Managing symptoms and exacerbations in pediatric asthma.

International guidelines indicate that the primary goals of asthma treatment are minimizing symptoms and preventing exacerbations. Symptoms last for short periods of time (minutes or hours) and usually disappear either spontaneously or with the use of bronchodilator therapy. Exacerbations last for 1 or more days and need more extensive bronchodilator therapy with the possible addition of a course of oral corticosteroids. Particularly in children, because of their active life style, exercise-induced symptoms may interfere with normal daily life, and nocturnal symptoms may cause severe sleep disturbance. Although the avoidance of triggers that provoke symptoms and exacerbations is advocated in the guidelines, this is not a practical option as it is extremely difficult for asthmatic children to lead a normal life and yet avoid exercise. Long-term use of medication is therefore necessary to achieve the treatment goals. Inhaled corticosteroids have been shown to be the most effective drugs for reducing asthma symptoms and exacerbations. However, most children will not be free of symptoms during corticosteroid therapy and intermittent use of bronchodilator therapy is required. Cessation of inhaled corticosteroid therapy, even after several years of use, is likely to result in a reoccurrence of asthma symptoms. Long-acting beta 2-agonists, such as salmeterol and formoterol, are now available as additional therapy to inhaled corticosteroids in patients who remain symptomatic despite at least a moderate dose of inhaled corticosteroid. Two recent studies in adults revealed addition of salmeterol superior to increasing inhaled corticosteroid dose. So far, no data in children are available, but theoretically it might be attractive to add a long-acting beta 2-agonist to on-going therapy for children who remain symptomatic, especially at nighttime, despite the use of inhaled corticosteroids. There is no place for the use of long-acting beta 2-agonists as monotherapy in pediatric patients.