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Get the basics right first in asthma

‘Treatment-resistant’ asthma in children often just needs better management

Louise Prime

Friday, 03 September 2010

At least half of children who have problematic, severe asthma that has not responded to treatment have either been misdiagnosed or are not using their prescribed treatments correctly, and their asthma could be effectively controlled with conventional therapies, say the authors of a review in The Lancet.

The authors of the research, Andrew Bush and Sejal Saglani from Imperial College London and the Royal Brompton Harefield NHS Foundation Trust, say that a thorough multidisciplinary assessment should result in at least half of children with ‘untreatable’ asthma being successfully managed with standard treatment. They conducted their review because of the lack of research into effective management of severe, therapy-resistant asthma.

They reviewed published evidence on adults with severe asthma and children with mild-to-moderate asthma, and also looked at data from their personal clinical practice.

The studies they reviewed found that fewer than half of children referred to a specialist with ‘treatment-resistant’ asthma were truly treatment resistant. Other factors such as poor adherence to treatment, poor inhaler technique, exposure to environmental triggers such as tobacco smoke and allergens, and comorbidities (including obesity, dysfunctional breathing and food allergies) could all be contributing to the problem.

  • They say this means that a multidisciplinary approach is needed to tackle severe asthma, to avoid misdiagnosis and improve management. Their recommendations for the management of severe asthma in children are:
    First, conduct a detailed diagnostic re-evaluation to exclude an alternative diagnosis (‘not asthma at all’)
  • Then, take a multidisciplinary approach (both at hospital and at home) to exclude comorbidities (‘asthma plus’); and to assess whether the child has difficult asthma (that improves when basic management, such as adherence and inhaler technique, are improved) or true, therapy-resistant asthma (that persists even when the basic management needs are addressed).
  • The authors’ personal practice is to follow this with two stages of invasive investigations including fibreoptic bronchoscopy under general anaesthesia, bronchoalveolar lavage, and endobronchial biopsy.
  • Look for potential environmental causes of secondary steroid resistance, such as exposure to tobacco smoke and allergens.
  • Devise an individualised treatment plan based on clinical symptoms and pathophysiological characterisation.

The reviewers point out that many treatment strategies for true treatment-resistant asthma include unlicensed therapies, and so should be used only after the benefits and risks have been thoroughly discussed with the child and family.

They conclude that: “Despite the interest in mechanisms, biomarkers, phenotypes, and novel treatment strategies for patients with severe, therapy-resistant asthma, the current best approach is thorough multidisciplinary assessment of children with problematic severe asthma, which should result in at least half of these children being successfully managed with conventional treatments.

“Getting the basics right in children with apparently severe asthma will remain the foundation of management in the foreseeable future.”

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