Contents · 12 sections
In a nutshell. Bronchial asthma (BA) is the most common chronic childhood disease (5–10%). Diagnosis triad: wheezing + reversible obstruction (↑ FEV₁ ≥ 12% after salbutamol) + atopy. GINA 2023 treatment: stepwise approach with ICS as the cornerstone; SABA "as needed" without ICS is no longer recommended. Severe exacerbation — oxygen + salbutamol + ipratropium + systemic GCS; if ineffective — IV MgSO₄ and mechanical ventilation.
1. Definition and epidemiology
Bronchial asthma is a chronic inflammatory airway disease characterized by variable airflow obstruction and bronchial hyperresponsiveness. Allergic (atopic) asthma is the most common form in children. Prevalence in Russia is 6–10% according to ISAAC data, and up to 20% globally. Onset occurs before 6 years of age in 80% of cases.
2. Phenotypes of Pediatric Asthma
- Transient wheezing — episodes up to 3 years of age, associated with viral infections, resolving by age 6.
- Non-progressing non-atopic asthma — school age, viral trigger, no allergy.
- Allergic (atopic) asthma — family history, early onset, eosinophilia, IgE-mediated reactions.
- Severe asthma — T2-high (eosinophilic, IL-4/IL-13/IL-5) or T2-low (neutrophilic, obesity).
3. Pathogenesis
Eosinophilic inflammation → release of IL-4, IL-5, IL-13, leukotrienes, histamine → hypersecretion of mucus, mucosal edema, bronchial smooth muscle spasm → expiratory narrowing of the airway lumen, "air trapping". Upon chronic progression — bronchial wall remodeling with basement membrane thickening and subepithelial fibrosis.
4. Clinical presentation
- Episodes of wheezing, shortness of breath, cough, chest tightness.
- Nighttime and early morning awakenings.
- Trigger association: physical exertion, cold air, infections, allergens (pollen, pet dander, dust mites), cigarette smoke.
- Family atopy (asthma, atopic dermatitis, allergic rhinitis — the "atopic march").
5. Diagnostics
In children ≥ 5 years old — spirometry
- FEV₁/FVC < 0.85 — obstruction.
- Increase in FEV₁ ≥ 12% after inhalation of 400 mcg salbutamol — reversibility.
- Peak expiratory flow (PEF) variability ≥ 13% over a week.
In children < 5 years old
- Diagnosis is primarily clinical: ≥ 3 episodes of wheezing + atopy/family history + response to trial ICS therapy.
Additional
- FeNO (fractional exhaled nitric oxide) > 35 ppb in children — supports the diagnosis of eosinophilic asthma.
- Total and specific IgE, skin prick tests.
- Blood and sputum eosinophils.
- Chest X-ray — to rule out other causes.
6. Assessment of Control
| Sign (over the last 4 weeks) | Well-controlled | Partly controlled | Uncontrolled |
|---|---|---|---|
| Daytime symptoms > 2 times/week | No | 1–2 features | 3–4 features |
| Nighttime awakenings | No | ||
| SABA need > 2 times/week | No | ||
| Activity limitation | No |
ACT (Asthma Control Test) score: ≥ 20 — controlled, 16–19 — partly controlled, ≤ 15 — uncontrolled. For children aged 4–11 — Childhood ACT.
7. GINA 2023 Stepwise Management (Ages 6–11)
| Step | Controller | Reliever |
|---|---|---|
| 1 | Low-dose ICS taken with every SABA inhalation | SABA (salbutamol) |
| 2 | Low-dose ICS daily OR LTRA | SABA |
| 3 | Low-dose ICS + LABA OR medium-dose ICS | SABA or ICS-formoterol |
| 4 | Medium-dose ICS + LABA (referral to specialist) | SABA or ICS-formoterol |
| 5 | High-dose ICS + LABA ± tiotropium, biologics | SABA |
In adolescents ≥ 12 years and adults
Key GINA change since 2019: SABA monotherapy is no longer recommended due to the risk of fatal exacerbations. The standard is MART therapy: low-dose budesonide/formoterol "as both controller and reliever".
8. Drug Classes
- ICS (budesonide, fluticasone, beclometasone) — cornerstone; inflammation control.
- LABA (formoterol, salmeterol) — always in combination with ICS; not for monotherapy!
- LTRA (montelukast) — alternative in children with virus-induced asthma and allergic rhinitis; in 2020, the FDA added a Black Box warning regarding neuropsychiatric adverse effects.
- SABA (salbutamol) — on-demand only, > 3 times a week = uncontrolled asthma.
- Biologics in severe asthma in adolescents: omalizumab (anti-IgE), mepolizumab/benralizumab (anti-IL-5/IL-5R), dupilumab (anti-IL-4Rα).
- Tiotropium — approved from 6 years of age as add-on therapy for poor control.
9. Asthma exacerbation in a child
Severity assessment
| Sign | Mild | Middle | Severe | Life-threatening |
|---|---|---|---|---|
| Speech | In sentences | In phrases | In words | Mute |
| RR (Respiratory Rate) | Normal | ↑ | ↑↑ | Bradypnea |
| SpO₂ | > 95 | 90–95 | < 90 | < 90 |
| Consciousness | Normal | Agitated | Distressed | Depressed consciousness |
Relief algorithm
- Oxygen via mask — target SpO₂ 94–98% (in infants — 92–95%).
- Salbutamol via spacer/nebulizer: 4–10 puffs every 20 minutes in the first hour or 2.5–5 mg via nebulizer.
- Ipratropium bromide 250–500 mcg via nebulizer in severe exacerbation, add to salbutamol.
- Systemic GCS — prednisolone 1–2 mg/kg (max 40–60 mg) orally or IV, course of 3–5 days.
- Magnesium sulfate 40–50 mg/kg IV over 20 minutes — if no response in the 1st hour.
- If respiratory failure persists — high-frequency ventilation or intubation.
10. Non-pharmacological interventions
- Allergen elimination (regular cleaning, allergen-proof covers, dust reduction).
- Cessation of passive smoking.
- Influenza and pneumococcal vaccination.
- Treatment of comorbid allergic rhinitis and GERD — improves asthma control.
- AIT (allergen-specific immunotherapy) — in monovalent sensitization, age ≥ 5 years.
- Parent education schools, action plan for exacerbation.
11. Prognosis
Up to 50% of children with early-onset asthma "grow out of" the disease by adolescence. Poor prognostic factors: early sensitization, severe exacerbations, family history, parental smoking, atopic dermatitis.
12. FAQ
Is spirometry necessary for every child with wheezing?
Only from 5 years of age and when asthma is suspected. In younger children, the diagnosis is clinical + a 2–3 month trial of ICS therapy.
Are ICS harmful to a child's growth?
Low and moderate doses of ICS are safe; final adult height is reduced by a maximum of 1 cm. Uncontrolled asthma inhibits growth more than therapy.
When to use montelukast?
Step 2 as an alternative to ICS in virus-induced asthma or concomitant allergic rhinitis. Warning parents about the risk of neuropsychiatric side effects.
What to do during an attack at home?
2–4 puffs of salbutamol via spacer, repeat every 20 minutes for up to 1 hour. If ineffective and signs of severity appear — call an ambulance.
Can children play sports?
Yes. Well-controlled asthma does not limit physical activity. Swimming, team sports are recommended. Before exertion — 1–2 puffs of salbutamol 15 minutes prior.
See also: COPD · Pneumonia · Pediatric rash-associated infections · Glucocorticoids · Pediatrics catalog