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To the Editors:The recently proposed term “problematic severe asthma” (PSA) [1] describes children with persistent symptoms and/or severe exacerbations despite high dose treatment [2]. They suffer significant morbidity and consume a disproportionate amount of healthcare resources. Children with PSA are heterogeneous with respect to lung function [3] and asthma phenotype [4] and warrant careful evaluation. PSA [5] encompasses 1) wrong diagnosis; 2) significant comorbidities; 3) difficult asthma with potentially reversible factors such as poor inhaler technique, ongoing allergen exposure or poor adherence to treatment [6]; and 4) severe therapy-resistant asthma (STRA) that is refractory to maximal treatment despite optimised standard management [7].PSA children were enrolled in a staged assessment protocol to differentiate difficult asthma from STRA [6]. The different stages were as follows. Stage 1: a detailed re-evaluation of the child including a nurse-led outpatient assessment with evaluation of inhaler device and technique, psychosocial questionnaire, a home and school visit, an assessment of adherence including prescription uptake check and a final multidisciplinary team discussion to decide whether the child had difficult asthma or STRA [6]. Stages 2 and 3: children identified as STRA progressed to invasive investigations including bronchoscopy and assessment of steroid response [7]. Differentiating difficult asthma from STRA is important to avoid unnecessary invasive procedures and side effects from additional treatments such as methotrexate. Furthermore, the healthcare costs of these approaches cannot be justified if simply improving basic management may improve asthma control. There have been no longitudinal studies that have assessed the long-term efficacy of a staged assessment of paediatric PSA. We hypothesised that the stage 1 assessment distinguishes difficult asthma from STRA and results in …

Long-term effectiveness of a staged assessment for paediatric problematic severe asthma