Are inhaled corticosteroids (ICS) needed to treat expiratory wheezes?

Management of Expiratory Wheezes: Role of Inhaled Corticosteroids

Inhaled corticosteroids (ICS) are not routinely needed for isolated expiratory wheezes but are indicated when wheezing is associated with underlying asthma or eosinophilic airway inflammation. 1

Understanding Expiratory Wheezes

Expiratory wheezes are common clinical findings that can occur in various respiratory conditions. They are characterized by musical sounds generated during forced expiration due to airway narrowing. While wheezing is often associated with asthma, it's important to understand that not all wheezing requires corticosteroid treatment.

Clinical Significance of Wheezing

• Expiratory wheezing correlates with the severity of airway obstruction 2
• Biphasic wheezing (both inspiratory and expiratory) typically indicates more severe obstruction than expiratory wheezing alone 2
• Loudness and high pitch of wheezing are associated with greater airway obstruction 2

Diagnostic Approach to Expiratory Wheezes

Before deciding on treatment with ICS, it's essential to determine the underlying cause of wheezing:

1. Asthma: Consider if wheezing is associated with other symptoms like cough, breathlessness, and variable airflow obstruction 1
2. Non-asthmatic eosinophilic bronchitis (NAEB): Characterized by eosinophilic airway inflammation without variable airflow obstruction 1
3. COPD: May present with wheezing, especially during exacerbations 1
4. Other causes: Upper airway obstruction, bronchiectasis, heart failure, viral infections 1

Treatment Recommendations

For Asthma-Related Wheezing:

• First-line treatment: Inhaled corticosteroids are recommended for persistent asthma symptoms, including wheezing 1
• Cough-variant asthma: ICS should be considered as first-line treatment 1
• Monitoring: If response is incomplete, consider stepping up ICS dose or adding a leukotriene inhibitor 1

For Non-Asthmatic Eosinophilic Bronchitis (NAEB):

• ICS are recommended as first-line treatment 1
• If response is incomplete, consider stepping up the ICS dose or adding a leukotriene inhibitor 1

For COPD-Related Wheezing:

• ICS may provide modest benefits in advanced COPD (FEV1 <50% predicted) by reducing exacerbations 1
• Combination therapy with long-acting bronchodilators may be more effective than ICS alone 1

For Isolated Expiratory Wheezes:

• Without evidence of asthma or eosinophilic inflammation, bronchodilators alone may be sufficient 1
• FeNO testing can help identify patients likely to benefit from ICS (FeNO >50 ppb in adults, >35 ppb in children) 1

Special Considerations

In Children:

• For infants with persistent wheezing despite bronchodilators, ICS or systemic corticosteroids may be indicated 1
• For children 5-16 years with recurrent wheezing, objective testing should be performed before starting ICS 1
• In preschool children with recurrent episodic wheezing, intermittent high-dose ICS during episodes can be effective 3

In Acute Settings:

• For acute wheezing episodes, bronchodilators are first-line treatment 4
• Systemic corticosteroids (oral prednisolone 30-60 mg or IV hydrocortisone 200 mg) are indicated for moderate to severe exacerbations 4

Benefits of ICS Beyond Symptom Control

• ICS therapy in asthma has been associated with reduced cardiovascular mortality and all-cause mortality 5
• Regular ICS use can prevent exacerbations in patients with persistent asthma 3

Common Pitfalls to Avoid

1. Overtreatment: Prescribing ICS for all wheezing without identifying the underlying cause
2. Undertreatment: Failing to prescribe ICS for persistent asthma symptoms
3. Inadequate follow-up: Not reassessing response to therapy after 4-6 weeks
4. Misdiagnosis: Treating all wheezing as asthma without considering other causes
5. Poor technique: Not ensuring proper inhaler technique, which can lead to treatment failure

Conclusion

The decision to use ICS for expiratory wheezes should be based on the underlying cause. For asthma and eosinophilic airway inflammation, ICS are indicated and effective. For isolated expiratory wheezes without evidence of these conditions, bronchodilators alone may be sufficient. Objective testing, such as spirometry and FeNO measurement, can help guide treatment decisions.