Indian Journal of Pediatrics (April 2022) 89(4):373-377

https://doi.org/10.1007/s12098-021-04069-w

REVIEW ARTICLE

Asthma Attacks in Children—Challenges and Opportunities

Helena Jones1 · Adam Lawton1 · Atul Gupta2

Received: 1 October 2021 / Accepted: 10 December 2021 /Published online: 21 January 2022
© The Author(s) 2022

Abstract
Asthma is the most common chronic disease of childhood worldwide, and is responsible for significant morbidity and mor-
tality in children and young people (CYP). Given the inherent dangers of a child experiencing even a single asthma attack,
it is essential to identify and manage modifiable risk factors at every clinical opportunity. Following an attack, there is an
opportunity to prevent future attacks by assessing compliance and optimizing asthma control. Careful questioning will
allow physicians to identify asthma triggers, barriers to good asthma control, and health beliefs or socioeconomic obstacles
that may have contributed to this attack. The vast majority of children with asthma can achieve good symptom control with
appropriate use of low-dose inhaled corticosteroids.

Keywords Asthma · Children · Respiratory · Pulmonology · Asthma attack · Asthma exacerbation · Acute asthma

Introduction asthma control is more likely the result of difficulties with

medication adherence, lack of asthma education, man-
Asthma is the most common chronic disease of childhood agement of comorbidities, and social and environmental
worldwide, and is responsible for significant morbidity and factors.
mortality in children and young people (CYP). Asthma
results from interactions between genetic and environmen-
tal factors that ultimately lead to airway hyper-reactivity,
bronchial inflammation, and airway remodelling. This mani- Definition of Asthma Attacks
fests clinically as variable airflow obstruction and respira-
tory symptoms such as wheeze, cough, chest tightness, and The phrase ‘asthma attack’ or ‘lung attack’ has been pro-
breathlessness. posed as a preferable term to ‘asthma exacerbation’, reflect-
Poorly-controlled asthma is associated with persistent ing the severity of an incident that is not merely a temporary
symptoms, accelerated decline in lung function, and a inconvenience but a potentially fatal event that may cause
greatly increased risk of future attacks, which may be life- lasting and progressive lung injury [2]. Others use the term
threatening. The majority of CYP with asthma can achieve ‘flare-up’, which implies that asthma is a chronic disease that
good symptom control through regular use of inhaled cor- remains present even when the patient is not symptomatic
ticosteroids (ICS). Despite the dawn of new biologic con- [3].
troller therapies, access to these treatments is limited due An asthma attack represents a sudden decrease in lung
to relatively high costs. However, most patients will never function (measurable by a fall in forced expiratory vol-
require these therapies, and only a minority of those with ume in 1 s (FEV1) and peak expiratory flow rate (PEFR)),
asthma have true therapy-resistant severe asthma [1]. Poor accompanied by respiratory symptoms. Objective measure-
ment of PEFR is used in the stratification of asthma attack
severity in children, although it must be noted that this can
* Atul Gupta be difficult in those who are severely unwell, or very young
[email protected] [4]. For the purposes of directing emergency treatment of
1
Department of Pediatrics, North Middlesex Hospital,
an asthma attack, many asthma guidelines stratify the sever-
London, UK ity of the attack according to presenting features including
2
Pediatric Respiratory Department, King’s College Hospital,
PEFR.
Denmark Hill, Brixton, London SE5 9RS, UK
374 Indian Journal of Pediatrics (April 2022) 89(4):373-377

