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Corticosteroid responsiveness and clinical characteristics in childhood difficult asthma

Depts of ¹ Respiratory Paediatrics, and ⁴ Histopathology, Royal Brompton Hospital, and ² Imperial College, London, UK. ³ Dept of Paediatrics and Child Health, University of Western Australia, Perth, Australia.

CORRESPONDENCE: A. Bush, Dept of Respiratory Paediatrics, Royal Brompton Hospital, Sydney Street, London, SW3 6NP, UK. E-mail: a.bush{at}rbht.nhs.uk

Keywords: Corticosteroid responsiveness, difficult asthma, eosinophil, nitric oxide, paediatric asthma

Received: December 9, 2008
Accepted May 27, 2009

This study describes the clinical characteristics and corticosteroid responsiveness of children with difficult asthma (DA). We hypothesised that complete corticosteroid responsiveness (defined as improved symptoms, normal spirometry, normal exhaled nitric oxide fraction (F_eNO) and no bronchodilator responsiveness (BDR <12%)) is uncommon in paediatric DA.

We report on 102 children, mean±SD age 11.6±2.8 yrs, with DA in a cross-sectional study. 89 children underwent spirometry, BDR and F_eNO before and after 2 weeks of systemic corticosteroids (corticosteroid response study). Bronchoscopy was performed after the corticosteroid trial.

Of the 102 patients in the cross-sectional study, 88 (86%) were atopic, 60 (59%) were male and 52 (51%) had additional or alternative diagnoses. Out of the 81 patients in the corticosteroid response study, nine (11%) were complete responders. Of the 75 patients with symptom data available, 37 (49%) responded symptomatically, which was less likely if there were smokers in the home (OR 0.31, 95% CI 0.02–0.82). Of the 75 patients with available spirometry data, 35 (46%) had normal spirometry, with associations being BAL eosinophilia (OR 5.43, 95% CI 1.13–26.07) and high baseline forced expiratory volume in 1 s (FEV₁) (OR 1.08, 95% CI 1.02–1.12). Of these 75 patients, BDR data were available in 64, of whom 36 (56%) had <12% BDR. F_eNO data was available in 70 patients, of whom 53 (75%) had normal F_eNO. Airflow limitation data was available in 75 patients, of whom 17 (26%) had persistent airflow limitation, which was associated with low baseline FEV₁ (OR 0.93, 95% CI 0.90–0.97).

Only 11% of DA children exhibited complete corticosteroid responsiveness. The rarity of complete corticosteroid responsiveness suggests alternative therapies are needed for children with DA.