A quick outpatient approach to “Difficult Asthma” in a GP setting

1. Ravinder PS Makkar, MD

Medical Advisor, Department of Medical Assistance
International SOS, 507-509, Meridien Commercial Tower, New Delhi-100001, India
2. NP Singh, MD
Professor of Medicine, Maulana Azad Medical College, New Delhi-110002, India
3. Gopal Kr. Sachdev, MBBS, MD, DM
Professor of Medicine and Gastroenterology, Maulana Azad Medical College, New Delhi-110002, India
 Corresponding address:

Ravinder PS Makkar, MD

Medical Advisor, Department of Medical Assistance

International SOS, 507-509, Meridien Commercial Tower, New Delhi-100001, India

Tel: 91-11-23352702, Fax: 23352701

E-mail: ravinder.makkar@nternationalsos.com


Case scenario:

A 30-year-old asthmatic has been on salbutamol inhaler and inhaled steroids for many years. The asthma has never really been under control and the requirement of steroid and beta-agonist usage has increased steadily.

What should be covered in the history?

A very common cause of ‘difficult-to-treat’ asthma (defined as requiring > 10 mg of prednisolone every other day for at least 3 consecutive months per year) is improper inhaler technique and poor compliance by the patients. Carefully ascertain whether the patient is taking the inhaler correctly, in adequate doses, and is complying with the treatment.

Co-presence of chronic sinusitis can exacerbate asthma symptoms. Ask for presence of symptoms suggestive of chronic sinusitis (e.g. chronic nasal stuffiness, sinus headaches, postnasal drip, chronic hacking cough, tenderness over sinus areas etc).

Presence of associated Gastro-ooesophageal reflux disease (GERD), either overt or occult, can worsen the symptoms of asthma. Carefully question about the presence of classic GERD symptoms (heartburn, regurgitation, water-brash, sour eructations and dysphagia). Inquire if cough, breathlessness or wheezing is associated with reflux episodes or if the patient uses inhalers while experiencing reflux symptoms. Ask if asthma symptoms exacerbate at night after lying down, or after eating foods known to decrease lower oesophageal sphincter (LES) pressure (large high fat meals, chocolates, caffeine, alcohol etc).  Presence of these symptoms can point to the diagnosis of reflux-triggered asthma.

Occasionally some patients with asthma will have cough that is resistant to treatment. Ask if the patient takes any drug from Angiotensin-converting enzyme (ACE) inhibitor family (e.g. enalapril, lisinopril , ramipril etc) given for hypertension, that can cause resistant dry cough.

Allergic bronchopulmonary aspergillosis (ABPA) can be a factor in difficult-to-treat asthmatics. Order chest x-ray or CT-thorax, skin-prick test to aspergillus extract, eosinophil count, and serum IgE levels to look for evidence of ABPA.

What you should do?

Start with reassuring the patient. Patiently educate the patient on the etiopathogenesis of asthma and its mechanisms in simple layman’s terms to allay any anxiety regarding the disease.

Order x-ray or CT of the sinuses to rule out presence of chronic sinusitis. If confirmed, prescribe antibiotics and decongestants for 2-3 weeks. If medical treatment fails, refer to an otorhinolaryngology specialist for possible fenestrated endoscopic sinus surgery (FESS) for sinus drainage. Many patients with ‘difficult-to-treat’ asthma will have dramatic improvements in asthma symptoms when their chronic sinusitis is treated medically or surgically.

If the history is consistent with GERD, no further diagnostic workup is necessary and a trial of aggressive antireflux medical therapy can be started. Order diagnostic testing (upper gastrointestinal endoscopy) in those who have symptoms suggesting complicated GERD (severe esophagitis, stricture, Barrett’s esophagus etc) or when empiric therapy of GERD has been unsuccessful in the past. 24-hour oesophageal-pH testing can be ordered in asthmatics without classical reflux symptoms to rule out underlying occult GERD. Advise adequate control of reflux with life-style modification (stop smoking, avoid eating large meals, and avoid foods like chocolates, caffeine, alcohol etc. Advise to sleep with raised head end of the bed to decrease the nocturnal reflux episodes. Prescribe proton pump inhibitors (PPI; for example omeprazole 20-40 mg/day for 3 months) for treating GERD. The efficacy of various newly available PPI is considered to be similar; hence no particular PPI can be preferred. Send the patient home with advice to follow-up regularly to monitor the symptoms and to modify the dose and frequency of bronchodilators and steroid usage.

If the patient takes ACE-inhibitors for hypertension, switch to other class of anti-hypertensives like calcium-channel blockers or diuretics. Beta-blockers should be avoided as they can precipitate asthma attacks.

Presence of peripheral eosinophilia, pulmonary infiltrates, central bronchiectasis, a positive skin-prick test and raised serum IgE levels can point to ABPA. Prescribe systemic steroids for treatment of ABPA. Presence of aspergilloma needs hospitalization, anti-fungal therapy with intravenous amphotericin-B or possible lung surgery for the removal of the aspergilloma.

Teach correct technique of inhaler-use to the patient. Stress the importance of regular treatment and ensure compliance.


Suggested further reading:

1.     Irwin RS. Difficult to control asthma: contributing factors and outcome of a systematic management protocol. Chest.1993; 103:1662-1669.

  2.      De Benedictis FM, Del Giudice MM, Severini S, Bonifazi F. Rhinitis, sinusitis and asthma: one linked airway disease. Paediatr Respir Rev. 2001; 2(4): 358-64.

  3.      Bruno G, Graf U, Andreozzi P. Gastric asthma: an unrecognized disease with an unsuspected frequency. J Asthma. 1999; 36(4): 309-314.

  4.      Soubani AO, Chandrasekar PH. The clinical spectrum of pulmonary aspergillosis. Chest. 2002; 121(6): 1988-99.

  5.      Hunt LW. How to manage difficult asthma cases. An action plan for physicians and patients. Postgrad Med. 2001; 109(5): 61-8.


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 Published December 2003