Asthma: beyond the guidelines

摘要

Although most children with asthma can easily be treated, a small minority have symptoms resistant to conventional therapy. Such children mandate a detailed re-evaluation. Alternative diagnoses should be considered, as well as factors which co-exist with asthma and may exacerbate the condition or be mistaken for uncontrolled asthma. Other important issues are the appropriateness of the drug delivery device; adverse environmental factors, including persistent allergen exposure and environmental tobacco smoke; and psychological factors, which include adherence to treatment. Finally, we suggest a detailed systematic approach to address the individual phenotype: for example, persistent airway eosinophilia, neutrophilia, or non-inflammatory. The protocol includes non-invasive measurement of airway inflammation and reactivity before and after systemic steroids, with bronchoscopy, lavage and biopsy at the end of the course. This approach leads us to develop an individual treatment plan. The validity of this approach needs to be tested in larger studies.