Asthma remains the cause of substantial morbidity and even mortality in children and young adults. Discerning the relative degree of disease severity can be challenging. Although severe, difficult-to-control asthma is distributed asymmetrically across sex (female predominance), socioeconomic strata (uninsured), and race (black children), and children are afflicted irrespective of geography, wealth, or race.
On Sunday, October 27, 2019, Susan S. Laubach MD, associate clinical professor, University of California San Diego, and director, Allergy Clinic, Rady Children’s Hospital, San Diego, California, provided an overview of factors that make asthma difficult to control during a session titled “Breathe easy: Diagnosis and management of difficult-to-control asthma.”
Several aspects of the presentation and difficult-to-control asthma merit comment. First, difficult-to-control asthma may derive from a cause that is addressable. Undertaking a careful history that includes environmental exposures (pollutants, volatile chemicals, dust mites), living situation (smokers, pets, heat source), as well as allergic and family history can inform both diagnosis and treatment. Prolonged exposure to an inflammatory stimulus can lead to chronic inflammation and poorly controlled asthma.
Second, clinicians managing children with difficult-to-control asthma should ensure both compliance and the diagnosis. From a compliance perspective, patients may be in possession of the correct medication, but they are delivering it incorrectly. Review of delivery techniques and capacity for the patient and family to comply with the medications as prescribed is essential. Moreover, considering the difficult-to-control asthma patient from a comprehensive perspective is important as highly labile asthma may result from a cause such as aspiration, allergy, or reflux.
The significance of the difficult-to-control asthma patient is amplified further by the changes unfolding in our environment. With global warming and increasing levels of particulate matter in the air, especially in developing countries and inner cities, there is reason to believe that the prevalence of difficult-to-control asthma will be increasing. Further, the advent of increasingly specific therapeutic tools, more precise and more personal, will allow for the delivery of more bespoke care than ever before. Thus, being able to achieve a highly defined, “thin” phenotype will enable clinicians to mitigate the clinical harm associated with difficult-to-control asthma by providing therapies that address the underlying cause.
David N. Cornfield, MD, is the Anne T. and Robert M. Bass Professor in Pulmonary Medicine, and director, Center for Excellence in Pulmonary Biology, Department of Pediatrics and (by courtesy) Surgery, Stanford University School of Medicine, Stanford, California.