The Trust’s paediatric difficult asthma service has an international reputation for the assessment and management of children with difficult to control asthma. We receive referrals from all over the UK because children can be offered such a high standard of assessment by the multi-disciplinary team.

What is difficult asthma?

Asthma is a common lung condition which causes breathing difficulties. Most children with asthma have good control of their symptoms with low doses of asthma medications. However, for some children, this is not the case. They continue to have troublesome symptoms which may result in asthma attacks despite being prescribed increasing doses of medications.

Difficult asthma assessment

The paediatric difficult asthma team, which includes specialist children’s asthma nurses, doctors, psychologists and physiotherapists, carry out a detailed assessment to try and find out as much as possible about why a child’s asthma is difficult to control. There can be lots of different reasons why asthma may be poorly controlled and we work in partnership with the child and their family, the local hospital, GP and school to identify possible causes so that we can suggest the best treatment for each child.

Outpatient appointments

Outpatient clinics are run in the Fulham Road Wing (mezzanine floor). Most appointments will be on a Tuesday morning but we also see children with difficult asthma on a Friday morning and Wednesday afternoon. 

At the first appointment, the child and their carer(s) meet with one of the doctors from the difficult asthma team and one of the children’s specialist asthma nurses. We ask lots of questions about a child’s asthma, complete several questionnaires and carry out a number of tests (see leaflet). The family may also meet with the physiotherapist and a member of the psychology team during the first appointment. 

The assessment takes time to complete: usually a whole morning or afternoon (depending on the time of the appointment). Sometimes we may arrange another time to complete the assessments.

If you are unable to come to your appointment it is very important that you contact one of the children’s respiratory nursing team so that the appointment can be offered to another patient and we can rearrange all the assessments for your child. Contact details will be included in your appointment letter.

Home visits

It can be very useful to carry out a home visit to give us the opportunity to meet the child’s carer(s) again and to find out more about a child’s asthma. If we feel a home visit would be useful one of the specialist nurses will discuss this and arrange the visit at a convenient time.


A physiotherapist may carry out an assessment of a child’s breathing pattern and can provide advice about breathing control exercises. These exercises can help ease the asthma symptoms, especially during an attack. Find out more about breathlessness during exercise.


We refer some children to a specialist asthma psychologist if we feel that anxiety and stress are affecting a child’s asthma. Sometimes a member of the psychology team will join the specialist nurse during the initial assessment to help identify children who may benefit from further psychology input.  

Admission to hospital

It can be helpful to find out more about a child’s asthma during a planned admission. This gives us the opportunity for further observation and assessment. This is usually for two weeks. Each admission is tailored to the individual and the plan for the admission will be discussed with the child and their family.

Severe asthma

Most children with difficult asthma have an improvement in their symptoms following the initial assessment but a small number of children continue to have poor asthma control despite high levels of asthma treatment. We have pioneered an approach that includes bronchoscopy (a procedure during which a flexible fibre-optic tube is used to evaluate a patient's airways) to understand more about the type of asthma that a child has so that we can determine the best add-on treatment for each child.

Younger children

Many young (pre-school) children have severe episodes of wheeze and difficulty breathing. It can be difficult to diagnose asthma in these children. We adapt the assessments described for older children to try and establish the cause of the symptoms and choose the most appropriate treatment for the individual child.

Breathlessness during exercise

We offer a specialist service for children who are particularly troubled by breathlessness during exercise or in response to other activities (such as playing a musical instrument). It may be necessary to carry out further tests such as a cardiopulmonary exercise test (CPET), a histamine challenge (provocation test) or continuous laryngoscopy during exercise (CLE). The physiotherapy team have specialist expertise in this area.


From the age of about 14 years, we start to discuss transition with young people. This includes ensuring they have a good knowledge and understanding about asthma and asthma treatments and giving lifestyle advice including diet, exercise and smoking. A young person may also be offered time alone (without their parent/carer) during a consultation. 

We will also discuss the options for ongoing care. Some young people will be followed up by their GP, some by their local hospital and some will transfer to our adult asthma service. The decision about where a young person will be followed up and the timing of the transfer (usually between 16 – 17 years) will be made in partnership with the young person and their family. We have a dedicated adolescent clinic where we see teenagers with asthma and other respiratory conditions. For those transferring to our adult asthma service, there will be an opportunity to meet with the adult team in the adolescent clinic at least once before care is transferred. 

    Difficult asthma assessment

    This assessment looks at the many possible reasons why a child's asthma may be difficult to control and identifies possible causes so that we can suggest the best treatment for the child....


    A bronchoscopy is a procedure where a doctor can look at the trachea (windpipe), the bronchi (branches of the airways) and into some areas of the lungs.

    Cardiopulmonary exercise test

    A cardiopulmonary exercise test (CPET) lets your doctor see how your lungs, heart and muscles react together when you exercise. 

    Meet the team

    Paediatric respiratory consultants

    Dr Louise Fleming 
    Professor Sejal Saglani
    Professor Andrew Bush
    Dr Ian Balfour-Lynn

    Specialist children’s asthma nurses

    Pippa Hall (lead children’s nurse specialist)
    Angela Jamalzadeh
    Rachael Moore-Crouch
    Yvie Bingham (research nurse)


    Dr Georgie Housley
    Charlotte Wells


    Dr Fran Beresford


    Sukeshi Makhecha

    Useful information

    This leaflet gives more information:

    Your child's difficult asthma assessment - June 2016 (PDF, 2.5MB)

    These websites also contain more useful information on asthma.