Article Text


Paediatric asthma
P76 Long-term effectiveness of a staged assessment for problematic severe asthma
  1. J Sharples1,
  2. A Gupta1,
  3. L Fleming1,
  4. C J Bossley1,
  5. M Bracken2,
  6. P Hall2,
  7. A Hayward2,
  8. M Puckey3,
  9. I M Balfour-Lynn1,
  10. M Rosenthal1,
  11. A Bush1,
  12. S Saglani1
  1. 1Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, and Imperial College London, London, UK
  2. 2Department of Respiratory Paediatrics, Royal Brompton Hospital, London, UK
  3. 3Department of Clinical Psychology, Royal Brompton Hospital, London, UK


Background Children with problematic severe asthma (PA) may have genuine therapy-resistant disease, or may be difficult-to-treat because of unaddressed potentially modifiable factors.

Objectives Evaluate the long-term efficacy of a structured protocol including a nurse-led assessment1 (Stage 1) in identifying modifiable factors and differentiating difficult asthma (DA) from severe therapy-resistant asthma (STRA) in children with PA. As a secondary aim, we determined whether DA and STRA could be identified without the detailed assessment.

Methods 78 children, median age 11.8 years (range 5–17 years), that underwent Stage 1 assessment between 2005 and 2008 were included. Lung function, medications, symptoms and exacerbations were obtained at 1 year, 2 years, and up to 6 years (current status) after initial assessment. Children in whom modifiable factors were identified were classified as DA and those that progressed to further investigations (Stages 2 & 3) as STRA.

Results Median duration of follow-up was 3.9 years (range 2.5–6.1 years). 31/78 (40%) children were classified as DA, and did not proceed to Stages 2 & 3. Children with DA had significantly lower dose inhaled corticosteroids prescribed at follow-up compared to STRA (DA vs STRA: median [IQR] 800 μg [400 μg–1425 μg] vs 1600 μg [800 μg–2400 μg], p<0.05), and significantly fewer oral corticosteroid bursts per year (DA vs STRA: median [IQR] 1 [0–2] vs 4 [1.5–8], p<0.001). DA children had improved lung function at follow-up compared to baseline (median [IQR] FEV1 % predicted: 91% [86.5%–102.5%] vs 80% [73%–86%], p<0.01) despite lower dose inhaled corticosteroids. DA and STRA had different characteristics at baseline: DA children had a higher FEV1 % predicted (p<0.01), less bronchodilator reversibility (p<0.05), lower fractional exhaled nitric oxide (p<0.05), and less sensitisation to food and aeroallergens (both p<0.05) compared to STRA. However, there was considerable overlap between the groups and the two could not reliably be distinguished in advance of the detailed Stage 1 assessment.

Conclusion As a result of our assessment, 40% of children with PA did not undergo invasive investigations and escalation of therapy. Up to 6 years later, children with DA had a significant improvement in lung function and fewer exacerbations despite reduced maintenance medication.

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