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Difficult asthma: defining the problems
S C Ranganathan1, D N Payne, A Jaffe
1Royal London Hospital, London, UK.
Insights
Difficult childhood asthma is often linked to adverse home environments, poor adherence, alternative diagnoses, and reduced corticosteroid responsiveness, not just higher inhaled corticosteroid doses.
Area of Science:
- Pediatric Pulmonology
- Allergy and Immunology
- Respiratory Medicine
Background:
- Difficult-to-control asthma in children poses a significant clinical challenge.
- High doses of inhaled corticosteroids (ICS) are often prescribed, raising concerns about side effects.
- Understanding factors contributing to poor control is crucial for effective management.
Purpose of the Study:
- To compare clinical and laboratory profiles of children with difficult asthma on high-dose ICS versus well-controlled children.
- To identify key factors associated with poorly controlled asthma despite adequate inhaled corticosteroid therapy.
Main Methods:
- Retrospective survey of children with difficult asthma (>= 800 microg ICS) and well-controlled asthmatic children.
- Evaluated atopy, growth, lung function, treatment adherence, home environment, and corticosteroid responsiveness.
- Compared characteristics between the poorly controlled and well-controlled groups.
Main Results:
- Significant differences in home environment, with more smoking in the difficult-to-control group.
- Nine children had alternative diagnoses, and 10 showed poor corticosteroid responsiveness.
- Adverse home environments, poor supervision, alternative diagnoses, and CS unresponsiveness were key factors.
Conclusions:
- Difficult asthma in children is multifactorial, involving more than just ICS dosage.
- Thorough assessment, including evaluation for alternative diagnoses and home environment factors, is essential.
- Bronchoscopy may be indicated to guide treatment and avoid excessive corticosteroid use and potential side effects.
Abstract:
A retrospective survey was undertaken of children with difficult asthma, attending a respiratory clinic. The clinical and laboratory profiles of asthmatic children who were poorly controlled on > or = 800 microg of inhaled corticosteroids (ICS) were studied and compared to children well-controlled on > or = 800 microg ICS. Assessments were made of atopy, growth, lung function, treatment adherence, home environment, and responsiveness to corticosteroids (CS). Fiftyseven "difficult" and 23 well-controlled children were studied. Significant differences in the home environment were identified. Smoking was significantly more common in the difficult-to-control group. Nine children had alternative diagnoses. Poor CS responsiveness was present in 10 children. Adverse home environments, poor treatment supervision, alternative diagnoses, and unresponsiveness to CS were the most important factors in difficult asthma. A full assessment, including bronchoscopy, is indicated to avoid unnecessary increases in CS to doses that could cause side-effects.