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It is hoped that the systematic approach to managing patients with therapy resistant asthma reported in this issue of Thorax will encourage others to study this difficult group of patients and to test hypotheses about improving their management.
Central to any description of difficult asthma1 is a disconnection between expectations and outcome. Difficult asthma may be defined as being present in a patient with a confirmed diagnosis of asthma whose symptoms and/or lung function abnormalities are poorly controlled with treatment which experience suggests would usually be effective. This immediately begs the questions of who confirmed the diagnosis, how the diagnosis was made, whether the symptoms and lung function abnormalities are due entirely to the diagnosis of asthma, and whose “experience” is being used. It is certainly wise when seeing a patient with difficult asthma to question the diagnosis. If it is confirmed, are there any co-existing organic respiratory conditions such as COPD or bronchiectasis or psychogenic conditions such as hyperventilation or vocal cord dysfunction with wheeze? If there are co-existing problems, are these the main cause of the uncontrolled symptoms as in pseudo-steroid resistant asthma?2 It is also wise to be alert when there is discordance between the patient’s symptoms and objective lung function assessment, with the poor perceiver on the one hand3,4 and the over reactor on the other. Be aware, too, of the mood enhancing properties of oral steroids and the placebo effect of any new medication in patients at the over reactor end of the spectrum. The combination of supramaximal doses of inhaled steroid and multiple β2 agonist preparations in patients referred with asthma should always raise alarm bells. Difficult asthma can occur in patients with objectively mild, moderate, or severe disease, but the consequences are most dramatic in patients with severe …
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