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Difficult asthma: beyond the guidelines
  1. Ian Balfour-Lynn
  1. Department of Paediatric Respiratory Medicine, Royal Brompton & Harefield NHS Trust; Department of Paediatrics, Chelsea and Westminster Hospital, London, UK
  1. Dr I Balfour-Lynn, Department of Paediatric Medicine, Royal Brompton & Harefield NHS Trust, Sydney Street, London SW3 6NP, UK. email: i.balfourlynn{at}ic.ac.uk

https://doi.org/10.1136/adc.80.2.201

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    The current guidelines for prophylactic treatment of paediatric asthma culminate in the addition of regular oral corticosteroids after a stepwise increase in treatment.1-3 However, there are still a few patients whose asthma is not controlled despite such maximal conventional treatment and these children are often referred to a tertiary paediatric respiratory centre. Childhood asthma has several manifestations and different approaches may be required for different patterns of asthma. Unfortunately, some of these children are difficult to treat. These include infants with severe recurrent viral wheezing who respond poorly to medication but generally have a good prognosis. There are those said to have “brittle asthma”; this has been classified into those with a wide peak flow variation despite maximal treatment (type 1), and those who are well controlled in between attacks, which when they occur are often sudden and severe (type 2).4 This article concentrates on another group—children who have severe chronic background symptoms with acute exacerbations superimposed.

    Confirming the diagnosis

    The first question when confronted by a child with severe symptoms despite conventional treatment is: does the child really have asthma? There are several alternative diagnoses that should be considered, some more rare than others. Relevant investigations should be carried out when the history or examination suggests one of these other diagnoses (table 1). In particular, the presence of finger clubbing is incompatible with the lone diagnosis of asthma. An asthmatic child may be affected by another condition that contributes to or worsens the asthma symptoms. In particular, gastro-oesophageal reflux should be looked for and treated although its significance is not always clear.5 Immunodeficiencies should also be excluded; an initial screen should include serum immunoglobulins and IgG subclasses, complement concentrations, and antibody responses to common antigens (diphtheria, tetanus, Haemophilus influenzaetype b, and pneumococcus) (Jones A, personal communication, 1998).

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    Table 1

    Some …

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