Difficult asthma.

Children with asthma who are not well controlled in spite of optimum therapy outlined in Asthma Management Guidelines are said to have 'difficult-to manage asthma' or 'difficult asthma'. Several phenotypes of this subset of asthma have been described. However, before any child is labeled as difficult asthma a thorough search for an alternative diagnosis should be made. Thus, one should look for recurrent aspiration pneumonia, tuberculosis, foreign body aspiration, tracheomalacia, bronchomalacia, cystic fibrosis etc. Causes of treatment failure range from unidentified exacerbating factors, noncompliance, inappropriate inhalers and spacers and true steroid dependence or resistance. Economics of the treatment and social beliefs should also be taken into consideration at the time of finalizing the management plan. Management involves recognizing and correcting the above factors. However, steroids form the main pillar of treatment. Majority of the patients can be controlled by optimizing inhaled steroid therapy and possibly adding steroid sparing agents. Thus, long acting bata-2 agonists, long acting theophyllines and leukotriene inhibiters may be useful. A few children will require continuous oral steroid therapy and an occasional one may be actually steroid steroid resistant. Such children are best managed at asthma specialist centers where experimental drugs like, methotrexate cyclosporin or IVIG may be tried on an individual basis under close monitoring.