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British Guideline on the MAnAGeMent of AsthMA
84
A meta-analysis of behavioural adjustment in children suggested increasing ‘asthma severity’,
defined on the basis of treatment requirements was associated with greater behavioural
difficulties. 498 The core issue of ‘cause and effect’ remains unclear; specifically the extent to which
persistent asthma symptoms despite aggressive treatment results in psychological morbidity or
whether pre-existing psychological morbidity makes asthma difficult to control.
There is a lack of evidence that interventions specifically targeting psychological morbidity in
difficult asthma are of benefit. A small proof of concept study targeting depression demonstrated
a reduction in oral steroid use499 and an observational study in ‘high-risk’ children with
asthma suggested potential benefit from joint consultation with a child psychiatrist with an
improvement in symptom scores and adherence with therapy. 500 However, a non-blinded
randomised intervention study in adults with difficult asthma showed no benefit from a six
month nurse-delivered psychoeducational programme. 501 A meta-analysis of psychoeducational
interventions in difficult asthma concluded that many of the studies were of poor quality,
though there was some evidence of positive effect of psychosocial educational interventions on
hospital admissions in adults and children and on symptoms in children. There was not enough
evidence to warrant significant changes in clinical practice and little information available on
cost effectiveness. 502
C Healthcare professionals should be aware that difficult asthma is commonly associated
with coexistent psychological morbidity.
d Assessment of coexistent psychological morbidity should be performed as part of a
difficult asthma assessment. In children this may include a psychosocial assessment of
the family.
7.3.3 DySFUNCTIONAL BREATHING
Observational uncontrolled studies in subjects with difficult asthma have identified high
rates of dysfunctional breathing as an alternative or concomitant diagnosis to asthma causing
symptoms. 29,488 It remains unclear what is the best mechanism of identifying and managing
this problem.
d dysfunctional breathing should be considered as part of a difficult asthma
assessment.
7.3.4 ALLERGy
Acute asthma has been associated with IgE dependent sensitisation to indoor allergens. 503 In case
control studies, mould sensitisation has been associated with recurrent admission to hospital
and oral steroid use504, 505 and with intensive care unit admissions and respiratory arrest. 506,507
There is no published evidence of any intervention study in this group. Research in this area
is required.
C In patients with difficult asthma and recurrent hospital admission, allergen testing to
moulds should be performed.
7.3.5 MONITORING AIRWAy RESPONSE
Two randomised blinded controlled trials and one open randomised study have supported
the use of titrating steroid treatment against sputum eosinophilia in adults with moderate to
severe asthma, with greatest benefit seen in patients receiving higher doses of inhaled steroid
therapy. 84,86,508 In the study with the largest numbers of patients receiving high dose inhaled
steroid treatment, patients who were considered to be poorly adherent with treatment, or had
inadequately controlled aggravating factors, such as rhinitis or gastro-oesophageal reflux were
specifically excluded. 84 Case series have suggested that sputum induction is safe in patients
with difficult to control asthma. 57,509-512
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