Asthma diagnosis and treatment
Advances in adult and pediatric asthma

https://doi.org/10.1016/j.jaci.2005.12.1353Get rights and content

This year we present updates on the management and therapeutics of asthma and research on the relationship of airway remodeling to clinically irreversible disease and continue a discussion about the origins of asthma. Significant advances are occurring in our understanding of the natural history of asthma, including the application of biomarkers and genetics. These tools should assist the clinician in defining patients at risk for significant morbidity related to asthma. Incorporating this knowledge will help prompt the development of more effective management techniques and new medications. Meanwhile, more effective health care strategies must be developed to reduce the reported disparities in asthma care noted in our patient populations.

Section snippets

Physiology: Airway remodeling

The irreversible obstruction in asthma noted in some patients is attributed to airway structural alterations resulting from airway remodeling.3, 4 The extent of remodeling varies among individuals and might explain the variable course of asthma. Recent emphasis has focused on the inflammatory and immunologically mediated aspects of remodeling as the primary determinants of asthma phenotype, with renewed attention to airway smooth muscle (ASM).3

Pepe et al5 examined airway structural changes in

Assessing clinical asthma

The clinical state must be accurately described to correlate histology with disease. A lack of consistency in the definitions of asthma12 and its severity13 and control14 were reported. Appleton et al12 compared the relative performance of reversibility criteria in different international guidelines in 4060 adults with and without a diagnosis of asthma. The different guidelines identified different groups of patients with asthma. Miller et al13 used Global Initiative for Asthma guidelines,

Reports relevant to childhood asthma and respiratory diseases

An April 2005 theme issue was devoted to pediatric asthma and highlighted the challenges we face in applying genetics and biomarkers to identify the onset of asthma, measure progression, and monitor treatment response.30

Exacerbations

Inflammatory mediators induced by viral infections could adversely affect lung development.42 Friedlander and Busse43 commented on the role of rhinovirus in asthma exacerbations. Risk factors for wheezing with colds include asthma and atopy, extremes in age, and perhaps having a deficient TH1 response to rhinovirus. Lemanske et al44 evaluated the relationship of viral respiratory tract infections during infancy to the development of subsequent wheezing, allergic diseases, or both in early

Obesity and asthma

Our high-calorie diets and lack of exercise promote obesity, which has reached epidemic proportions in children and adults in the United States and has been postulated to be associated with more severe asthma.52, 53 Several mechanisms for a causal relationship have been proposed; most suggest obesity is a risk factor for asthma, although clearly asthma could limit exercise and predispose to obesity. One set of theories suggests increased production of inflammatory mediators in adipose tissue.54

Biomarkers

Biomarkers might serve as predictors of response and monitors of response. Hartl et al61 reported that bronchoalveolar lavage CCR4+CD4+ and CXCR3+ cells and their ligands, thymus- and activation-regulated chemokine, macrophage-derived chemokine, and IFN-γ–inducible T-cell chemokine α chemoattractant, clearly differentiate asthmatic children from nonatopic children with chronic cough.

A report by the National Heart, Lung, and Blood Institute's Childhood Asthma Research and Education Network,

Conclusions

As indicated in this review of 2005 Journal publications, significant advances (Table I) are occurring in understanding the natural history of asthma, including the application of biomarkers and genetics. These tools should assist the clinician in defining patients at risk for significant morbidity related to asthma. Incorporating this knowledge will help prompt the development of more effective management strategies and the development of new medications. Meanwhile, more effective health care

References (81)

  • M.K. Miller et al.

    Severity assessment in asthma: an evolving concept

    J Allergy Clin Immunol

    (2005)
  • D.A. Stempel et al.

    Defining the responder in asthma therapy

    J Allergy Clin Immunol

    (2005)
  • M. Schatz et al.

    Relationships among quality of life, severity, and control measures in asthma: an evaluation using factor analysis

    J Allergy Clin Immunol

    (2005)
  • M.D. Cabana et al.

    Challenges in asthma patient education

    J Allergy Clin Immunol

    (2005)
  • C. Kim et al.

    Influences of earlier adherence and symptoms on current symptoms: a marginal structural models analysis

    J Allergy Clin Immunol

    (2005)
  • L.M. Rasmussen et al.

    Internet-based monitoring of asthma: a long-term, randomized clinical study of 300 asthmatic subjects

    J Allergy Clin Immunol

    (2005)
  • C.P. McSharry et al.

