Pseudo-steroid resistant asthma

Background-Steroid resistant asthma (SRA) represents a small subgroup of th ose patients who have asthma and who are difficult to manage. Two patients with apparent SRA are described, and 12 additional cases who were admitted to the same hospital are reviewed. Methods-The subjects were selected from a tertiary hospital setting by revi ew of all asthma patients admitted over a two year period. Subjects were de fined as those who failed to respond to high doses of bronchodilators and o ral glucocorticosteroids, as judged by subjective assessment, audible wheez e on examination, and serial peak flow measurements. Results-In 11 of the 14 patients identified there was little to substantiat e the diagnosis of severe or steroid resistant asthma apart from symptoms a nd upper respiratory wheeze. Useful tests to differentiate this group of pa tients from those with severe asthma appear to be: the inability to perform reproducible forced expiratory manoeuvres, normal airway resistance, and a concentration of histamine causing a 20% fall in the forced expiratory vol ume (FEV1) being within the range for normal subjects (PC20). Of the 14 sub jects, four were health care staff and two reported childhood sexual abuse. Conclusion-Such patients are important to identify as they require supporti ve treatment which should not consist of high doses of glucocorticosteroids and beta(2) adrenergic agonists. Diagnoses other than asthma, such as gast ro-oesophageal reflux, hyperventilation, vocal cord dysfunction and sleep a pnoea, should be sought as these may be a cause of glucocorticosteroid trea tment failure and pseudo-SRA, and may respond to alternative treatment.