Cluster analysis of patients with chronic rhinosinusitis and asthma after endoscopic sinus surgery

BackgroundPatients with chronic rhinosinusitis with nasal polyps and asthma (CRSwAS) are highly heterogenous in severity and prognosis. The clinical phenotypes and inflammatory endotypes of CRSwAS and their association with outcomes of endoscopic sinus surgery (ESS) have not been fully studied yet.ObjectiveWe aimed to find out the clinical phenotypes of CRSwAS and explore their relationship with ESS outcomes using cluster analysis.MethodsWe recruited 103 consecutive adult patients with CRSwAS who had undergone ESS and been followed up for more than 1 year. For cluster analysis, we collected the data from 63 variables pertaining to demographic characteristics, preoperative disease status, surgical techniques, postoperative medical treatment, and outcomes. Eosinophilic CRS was defined as greater than or equal to 10 eosinophils/high-power field, and sinus computed tomography was evaluated by Lund-Mackay sinus computed tomography score (LM score).ResultsWe screened 92 eligible patients and 13 preoperative variables for balanced iterative reducing and clustering using hierarchies cluster analysis. Patients with CRSwAS were divided into 4 clusters with distinct ESS outcomes: (1) cluster 1, characterized by aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (2) cluster 2, characterized as having female dominance (66.67%), non–aspirin-exacerbated respiratory disease, eosinophilic CRS, high preoperative LM score, moderate-to-severe asthma, and uncontrolled CRS after ESS; (3) cluster 3, characterized as having female dominance (95.83%), noneosinophilic CRS, low preoperative LM score, moderate asthma, and controlled CRS after ESS; and (4) cluster 4, characterized as men-only, smoker, noneosinophilic CRS, low preoperative LM score, mild asthma, and controlled CRS after ESS.ConclusionCRSwAS has distinct clusters, each corresponding to unique clinical and inflammatory characteristics and ESS outcomes.     

Diagnosis and Immunotherapy of Mould Allergy

Twenty-four adult asthmatics with autumnal asthma and positive bronchial provocation test to the mould species Cladosporium were evaluated by daily symptoms scores during 11 weeks in the peak mould spore season. A significant association with fluctuation in Cladosporium spore count was found regarding the relative weekly symptom score (mean of subjective asthma and peak flow scores), relative use of antiasthmatic medication and the combined (total) score (mean of symptom and medication scores). The median weekly symptom, medication, and total scores were positively correlated to Cladosporium spore count, but only significantly so in the medication score. Eighteen patients were allergic to both Cladosporium and Alternaria, but asthma symptoms were not associated to Alternaria spore counts; on the contrary, a negative correlation indicated that Alternaria only played a minor role in eliciting asthma. Neither mugwort nor house dust mites seemed to be of importance. The results of diagnostic tests (bronchial provocation test, quantitative skin prick test, RAST and histamine release) were correlated to the mean absolute symptom score of the spore season. The highest correlation to asthma score, peak flow score, medication score, and the combined score was found with the bronchial provocation test. The data indicate that autumnal asthma, to a high degree, is elicited by Cladosporium spores, and further, that the specific allergic diagnosis can only be established by a combination of positive diagnostic tests and careful recording of symptoms elicited by the causative allergen.     

Relationship between symptoms and objective measures of airway obstruction in asthmatic patients.

The objective of this study was to determine the relationship between asthma symptoms and the degree of airway obstruction as measured by the forced expiratory volume in one second (FEV1) and peak expiratory flow rate (PEFR) in a group of 64 asthmatic patients with clinically stable disease attending a university-based urban asthma clinic. Asthma symptoms did not correlate with the degree of airway obstruction as measured by prebronchodilator PEFR (total asthma symptom score vs PEFR: r = -0.214, p = 0.104, n = 59) and only correlated poorly with prebronchodilator FEV1 (total asthma symptom score vs FEV1: r = -0.256, p = 0.041, n = 64). These results lend support to the recommendation that airway obstruction should be measured objectively when assessing patients with chronic persistent asthma.     

