A Structured Approach to Specialist-referred Difficult Asthma Patients Improves Control of Comorbidities and Enhances Asthma Outcomes

J Allergy Clin Immunol Pract. 2017 Jul-Aug;5(4):956-964.e3. doi: 10.1016/j.jaip.2016.12.030. Epub 2017 Mar 9.


Background: Systematic evaluation is advocated for difficult asthma, but how best to deliver such care is unclear and outcome data are scarce.

Objective: We describe our institution's structured approach to difficult asthma management and report on the outcomes of such an approach.

Methods: Eighty-two consecutive patients with difficult asthma referred to our clinic from respiratory specialists were evaluated in 3 key areas: diagnostic confirmation, comorbidity detection, and inflammatory phenotyping. We then optimized treatment including relevant comorbidity interventions. The outpatient protocol was supported by comorbidity questionnaires, an electronic clinic template, and standardized panel discussion. Asthma outcomes were assessed at 6 months.

Results: Sixty-eight patients completed follow-up. Asthma diagnosis was refuted in 3 patients and the remaining 65 patients were included in the study analysis. There was no overall escalation of inhaled or oral corticosteroids. Patients had a median of 3 comorbidities, and a median of 3 comorbidity interventions. Control of chronic rhinosinusitis and dysfunctional breathing improved among patients with these diagnoses (22-item Sino-Nasal Outcome Test score from 47 ± 20 to 37 ± 22, P = .017; Nijmegen score from 32 ± 6 to 25 ± 9, P = .003). There were overall improvements in the Asthma Control Test score (from 14 ± 5 to 16 ± 6, P < .001), the Asthma Quality of Life Questionnaire (from 4.29 ± 1.4 to 4.65 ± 1.5, P = .073), and the frequency of exacerbations over 6 months (from 2 [interquartile range, 0-4] to 0 [interquartile range, 0-2], P < .001).

Conclusions: In patients referred with difficult asthma from respiratory specialists, a structured approach coupled with targeted comorbidity interventions improved control of key comorbidities and enhanced asthma outcomes.

Keywords: Asthma; Comorbidity; Difficult; Severe; Systematic assessment.

Publication types

  • Observational Study

MeSH terms

  • Adrenal Cortex Hormones / therapeutic use
  • Adult
  • Aged
  • Anti-Asthmatic Agents / therapeutic use
  • Asthma* / diagnosis
  • Asthma* / drug therapy
  • Asthma* / epidemiology
  • Comorbidity
  • Female
  • Gastroesophageal Reflux / epidemiology
  • Humans
  • Male
  • Middle Aged
  • Obesity / epidemiology
  • Paranasal Sinus Diseases / epidemiology
  • Phenotype
  • Respiration Disorders / epidemiology
  • Specialization
  • Treatment Outcome


  • Adrenal Cortex Hormones
  • Anti-Asthmatic Agents