Addressing the challenges of severe asthma

D espite advances in asthma therapy and worldwide distribution of asthma guidelines, a significant number of patients with asthma continue to experience poor control of their disease. This recalcitrant form of asthma is commonly referred to as severe or difficult-to-treat asthma and is characterized by corti-costeroid insensitivity, with persistent lack of control despite corticosteroid therapy or worsening of asthma control on reduction or discontinuation of corticoste-roid therapy. While poor asthma control is frequently attributed to poor adherence to prescribed medications and/or recommended environmental restrictions, 5 –10% of patients experience poor control because they suffer from an underlying severe asthma pathophysi-ology characterized by airway inflammation resistant to medical therapy. 1 Although the population of patients with severe asthma is relatively small, this group deserves special focus because they account for a substantial portion of total asthma morbidity, mortality and cost. Until recently, few clinical studies were specifically designed to investigate the many other facets of treatment failure of patients with severe asthma, that include inhaler technique or which offer newer forms of treatment such as thermoplasty. In this context, the majority of the nine asthma-related articles within this issue directly or indirectly relate to the severe asthma phenotype and focus on these unexplored areas. In addition to poor therapeutic adherence, poor asthma control may be significantly impacted by inadequate inhaler technique. To study this issue further, The Asthma and Allergy Foundation of America collected data from 590 questionnaire respondents. In their analysis of this data, Storms et al report that unnecessary health care utilization and avoidable loss of time at work or school were associated with the limited availability of properly functioning quick-relief inhalers. 2 They further observed that confidence around proper inhaler use was low and that adding a dose counter may improve satisfaction with quick-relief in-halers. Among other emerging treatments, bronchial ther-moplasty is the only nonpharmacologic intervention approved by the United States Food and Drug Administration in 2010, available as a new treatment option for the patient with severe asthma. In the interest of assisting the allergist-immunologist in the decision-making process for the use of this new treatment modality , two separate articles by Dunn/Wechsler 3 and Iyler/Lim 4 are presented in this issue of the Proceedings offering opposing viewpoints on the role of bronchial thermoplasty in a pro/con debate format. In addition , employing a novel publication format, each author was given an opportunity to make rebuttal comments …