Intended for healthcare professionals

Rapid response to:

Book Book

Difficult Asthma

BMJ 1999; 319 doi: https://doi.org/10.1136/bmj.319.7217.1141a (Published 23 October 1999) Cite this as: BMJ 1999;319:1141

Rapid Response:

Does the patient with difficult asthma really have asthma ?

The first question when confronted by a patient with severe symptoms
despite conventional treatment is: does the patient really have asthma?
Several alternative and concomitant diagnoses that should be considered
are vocal cord dysfunction, cystic fibrosis, recurrent aspiration, gastro-
oesophageal reflux, congenital heart disease and primary ciliary
dyskinesia[1]. For the clinical diagnosis of the disease there are some
key indicators but as there is no ‘ gold standard’ a correct diagnosis
will not be obtained. In India treatment prescribed by unqualified doctors
is quite rampant and its very common to see patients of interstitial lung
disease, bronchiectasis and chronic obstructive pulmonary disease being
treated for bronchial asthma.

The term ‘asthma-like’ has been used to an increasing extent, which
may indicate that asthma-like symptoms are not always classical asthma[2].

It has been suggested that assessment of bronchial
hyperresponsiveness is the single most useful test of asthma severity[3].
Measurement of exhaled nitric oxide may be used to monitor the effects of
corticosteroids on the underlying inflammation.

Psychological aspects may play a large role in the wellbeing of
asthmatics particularly an adolescent with asthma. Difficult home
circumstances may lead to a worsening of symptoms and sometimes the
illness is used as a weapon for help.

Assuming the patient genuinely has severe asthma responding poorly to
treatment, it may be possible to improve matters by simple means –
allergens and other avoidable factors, inappropriate devices, inadequate
doses and non-adherence to treatment. Steroid resistant asthma occurs in a
small subset of patients with genuine asthma that fails to show a clinical
response to high dose systemic corticosteroids that are genuinely taken.
Steroid resistant asthma may be defined as failure to improve morning
FEV1( forced expiratory volume in one second ) by more than 15% predicted
after 14 days of 40mg prednisolone[4].

References

1. Balfour-Lynn I. Difficult asthma : beyond the guidelines. Arch Dis
Child 1999; 80: 201-206

2. Lowhagen O. Asthma and asthma-like disorders. Res Medicine 1999; 93:
851-855

3. Woolcork AJ, Dusser D, Fajac I. Severity of chronic asthma. Thorax
1998, 53: 442-444

4. Barnes PJ, Pederson S, Busse WW. Efficacy and safety of inhaled
steroids : new developments. Am J Resp Crit Care Med 1998;157:S 1-53

Competing interests: No competing interests

25 May 2000
S K Agarwal
Prof
Department of Chest Diseases, Institute of Medical Sciences, BHU, Varanasi 221 005, India