Nebulization treatment with saline compared to bromhexine in treating chronic sinusitis in asthmatic children

Twenty children aged 3 to 14 years with a history of bronchial asthma complicated by chronic sinusitis were studied in a double-blind study. Patients received, at random, over a period of 2 weeks, either 2 ml saline or 2 ml bromhexine (2 mg/ml) t.i.d. by means of a home nebulizer. A significant decline of clinical symptoms during both nebulization treatments as compared to the pretreatment symptom score was observed (mean score of 1.5 +/- 0.7 and 0.5 +/- 0.8, respectively, P less than 0.01). Both types of nebulization were equally efficient in reducing the symptom score. Radiological abnormalities were significantly more reversed after saline nebulization as compared with bromhexine (P less than 0.05), although both treatments showed radiological improvement (P less than 0.01). The present study indicates that nebulization with saline may have some beneficial effect on chronic sinusitis in asthmatic children. Bromhexine was not superior to saline for this purpose.     

Effects of suplatast tosilate on allergic eosinophilic airway inflammation in patients with mild asthma

BACKGROUND: Bronchial asthma is a chronic inflammatory disease characterized mainly by infiltration of the airway mucosa by various inflammatory cells, notably eosinophils. T(H)2-type cytokines are suggested to be deeply involved in the pathogenesis of asthma. OBJECTIVE: We sought to determine the suppressive effects of suplatast tosilate, an inhibitor of T(H)2-type cytokines, on eosinophilic inflammation of the bronchial mucosa in patients with mild asthma. METHODS: Airway hyperresponsiveness tests, pulmonary function tests, eosinophil measurements in induced sputum, and bronchial mucosa biopsies were performed before and after treatment with suplatast tosilate for 6 weeks in 15 patients with mild asthma and in 13 control patients with mild asthma not receiving suplatast tosilate. This study was performed as a case-controlled open study. RESULTS: In the treatment group a significant improvement in the provocation concentration of histamine was observed (P <.05). Improvements in peak expiratory flow (P <.01) and in symptom score (P <.05) were also noted in the suplatast tosilate-treated group. Moreover, the average number of infiltrating eosinophils and EG2(+) cells significantly decreased (both P <.05), as did the ratios of eosinophils and EG2(+) cells in sputum (both P <.01). The average number of CD4(+) and CD25(+) T lymphocytes also decreased (both P <.05). CONCLUSION: Suplatast tosilate appears to inhibit allergic airway inflammation mediated by T(H)2-type cytokine and to improve clinical symptoms in patients with mild asthma.     

Nasal beclomethasone prevents the seasonal increase in bronchial responsiveness in patients with allergic rhinitis and asthma.

Experimental studies have demonstrated that induction of a nasal allergic reaction can lead to an increase in bronchial responsiveness (BR). To assess the clinical relevance of these experimental changes to chronic asthma, we sought to determine the effect of nasal beclomethasone dipropionate (Bdp) on BR in patients with seasonal allergic rhinitis and asthma. Eighteen subjects with histories of seasonal allergic rhinitis and asthma during the fall pollen season with positive skin tests to short ragweed and bronchial hyperresponsiveness to inhaled methacholine were assigned to receive either nasal Bdp (336 micrograms/day) or placebo for the entire ragweed season. Patients recorded daily nasal and chest symptoms, nasal blockage index, oral peak expiratory flow rates, and supplemental medication use. BR to methacholine was measured during the baseline period and 6 weeks into the ragweed season. Although the Bdp group did have a significant improvement in nasal blockage index, there was no improvement in daily asthma symptom scores, oral peak expiratory flow, or asthma medication use. However, subjects treated with Bdp were protected from the increase in BR seen in the placebo group (geometric mean PC20 placebo group: baseline = 0.70, week 6 = 0.29; Bdp group: baseline = 0.80, week 6 = 0.93; intergroup difference, p = 0.022). We conclude that nasal corticosteroid therapy can prevent the increase in BR associated with seasonal pollen exposure in patients with allergic rhinitis and asthma.     

Sinonasal pathology in nonallergic asthma and COPD: 'united airway disease' beyond the scope of allergy