    Short and long-term effects of cigarette smoking independently influence exhaled nitric oxide concentration in asthma

    J Allergy Clin Immunol

    (2005)
  • P.J. Busse et al.

    Allergen sensitization evaluation and allergen avoidance education in an inner-city adult cohort with persistent asthma

    J Allergy Clin Immunol

    (2005)
  • J.P. Wisnivesky et al.

    Predictors of asthma-related health care utilization and quality of life among inner-city patients with asthma

    J Allergy Clin Immunol

    (2005)
  • A.A. Litonjua et al.

    Variation in total and specific IgE: effects of ethnicity and socioeconomic status

    J Allergy Clin Immunol

    (2005)
  • K. Eldeirawi et al.

    Associations of place of birth with asthma and wheezing in Mexican American children

    J Allergy Clin Immunol

    (2005)
  • D.R. Gold et al.

    Immigration to the United States and acculturation as risk factors for asthma and allergy

    J Allergy Clin Immunol

    (2005)
  • L.N. Bakhireva et al.

    Asthma medication use in pregnancy and fetal growth

    J Allergy Clin Immunol

    (2005)
  • C. Lemiere et al.

    Are inhaled corticosteroids taken during pregnancy harmless?

    J Allergy Clin Immunol

    (2005)
  • S.J. Szefler

    Facing the challenges of childhood asthma: what changes are necessary?

    J Allergy Clin Immunol

    (2005)
  • Y.J. Juhn et al.

    Mode of delivery at birth and development of asthma: a population-based cohort study

    J Allergy Clin Immunol

    (2005)
  • A. Adler et al.

    Decreased prevalence of asthma among farm-reared children compared with those who are rural but not farm-reared

    J Allergy Clin Immunol

    (2005)
  • R. Enriquez et al.

    The relationship between vaccine refusal and self-report of atopic disease in children

    J Allergy Clin Immunol

    (2005)
  • C.C. Johnson et al.

    Antibiotic exposure in early infancy and risk for childhood atopy

    J Allergy Clin Immunol

    (2005)
  • A. Simpson et al.

    IgE antibody quantification and the probability of wheeze in preschool children

    J Allergy Clin Immunol

    (2005)
  • J.E. Brussee et al.

    Allergen exposure in infancy and the development of sensitization, wheeze, and asthma at 4 years

    J Allergy Clin Immunol

    (2005)
  • E.A. Erwin et al.

    Cat and dust mite sensitivity and tolerance in relation to wheezing among children raised with high exposure to both allergens

    J Allergy Clin Immunol

    (2005)
  • S.H. Arshad

    Primary prevention of asthma and allergy

    J Allergy Clin Immunol

    (2005)
  • M. Chan-Yeung et al.

    The Canadian Childhood Asthma Primary Prevention Study: outcomes at 7 years of age

    J Allergy Clin Immunol

    (2005)
  • S.L. Friedlander et al.

    The role of rhinovirus in asthma exacerbations

    J Allergy Clin Immunol

    (2005)
  • R.F. Lemanske et al.

    Rhinovirus illnesses during infancy predict subsequent childhood wheezing

    J Allergy Clin Immunol

    (2005)
  • N.W. Johnston et al.

    The September epidemic of asthma exacerbations in children: a search for etiology

    J Allergy Clin Immunol

    (2005)
  • D.A. Stempel

    September epidemic of asthma exacerbations in children: a manifestation of persistent or episodic disease?

    J Allergy Clin Immunol

    (2005)
  • J.V. Williams et al.

    Human metapneumovirus infection in children hospitalized for wheezing

    J Allergy Clin Immunol

    (2005)
  • P.W. Heymann et al.

    Viral infections in relation to age, atopy, and season of admission among children hospitalized for wheezing

    J Allergy Clin Immunol

    (2004)
  • Cited by (0)

    Disclosure of potential conflict of interest: A. J. Apter has received grant support from the National Heart, Lung & Blood Institute of the National Institutes of Health. S. J. Szefler has consultant arrangements with AstraZeneca, GlaxoSmithKline, Aventis, Genetech, and Merck and has grants, research support, or both from the National Institutes of Health, the National Institute of Allergy and Infectious Diseases, and Ross Pharmaceuticals.

    View full text