433 ISSN 1745-5111 Pediatric Health (2010) 4 (4), 433–446 10.2217/PHE.10.37 © 2010 Future Medicine Ltd Asthma Education and Prevention Program (NAEPP) [3] and GINA [1] guidelines assess disease severity on the basis of asthma symp- toms, short-acting bronchodilator requirements, asthma exacerbations and baseline lung-function measurements before treatment. However, there are dif fculties with using these parameters to assess severity as patients subjective reporting of asthma symptoms (e.g., frequency, severity and medication usage) may correlate poorly with objective data such as pulmonary function mea- surements. In one prospective study of children aged 5–18 years with asthma, forced expiratory volume in 1 s (FEV 1 ) was generally normal even in severe persistent asthma whilst a reduction in the percentage of the forced vital capacity (FVC) exhaled in the frst 1 s of the forced expiration (FEV 1 /FVC ratio) was observed in increasing asthma severity [4] . The European Respiratory Society task force employed similar measures to defne dif fcult/ therapy resistant asthma, and in addition to quan- tifcation of symptoms the defnition includes the amount of inhaled anti-infammatory treatment required to achieve control of asthma [2] . They defne dif fcult/therapy-resistant asthma as that which is poorly controlled with ongoing chronic symptoms, episodic exacerbations and a contin- ued requirement for short-acting b 2 -agonists despite a daily dose of at least budesonide 800 µg or equivalent for 6 months or longer [2] . There is also an emphasis on the importance of a period of observation of at least 6–12 months in order to allow for a more accurate diagnosis, assessment of disease severity and asthma control on therapy. In 2000, the American Thoracic Society (ATS) developed a consensus definition for severe asthma [5] , which takes into account medication Asthma is one of the most common chronic conditions affecting childhood. The Global Initiative for Asthma (GINA) [1] , a project con- ducted in collaboration with the National Heart, Lung and Blood Institute and The WHO, esti- mate that approximately 300 million people in the world currently have asthma and that this prevalence is increasing. Asthma continues to cause signifcant morbidity and mortality and consumes a substantial amount of resources; medical, fnancial and social. Effective treatments exist for asthma and in the majority of cases symptoms are controlled. However, a subgroup of patients have dif fcult asthma, which means they do not respond adequately to conventional treatment, and this treatment-resistant asthma poses a challenge to those managing it. The exact incidence of treatment-resistant asthma is unknown and this is largely due to the dif fculties in making a diagnosis of asthma and the variations in diagnostic criteria. It is how- ever estimated that around 5–10% of asthmatic patients have treatment-resistant asthma [2] . This article will focus on the management of this group of patients in the school-age population. Defnitions of treatment-resistant asthma Various terms are used to describe treatment- resistant asthma: severe persistent, severe refractory, dif fcult, corticosteroid resistant or corticosteroid dependent and life threatening. Indeed several task forces have been estab- lished to address the various issues pertaining to this group of patients, including formulat- ing a consensus on how best to defne, evalu- ate and optimize management. The National REVIEW Treatment-resistant asthma: options and decision making Alison Ting 1 & Clare S Murray †1 Asthma represents one of the most common chronic conditions affecting children. Effective therapies exist, but some children continue to have treatment-resistant asthma. Management remains a signifcant challenge and evidence for the treatment of asthma at the severe end of the spectrum is lacking. However, a structured approach to assessment and management can be used to improve patient outcomes. For the minority in whom symptoms persist, further investigations, alternative anti-infammatory drugs or more novel therapies, such as anti-IgE, may need to be considered and these are best carried out by a specialist pediatric pulmonologist. Further developments in the use of noninvasive biomarkers to help individualize treatment will be helpful in the future treatment of severe asthma. 1 Royal Manchester Children’s Hospital, Oxford Road, Manchester, UK † Author for correspondence: School of Translational Medicine (Respiratory Group), The University of Manchester, Education & Research Building, 2nd Floor, University Hospital of South Manchester, Manchester, M23 9LT, UK Tel.: +44 161 291 5876 Fax: +44 161 291 5730 clare.murray@manchester.ac.uk Keywords • assessment • asthma • childhood • management • treatment-resistant part of For reprint orders, please contact: reprints@futuremedicine.com