Med Clin North Am. 2022 Nov;106(6):971-986. doi: 10.1016/j.mcna.2022.08.003.
As many as 15% to 20% of patients with asthma have incompletely or poorly controlled asthma despite treatment with inhaled corticosteroids and long-acting beta-agonist bronchodilators. They are vulnerable to burdensome symptoms, limitations to their exercise capacity, and asthma attacks that can be frightening and potentially life-threatening. This article outlines a systematic approach to their evaluation, attempting to identify remediable factors that are making their asthma more severe than most other persons with asthma. This approach includes an emphasis on ensuring the correct diagnosis, minimizing exposures to stimuli that worsen airway inflammation, alleviating modifiable comorbidities such as chronic rhinosinusitis and gastroesophageal reflux, and supporting regular medication adherence and effective technique for administering inhaled medications. A basic diagnostic laboratory work-up is recommended, to be modified and amplified according to individual patient needs.