Background:  In contrast to the epidemiological and clinical association between allergic rhinitis and asthma, upper airway inflammation is less characterized in patients with nonatopic asthma and virtually unexplored in chronic obstructive pulmonary disease (COPD). Here, sinonasal pathology is studied in patients with allergic asthma, nonallergic asthma and COPD.
Methods:  Ninety patients with stable bronchial disease were included in the study, of which 35 were diagnosed with allergic asthma, 24 with nonallergic asthma and 31 with COPD. Concurrently, 61 control subjects without pulmonary disease were included and matched for age and smoking habits respectively with the asthma and the COPD group. Sinonasal symptoms were evaluated on a visual analogue scale and rhinosinusitis-related impairment of quality of life was assessed with the sino-nasal outcome test-22 (SNOT-22) questionnaire. Nasal mucosal abnormalities were quantified with nasal endoscopy and nasal secretions collected for measuring inflammatory mediators.
Results:  Allergic asthmatics, nonallergic asthmatics and COPD patients reported more nasal symptoms than their respective control subjects, had a higher SNOT-22 score and presented more mucosal abnormalities in the nose. Nasal secretions of both allergic and nonallergic asthmatics contained higher levels of eotaxin, G-CSF, IFN-γ and MCP-1 than controls. Allergic asthmatics had higher nasal IP-10 levels as well. COPD-patients had higher nasal levels of eotaxin, G-CSF and IFN-γ than controls.
Conclusion:  Patients with allergic and nonallergic asthma and COPD show increased nasal symptoms and more nasal inflammation. Hence, our data confirm the 'united airways' concept to be beyond the scope of allergic asthma.     

Diagnosis of asthma and chronic obstructive pulmonary disease in general practice.

There may be an overlap between the clinical pictures of asthma and chronic obstructive pulmonary disease which hampers a clear distinction between the two diseases. Most symptoms presented by patients do not clearly belong exclusively to either asthma or chronic obstructive pulmonary disease. By the nature of their discipline and training, general practitioners focus mainly on symptoms presented, which do not give a decisive answer in the differential diagnosis between the two diseases. Therefore, general practitioners must rely on objective parameters, such as determining the presence and degree of reversibility of airway obstruction, diurnal peak flow variability, bronchial hyper-responsiveness and allergy. This paper puts forward a pragmatic, primary care definition of asthma and chronic obstructive pulmonary disease.     

Chronic cough, sinusitis, and hyperreactive airways in children: an often overlooked association

Ten patients, aged 7 to 16 years, were prospectively evaluated for chronic cough of more than 4 months duration. All patients denied wheezing, but in addition to cough complained of chronic obstructive nasal symptoms. Sinus roentgenograms were consistent with sinusitis in 7/10 patients. Methacholine bronchial provocation was positive in 6/9 patients. The patients were recalled for a 2-year follow-up evaluation. Of seven follow-up patients, bronchial asthma had developed in three, two patients had chronic cough and exercise-induced bronchospasm, and two patients had chronic cough without wheezing. Methacholine bronchial provocation was positive in 6/6 patients. Sinus roentgenograms were compatible with sinusitis in 4/7 patients. Chronic cough in some children may be a complaint of diffuse hyperreactive airways complicated by sinusitis. In some of the children the clinical course evolved into a diffuse respiratory tract disorder including chronic obstructive eosinophilic rhinitis, recurrent or chronic sinusitis and bronchial asthma. An IgE-mediated mechanism usually could not be shown in the pathogenesis.     

Asthma treatment and asthma prevention: a tale of 2 parallel pathways

Three recent clinical trials used different study designs to test the hypothesis that early introduction of inhaled corticosteroids in infants and young children at high risk for the development of asthma could change the natural course of the disease. All 3 trials reached the same conclusion: treatment requirement, symptom frequency while off treatment, and lung function did not differ between children receiving active drug or placebo, with outcomes measured 2 to 4 years after randomization. These findings challenge the concept that the inflammatory processes that cause asthma symptoms and are responsive to inhaled corticosteroids are also responsible for the chronic changes in airway structure and function that are believed to predispose to the development of persistent asthma. This conclusion is supported by studies showing that bronchial hyperresponsiveness, independent of current asthma symptoms, is associated with subsequent deficits in airway function growth during childhood. Successful strategies for the prevention of asthma will require a better understanding of the genetic, environmental, and developmental factors that predispose toward inappropriate responses to airway injury. Abnormal airway remodeling and persistent dysregulation of airway tone might be the final common pathway for different disease mechanisms, and this might explain the heterogeneity of clinical phenotypic syndromes that go under the common label of "asthma."     

