National Asthma Education and Prevention Program guidelines: what is new?

New guidelines for the diagnosis and management of asthma were released in 2007. Separate recommendations are presented for three separate age groups (ages 0–4, 5–11 and ≥ 12). Six pharmacologic steps of therapy are defined for each age group. Severity is assessed in patients not on long-term control medication as a guide to initiating therapy. Control is assessed in patients on long-term control therapy to determine whether a step up, no change or a step down in therapy is indicated. Before increasing pharmacologic therapy in patients with uncontrolled asthma, adverse environmental exposure, poor adherence and inadequately treated comorbidities should be considered as targets of therapy. Guidelines for the management of asthma exacerbations are also presented.     

EAACI position statement on asthma exacerbations and severe asthma

Asthma exacerbations and severe asthma are linked with high morbidity, significant mortality and high treatment costs. Recurrent asthma exacerbations cause a decline in lung function and, in childhood, are linked to development of persistent asthma. This position paper, from the European Academy of Allergy and Clinical Immunology, highlights the shortcomings of current treatment guidelines for patients suffering from frequent asthma exacerbations and those with difficult‐to‐treat asthma and severe treatment‐resistant asthma. It reviews current evidence that supports a call for increased awareness of (i) the seriousness of asthma exacerbations and (ii) the need for novel treatment strategies in specific forms of severe treatment‐resistant asthma. There is strong evidence linking asthma exacerbations with viral airway infection and underlying deficiencies in innate immunity and evidence of a synergism between viral infection and allergic mechanisms in increasing risk of exacerbations. Nonadherence to prescribed medication has been identified as a common clinical problem amongst adults and children with difficult‐to‐control asthma. Appropriate diagnosis, assessment of adherence and other potentially modifiable factors (such as passive or active smoking, ongoing allergen exposure, psychosocial factors) have to be a priority in clinical assessment of all patients with difficult‐to‐control asthma. Further studies with improved designs and new diagnostic tools are needed to properly characterize (i) the pathophysiology and risk of asthma exacerbations, and (ii) the clinical and pathophysiological heterogeneity of severe asthma.     

Asthma diagnosis and treatment: filling in the information gaps

Current approaches to the diagnosis and management of asthma are based on guideline recommendations, which have provided a framework for the efforts. Asthma, however, is emerging as a heterogeneous disease, and these features need to be considered in both the diagnosis and management of this disease in individual patients. These diverse or phenotypic features add complexity to the diagnosis of asthma, as well as attempts to achieve control with treatment. Although the diagnosis of asthma is often based on clinical information, it is important to pursue objective criteria as well, including an evaluation for reversibility of airflow obstruction and bronchial hyperresponsiveness, an area with new diagnostic approaches. Furthermore, there exist a number of treatment gaps (ie, exacerbations, step-down care, use of antibiotics, and severe disease) in which new direction is needed to improve care. A?major morbidity in asthmatic patients occurs with exacerbations and in patients with severe disease. Novel approaches to treatment for these conditions will be an important advance to reduce the morbidity associated with asthma.     

Asthma in the older adult: presentation,considerations and clinical management

Asthma affects older adults to the same extent as children and adolescents. However, one is led to imagine that asthma prevalence decreases with aging and becomes a rare entity in the elderly. From a clinical perspective, this misconception has nontrivial consequences in that the recognition of the disease is delayed and the treatment postponed. The overall management of asthma in the elderly population is also complicated by specific features that the disease develops in the most advanced ages, and by the difficulties that the physician encounters when approaching the older asthmatic subjects. The current review article aims at describing the specific clinical presentations of asthma in the elderly and highlights the gaps and pitfalls in the diagnostic and therapeutic approaches. Relevant issues with regard to the clinical management of asthma in the elderly are also discussed.     

Asthma and autoimmunity: a complex but intriguing relation

Asthma and autoimmune diseases apparently have little to share except for the involvement of the immune system in both types of disorder. However, epidemiological studies have shown that asthma and Type 1 diabetes, a typical autoimmune disease, are associated at the population level, and some experimental findings have suggested that autoimmune mechanisms might be operating in asthma as well. Female preponderance, increased incidence of antinuclear autoantibodies and detection of autoantibodies against either bronchial epithelial antigens or endothelial antigens in patients with nonallergic asthma suggest that the disease may have an autoimmune basis. Approximately 50% of patients with nonallergic asthma react to intradermal injection of autologous serum, indicating the presence of circulating vasoactive factors and suggesting an autoreactive mechanism. Recent findings in experimental animals support the involvement of an autoreactive mechanism in allergic asthma as well, indicating that human α-nascent polypeptide-associated complex, identified as an IgE-reactive autoantigen, has the potential to sensitize and induce immediate skin reactions and airway inflammation. In summary, asthma is a heterogeneous disorder characterized by chronic inflammation of the respiratory airways that can be triggered by allergen exposure or by other mechanisms, possibly autoreactive/autoimmune. The autoimmune hypothesis is further, indirectly, supported by the response to immunosuppressive drugs.     

Work-related asthma: a case-based approach to management

The management of work-related asthma has some differences from management of other asthma. Components of management include not only making as accurate a diagnosis as possible, identifying the causative agent or triggers at work, and managing the asthma with pharmacologic treatment as for other patients with asthma, but also advising on the appropriate work changes that may be needed, assisting the worker with appropriate compensation claims, and supporting protective measures for?coworkers. This article discusses the approaches that may be taken for patients with different forms of work-related asthma.     

Prevalence of asthma and asthma symptoms in a general population sample from northern Italy

The European Community Respiratory Health Survey is an international survey of the general population which aims to establish whether there are significant variations in the prevalence of asthma among European countries. The present paper reports the prevalence of asthma and asthma-like symptoms in a sample of subjects living in three areas of northern Italy: Turin, Pavia, and Verona. Samples of residents 20–44 years old (3000 subjects in Turin and Verona and 1000 in Pavia) stratified by sex (M:E= 1/1) were randomly selected from local health authority lists in the three participating areas. To correct the observed prevalence estimate for nonresponse bias, a method proposed by Drane was applied. Of the sampled subjects, 86% (6031) participated in the survey. Two different definitions of asthma were adopted: 1) prevalence of asthma attack in the last 12 months; 2) prevalence of asthma attack or treatment with antiasthmatic drugs, or both wheezing apart from the common cold and wheezing with shortness of breath. This combination of symptoms has been called current asthma. According to these definitions, the prevalence of asthma attack was 3.47% (3.74%, in men and 3.14% in women), and the prevalence of current asthma was 5.01% (5.07% in men and 4.90% in women). The lowest prevalence was found in Pavia; the highest in Turin. Our findings support the hypothesis that the difference in prevalence reflects the difference in mortality.