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0:00
ANDREW BUSH: Thank you for
listening to this online lecture.
My name's Andrew Bush.
I'm professor of Pediatrics
at Imperial College.
0:09
The aim of my presentation is to
discuss the approach to the child
with 'nightmare asthma',
to demonstrate a protocol
for the assessment of
problematic, 'severe asthma',
and review the potential
phenotype-driven treatment options
that we have available to us.
0:27
The basics of asthma are
very straightforward.
Most children with asthma
are very easily treated.
Most respond to modest doses
of inhaled corticosteroids,
and neither need, nor get no
benefit from higher doses,
and high dose inhaled
corticosteroids may be harmful.
So the question faced with a
child with nightmare asthma is,
what makes this child's asthma
different from the run of the mill
asthma and makes it
difficult to treat?
0:56
We can get a clue from this
study from North America,
which was a study in futility.
The aim of this study was to
assess whether azithromycin
or a leukotriene receptor antagonist
was a better add-on therapy
for children who were
still symptomatic,
despite inhaled corticosteroids and
inhaled long-acting bronchodilator.
292 children were assessed
for eligibility, but only 55
could be randomized.
The others were excluded
due to nonadherence
or they did not have asthma,
and this underscores the fact
that many children with so-called
"difficult asthma," in fact,
do not have any such thing.
1:39
This study, looking at daily
monitoring of exhaled nitric oxide
was an excellently conducted
piece of work in over 150 children.
It was a 30-week study, there
were on a reasonable dose
of inhaled corticosteroids,
and they were randomized
to either a telemonitoring
of exhaled nitric oxide
and a detailed management
program of inhaled corticosteroids,
with regular and detailed
titration of the dose,
or the standard symptom-based
steroid management protocol.
They were telephoned
every three weeks,
the end-point was symptom
free days, and the results
showed that the time to
exacerbation and symptom
free days were exactly the
same in the two groups.
In other words,
standard care was just
as good as sophisticated
monitoring of airway inflammation.