Gastroesophageal reflux disease in bronchial asthma and the response to omeprazole

The objective of this study was to determine the incidence of gastroesophageal reflux disease (GERD) in bronchial asthma and the role of omeprazole for asthmatics with symptoms of GERD. Seventy asthmatics were screened for GERD by questionnaire. Patients with a history suggestive of GERD were confirmed by Bernstein test and further investigated for airway responsiveness to instillation of HCl in the esophagus. Symptom score, drug score and spirometric values were recorded initially and after four weeks of treatment with omeprazole. It was found that 74.28% of asthmatics had a history of GERD. Forty patients tested positive by Bernstein test and also showed airway responsiveness to instillation of HCl in the esophagus. There was a significant improvement in symptom scores (p < 0.001), drug scores (p < 0.001) and spirometric values (p < 0.001) after adding omeprazole to their treatment regimen. It was concluded that bronchial asthma and GERD are associated in the majority of patients (57.14%) and such patients are likely to improve with omeprazole.     

Outcomes in occupational asthma caused by reactive dye after long-term avoidance

BACKGROUND: Reactive dye (RD) is known to be a causative agent of occupational asthma (OA). However, to date, no report has been issued concerning the long-term outcomes of RD-induced OA. OBJECTIVES: We sought to evaluate the long-term outcomes in cases of OA caused by RD. METHODS: A total of 11 OA patients confirmed by RD bronchial challenge were enrolled in this study. First and second follow-up examinations were conducted at 4.3+/-2.3 and 13.7+/-2.3 years (means+/-SD) after the initial examinations, respectively. Skin prick test with RD and 11 common inhalant allergens, pulmonary function test, methacholine bronchial provocation testing, symptom and medication scores were determined at each visit. In addition, inflammatory cells in induced sputum were measured at the second follow-up examinations. RESULTS: Reduced lung function at initial examinations did not recover at the first and second examinations despite cessation of exposure and proper pharmacological treatment. In addition, asthma severity (as determined by symptom and medication scores) and non-specific airway hyper-responsiveness to methacholine also did not improve. However, skin reactivity to RD almost disappeared at the second examinations. Interestingly, four of the six patients who showed negative skin responses to all 11 common inhalant allergens at initial examinations were found to be atopic at the second examinations. Moreover, in terms of airway inflammation, seven of the 11 patients showed eosinophilia in induced sputum (> or =3%) at the second examinations despite having been on high-dose inhaled corticosteroid medication. CONCLUSION: The present study demonstrates that reduced lung function and asthmatic symptoms persist in RD-induced OA even after long-term exposure avoidance.     

A statistical investigation of the influence of allergic factors on intractable asthma by multiple factor analysis]

The relationships of the development of intractability in bronchial asthma with 11 factors, namely 1) sex, 2) age of onset, 3) duration of the disease, 4) severity of the disease, 5) disease type, 6) family history within the third degree of consanguinity, 7) history of smoking, 8) history of atopic dermatitis, 9) history of allergic rhinitis, 10) history of chronic sinusitis and 11) history of nasal polyp were studied by multiple factor analysis in 95 patients. The severity of the disease was shown to be the most important factor in whether the disease becomes intractable or not, followed by the age of onset. The history of atopic dermatitis had the least influence, and the influences of the other factors were not markedly different from one another. Evaluation of each factor according to the category score suggested that severe or moderate non-atopic bronchial asthma in males with a positive family history and positive histories of smoking, chronic sinusitis, nasal polyp and atopic dermatitis within a short period after the onset in the second decade or fifth decade or later tend to become intractable.     

Asthma score: predictive ability and risk factors

BACKGROUND: Definition of asthma as a continuous score is a promising tool for population studies that has not yet been fully evaluated. OBJECTIVE: We assessed (i) the predictive ability of an asthma score against the occurrence of different asthma-related outcomes and (ii) the risk factors identified when using an asthma score. METHODS: The European Community Respiratory Health Study II included subjects from the general population randomly studied during 1991-1993 who were followed up in the years 1998-2001, from 29 centres in 14 countries. A total of 8956 subjects were included. The asthma score consisted of a simple sum of the positive answers to five respiratory symptoms. RESULTS: Asthma score at baseline showed a linear relationship with incidence of asthma, the occurrence of asthma attacks, use of asthma medication and bronchial reactivity at the end of the follow-up. Asthma score at the end of follow-up was associated with known risk factors at baseline such as IgE to grass, rhinitis or body mass index, in addition to passive smoking in men [average score ratio (RR) = 1.30; 95% confidence interval (CI) 1.09-1.50] or changes in body mass index (RR = 1.27; 95% CI 1.05-1.27, per each kg/m(2)). CONCLUSION: The asthma score had good predictive ability against outcomes related with asthma and also good ability to detect risk factors. This encourages the use of the score as a measure of asthma in epidemiological studies on aetiology of asthma.     

