Asthma: A Heterogeneous and Challenging Chronic Condition

  • David R. StukusEmail author
  • William C. AndersonIII


Asthma is the most common chronic health condition affecting children and a leading cause of emergency department visits and hospitalizations. The diagnosis of asthma can be challenging, but focusing on pertinent aspects of the clinical history can help establish the proper diagnosis. Asthma symptoms can be triggered by exposure to multiple different triggers, which may occur acutely or on a chronic basis. The level of asthma severity and/or control can be readily assessed for all patients and should be utilized to guide treatment. Asthma therapy relies upon the acquisition of self-management skills, use of controller medications for persistent asthma, and avoidance of known triggers. There are multiple types of medications that can be utilized to help control persistent asthma, with inhaled corticosteroids as the mainstay of treatment. Asthma varies considerably in regard to phenotypes, endotypes, severity, and prognosis. This chapter will help identify factors specific to each individual that contribute to the heterogeneity of asthma.


Asthma Bronchospasm Controller medications Cough Exacerbations Exercise Inhaler Rescue medications Treatment plan Triggers Wheeze 


  1. 1.
    Akinbami LJ, Simon AE, Rossen LM. Changing trends in asthma prevalence among children. Pediatrics. 2016;137(1):e20152354.CrossRefGoogle Scholar
  2. 2.
    Nath JB, Hsia RY. Children’s emergency department use for asthma, 2001–2010. Acad Pediatr. 2015;15(2):225–30.CrossRefPubMedPubMedCentralGoogle Scholar
  3. 3.
    Hasegawa K, Tsugawa Y, Brown DFM, Camargo CA. Childhood asthma hospitalizations in the United States, 2000-2009. J Pediatr. 2013;163(4):1127–33.e3.CrossRefPubMedPubMedCentralGoogle Scholar
  4. 4.
    Sullivan PW, Ghushchyan V, Navaratnam P, Friedman HS, Kavati A, Ortiz B, Lanier B. The national cost of asthma among school-aged children in the United States. Ann Allergy Asthma Immunol. 2017;119(3):246–52.CrossRefPubMedGoogle Scholar
  5. 5.
    Arroyo AJC, Chee CP, Camargo CA Jr, Wang NE. Where do children die from asthma? National data from 2003 to 2015. J Allergy Clin Immunol Pract. 2017. Epub ahead of print in pressGoogle Scholar
  6. 6.
    Burbank AJ, Sood AK, Kesic MJ, Peden DB, Hernandez ML. Environmental determinants of allergy and asthma in early life. J Allergy Clin Immunol. 2017;140(1):1–12.CrossRefPubMedPubMedCentralGoogle Scholar
  7. 7.
    Daley D. The evolution of the hygiene hypothesis: the role of early-life exposures to viruses and microbes and their relationship to asthma and allergic diseases. Curr Opin Allergy Clin Immunol. 2014;14(5):390–6.CrossRefPubMedGoogle Scholar
  8. 8.
    Lynch SV, Boushey HA. The microbiome and development of allergic disease. Curr Opin Allergy Clin Immunol. 2016;16(2):165–71.CrossRefPubMedPubMedCentralGoogle Scholar
  9. 9.
    National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma-summary report 2007. J Allergy Clin Immunol. 2007;120(5):S94–138.CrossRefGoogle Scholar
  10. 10.
    Schatz M, Rosenwasser L. The allergic asthma phenotype. J Allergy Clin Immunol Pract. 2014;2(6):645–8.CrossRefPubMedGoogle Scholar
  11. 11.
    Murdoch JR, Lloyd CM. Chronic inflammation and asthma. Mutat Res. 2010;690(1–2):24–39.CrossRefPubMedPubMedCentralGoogle Scholar
  12. 12.
    Spycher BD, Silverman M, Kuehni CE. Phenotypes of childhood asthma: are they real? Clin Exp Allergy. 2010;40(8):1130–41.CrossRefPubMedGoogle Scholar
  13. 13.
    Lotvall J, Akdis CA, Bacharier LB, Bjermer L, Casale TB, Custovic A, et al. Asthma endotypes: a new approach to classification of disease entities within the asthma syndrome. J Allergy Clin Immunol. 2011;127(2):355–60.CrossRefPubMedGoogle Scholar
  14. 14.
    Smith JA, Woodcock A. Chronic cough. N Engl J Med. 2016;375(16):1544–51.CrossRefPubMedGoogle Scholar
  15. 15.
    Gautier C, Charpin D. Environmental triggers and avoidance in the management of asthma. J Asthma Allergy. 2017;10:47–56.CrossRefPubMedPubMedCentralGoogle Scholar
  16. 16.
