Severe asthma continues to be a significant cause of morbidity in children. Despite optimised standard therapy, many children remain symptomatic with subsequent impact on their quality of life and increased healthcare utilisation [1]. Children with ongoing poorly controlled asthma despite maximally prescribed treatment are identified as having problematic severe asthma [2]. Those whose poor control is due to modifiable factors including poor adherence to medications, continued exposure to allergens, social issues and psychological factors have difficult asthma. Severe therapy-resistant asthma is the term used for those with persistent symptoms despite attention to the basics of asthma management [3]. In children with problematic severe asthma, differentiating difficult asthma from severe therapy-resistant asthma is vital as correction of modifiable factors in patients with difficult asthma may result in improved symptom control and limit further investigations and exposure to expensive medications with potentially significant side effects. We have demonstrated that a structured outpatient nurse-led assessment that addresses the basics of asthma management leads to long-term benefits [1, 4]. The basics include confirming the diagnosis, ensuring correct inhaler technique, monitoring adherence, minimising allergen and smoke exposure, and assessing psychosocial factors. This involves nurse-led hospital, home and school visits, and a multidisciplinary evaluation. The assessment has been described in full previously [4]. Only once these factors have been addressed are children classified as having severe therapy-resistant asthma and consideration given to further assessments and add-on therapies such as omalizumab. Despite this rigorous assessment process, a small number of cases remain perplexing and cause concern, particularly when reported symptoms are discrepant with objective measures.
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