Effects of ketotifen on symptoms and on bronchial mucosa in patients with atopic asthma

Ketotifen is marketed throughout the world as an antiallergy drug, but whether it affects infiltration of inflammatory cells into airway mucosa is not known. We studied the effects of ketotifen on symptoms, pulmonary function, and airway inflammation in 25 patients with atopic asthma. Patients took ketotifen (1 mg twice daily) or a matching placebo for 8 weeks in a double-blind, parallel-group study. Data recorded on diary cards were used for 2 weeks before treatment began, and they were used for the last 2 weeks of treatment to study asthma symptoms, use of β2–agonists, and peak expiratory flow (PEF). Pulmonary function tests, bronchial responsiveness to methacholine, and fiberoptic bronchoscopy were performed before and after treatment. Biopsy specimens were obtained by bronchoscopy. Specimens were stained immunohistochemically with monoclonal antibodies against stored eosinophil cationic protein (EG1), the secreted form of eosinophil cationic protein (EG2), mast-cell tryptase (AA1), neutrophil elastase (NP57), CD3, CD4, CD8, and CD25. The numbers of positively stained cells in the lamina propria were counted. Compared with the placebo, the ketotifen-treated group exhibited significant improvement of asthma symptoms ( P <0.05) and bronchial responsiveness (P<0.05). This was accompanied by a reduction of EG2+ eosinophils ( P <0.05), CD3+ T cells ( P <0.001), CD4+ T cells (P<0.01), and CD25+ activated T cells ( P <0.01) in the bronchial mucosa. These results suggested that the beneficial effects of ketotifen in bronchial asthma may result from consequent inhibition of activated eosinophils and T-cell recruitment into the airway. Moreover, ketotifen may relieve allergic inflammation in bronchial asthma.     

Airway inflammation in asthma and chronic obstructive pulmonary disease with special emphasis on the antigen-presenting dendritic cell: influence of treatment with fluticasone propionate

Asthma is a chronic inflammatory disorder of the airways characterized by variable airflow limitation and airway hyperresponsiveness. The type of inflammatory response in asthma is compatible with a major contribution of professional antigen-presenting cells. The airways in chronic obstructive pulmonary disease (COPD) are also markedly inflamed; however, the predominant types of inflammatory cells and the main anatomical site of the lesion appear to differ from those in asthma. COPD is characterized by reduced maximum expiratory flow and slow forced emptying of the lungs. Steroids are the most prominent medication used in the treatment of asthma and COPD; however, the beneficial effect of steroid treatment in COPD is subject of debate. We investigated the efficacy of fluticasone propionate (FP) treatment in atopic asthmatics and in COPD patients with bronchial hyperreactivity who smoke. The effect of the treatment on bronchial hyperreactivity and indices of the methacholine dose–response curve were analysed, as well as indices of inflammation of the airway mucosa with special emphasis on the antigen presenting dendritic cell. Treatment of allergic asthmatic patients resulted in improvement of lung function (FEV₁), a decrease in bronchial hyperresponsiveness and a decrease of maximal airway narrowing. During the FP-treatment of COPD patients, FEV₁ remained stable, while FEV₁ deteriorated significantly in the placebo group. Therefore, steroid treatment may have a beneficial effect in COPD patients with bronchial hyperresponsiveness (BHR). Since immunohistochemical analysis of bronchial biopsy specimens from asthma and COPD patients show disease-specific aspects of inflammation, the anti-inflammatory effect of FP is obtained through modulation of different cell populations in asthma and COPD.     

Grass pollen immunotherapy for seasonal rhinitis and asthma: a randomized, controlled trial

