Albert M Li

Abstract

The prevalence of asthma and other allergic diseases has increased dramatically worldwide over the last few decades though some researchers may argue that the condition seems to have reached a plateau. However, asthma is still responsible for a significant degree of morbidity and more importantly, a great proportion of our clinical workload. The aim of asthma management is relief of symptoms and suppression of on-going airway (usually eosinophilic) inflammation. To this end, no drugs are more successful in achieving this than inhaled corticosteroids (ICS), and their use has heralded an effective and relatively safe management for the many patients who suffer from asthma.

The care for infants and small children with wheezing episodes is a different story, and has been a challenging endeavor because of the multiple issues one has to tackle, namely selection of suitable patients for intervention, correct choice of medications, route of administration of medications, and lack of objective markers to assess disease control. The management of wheeze in infancy has largely been ignored in the asthma guidelines despite evidence suggesting different aetiology and response to treatment when compared to older children. Many a times I see referrals of infants given ICS for their episodic (viral) wheeze. These children are very well in between episodes, and usually without a parental history of asthma or markers of atopy. The use of ICS in this group of patients raises questions as to their effectiveness and possible long-term complications.

The first issue of 2010 edition of the Journal kicks off with an article on "Pre-school wheezers: not small asthmatic children" by Professor Andrew Bush from the Royal Brompton Hospital, London. The material included in the article was presented at the 19th James Hutchison Memorial Lecture. Professor Bush elaborated on the pros and cons of different ways in phenotyping pre-school wheeze and introduced the useful European Respiratory Task Force approach which classifies pre-school wheezers into episodic or multiple trigger types. As he puts it, this classification helps in planning treatment. He further explained mechanism of pre-school wheeze using physiological, pathological and epidemiological research findings. Episodic wheeze is classically a viral driven neutrophilic process and this explains why ICS does not work. Professor Bush went on to present evidence-based data on management, looking at ways albeit few if any to modify the course of disease and his own approach in the symptomatic treatment of this group of "difficult" patients. In his concluding remark, he quite rightly pointed out that "the paediatrician managing the pre-school child with wheeze needs to remember that this is different from asthma in school age children, and therefore there need to be some differences in approach."

While wheezing is commonly considered synonymous with asthma, the standard reminder among health professionals is, "All that wheezes is not asthma."