New guidelines on asthma and allergic bronchopulmonary aspergillosis: Solving the riddle!

Allergic bronchopulmonary aspergillosis (ABPA) can occur in children with asthma, though it is relatively uncommon.[1] ABPA is a specific type of allergic lung disease caused by an immune response to the fungus Aspergillus, which is commonly found in the environment.[1] It typically affects individuals with a history of asthma or cystic fibrosis, and children with asthma can also be at risk. ABPA is more commonly seen in adults with asthma, but it can occur in children as well, especially in those with severe and poorly controlled asthma.[1] The condition arises when the immune system overreacts to Aspergillus spores in the airways. Children with asthma may inhale these spores, leading to an immune response that causes inflammation and damage in the lungs. Symptoms of ABPA in children with asthma may include wheezing, coughing, increased production of mucus, difficulty breathing, fatigue, and recurrent respiratory infections. Diagnosing ABPA in children can be challenging because its symptoms can overlap with poorly controlled asthma.[2] A combination of clinical evaluation, laboratory tests, lung function tests, chest X-rays or computed tomography scans, and specific immunological tests (e.g., serological and Aspergillus skin tests, etc.,) are required to make a definitive diagnosis.[2,3] The management of ABPA in children with asthma involves a combination of antifungal therapy, corticosteroids, and asthma management.[4] In refractory cases, biological agents (e.g., omalizumab, mepolizumab, and dupilumab) are used with success.[5] It aims to control Aspergillus infection, reduce inflammation in the airways, and optimize asthma control. Corticosteroids are essential in the treatment of ABPA to reduce airway inflammation. Children with ABPA may require oral corticosteroids during acute exacerbations or when there is significant inflammation and symptoms are not adequately controlled. However, long-term use of systemic corticosteroids should be avoided due to potential side effects, especially in children. Inhaled corticosteroids can be used for asthma management, but they may not be sufficient to control ABPA-related inflammation on their own. The primary antifungal agent used in the management of ABPA is itraconazole. It may improve lung function, reduce asthma exacerbations, and decrease the need for systemic corticosteroids in children with ABPA. Optimizing asthma control is crucial in managing ABPA in children with asthma. This involves using inhaled corticosteroids, bronchodilators, leukotriene modifiers, and other asthma medications as per Global Initiative for Asthma guidelines.[6] Proper asthma management can help reduce the risk of asthma exacerbations and improve overall respiratory health. Regular monitoring and follow-up with a pediatric pulmonologist or respiratory specialist are essential to assess treatment effectiveness, adjust medications as needed, and identify any potential complications. Encouraging allergen avoidance practices can be beneficial for children with ABPA, as reducing exposure to Aspergillus and other asthma triggers may help improve asthma control and prevent ABPA exacerbations. It is crucial to individualize the treatment plan for each child with ABPA and asthma, taking into account the severity of both conditions and the child’s overall health status. As the management of ABPA can be complex, it is best handled by health-care professionals experienced in treating allergic lung diseases in children. Always consult with a qualified pediatric pulmonologist or respiratory specialist for proper evaluation and management of ABPA in children with asthma based on the most current evidence and guidelines. Various societies (e.g., the American Thoracic Society and European Respiratory Society) have published guidelines related to the management of ABPA in asthma, but these are mainly concentrated on adult patients.[7] Till date, no pediatric-specific guidelines covering different aspects of ABPA management in asthma have been published.[4] In this special supplement of the journal, a set of guidelines focusing exclusively on children is being published by renowned pediatric pulmonologists of the country.[4] These guidelines were commissioned by the Indian Academy of Pediatrics National Respiratory Chapter, and these are the first set of guidelines published by the society that owns the journal. I am sure these guidelines will help to solve the riddle of ABPA in children with asthma and will guide future research on this burning topic.