Asthma is a chronic airway inflammatory disease, and its medical complexity essentially resides in the management of the difficult-to-treat and severe forms. Previous studies have focused essentially on severe asthma and endotypes. Using the concept of precision medicine, we addressed the less standardized management of difficult-to-treat asthma based upon clinical features solely.

The objective of this work was to identify possible reasons for adults and children for suffering from difficult-to-treat asthma, to propose the best therapeutical and diagnostic approach.

We conducted a qualitative analysis of the medical records of 42 consecutive adult and pediatric patients suffering from difficult-to-treat asthma seen in a tertiary hospital and based on the French respiratory medicine society questionnaire for severe asthma. The study of all records was performed by two independent clinicians. In all cases, missing data were openly discussed among all coauthors until resolution was achieved.

Our findings show that, in a real-life setting, patients with difficult-to-treat asthma may be better approached if considering one or more of the nine following groups of cointervention: metabolic comorbidities; ENT comorbidities; other comorbidities such as gastro-esophageal reflux; non-allergic environment; allergic environment linked to respiratory or food allergens; inappropriate behavior; error of diagnosis; insufficiently treated patients; and intrinsic resistance. When these groups are identified and targeted with the appropriate treatment in one patient, including their approach in the management of asthma allow reaching better control of symptoms.

Behind each group of intervention, a specific pedagogic challenge is hidden on which physicians may implement their management strategy to optimize the treatment of their patients based on their own individual characteristics.