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Managing problematic severe asthma: beyond the guidelines
  1. Katharine C Pike1,
  2. Mark L Levy2,
  3. John Moreiras3,
  4. Louise Fleming4
  1. 1 Respiratory, Critical Care and Anaesthesia Section, UCL Great Ormond Street Institute of Child Health, London, UK
  2. 2 Harrow, Respiratory Lead, Harrow CCG, & Clinical Lead National Review of Asthma Deaths, Harrow, London, UK
  3. 3 Department of Paediatrics, Whittington Health, London, UK
  4. 4 National Heart and Lung Intitute, Imperial College London, and Royal Brompton and Harefield NHS Foundation Trust, London, UK
  1. Correspondence to Dr Katharine C Pike, Critical Care and Anaesthesia Section, UCL Great Ormond Street Institute of Child Health, London, WC1N 1EH, UK; k.pike{at}


This review discusses issues related to managing problematic severe asthma in children and young people. A small minority of children have genuinely severe asthma symptoms which are difficult to control. Children with genuinely severe asthma need investigations and treatments beyond those described within conventional guidelines. However, the majority of children with poor symptom control despite high-intensity treatment achieve improvement in their asthma control once attention has been paid to the basics of asthma management. Basic asthma management requires optimisation of inhaler technique and treatment adherence, avoidance of environmental triggers and self-management education. It is also important that clinicians recognise risk factors that predispose patients to asthma exacerbations and potentially life-threatening attacks. These correctable issues need to be tackled in partnership with children and young people and their families. This requires a coordinated approach between professionals across healthcare settings. Establishing appropriate infrastructure for coordinated asthma care benefits not only those with problematic severe asthma, but also the wider asthma population as similar correctable issues exist for children with asthma of all severities. Investigation and management of genuine severe asthma requires specialist multidisciplinary expertise and a systematic approach to characterising patients’ asthma phenotypes and delivering individualised care. While inhaled corticosteroids continue to play a leading role in asthma therapy, new treatments on the horizon might further support phenotype-specific therapy.

  • Asthma
  • Severe Asthma
  • Management

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  • Contributors KCP: drafted the article which was edited by all four authors. All authors: approved the final manuscript.

  • Competing interests LM reports other from Vectura, other from Novartis, personal fees from Astra Zeneca, other from Boehringer Ingelheim, outside the submitted work. MLL reports personal fees from Novartis, personal fees from Clement Clarke International, personal fees from Teva, personal fees from Astra Zeneca, non-financial support from GINA, personal fees from Clinical Lead, NRAD 2011-2014, personal fees from Chiesi, grants from CONSORZIO FUTURO IN RICERCA, outside the submitted work. KCP and JM have no competing interests.

  • Provenance and peer review Commissioned; externally peer reviewed.

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