Acute asthma exacerbation in children - Emerging treatments

Heliox

Heliox is a helium/oxygen mixture that has a lower gas density and higher viscosity than room air or oxygen; its use therefore reduces flow resistance and enhances airway penetration. It may have a limited role for patients who do not respond to standard therapy, particularly where availability and cost are not issues, but it is not used in routine care.[7] Small randomized controlled trials indicate potential benefit in severe acute asthma, with the potential to improve clinical scores at 2-4 hours, increase discharge rates at 12 hours, and thereby reduce hospital admissions.[87][126][127] One retrospective study suggested that it provided no benefits over noninvasive ventilation in pediatric patients.[124]

Leukotriene receptor antagonists

Leukotrienes are proinflammatory mediators that play important roles in both early and late asthma airway response to allergen challenge. Leukotriene receptor antagonists (LTRAs) inhibit a part of the asthma inflammatory response that is relatively unaffected by oral corticosteroids. Although they can provide some bronchodilation and improvements in lung function, there is currently limited evidence to support a role for oral or intravenous LTRAs in acute asthma.[128][129][130][131] [ ] They are not recommended in the acute setting.[7] The US Food and Drug Administration has released a warning about the potentially serious behavior and mood-related adverse effects of montelukast, advising healthcare professionals to consider the benefits and risks before prescribing montelukast.[132]

Maintenance and reliever therapy

Maintenance and reliever therapy (MART), defined as the use of an inhaled corticosteroid (ICS)-formoterol inhaler every day (maintenance dose) and as needed for symptom relief (reliever doses), is now commonplace in routine care. Only combination ICS-formoterol inhalers are approved for MART.[7] Data suggest that MART is likely to be safe and effective in children, but further research is needed with other long-acting beta agonists.[7][55]Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70. [ ] NHLBI guidelines recommend MART as both a controller and a reliever in children ages 4 years and older, whereas GINA only advocates ICS-formoterol treatment for children ages 6-11 years (e.g., steps 3 and 4).[7][55]Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC), Cloutier MM, Baptist AP, et al. 2020 focused updates to the asthma management guidelines: a report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group. J Allergy Clin Immunol. 2020 Dec;146(6):1217-70. Evidence for the use of MART in emergency departments suggests that budesonide/formoterol would not be less effective than a short-acting beta-2 agonist in the management of asthma exacerbations, and that it would be associated with lower heart rates.[7][133][134][135]

Vitamin D

There is currently insufficient evidence to make a recommendation for the use of vitamin D as a preventive treatment for asthma attacks in children.[136][137]