Impact of Asthma Attacks scrutiny is being paid to the operational barriers that pre-
vent children with ancestral origins in India, Pakistan, and
Asthma attacks frequently require hospital admissions, Bangladesh from accessing asthma care [18].
and consequently children with poorly controlled asthma
may suffer the multiplying effects of poor sleep due to
nocturnal symptoms, poor school attendance due to hos- After an Asthma Attack: An Opportunity
pital admissions, and reduced participation in recreational for Intervention
sports due to fears of worsening symptoms. The impact of
frequent asthma attacks is also felt on the wider family, Following an attack, there is an opportunity to prevent future
with parents having to miss work and lose income to care attacks by assessing compliance and optimizing asthma con-
for their children during hospital admissions [5]. trol. Careful questioning will allow physicians to identify
asthma triggers, barriers to good asthma control, and health
beliefs or socioeconomic obstacles that may have contrib-
uted to this attack.
Modifiable Risk Factors for Asthma Attacks When enquiring about compliance, it is important to
adopt a nonaccusatory approach. One suggested way of sen-
Given the inherent dangers of a child experiencing even a sitively enquiring without sounding accusatory is as follows;
single asthma attack, it is essential to identify and manage “many patients don’t use their inhalers as prescribed. In the
modifiable risk factors at every clinical opportunity. Risk last four weeks, how many days a week have you been taking
factors for asthma attacks include genetic, environmental, it—not at all, 1 day a week, 2, 3 or more?” [19].
socioeconomic, and clinical management factors. Provided inhaler technique and compliance have been
Current level of asthma control is a risk factor for future optimzed and modifiable risk factors addressed, the clinician
asthma attacks, as is recent need for a course of oral ster- may consider stepping-up treatment. After any step-up in
oids or hospitalization [6]. Over-reliance on short-acting treatment, symptoms should be reviewed 2–3 mo later.
beta-agonist medications (SABA), inadequate ICS [7], and If there has been no response, treatment should be stepped
poor inhaler technique [8] all contribute to poor asthma back down to the previous level, and alternative management
control. Comorbidities such as rhinitis, gastro-oesophageal options, or referral to a specialist respiratory pediatrician,
reflux, dysfunctional breathing, anxiety, psychological should be considered.
issues, obstructive sleep apnea, and obesity exacerbate
symptoms if not optimally managed. Elevated fractional
exhaled nitric oxide (FeNO) [9], low FEV1 [10], high bron- Confirming the Diagnosis of Asthma
chodilator reversibility [11], and higher levels of sputum
eosinophilia [12] have all been associated with a higher As the symptoms of an asthma attack can sometimes be dif-
likelihood of asthma exacerbations. Environmental risk ficult to differentiate from symptoms of other respiratory
factors include exposure to household allergens, poor air diseases in children, it is sensible to ensure that asthma is
quality [13] and exposure to respiratory viruses. the correct diagnosis (Supplementary Box S1).
Children from socially disadvantaged families have The clinical history should be revisited in full to ensure
worse asthma control and are at increased risk of asthma that an alternative diagnosis or comorbidity has not been
attacks for a number of reasons including increased like- overlooked, and the child should undergo a clinical exam-
lihood of exposure to allergens such as tobacco smoke, ination. Clinical examination may be normal even in the
both indoor and outdoor air pollution in areas of low presence of asthma, especially if examined when not symp-
socioeconomic housing developments, and poorer finan- tomatic. Although wheeze is one of the cardinal respira-
cial and educational status impacting ability to access tory symptoms of asthma, there is significant discrepancy
healthcare facilities and medication [14]. Psychological between what ‘wheeze’ means to parents and physicians
stress and exposure to negative life events also increase [20]. Repeated normal examination of the chest when symp-
risk of asthma attacks, and the direct effect of psycho- tomatic does, however, reduce the probability of asthma.
social stressors on lung inflammation has been observed There is no consensus regarding the diagnostic require-
[15]. Education has been shown to reduce the frequency ments for asthma in children, and previously the diagno-
of acute hospital presentations [16], as well as improve the sis has been made based on a thorough history and clinical
quality of life and reduce mortality in CYP with asthma examination [21]. The European Respiratory Society (ERS)
[17]. CYP from certain minority ethnic groups have poorer task force on asthma has recently published evidence-
asthma outcomes in the United Kingdom, and increasing based guidelines on diagnosing asthma in children [22].
Indian Journal of Pediatrics (April 2022) 89(4):373-377 375

