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Dr. Speir is Professor of Medicine, Section of Pulmonary and Critical Care Medicine, Medical Director, Medical Intensive Care Unit, Medical College of Georgia.
Correspondence to: William A. Speir, Jr., MD, FCCP, Section of Pulmonary and Critical Care Medicine, Medical Director, Medical Intensive Care Unit, Medical College of Georgia, Augusta, GA 30912-3135
Asthma is a strange disease. It is a heterogeneous syndrome characterized by hyperreactive airways. Definitions of asthma are largely unsatisfactory, and, if the reported trends of increased morbidity and mortality are correct, the present approaches to management of the disease called asthma are largely unsatisfactory for many patients.
It would be ideal if all patients responded to our ministrations as they should. Medical treatment could be reduced to easily followed stepwise algorithms. Unfortunately, individual patients have a propensity for fickleness, and individual patients with asthma are more fickle than most. The heterogeneous nature of the syndrome does not lend itself to rigid stepwise algorithmic approaches.
The asthmatic patients referred to me and my colleagues for outpatient management are often "brittle," difficult to manage, and require a great deal of attention and frequent changes in therapy. They invariably have perennial asthma, precipitated by exposure to a variety of nonspecific airway irritants. Most are referred because of frequent exacerbations. A number of these patients merely require an aggressive approach to maintenance therapy. Many patients, however, have confounding factors. The most common is untreated or undertreated sinusitis/rhinitis with postnatal drainage. Recognition and vigorous treatment of this complicating condition may dramatically reduce the frequency and severity of asthmatic attacks. Unfortunately, quite a few referrals are asthmatic outliers with perennial asthma who do not respond well to any of the current approaches to therapy, alone or in combination.
It has been known for years that patients, patients’ families, and patients’ physicians frequently underestimate the severity of asthma.1 2 3 Despite the widespread use of peak flowmeters in the home, I think the tendency is still to underestimate the severity of the disease in adults. Perhaps my view is skewed. Quite often, my first encounter with an individual asthmatic patient is in the medical ICU, and most of these patients require intubation and mechanical ventilatory support. Each patient seems to have a similar story: a failure to recognize the severity of the disease, leading to undertreatment.
Years ago, our therapeutic armamentarium was limited. Now
long-acting ß2-agonists, supplemented with effective
shorter-acting ß2-agonists as well as improved inhaled
corticosteroids, are available. Newer drugs for preventing acute
exacerbations include antagonists of metabolites of both lipooxygenase
and cyclooxygenase arms of the arachidonic acid pathway. Leukotriene
inhibitors have proven quite effective in some patients. In this issue
of CHEST (see page 73), Tamaoki et al present data on the
efficacy of a thromboxane 
2-receptor antagonist in
reducing the quantity and viscosity of sputum in stable asthmatics.
Theophylline, long out of favor as a therapy for adults, has an
immunomodulatory effect at low doses and should be
readdressed.4
Manipulation of the variety of therapeutic
modalities now available, in order to provide the most effective
program for the individual patient with asthma, will undoubtedly be
helpful in preventing acute exacerbations. However, our ongoing
assessment of the severity and "brittleness" of a patient’s
disease must improve if we are to reduce morbidity and mortality.
As an intensivist who sees the morbidity and mortality of asthma almost daily, I remain convinced that regularly scheduled inhaled bronchodilators are the mainstay of maintenance therapy in all but the very mildest of asthmatic patients ("the open airway approach"). Both ß2-agonists and anticholinergic bronchodilators, alone or preferably in combination, are effective in patients with asthma (the dichotomy, ß2-agonists for asthma, anticholinergics for COPD, does not hold).
My major concern is that patients with the disease called asthma be treated individually and vigorously, that tapering doses of systemic corticosteroids be used early and liberally with exacerbations, and that the severity of the patient’s disease not be underestimated. I would be happy never to admit another patient with status asthmaticus to my unit.
References
This article has been cited by other articles:
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  L.-P. Boulet, D. W. Cockcroft, and W. A. Speir Jr Regularly Scheduled Inhaled Bronchodilators and Maintenance Asthma Therapy Chest, March 1, 2001; 119(3): 987 - 988. [Full Text] [PDF]
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