From the Guidelines
For preventing viral-induced wheeze, inhaled corticosteroids (ICS) are the primary preventive medication, with montelukast as an alternative option. According to the expert panel report 3 (epr-3) guidelines for the diagnosis and management of asthma-summary report 2007 1, ICS are recommended for reducing impairment and risk of exacerbations in infants and young children who had 4 or more episodes of wheezing in the past year. The guidelines suggest that ICS, such as budesonide nebulizer solution, are preferred long-term control medications for initiating therapy in this age group.
Key Considerations
- The decision to start long-term daily therapy should be based on consideration of issues regarding diagnosis and prognosis, as not all wheeze and cough are caused by asthma 1.
- Viral respiratory infections are the most common cause of asthma symptoms in young children, and many children who wheeze with respiratory infections respond well to asthma therapy even though the diagnosis of asthma is not clearly established 1.
- Selecting medications should be based on individual drug efficacy studies in this age group, and the doses received may vary considerably among devices and age groups 1.
Treatment Options
- Regular use of low-dose ICS, such as budesonide (100-200mcg twice daily) via a nebulizer, can reduce the frequency and severity of wheezing episodes in children with recurrent viral-induced wheeze.
- Montelukast (4mg daily for children 2-5 years, 5mg daily for 6-14 years) can be used as an alternative or add-on therapy, particularly in children who don't respond well to ICS.
- A short course of oral prednisolone (1-2mg/kg/day for 3-5 days) may be prescribed for acute episodes.
Non-Pharmacological Interventions
- Mask use and hand hygiene are strong recommendations for prevention of viral transmission, as suggested by the evidence-based review of nonpharmacological interventions to reduce respiratory viral transmission 1.
- Good hydration, nasal saline drops, and humidified air can provide symptomatic relief.
Monitoring and Follow-up
- Monitor response to therapy closely, and consider stopping treatment if a clear and beneficial response is not obvious within 4 to 6 weeks 1.
- Regular follow-up with a healthcare provider is essential to adjust the treatment plan based on the frequency and severity of wheezing episodes.
From the Research
Viral Induced Wheeze Preventers
- The use of inhaled corticosteroids has been studied as a potential preventer for viral induced wheeze, with some evidence suggesting that episodic high dose inhaled corticosteroids can be effective in reducing the requirement for oral corticosteroids 2.
- However, maintenance low dose inhaled corticosteroids have not been shown to be effective in preventing viral induced wheeze 2.
- Leukotriene receptor antagonists, such as montelukast, have also been investigated as a potential treatment for viral induced wheeze, with some studies suggesting that they can be effective in reducing the frequency and severity of wheezing episodes 3.
- However, other studies have found that montelukast is not effective in preventing wheezing episodes or reducing unscheduled medical attendances in preschool children with recurrent wheeze 4.
- A meta-analysis of montelukast for recurrent wheeze in preschool children found that it did not provide a significant benefit in preventing episodes of wheeze or reducing unscheduled medical attendances 4.
- Other potential preventers for viral induced wheeze include azithromycin, which has been shown to reduce the risk of severe lower respiratory tract illnesses in children 5.
- Vitamin D supplementation has also been suggested as a potential preventative measure, with some evidence suggesting that reduced vitamin D intake during pregnancy may be associated with an increased risk of preschool wheeze in offspring 6.
Treatment Options
- Bronchodilators are currently considered first-line therapy for viral wheeze 6.
- Maintenance montelukast or inhaled steroids may be considered in preschool wheezers with persistent symptoms and risk factors for future asthma 6.
- Early administration of azithromycin may reduce the risk of severe lower respiratory tract illnesses in children 5.
- The effect of oral corticosteroids on wheezing episodes in young children varies by degree of episode severity 5.
Future Directions
- Further research is needed to define optimal strategies for the prevention and treatment of viral induced wheeze, and to identify specific phenotypes and endotypes that may respond to different treatments 5.
- New therapeutic options for preschool wheezing disorders are desperately needed, and may include therapies directed specifically at the viral triggers 5, 6.