The ERS guidelines recommend against making a diagno- a free radical producing molecule. Furthermore, evidence
sis on clinical grounds, which was advocated in the BTS/ from adult data suggests that oxygen does not reduce the
SIGN guidelines [4]; or by using PEFR variability, which sensation of breathlessness in nonhypoxaemic patients,
is an acceptable diagnostic test in the Global Initiative for obviating its use for this indication in those not already
Asthma (GINA) guidelines [19]. ERS guidelines propose a hypoxemic [28].
diagnostic algorithm for symptomatic children aged 5–16. Bronchoconstriction in acute asthma is chiefly combated
In this algorithm, the simplest diagnostic pathway is by with inhaled SABA (such as salbutamol), delivered every
identifying abnormal spirometry and then subsequently 20 min for one hour via an inhaler device with a spacer. A
demonstrating significant bronchodilator reversibility (Sup- Cochrane review on additional bronchodilator use in chil-
plementary Fig. S1). In low-resource settings, such as devel- dren with acute asthma found that anticholinergic medica-
oping countries, spirometry may not always be possible and tion such as ipratropium bromide reduces the side effects of
hence, using gold-standard methods is not attainable. In this nausea and tremor, commonly caused by heavy salbutamol
instance, the clinician may choose to follow guidance from use during an acute attack. Both ipratropium and intravenous
GINA which recommends, in the absence of spirometry, magnesium sulfate were found to reduce the risk of hospital
providing the patient with a PEFR diary to assess diurnal admission, but no additional medication was found to reduce
PEFR variability (requiring only a basic PEFR meter) from the risk of admission to intensive care [29].
twice-daily readings over 1 to 2 wk. In CYP, diurnal vari- Steroids are essential in acute asthma to combat the under-
ation greater than 13% is considered excessive. If PEFR is lying lung inflammation. They work by binding to cellular
also not possible, GINA recommends a decision whether to glucocorticoid receptors, leading to the down-regulation of
start asthma treatment should depend on clinical urgency transcription of various proinflammatory molecules. Provided
and availability to other testing elsewhere [19]. a patient can tolerate oral medication, there is no benefit of
giving these medications intravenously or intramuscularly.
Oral steroids take several hours to have an effect, so should
Assessing Asthma Control be administered promptly in the Emergency Department. If
given within one hour (‘The Golden Hour’) of arriving in
There are several validated questionnaires for assessing the Emergency Department, the need for hospital admission
asthma control in CYP, including the Asthma Control is significantly reduced [30]. A Cochrane review was unable
Questionnaire (ACQ) [23], Childhood Asthma Control Test to demonstrate superiority of any particular steroid due to
(C-ACT) [24], Pediatric Asthma Quality-of-life Question- paucity of high-quality evidence [31].
naire (PAQLQ) [25], Test for Respiratory and Asthma Con- The 2021 GINA guidelines [19] recommend against anti-
trol in Kids (TRACK) [26], and Composite Asthma Severity biotics and obtaining a chest radiograph in most children
Index (CASI) [27]. with an asthma attack requiring treatment in the Emergency
There is no data regarding which of these questionnaires, Department.
if any, is superior for assessing asthma control in a real-
world setting. However, using a validated questionnaire for
assessing asthma control is strongly recommended; the most Preventing Asthma Attacks:
commonly used are ACQ and C-ACT. Pharmacological Management

The vast majority of CYP with asthma can achieve good

Management of an Acute Asthma Attack symptom control with appropriate use of low-dose ICS.
Traditionally, pharmacological management in children has
The treatment aims during an acute asthma attack are to pre- followed a stepwise approach that begins regular preven-
vent respiratory failure and treat respiratory symptoms and ter therapy with inhaled corticosteroids (Supplementary
acute respiratory distress by reversing bronchoconstriction Fig. S2). In the face of ongoing asthma symptoms, increased
and reducing lung inflammation. The fundamental pharma- doses of ICS or additional controller therapies are trialled
cological management of acute asthma includes the use of before referral for specialist management and the considera-
bronchodilators, oxygen, and steroids. tion of regular oral corticosteroids, or the newer biologic
Oxygen should be considered a prescribed medication drugs such as omalizumab and mepolizumab. These biologic
and its use titrated to achieve targeted oxygen saturations of agents are monoclonal antibodies targeted at various com-
94%–98%. Whilst it is clearly essential to avoid hypoxemia ponents of the inflammatory pathways that cause asthma.
and consequent organ damage, hyperoxemia has no clini- For selected patients, biologics can lead to improved symp-
cal benefit and has been shown to be harmful in a range tom control, fewer asthma attacks, and reduced use of oral
of circumstances—likely stemming from oxygen’s role as steroids [32].
376 Indian Journal of Pediatrics (April 2022) 89(4):373-377

