COVID-19 associated asthma exacerbation [2] is rare; although there is a theoretical risk of COVID-19 causing a virus triggered asthma exacerbation. Previous epidemics of the coronavirus also did not report significant numbers of asthma exacerbations [3].

Severe respiratory manifestations of COVID-19, though uncommon in children have been reported and may be presumed to involve clinical presentations related to small airways or alveolar involvement or both. If small airways are predomi-nantly affected, treatment modalities will include broncho-dilators, corticosteroids, oxygen supplementation and respi-ratory support as required. However, bronchodilators are potentially detrimental in a scenario of alveolar disease due to pro-inflammatory effects on alveoli, worsening of ventilation-perfusion mismatch and increased tachycardia [4]. There is no clear-cut separation of these phenotypes and overlap may be expected. Corticosteroids, typically in courses longer than that used in exacerbations of asthma, are currently in use for treating severe COVID-19 [4,5]. The role of antiviral treatment is not precisely known especially in the pediatric context [4].

In our cases, we utilized C-reactive protein (CRP) levels as an indicator of severity of inflammation. In one child CRP was elevated but other markers of inflammation including D-dimer, S. ferritin and serum fibrinogen were normal. More data is required to know if inflammation and hypercoagulable states more commonly occur with alveolar disease in contrast to small airways involvement as seen in these three cases. The limitation of our workup lies in not testing for viral co-infection which may have triggered the exacerbation as well.

Literature on pediatric asthma and COVID-19 is sparse and limited to case reports highlighting mild disease mostly not requiring hospitalizations and ICU care [1,6]. One of the mainstays of aerosol therapy in acute wheezing episodes is nebulizations. However, it also amplifies the risk of infection transmission by stimulating a cough reflex, as well as generating a high volume of respiratory aerosols that may be propelled over a longer distance thus infecting bystander hosts. An added disadvantage being an increased risk of deposition of virus in the lower lung [7], nebulizations in COVID-19 remains the least suitable preference. Poor response to a metered dose inhaler/spacer, a child who is uncooperative or unable to follow the directions required for metered dose inhaler use and medication shortage remain the only possible indications of using nebu-lizers in these children. The Global initiative for asthma guidelines suggest that asthma exacerbations due to COVID-19 should be treated with corticosteroids as appropriate [8]. However, there is no research on the choice of corticosteroid. No adverse effects attributable to the use of steroids were noted in these children.

Though rare, COVID-19 infection in children may trigger a viral-induced wheeze that requires distinguishing from other viral and asthma triggers. Severe illness requiring substantial respiratory support may occur in these circumstances. Identifying similar presentations and reporting may help also to resolve the therapeutic dilemmas.