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Nurse-led assessments including a home visit can help identify potentially modifiable factors for poorly controlled symptoms in children with problematic asthma.

Rationale: Lung inflammation and injury is critical in cystic fibrosis. An ideal antiinflammatory agent has not been identified but inhaled corticosteroids are widely used despite lack of evidence. Objectives: To test the safety of withdrawal of inhaled corticosteroids with the hypothesis this would not be associated with an earlier onset of acute chest exacerbations. Methods: Multicenter randomized double-blind placebo-controlled trial in 18 pediatric and adult UK centers. Eligibility criteria included age Ͼ 6.0 yr, FEV 1 у 40% predicted, and corticosteroid use Ͼ 3 mo. During the 2-mo run-in period, all patients received fluticasone; they then took either fluticasone or placebo for 6 mo. Measurements and Main Results: Fluticasone group: n ϭ 84, median age 14.6 yr, mean (SD) FEV 1 76% (18); placebo group: n ϭ 87, median age 15.8 yr, mean (SD) FEV 1 76% (18). There was no difference in time to first exacerbation (primary outcome) with hazard ratio (95% confidence interval) of 1.07 (0.68 to 1.70) for fluticasone versus placebo. There was no effect of age, atopy, corticosteroid dose, FEV 1 , or Pseudomonas aeruginosa status. There was no change in lung function or differences in antibiotic or rescue bronchodilator use. Fewer patients in the fluticasone group withdrew from the study due to lung-related adverse events (9 vs. 15%); with a relative risk (95% confidence interval) of 0.59 (0.23-1.48) fluticasone versus placebo. Conclusions:In this study population (applicable to 40% of patients with cystic fibrosis in the UK), it appears safe to consider stopping inhaled corticosteroids. Potential advantages will be to reduce the drug burden on patients, reduce adverse effects, and make financial savings.

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.

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