Asthma management is generally dete...

Asthma management is generally determined on clinical features that do not necessarily correspond to the step of airway inflammation. Sputum eosinophilia is an early indicator of lower airway inflammation, developing several weeks prior to clinical exacerbation of symptoms. undecayed and colleagues tested a novel approach of guiding asthma management on eosinophilia rather than symptoms or clinical measurements, in the same state [i]or[/i] condition as peak flow readings.

The investigators recruited patients 18 to 75 years of age with asthma who were attending three specialist clinics in Great Britain. The patients were required to have no significant comorbidity (including smoking) or late severe exacerbations and were assessed by way of their physicians as likely to adhere to the inquiry protocols. All of the patients met criteria for moderate to rigorous asthma. During an initial two-week period, baseline function was assessed while receiving usual treatment. Seventy-four patients were then randomly assigned to management based forward British Thoracic Society (BTS) guidelines or eosinophilia. In the BT assign places to management was based on symptoms, peak expiratory run and use of beta agonists. In the eosinophilia assemblage management was determined by an algorithm designed to maintain the cast below 3 percent with the minimum dose of anti-inflammatory treatment. All patients were assessed monthly for four month then each two months for one year.

The assign places tos were well matched. Thirty-four patients in each form into groups completed the study. No patients withdrew because of side results or poor control of symptoms. The eosinophilia-managed assign places to had significantly fewer severe clinical exacerbations (35 compared with 109) and fewer save courses of oral corticosteroids (24 compared with 73) than the BTS-managed clump In the BTS group, 26 patients had more than single in kind exacerbation during the year compared with 18 patients in the eosinophilia-managed group

The arranges differed significantly in hospital admissions for asthma (one in the eosinophilia assign places to and six in the BT group) The collections did not differ in measures of quality of life, use of long-acting beta agonists, leukotriene antagonists, or mean dose of corticosteroids. The sputum eosinophil estimate was 63 percent lower during the year in the sputum management group

The authors end that management directed at normalizing the sputum eosinophil reckon effectively reduces asthma exacerbations and hospital admissions. They call for further research and testing of management strategies targeting the basic inflammatory pathology of asthma, rather than the "downstream" symptom complexe They anticipate that this approach could improve quality of life and shape morbidity, mortality, and costs attributable to asthma.

verdant RH, et al. Asthma exacerbations and sputum eosinophil counts: a randomised controll trial. Lancet November 30 2002;360:1715-21

EDITOR'S NOTE: Physicians and patients find the existing management of asthma frustrating. As with principally recurrent conditions, patients frequently wait to diocese how bad an exacerbation is going to be before initiating or increasing treatment. Health professionals find this perplexing and are further frustrated at frequently having to make treatment decisions based onward subjective reports of symptoms. "Just a certain wheezing" for some patients means a becoming increase in symptoms, while for others it indicates impending respiratory failure. This investigation holds out the prospect of an earlier and more scientific monitoring regularity Will patients come in for regular "eo counts?" Will self-testing kits become available? individual benefit of such an advance would be a reduction in the "blame game" between patients and physicians. Whatever happens, the in the greatest degree vulnerable patients may be the least likely to benefit. As physicians, we must find ways to make advances understandable, acceptable, affordable, and accessible to those patients with the fewest resources. This takes more than currency It involves making patients have feeling safe, welcome, and cared for regardless of their situation or behaviors.--A.D.W.

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