When is difficult asthma severe

Abstract Asthma is the commonest childhood chronic disease in the UK. Most children with asthma are classed as having mild to moderate disease. Regular treatment with inhaled steroids and bronchodilators are enough to successfully control the symptoms. A small proportion of asthmatic children continue to have sub-optimal control despite apparent appropriate therapy (problematic asthma). Most of these children have modifiable factors resulting in poor asthma control (difficult asthma). True therapy-resistant asthma is rare in children and the paediatric community should focus on ensuring the correct diagnosis, identifying and managing modifiable risk factors before using the label severe asthma. Often it is arduous to identify who the asthma is ‘difficult for’ – is it for the child or health professional or parents. Management of problematic asthma requires a multidisciplinary approach. In the UK, children with symptomatic asthma on high dose therapy or in who diagnostic uncertainty persists should be referred to multidisciplinary severe asthma services which have a range of enhanced diagnostic tools and can access newer biologic therapies. This review outlines the management of difficult and severe asthma emphasising the importance of getting the basics right and referral to specialist centre before escalating therapies.