Recently, attention has focused on the safety of only identify specific asthma phenotypes are being actively
prescribing intermittent SABA reliever therapy, following sought, with the aim of categorizing people with asthma into
evidence that many children who subsequently die from cohorts likely to respond to specific novel therapies [37]. As
an asthma attack are seen to have used these medications the cost of the novel biologics fall, more patients are likely to
heavily, and have been underprescribed the essential steroid benefit from access to these effective, steroid-sparing agents.
medications that would control the inflammation causing The COVID-19 pandemic has accelerated technological
their asthma. The 2014 National Review of Asthma Deaths innovation in healthcare. Home monitoring of lung func-
(NRAD) in the UK found that 9% of deaths were in those tion, home self-administration of biologic medication, and
using SABA only; and of these, 39% had received excess remote consultations have all taken place in the UK recently.
prescriptions for SABA, indicating over-reliance on SABA Remote physical examination is also now possible with
without adequate control of the underlying mechanisms of devices that enable a clinician to remotely auscultate the
disease [33]. lungs, and more [38]. These innovations suggest that remote
It is crucial that asthma treatment is targeted at the under- consultations for asthma management may well become
lying pathophysiological mechanisms of chronic inflamma- more popular in the near future.
tion. Therefore, the 2021 GINA guidelines have proposed
that children should be started on a combined short-acting Supplementary Information The online version contains supplemen-
tary material available at https://d​ oi.o​ rg/1​ 0.1​ 007/s​ 12098-0​ 21-0​ 4069-w.
beta-agonist with low-dose inhaled corticosteroid inhaler,
ensuring that a dose of steroid is received every time a child Authors' Contributions AG conceived of the paper; HJ wrote the first
requires reliever treatment for asthma symptoms [19]. draft; AG, HJ, and AL were involved in editing further versions of the
work. AG will act as the guarantor for this paper.

Preventing Asthma Attacks: Declarations

Nonpharmacological Management
Conflict of Interest None.
Despite the plethora of novel or advanced treatments, it must
Open Access This article is licensed under a Creative Commons Attri-
be re-emphasised that asthma attacks in children and young bution 4.0 International License, which permits use, sharing, adapta-
people can be significantly reduced by identifying and treat- tion, distribution and reproduction in any medium or format, as long
ing modifiable risk factors (Supplementary Box S2). as you give appropriate credit to the original author(s) and the source,
Asthma education should cover topics that include correct provide a link to the Creative Commons licence, and indicate if changes
were made. The images or other third party material in this article are
use of inhaler devices with spacers, adherence to control- included in the article's Creative Commons licence, unless indicated
ler therapy, recognizing asthma attacks and when asthma otherwise in a credit line to the material. If material is not included in
control is poor, the importance of exercise and diet, and the article's Creative Commons licence and your intended use is not
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All children with asthma should be provided with a writ-
ten asthma action plan that explains how to identify dete-
riorating asthma control and how to respond. Evidence has
shown that the provision of personalized asthma action References
plans improve caregiver's self-confidence and reduces the
recurrence of asthma symptoms at 14 d following an Emer- 1. Bush A, Fleming L, Saglani S. Severe asthma in children.
gency Department presentation [34]. Lack of a personalized Respirology. 2017;22:886–97.
asthma action plan was identified in the 2014 NRAD report 2. Bush A, Pavord I. Following nero: fiddle while Rome burns, or is
there a better way? Thorax. 2011;66:367.
as a risk factor for a fatal asthma attack. GINA provides a 3. Blaiss MS, Nathan RA, Stoloff SW, Meltzer EO, Murphy KR,
sample plan in their asthma toolbox (Supplementary Fig. S3) Doherty DE. Patient and physician asthma deterioration terminol-
[35]. ogy: results from the 2009 asthma insight and management survey.
Allergy Asthma Proc. 2012;33:47–53.
4. BTS/SIGN. British Guideline on the Management of Asthma.
2019. Available at: https://​www.​brit-​t hora​cic.​org.​uk/​quali​ty-​
Future Directions of Research impro​vement/​guide​lines/​asthma/. Accessed on 17 Sept 2021.
5. Diette GB, Markson L, Skinner A, Nguyen TT, Algatt-Bergstrom
Asthma is increasingly being considered an umbrella term P, Wu AW. Nocturnal asthma in children affects school attend-
ance, school performance, and parents’ work attendance. Arch
for a group of respiratory diseases of varied etiology that Paediatr Adolesc Med. 2000;154:923–8.
have distinct pathophysiological mechanisms which lead 6. Wu AC, Tantisira K, Li L, Schuemann B, Weiss ST, Fuhlbrigge
to similar symptoms [36]. Low-cost biomarkers that can AL. Childhood Asthma Management Program Research Group.
Indian Journal of Pediatrics (April 2022) 89(4):373-377 377

