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01.12.2015 | Research article | Ausgabe 1/2015 Open Access

BMC Pulmonary Medicine 1/2015

Phenotypes of severe asthma among children and adolescents in Brazil: a prospective study

BMC Pulmonary Medicine > Ausgabe 1/2015
Wenderson Clay Correia de Andrade, Laura Maria de Lima Belizário Facury Lasmar, Cristiane de Abreu Tonelli Ricci, Paulo Augusto Moreira Camargos, Álvaro A Cruz
Wichtige Hinweise

Competing interests

The authors declare that they have no competing interests.

Authors’ contributions

LMLBFL and WCCA designed the study and drafted the manuscript; LMLBFL and WCCA performed the statistical analysis; LMLBFL, WCCA and CATR participated in the enrollment and follow-up of the children and in drafting the manuscript; LMLBFL, WCCA and CATR participated in the enrollment and follow-up of the children; LMLBFL and WCCA supervised the data entry and management; PAMC and AAC assisted with data interpretation and manuscript development; LMLBFL, WCCA, PAMC and AAC critically revised the study design and manuscript. All of the authors read and approved the final version of the manuscript.



The morbidity associated with severe uncontrolled asthma is disproportionately higher in low- and middle-income countries than in high-income countries. The aim of this study was to describe the phenotypic characteristics of difficult-to-treat severe asthma and treatment-resistant severe asthma in a sample of children and adolescents in Brazil.


This was a prospective study, conducted between 2010 and 2014, following 61 patients (6–18 years of age) who had been diagnosed with severe uncontrolled asthma. The patients were classified and managed in accordance with the World Health Organization asthma follow-up protocol, which calls for re-evaluations of the diagnosis, level of control (functional and clinical), comorbidities, inhaler technique, and environmental factors, together with adjustment of the treatment to achieve a target level of control. We assessed pulmonary function, measured fractional exhaled nitric oxide, and performed sputum cytology. After the target rate of ≥ 80% adherence to inhaled corticosteroid treatment had been reached and all of the re-evaluations had been performed, the patients incorrectly diagnosed with severe uncontrolled asthma were excluded and the remaining patients were classified as having treatment-resistant or difficult-to-treat severe asthma.


We found that, of the 61 patients evaluated, 10 had been misdiagnosed (i.e., they did not have asthma), 15 had moderate asthma, and 36 had severe uncontrolled asthma. Among those 36 patients, the asthma was classified as treatment-resistant in 20 (55.6%) and as difficult-to-treat in 16 (44.4%). In comparison with the patients with difficult-to-treat severe asthma, those with treatment-resistant severe asthma showed a higher median level of fractional exhaled nitric oxide (40 ppb vs. 12 ppb; P < 0.037) and a lower median forced expiratory volume in one second (61% vs. 87%; P < 0.001).


Although patients with treatment-resistant severe asthma cannot always be distinguished from those with difficult-to-treat severe asthma on the basis of baseline clinical characteristics, reduced airflow and elevated fractional exhaled nitric oxide are factors that could distinguish the two groups. Patients diagnosed with severe uncontrolled asthma should be re-evaluated on a regular basis, in order to exclude other diagnoses, to reduce exacerbations, and to identify patients with persistent airflow limitation.
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