Before escalating treatment for difficult asthma, confirm the diagnosis and check adherence, inhaler technique, ongoing exposures and comorbidities such as rhinosinusitis, reflux and obesity. Many apparently severe cases improve once these are addressed.
Ask directly about missed doses, watch the patient use the device, and record exposures at home and work, including tobacco smoke. Smoking cessation support belongs in every review of a patient who smokes.
- Confirm variable airflow obstruction with spirometry or peak flow.
- Watch the patient use the inhaler.
- Ask about missed doses without judgement.
- Offer cessation support at each visit if the patient smokes.
Why it matters
Escalation without these checks treats a problem that may not be biological.
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