Predictors of symptoms are different from predictors of severe 24. Liu AH, Zeiger R, Sorkness C, et al. Development and cross-
exacerbations from asthma in children. Chest. 2011;140:100–7. sectional validation of the childhood asthma control test. J Allergy
7. Smith L, Bokhour B, Hohman KH, et al. Modifiable risk factors Clin Immunol. 2007;119:817–25.
for suboptimal control and controller medication underuse among 25. Juniper EF, Guyatt GH, Feeny DH, Ferrie PJ, Griffith LE,
children with asthma. Pediatrics. 2008;122:760–9. Townsend M. Measuring quality of life in children with asthma.
8. Al-Jahdali H, Ahmed A, Al-Harbi A, et al. Improper inhaler tech- Qual Life Res. 1996;5:35–46.
nique is associated with poor asthma control and frequent emer- 26. Murphy KR, Zeiger RS, Kosinski M, et al. Test for respiratory
gency department visits. Allergy Asthma Clin Immunol. 2013;9:8. and asthma control in kids (TRACK): a caregiver-completed ques-
9. Bjermer L, Alving K, Diamant Z, et al. Current evidence and tionnaire for preschool-aged children. J Allergy Clin Immunol.
future research needs for FeNO measurement in respiratory dis- 2009;123:833–9.
eases. Respir Med. 2014;108:830–41. 27. Wildfire JJ, Gergen PJ, Sorkness CA, et al. Development and vali-
10. Fielding S, Pijnenburg M, de Jongste JC, et al. Change in FEV1 dation of the Composite Asthma Severity Index-an outcome meas-
and feno measurements as predictors of future asthma outcomes ure for use in children and adolescents. J Allergy Clin Immunol.
in children. Chest. 2019;155:331–41. 2012;129:694–701.
11. Galant SP, Morphew T, Newcomb RL, Hioe K, Guijon O, Liao 28. O'Driscoll BR, Howard LS, Earis J, Mak V. British Thoracic Soci-
O. The relationship of the bronchodilator response phenotype to ety Guideline for oxygen use in adults in healthcare and emer-
poor asthma control in children with normal spirometry. J Pediatr. gency settings. BMJ Open Respir Res. 2017;4:e000170.
2011;158:953–9. 29. Craig SS, Dalziel SR, Powell CVE, Graudins A, Babl FE, Lunny
12. Gibson PG, Simpson JL, Hankin R, Powell H, Henry RL. Rela- C. Interventions for escalation of therapy for acute exacerbations
tionship between induced sputum eosinophils and the clinical pat- of asthma in children: an overview of cochrane reviews. Cochrane
tern of childhood asthma. Thorax. 2003;58:116–21. Database Syst Rev. 2020. https://​doi.​org/​10.​1002/​14651​858.​
13. Dick S, Doust E, Cowie H, Ayres JG, Turner S. Associations between CD012​977.
environmental exposures and asthma control and exacerbations in 30. Rowe BH, Spooner C, Ducharme FM, Bretzlaff JA, Bota
young children: a systematic review. BMJ Open. 2014;4:e003827. GW. Early emergency department treatment of acute asthma
14. Kopel LS, Phipatanakul W, Gaffin JM. Social disadvantage and with systemic corticosteroids. Cochrane Database Syst Rev.
asthma control in children. Paediatr Respir Rev. 2014;15:256–62. 2001:CD002178. https://​doi.​org/​10.​1002/​14651​858.​CD002​178.
