Footnote Increased IL-33 expression is associated with structural changes in the airways.

Question 31

What is the definition of persistent airflow limitation (PAL)?

Answer 31

FEV1 <80% despite a trial of systemic steroids and acute administration of SABA ## Footnote This definition is used to assess long-term asthma control.

Question 32

What percentage of children with severe asthma are total nonresponders to steroids?

Answer 32

About 10% ## Footnote This reflects the variability in response to steroid treatments among children.

Question 33

What is the recommended duration for a trial of omalizumab?

Answer 33

16 weeks ## Footnote Detailed monitoring of the response is necessary during this period.

Question 34

What is the pragmatic decision for diagnosing PAL?

Answer 34

Provisionally diagnosed after a single dose of triamcinolone and albuterol ## Footnote This approach helps in managing difficult cases of asthma.

Question 35

What is the starting dose for oral prednisolone in children?

Answer 35

0.5 mg/kg, tapering down to the lowest dose needed ## Footnote This is a non-evidence-based starting dose used in practice.

Question 36

What is the SMART regime used for?

Answer 36

To simplify treatment for adolescents with asthma ## Footnote This approach aims to manage symptoms effectively with fewer medications.

Question 37

What are the possible approaches for using nonstandard medications in severe asthma?

Answer 37

Macrolide antibiotics, immunosuppressives, intravenous Ig, continuous subcutaneous infusion of terbutaline ## Footnote These options may be considered for specific phenotypes or conditions.

Question 38

What is the risk associated with antifungal treatment in asthma?

Answer 38

Interaction with ICS leading to iatrogenic Cushing syndrome ## Footnote This potential side effect must be monitored carefully.

Question 39

What is the definition of SAFS?

Answer 39

Defined in Table 46.4 ## Footnote SAFS stands for Severe Asthma with Fungal Sensitization, a specific asthma phenotype.

Question 40

What factors predict asthma lung attacks in older children?

Answer 40

Respiratory viral infection, sensitization, exposure to high allergen levels ## Footnote These factors are critical in understanding and preventing acute asthma attacks.

Question 41

What is the recommended treatment for children with multiple asthma lung attacks?

Answer 41

Increase the baseline dose of ICS ## Footnote This aims to control eosinophilic inflammation and improve overall management.

Question 42

What is the recommended annual assessment for children with severe asthma?

Answer 42

Reevaluation of adherence, allergen exposure, spirometry, and side effects monitoring ## Footnote This assessment helps in adjusting treatment plans effectively.

Question 43

What is the role of the Synacthen test in monitoring children with severe asthma?

Answer 43

To assess adrenal insufficiency ## Footnote This test is recommended annually to monitor potential side effects of steroid treatments.