title: Phenotype-specific treatment of difficult asthma in children.
abstract: Most children with asthma can be treated successfully with low-to-moderate doses of inhaled corticosteroid and long-acting beta-2 agonist. Those that fail to respond are a heterogeneous group. We propose that the nature and type of any steroid-resistant inflammation, the extent of any persistent airflow limitation and the extent of bronchial hyper-reactivity should be determined separately to allow a rational treatment approach to these children, rather than the haphazard advice of many current guidelines. Reasons for persistent difficult asthma include persistent eosinophilic inflammation, non-eosinophilic inflammation, airway reactivity without residual inflammation and persistent airflow limitation. We propose a protocol that uses non-invasive and invasive (bronchoscopic) methods to document the response to systemic steroids (depot triamcinolone). The aim of the protocol is to determine an individualised treatment plan; for example, cyclosporin for persistent eosinophilic inflammation, azithromycin for persistent neutrophilic inflammation and continuous subcutaneous terbutaline if there is airway reactivity without residual inflammation. Multi-centre studies are required to test the utility of this approach.
authors.affiliation: Department of Paediatric Respiratory Medicine, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.
authors.forename: Donald
authors.initials: D
authors.lastname: Payne
authors.forename: Andrew
authors.initials: A
authors.lastname: Bush
mesh_terms: D001249:Asthma / Q000145:classification / Q000188:drug therapy* / Q000473:pathology / Q000503:physiopathology; D001980:Bronchi / Q000473:pathology; D016535:Bronchial Hyperreactivity; D002648:Child; D004804:Eosinophils / Q000473:pathology; D005938:Glucocorticoids / Q000627:therapeutic use; D006801:Humans; D007249:Inflammation; D010641:Phenotype; D012123:Pulmonary Ventilation
chemical_list: D005938:Glucocorticoids