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Abstract
Introduction A structured out-patient assessment of children with problematic severe asthma (PSA) differentiates difficult (DA) from true severe therapy resistant asthma (STRA)(Bracken: ADC: 2009) and addressing the basics of management leads to long term benefits (Sharples: ERJ: 2011). However, a small number of children continue to cause concern, particularly when reported symptoms are discrepant with objective measures. We hypothesised that these children would benefit from in-patient assessment.
Aim To assess the role of inpatient observation, investigations and detailed multidisciplinary assessment of patients with PSA.
Methods Observational retrospective analysis of 26 children with PSA admitted to a tertiary referral centre during 2012–2014. Children were admitted for up to 20 days of supervised therapy and observation. All children participated in a daily physiotherapy led exercise programme and were offered psychological support. Spirometry and exhaled nitric oxide (FeNO) were measured twice weekly.
Results 26 children aged 6–15 years were included (Table 1). Exhaled nitric oxide (FeNO) and FEV1 improved significantly from admission to discharge (38 ppb vs 20.7 ppb, p = 0.007 and 92 vs 99% predicted, p = 0.003 respectively) likely reflecting improved adherence (Figures 1 and 2). The information gained as part of the admission had a significant impact on the management of most patients:
6 patients were referred to social services due to concerns regarding adherence to medications at home or over reporting of symptoms
8 children had normal lung function, were asymptomatic, and required no salbutamol during the in-patient stay despite high levels of symptom reporting. Asthma medications were weaned either at discharge or at follow up
6 children were diagnosed with a breathing pattern disorder
8 children were found to have significant psychological issues and were referred for further management
Demographics. Data presented as dmedian (range)
*ppb: parts per billion measured at 50 L/min
Significant improvement in FeNO (measured at 50 L.min)
FEV1 during inpatient assessment. Paired data assessed by Wilcoxon signed rank test
(Some children appear in more than one of these categories.)
Discussion Valuable objective insights can be gained as part of a prolonged in-patient stay in children with problematic severe asthma. An admission should be considered in those with a discrepancy in the severity of reported symptoms and objective evidence of severe disease, particularly where there are safeguarding concerns.