title: [Management of difficult-to-treat asthma using a flow sheet for systematic evaluation and therapeutic intervention].
abstract: BACKGROUND
  Although most patients of asthma can be controlled by inhaled corticosteroid (ICS), some patients remain uncontrolled even after the introduction of ICS treatment. In management of such difficult-to-treat asthma, systematic review including additional differential diagnosis and avoidance of exacerbating factors is very important.
  
  
  METHODS
  Here we postulate a flow sheet presenting an algorithm which intends to achieve better asthma control following ATS refractory asthma guidance. For patients with poor controlled asthma even after using ICS more than moderate dose, we used the sheet in our daily outpatient management and investigated whether we could improve the control in such patients. The sheet was constructed by an algorithm which included (1) reevaluation of inhalation technique of ICS; (2) additional differential diagnosis of COPD and other similar diseases; and (3) reevaluation of presence of exacerbating factors.
  
  
  RESULTS
  In our outpatient department, seven clinicians managed 22 difficult-to-treat asthma patients using this sheet. Additional factors which might worsen asthma control could be detected in 21 patients (95.5%). Firstly, smoking was disclosed in 8 patients (36.4%). Secondly, keeping pets was identified in 7 patients (31.8%). 5 patients (22.7%) were diagnosed as COPD rather than asthma and 4 patients (18.2%) were diagnosed as having rhinosinusitis. Some improvement of asthma control was achieved in 9 patients (40.9%).
  
  
  CONCLUSIONS
  Reevaluation of refractory asthma patients using our newly developed flow sheet is essential and it may facilitate understanding of management of difficult-to-treat asthma.
authors.affiliation: Department of Respiratory Medicine, Nagoya Daini Red Cross Hospital. hwaka@nagoya2.jrc.or.jp
authors.forename: Hisashi
authors.initials: H
authors.lastname: Wakayama
authors.forename: Tomohiko
authors.initials: T
authors.lastname: Ogasawara
authors.forename: Ai
authors.initials: A
authors.lastname: Sato
authors.forename: Mamiko
authors.initials: M
authors.lastname: Honda
authors.forename: Keiko
authors.initials: K
authors.lastname: Sakurai
authors.forename: Takehiro
authors.initials: T
authors.lastname: Uemura
authors.forename: Daishi
authors.initials: D
authors.lastname: Kasai
authors.forename: Hisaaki
authors.initials: H
authors.lastname: Kato
authors.forename: Yuka
authors.initials: Y
authors.lastname: Tomita
authors.forename: Jangchul
authors.initials: J
authors.lastname: Park
authors.forename: Akiko
authors.initials: A
authors.lastname: Mizuno
authors.forename: Masayuki
authors.initials: M
authors.lastname: Suzuki
mesh_terms: D000280:Administration, Inhalation; D000305:Adrenal Cortex Hormones / Q000008:administration & dosage; D000368:Aged; D000465:Algorithms; D000818:Animals; D000829:Animals, Domestic; D001249:Asthma / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D002908:Chronic Disease; D003937:Diagnosis, Differential; D019468:Disease Management; D004282:Documentation / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D012907:Smoking / Q000009:adverse effects
chemical_list: D000305:Adrenal Cortex Hormones