DiYcult asthma: beyond the guidelines

The current guidelines for prophylactic treatment of paediatric asthma culminate in the addition of regular oral corticosteroids after a stepwise increase in treatment. 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 diVerent approaches may be required for diVerent patterns of asthma. Unfortunately, some of these children are diYcult 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). This article concentrates on another group— children who have severe chronic background symptoms with acute exacerbations superimposed.