The following are unresolved  medical issues involving the diagnosis and treatment of Bronchial Asthma.

What is resolved, is well known to every certified Allergist, and is known or should be known to all physicians treating asthma - especially to Pulmonologists - is that most Bronchial Asthma  is allergic in origin and requires comprehensive diagnosis and management, including allergy immunotherapy in all but minor and sporadic cases.

The following are issues and my current professional opinions regarding those issues, based upon abundant relevant reading and upon long and continuing clinical experience.  Some of the research is reviewed in this web site’s sections on  Bronchial Asthma and in the section entitled “Wazzup - New and Notable”.

• Bronchial Asthma is one of the most under-diagnosed, under-treated and poorly treated serious medical conditions afflicting  the world today.  This is in spite of the abundance of information, diagnostic methods,  treatment modalities and professional “consensus statements” available.  This is a medical disgrace. It is highly treatable; its deterioration can be halted and in many cases reversed; its clinical manifestations can often be “cured” by treating the underlying causes; and it can be lethal, sometimes with little warning.  Any physician who does not recognize this and act accordingly is a danger to his patient and to himself.
• There can exist a substantial difference (a “discordance”) between absent clinical symptoms and normal pulmonary function studies, on the one hand, and the existence of airway hyper-reactivity, inflammation and remodeling (scarring), on the other hand.  Therefore, it is important to look for inapparent “twitchy lungs” in all cases of upper as well as lower respiratory allergies and also in patients with “COPD”, emphysema, and even “just a cigarette cough”.
• The existence of non-invasive testing for airway inflammation - the hallmark of injury, scarring and chronicity - now demands the broader use of such methods in clinical practice as well as in clinical research.  One such method is the measurement of “exhaled Nitric Oxide” as a marker of inflammation.
• Substantial airway inflammation may exist and  persist despite what appears to be clinically adequate control with optimum medications including inhalational - and even oral - corticosteroids.  This may give a false sense of security to physician and patient alike.
• There is some evidence and concern that, although corticosteroids (preferably inhaled) should be the mainstay of medicinal treatment of established Bronchial Asthma,  they may not only not adequately suppress the on-going inflammation - they might actually contribute to airway remodeling through their varied actions on connective tissue.  This is an area of active research, for obvious reasons.
• A related observation is that the atrophic (skin-thinning) effects of topical corticosteroids (creams and ointments) are more pronounced in normal skin than in inflamed skin.  This raises a concern regarding whether, when, and for how long  to add the use of inhaled steroids to the treatment of an asthmatic child.  It is all the more important in view of findings from the University of Arizona which emphasize the difficulty in identifying which  wheezing infants and children  will or  will not proceed to persistent asthma.
• “Steroid - Resistant Asthma”,  in which  the patient derives little or no benefit from steroid use, is a serious medical challenge.  In this regard, several points should be noted: 1) Steroid resistance is often not permanent...it may come and go; 2) Steroids not benefiting the asthma may nevertheless be causing progressive and potentially serious side-effects on other tissues of the body; 3) A steroid that rarely is ineffective, even in otherwise “steroid resistant asthmatics”, is Betamethasone (celestone)...a very potent agent which can have its own problems but which is often very useful in these circumstances.  4)  IVIG (intravenous gamma-globulin)  has been found to be useful as a steroid-sparing agent.
• Whether to use B2 bronchodilators like albuterol (proventil, ventolin) or salmeterol (serevent) on a regular or “as needed” basis is controversial.  In my opinion, their regular use leads to tolerance and  a progressive decline in  effectiveness.  Albuterol should be used only as needed and as “rescue medication”.  Serevent should be used, in selected cases, only at night.  Also, Atrovent is a different class of bronchodilator that is not subject to this problem and that can be very useful - on a regular basis - in that 30-40% of patients with asthma and COPD who respond to it.
• A special category of asthmatics appears to be well controlled  on good treatment - until a pulmonary function test is performed...revealing marked improvement after bronchodilator despite the apparent control including corticosteroids.    These patients have been found on proper testing to be having progression of their airway inflammation - and later remodeling - without obvious signs.  They require much more aggressive anti-inflamatory treatment  with objective end-points.
• The “Hygiene Theory” is alive and well, describing the “beneficial” effect of bacterial infections in early childhood in reducing the allergic predisposition of some of these children (through the preferential selection of Th1 cells over Th2 cells).  This has given some research legitimacy to the long-standing clinical efficacy of “stock bacterial vaccine” used in some children with recurrent acute asthmatic bronchitis and with recurrent ear infections and fluid.  A related finding is that staphylococcus toxin,  and  other bacterial  “super-antigens” and endotoxins  can contribute to chronic inflammation.  These observations should lead to related therapeutic interventions.  In fact, a product called “staphylococcal toxoid” was effective in treating patients with recurrent “boils” and other staph. infections - until it was taken off the market in the 1960’s because of “lack of proven efficacy”,  as was “stock bacterial vaccine”more recently.  This entire area should be reviewed once again by the FDA.  It must be remembered that many of our long-standing and current standard medications came to general use after astute clinical, rather than laboratory, observation (smallpox vaccination, digitalis, quinine, atropine, morphine, coumadin, aspirin...).
• The leukotriene-inhibitors (Accolate and especially Singulair)  have become  very useful additions  to  our treatment of Bronchial Asthma, again operating to reduce the inflamatory processes that are basic to the  clinical picture  and the damage of this  disease process.

FOR YOUR HEALTH CARE...CHOOSE, DON’T SETTLE

GS