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Managing the pediatric patient with refractory asthma: a multidisciplinary approach

Authors Cook J, Beresford F, Fainardi V, Hall P, Housley G, Jamalzadeh A, Nightingale M, Winch D, Bush A, Fleming L, Saglani S

Received 1 December 2016

Accepted for publication 25 January 2017

Published 20 April 2017 Volume 2017:10 Pages 123—130

DOI https://doi.org/10.2147/JAA.S129159

Checked for plagiarism Yes

Review by Single-blind

Peer reviewers approved by Dr Colin Mak

Peer reviewer comments 2

Editor who approved publication: Dr Luis Garcia-Marcos

James Cook,1,2 Fran Beresford,2 Valentina Fainardi,1 Pippa Hall,2 Georgie Housley,2 Angela Jamalzadeh,2 Michelle Nightingale,2 David Winch,2 Andrew Bush,1,2 Louise Fleming,1,2 Sejal Saglani1,2

1Inflammation, Repair and Development, National Heart and Lung Institute, Imperial College London, 2Respiratory Paediatrics, Royal Brompton Hospital, London, UK

Abstract: Children with asthma that is refractory to high levels of prescribed treatment are described as having problematic severe asthma. Those in whom persistent symptoms result from a failure of basic asthma management are described as having “difficult asthma”, while those who remain symptomatic despite these factors having been addressed are described as having “severe therapy-resistant asthma” (STRA). The majority of children have difficult asthma; asthma that is poorly controlled because of a failure to get the basics of asthma management right. Modifiable factors including nonadherence to medication, persistent adverse environmental exposures, and psychosocial factors often contribute to poor control in these patients. As our skill in identifying and addressing modifiable factors has improved, we have found that a progressively smaller proportion of our clinic patients is categorized as having true STRA, resulting in an infrequent resort to escalation of treatment. Many of the modifiable factors associated with the diagnosis of difficult asthma can be identified in a general pediatric clinic. Characterization of more complex factors, however, requires the time, skill, and expertise of multiple health care professionals within the asthma multidisciplinary team. In this review, we will describe the structured approach adopted by The Royal Brompton Hospital in the management of the child with problematic severe asthma. We highlight the roles of members of the multidisciplinary team at various stages of assessment and focus on prominent themes in the identification and treatment of modifiable factors.

Keywords: pediatric, asthma, multidisciplinary team

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