    Boulet LP, Turmel J, Irwin RS, CHEST Expert Cough Panel. Cough in the athlete: CHEST guideline and expert panel report. Chest. 2017;151(2):441–54.CrossRefPubMedGoogle Scholar
  17. 17.
    Hull JH, Ansley L, Price OJ, Dickinson JW, Bonini M. Eucapnic voluntary hyperpnea: gold standard for diagnosing exercise-induced bronchoconstriction in athletes? Sports Med. 2016;46:1083–93.CrossRefPubMedPubMedCentralGoogle Scholar
  18. 18.
    Porsbjerg C, Menzies-Gow A. Co-morbidities in severe asthma: clinical impact and management. Respirology. 2017;22(4):651–61.CrossRefPubMedGoogle Scholar
  19. 19.
    Dundas I, Mckenzie S. Spirometry in the diagnosis of asthma in children. Curr Opin Pulm Med. 2006;12(1):28–33.CrossRefPubMedGoogle Scholar
  20. 20.
    Tang S, Xie Y, Yuan C, Sun X, Cui Y. Fractional exhaled nitric oxide for the diagnosis of childhood asthma: a systematic review and meta-analysis. Clin Rev Allergy Immunol. 2016. Doi:
  21. 21.
    Nair P, Martin JG, Cockcroft DC, Dolovich M, Lemiere C, Boulet LP, et al. Airway hyperresponsiveness in asthma: measurement and clinical relevance. J Allergy Clin Immunol Pract. 2017;5(3):649–59.CrossRefPubMedGoogle Scholar
  22. 22.
    Schatz M, Sorkness CA, Li JT, Marcus P, Murray JJ, Nathan RA, et al. Asthma control test: reliability, validity, and responsiveness in patients previously followed by asthma specialists. J Allergy Clin Immunol. 2006;117(3):549–56.CrossRefPubMedGoogle Scholar
  23. 23.
    Skinner EA, Diette GB, Alqatt-Bergstrom PJ, Nguyen TT, Clark RD, Makson LE, et al. The asthma therapy assessment questionnaire (ATAQ) for children and adolescents. Dis Manag. 2005;7(14):305–13.Google Scholar
  24. 24.
    Juniper ER, Guffydd-Jones K, Ward S, Svensson K. Asthma control questionnaire in children: validation, measurement properties, interpretation. Eur Respir J. 2010;36:1410–6.CrossRefPubMedGoogle Scholar
  25. 25.
    Bender BG. Nonadherence to asthma treatment: getting unstuck. J Allergy Clin Immunol Pract. 2016;4(5):849–51.CrossRefPubMedGoogle Scholar
  26. 26.
    Nikander K, Nicholls C, Denyer J, Pritchard J. The evolution of spacers and valved holding chambers. J Aerosol Med Pulm Drug Deliv. 2014;27(Suppl 1):S4–23.CrossRefPubMedGoogle Scholar
  27. 27.
    Cates CJ, Welsh EJ, Rowe BH. Holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma. Cochrane Database Syst Rev. 2013;9:CD000052.Google Scholar
  28. 28.
    Dinakar C, Oppenheimer J, Portnoy J, Bacharier LB, Li J, Kercsmar CM, et al. Management of acute loss of asthma control in the yellow zone: a practice parameter. Ann Allergy Asthma Immunol. 2014;113(2):143–59.CrossRefPubMedGoogle Scholar
  29. 29.
    Wu AC, Carpenter JF, Himes BE. Mobile health applications for asthma. J Allergy Clin Immunol Pract. 2015;3(3):446–8.CrossRefPubMedGoogle Scholar
  30. 30.
    Chipps BE. Inhaled corticosteroid therapy for patients with persistent asthma: learnings from studies of inhaled budesonide. Allergy Asthma Proc. 2009;30(3):217–28.CrossRefPubMedGoogle Scholar
  31. 31.
    Loke YK, Blanco P, Thavarajah M, Wilson AM. Impact of inhaled corticosteroids on growth in children with asthma: systemic review and meta-analysis. PLoS One. 2015;10(7):e0133428.CrossRefPubMedPubMedCentralGoogle Scholar
  32. 32.
    Amlani S, McIvor RA. Montelukast in childhood asthma: what is the evidence for its use? Expert Rev Respir Med. 2011;5(1):17–25.CrossRefPubMedGoogle Scholar
  33. 33.
    Chauhan BF, Chartrand C, Ni Chroinin M, Milan SJ, Ducharme FM. Addition of long-acting beta2-agonists to inhaled corticosteroids for chronic asthma in children. Cochrane Database Syst Rev. 2015;11:CD007949.Google Scholar
  34. 34.
    Anderson WC 3rd, Szefler SJ. New and future strategies to improve asthma control in children. J Allergy Clin Immnol. 2015;136(4):848–59.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing AG, part of Springer Nature 2018

Authors and Affiliations

  1. 1.Division of Allergy and Immunology, Department of Pediatrics, Nationwide Children’s HospitalThe Ohio State University College of MedicineColumbusUSA
  2. 2.Allergy and Immunology Section, Department of PediatricsChildren’s Hospital Colorado, University of Colorado School of MedicineAuroraUSA

Personalised recommendations