Difficult-to-treat asthma: revisiting essential management principles

Difficult-to-treat asthma in children remains a significant clinical challenge, often resulting in high healthcare costs and poor outcomes. Despite many referrals to specialist centres, basic management principles are frequently overlooked, with premature escalation to high-dose corticosteroids. This review highlights the importance of a systematic approach to paediatric asthma, beginning with accurate diagnosis using objective tests such as spirometry and fractional exhaled nitric oxide (FeNO) and careful exclusion of alternative or co-existing diagnoses. Optimizing adherence, inhaler technique and environmental control—alongside identifying comorbidities such as allergic rhinitis, obesity and dysfunctional breathing—can dramatically improve outcomes in most cases without requiring advanced therapies. A multidisciplinary team approach, incorporating education, psychological support, and personalized asthma action plans, is essential. For children with truly severe therapy-resistant asthma (STRA), biologics offer promising control when traditional therapies fail, especially where modifiable factors are non-correctable. However, their use should follow thorough evaluation and shared decision-making. Ultimately, reinforcing fundamental asthma care in primary and secondary settings can prevent progression to specialist referral and reduce both direct and indirect healthcare burdens. Addressing modifiable factors enables over 70% of children with difficult asthma to achieve good control, emphasizing the need to revisit and reinforce core management strategies.