the difficult-to-control asthmatic a systematic approach抑制哮喘的一种系统化的方法.pdf

Review Article The Difficult-to-Control Asthmatic: A Systematic Approach Annie V. Le, MD; Ronald A. Simon, MD Abstract With the judicious use of inhaled corticosteroids, 2 agonists, and leukotriene modifiers, most patients with asthma are easily controlled and managed. However, approximately 5% of asthmatics do not 1 respond to standard therapy and are classified as “difficult to control.” Typically, these are patients who complain of symptoms interfering with daily living despite long-term treatment with inhaled corticosteroids in doses up to 2,000 g daily. Many factors can contribute to poor response to conventional therapy, and especially for these patients, a systematic approach is needed to identify the underlying causes. First, the diagnosis of asthma and adherence to the medication regimen should be confirmed. Next, poten- tial persisting exacerbating triggers need to be identified and addressed. Concomitant disorders should be discovered and treated. Lastly, the impact and implications of socioeconomic and psychological fac- tors on disease control can be significant and should be acknowledged and discussed with the individ- ual patient. Less conventional and novel strategies for treating corticosteroid-resistant asthma do exist. However, their use is based on small studies that do not meet evidence-based criteria; therefore, it is essential to sort through and address the above issues before reverting to other therapy. Incorrect Diagnosis tened inspiratory curve, for example, is indicative of upper airway obstruction (ie, vocal cord dys- It is important to remember that “all that wheezes function). A methacholine challenge should be is not asthma” (Table 1). When there is a lack of performed when there is a question of airwa