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ENFUMOSA (courriel: Chanez (at) montp.inserm.fr ) The European Network For Understanding Mechanisms of Severe Asthma BIOMED 2 Program - European Commission 4th quaterly meeting, with the support of INSERM and Merck Sharp & Dhome Laboratory February 13-14th 1998 in Montpellier- France (see programm, abstracts and experts comments ) Clinical aspects of difficult asthma Ph. Godard Vendredi 13 Février 1988 Présentateurs/Speakers Modérateurs Experts 8h30-10h00 Aspects cliniques Clincal aspects P. Godard (Montpellier) B. Wallaert (Lille) T. Perez (Lille) Discussion 15' 15' 15' 45' P. Duroux (Paris) C. Pison (Grenoble) E. Bel (Leiden, NL) S. Johnston (Southampton, UK) N. Siafakas (Heraklion, G) The severity of bronchial asthma covers a large range of different patterns; it has been defined by several reports, consensus or guidelines, at national and international levels. However difficult asthma has never been defined precisely and different phenotypes are not known. The aim of this short report is to propose a definition, which in fact appears to be multiple.

Does it exist one definition of difficult asthma ?

Difficult asthma is dependent upon several parameters including the patient itself (compliance, environmental control), the health care management (expertise of the doctor) and the absence of scientific knowledge. A long term follow-up (at least one year) by an asthma specialist or even in a specific care unit is therefore required to ensure the diagnosis of difficult asthma. Four different situations might be proposed as difficult asthma. Most of the clinical situations are linked with the absence of control of the disease despite an optimal therapeutical management :

• Patients who experienced a near fatal asthma necessitating a mechanical ventilation or having experienced a PaCO2 > 50mmHg must be considered as having difficult. A high numbers of acute exacerbations requiring recurent hospitalizations should be a slightly different presentation of the previous clinical presentation. The risk and precipitating factors should be assessed precisely. The onset of the near fatal exacerbations needs to be investigated and brittle asthma has to be precisely defined.
• Patients with nocturnal asthma symptoms, high variability over 24 h or 7 days in their diurnal PEFR measurements (>30%), high level of FEV1 improvement after ß2 agonist (>30% pred. val.) and a significant bronchial hyperreactivity despite antinflammatory treatments might be other indicators of difficult asthma.
• Patients with an incomplete or permanent pattern of airflow obstruction are another group of difficult asthmatics. The impairement of their quality of life is most of the time the major complain of this group of patients. The absence of smoking and the presence of asthma symptoms before the age of 45 are hallmarks of this difficult asthma.
• Patients who required longterm treatment with oral steroids or who required more than 4 short courses a year (total dose > 2 gr/year) to be symptom free are clearly difficult to treat. On the other hand, patients who did not satisfactory respond in term of airflow obstruction to a short course of steroids are called corticoresistant and are to be integrated in the picture of difficult to treat asthma.

How to assess difficult asthma in clinical practice ?

The severity of asthma is assessed on a prospective basis and several parameters are required for this follow-up. A severe asthmatic patient is drawn on the following figure. It’s not a difficult asthma because control has been obtained by an adequate treatment, in this case fluticasone 2000 µg/d.

Patient whose history is drawn on the following figure has typically a difficult asthma, because control is inadequate despite optimal treatment and the use of cyclophosphamide and methotrexate (not shown).

These figures have been obtained from an expert system which takes into account several parameters to assess severity and control of asthma. It’s used on a daily clinical basis in several hospitals in France and appears very usefull not only to follow-up the patients, but also to understand better their phenotypes.

. Asmanet ENFUMOSA Congrès Conçue et réalisée par: Michel Godard (at) Top
Date de création: 5 Décembre 1997-Dernière mise à jour: 23/07/98
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