“Oorzaken problematisch astma bij kinderen”

Background: Asthma is the most common chronic illness of childhood. Despite inhaled corticosteroid (ICS) treatment a considerable minority of children remain symptomatic (“problematic asthma”). The causes of problematic asthma fall into two broad categories: not getting the basics right (poor adherence to ICS, poor inhalation technique, ongoing exposure to environmental triggers and comorbidity) or true therapy-resistant asthma. No Dutch study has ever investigated what proportion of children with “problematic asthma” actually have true therapy-resistant asthma, and in how many children asthma can be well controlled by getting the basics of asthma management right. Objective: To investigate the underlying causes of problematic asthma in children referred from primary care to a hospital-based secondary care asthma clinic for evaluation of problematic asthma. Methods: All 142 children (age 5-18 year) referred to specialist care at the Princess Amalia Children’s clinic (Zwolle, the Netherlands) with problematic asthma (ongoing asthma symptoms or poor control despite maintenance therapy with ICS) over a 5-year period were included in this study. Charts were analyzed to identify the underlying cause of problematic asthma, which was classified as poor adherence to treatment, ongoing exposure to environmental triggers, comorbidity, incorrect inhaler technique, and wrong diagnosis. When no underlying cause was identified and asthma remained problematic despite getting all basics right and stepped-up therapy, a diagnosis of truly therapy-resistant asthma was made. Results: An underlying cause for problematic asthma was found in one of the basics of asthma management in 138 children (97.2%): poor adherence (n=53, 37.3%), persistent exposure to environmental triggers (n=40, 28.2%), comorbidities (n=28, 19.7%), incorrect inhaler technique (n=11, 7.7%) or incorrect diagnosis (n=6, 4.2%). Only 4 children (2.8%) fulfilled the criteria for truly therapy-resistant asthma. Asthma control improved after comprehensive self-management education and follow-up in the clinic, with significant improvement of pulmonary function (p = 0.005) and fraction of nitric oxide in exhaled air (FeNO) (p = 0.012), without prescribing more medication (p=0.24). Conclusion: An underlying cause in the basics of asthma management can be found in nearly all children with problematic asthma referred to a hospital-based asthma clinic. Truly therapy-resistant asthma was very rare in this cohort. By addressing adherence to treatment, exposure to environmental triggers, comorbidities, inhaler technique and differential diagnosis, almost all cases of problematic asthma can be well controlled.