15. Chen E, Strunk RC, Bacharier LB, Chan M, Miller GE. Socio- 31. Normansell R, Kew KM, Mansour G. Different oral corticos-
economic status associated with exhaled nitric oxide responses teroid regimens for acute asthma. Cochrane Database Syst Rev.
to acute stress in children with asthma. Brain Behav Immun. 2016;2016:CD011801.
2010;24:444–50. 32. Pijnenburg MW, Fleming L. Advances in understanding and
16. Walders N, Kercsmar C, Schluchter M, Redline S, Kirchner HL, reducing the burden of severe asthma in children. Lancet Respir
Drotar D. An interdisciplinary intervention for undertreated pedi- Med. 2020;8:1032–44.
atric asthma. Chest. 2006;129:292–9. 33. Royal College of Physicians. Why asthma still kills: the National
17. Shah S, Peat JK, Mazurski EJ, et al. Effect of peer led programme Review of Asthma Deaths (NRAD). Confidential Enquiry report.
for asthma education in adolescents: cluster randomised controlled London: RCP, 2014. Available at: https://​www.​rcplo​ndon.​ac.​uk/​
trial. BMJ. 2001;322:583–5. file/​870/​downl​oad. Accessed on 14th Nov 2021.
18. Hudson N, Culley L, Johnson M, et al. Asthma management in 34. Sockrider MM, Abramson S, Brooks E, et al. Delivering tailored
British South Asian children: an application of the candidacy asthma family education in a pediatric emergency department set-
framework to a qualitative understanding of barriers to effective ting: a pilot study. Pediatrics. 2006;117:S135–44.
and accessible asthma care. BMC Public Health. 2016;16:510. 35. Global Initiative for Asthma. GINA Implementation Toolbox.
19. Global Initiative for Asthma. Global Strategy for Asthma Man- 2019. Available at: https://​ginas​thma.​org/​gina–imple​menta​tion–
agement and Prevention. 2020. Available at: www.​ginas​thma.​org. guide/. Accessed on 21 Sept 2021.
Accessed on 17 Sept 2021. 36. Kuruvilla ME, Lee FE, Lee GB. Understanding asthma pheno-
20. Gidaris D, Cunningham S. Wheezing defined. Front Biosci (Elite types, edotypes, and mechanisms of disease. Clin Rev Allergy
Ed). 2013;5:1074–81. Immunol. 2019;56:219–33.
21. Mulholland A, Ainsworth A, Pillarisetti N. Tools in asthma evalu- 37. Bush A. Translating asthma: dissecting the role of metabo-
ation and management: when and how to use them? Indian J Pedi- lomics, genomics and personalized medicine. Indian J Pediatr.
atr. 2018;85:651–7. 2018;85:643–50.
22. Gaillard EA, Kuehni CE, Turner S, et al. European Respiratory 38. TytoCare for Professionals. On-Demand Remote Medical Exams.
Society clinical practice guidelines for the diagnosis of asthma in 2021. Available at: https://​www.​tytoc​are.​com/​profe​ssion​als/.
children aged 5–16 years. Eur Respir J. 2021;58:2004173. Accessed on 21 Sept 2021
23. Juniper EF, Bousquet J, Abetz L, Bateman ED. GOAL Committee.
Identifying 'well–controlled' and 'not well-controlled' asthma using Publisher's Note Springer Nature remains neutral with regard to
the Asthma Control Questionnaire. Respir Med. 2006;100:616–21. jurisdictional claims in published maps and institutional affiliations.