BACKGROUND: Grass pollen immunotherapy significantly reduces hay fever symptoms and medication requirements. Effects on seasonal asthma are less clear, and concerns over safety persist. OBJECTIVE: The goal of this study was to assess the effects of grass pollen immunotherapy on symptoms, bronchial hyperresponsiveness, and quality of life in seasonal rhinitis and asthma. METHODS: Forty-four patients with severe summer hay fever (of whom 36 reported seasonal chest symptoms and 28 had seasonal bronchial hyperresponsiveness) participated in a randomized, double-blind, placebo-controlled, parallel group study. After symptom monitoring for one summer, participants received injections of a depot grass pollen vaccine (n = 22) or matched placebo injections (n = 22) in a rapid updosing cluster regimen for 4 weeks, followed by monthly injections for 2 years. Outcome measures included hay fever symptoms and medication use, health-related quality of life, and measurements of nonspecific bronchial responsiveness. RESULTS: Significant reductions were observed in the immunotherapy group compared with the placebo group in hay fever symptoms (49%, 15%; P =.01), medication scores (80%, 18%; P =.007), and seasonal chest symptoms (90%, 11%; P <.05). Impairment of overall quality of life (mean score of 7 domains) during the pollen season was less in the immunotherapy group than in the placebo group (median difference [95% CI], 0.8 [0.18-1.5]; P =.02). During the pollen season there was no change in airway methacholine PC(20) (provocation concentration producing a 20% fall in FEV(1)) in the immunotherapy-treated group (P =.5), compared with an almost 3 doubling-dose decrease in the placebo-treated group (P =.01, between-group difference). There were no significant local or systemic side effects during the study. CONCLUSION: Grass pollen immunotherapy improves quality of life in seasonal allergic rhinitis and reduces seasonal asthma symptoms and bronchial hyperresponsiveness.     

Cromolyn in extrinsic and intrinsic asthma

Cromolyn sodium was evaluated in 30 patients with intrinsic bronchial asthma and in 29 patients with extrinsic bronchial asthma using a double-blind crossover method. Each patient was studied during a base line, placebo, and cromolyn period. Daily evaluation was performed with regard to upper respiratory tract symptoms, lower respiratory tract symptoms, oral medication scores, use of sympathomimetic agents by aerosolization and peak expiratory flow rates measured 5 times a day. Weekly evaluation consisted of a physician's evaluation and a timed vital capacity. At the end of each test period spirometry, airway resistance and an exercise tolerance test were performed. Evaluation of the intrinsic asthmatic patients revealed significant improvement during the cromolyn period as compared to the placebo and base line periods with regard to the daily recorded variables and the physician's evaluation. Study of the other parameters showed no significant trend. Evaluation of the use of cromolyn in extrinsic bronchial asthma revealed no general trends for any of the parameters measured.     

Prognosis of occupational asthma induced by isocyanates

Several studies on the prognosis of isocyanate-induced asthma show that a significant proportion of patients continue to experience asthmatic symptoms and nonspecific bronchial hyperresponsiveness after cessation of work, and that further exposure to isocyanates in sensitized subjects leads almost invariably to persistence of respiratory symptoms and of bronchial hyperresponsiveness and the deterioration of airway function. Specific bronchial reactivity to isocyanates may change after cessation of work; however, some subjects continue to be sensitive to TDI several months after cessation of work. The determinants of an unfavourable prognosis for asthma seem to be the same as those for other types of occupational asthma due to low molecular weight compounds (i.e. red cedar asthma): long duration of exposure before the onset of asthma, long duration of symptoms before diagnosis, airway obstruction, and dual airway response after specific challenge tests. Also, single acute exposure to high levels of TDI in the workplace (spills) can result in persistent nonspecific bronchial hyperresponsiveness. Potential mechanisms of persistence of symptoms and of nonspecific bronchial hyperresponsiveness may be chronic inflammation, bronchial smooth muscle alteration, autonomic nervous system disregulation.     

Airway wall remodelling: the influence of corticosteroids

PURPOSE OF THE REVIEW: We have attempted to bring together recent findings, mainly from airway endobronchial biopsies, on the structural changes that constitute 'remodelling' in airway disease, with a particular focus on asthma. We have tried to put this into the context of classic studies on the asthma pathological phenotype. Having described these basic changes, we have then given an update on recent studies investigating the effects of corticosteroid medication on the different manifestations of remodelled airways. RECENT FINDINGS: The effects of corticosteroid on airway remodelling seem to vary a great deal; some aspects are steroid responsive while others are not, or less so. It is likely that different manifestations of remodelling require different doses and timescales for treatment to be effective. SUMMARY: Further longitudinal interventional studies are required, with multiple airway sampling times, to fully elucidate the full potential for corticosteroids to benefit remodelling of the airways in chronic inflammatory diseases. There needs to be more attention to pathophysiological and clinical correlations in such studies. It is likely that even when used optimally corticosteroids will have limited efficacy overall in this aspect of asthma pathogenesis. The search is on for newer and better treatments.