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EDITORIALS: John Britton and Sarah Lewis Objective measures and the diagnosis of asthma BMJ 1998; 317: 227-228 [Full text]

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Tension between generalists and specialists

A J Wardlaw   (7 August 1998)

epidemiological versus clinical assessment of asthma

Henk Thiadens   (3 September 1998)

Tension between generalists and specialists 7 August 1998
A J Wardlaw Send response to journal: Re: Tension between generalists and specialists	Professor Britton and Dr Lewis1 are adopting a nihilistic position in suggesting that tests for asthma are of little value and that the diagnosis should be based on clinical criteria. The symptoms of asthma are very non-specific which is who so many of the patients we see in our clinics with a diagnosis of asthma turn out not to have the disease and are often being inappropriately treated. Asthma is now a well-defined disease, characterised by variable airflow obstruction, airway hyperresponsiveness and eosinophilic mucosal inflammation, caused in most cases by an aberrant immune response to inhaled allergens2. We would therefore take the opposite position to Britton and Lewis and suggest that clinicians should be much more pro-active in supporting a clinical suspicion of asthma with objective testing. We believe this should routinely include formal reversibility studies (home peak flow readings are insensitive, non-specific and have limited value in making a diagnosis3,4), measurement of airway responsiveness and assessment of airway inflammation, particularly using induced sputum to detect an airway eosinophilia5. Only in this way can we distinguish between asthma and the many other conditions which have a similar clinical presentation. Diagnosing asthma on clinical grounds alone is like diagnosing colitis from a change of bowel habit, or the cause of a PUO by feeling the patients' brow. Yours sincerely A J WARDLAW I D PAVORD SENIOR LECTURER/ CONSULTANT PHYSICIAN HONORARY CONSULTANT Department of Respiratory Dept of Respiratory Medicine Medicine Glenfield Hospital, Groby Road, Glenfield Hospital Leicester LE3 9QP 1 John Britton, Sara Lewis. Objective measures and the diagnosis of asthma. BMJ July 1998. No. 7153; 31:227-228 2 Wardlaw AJ. Asthma. Bios Scientific Publishers. 1993 UK 3 Siersted HC, Hansen HS, Hansen NG, Hyldebrandt N, Mostgaard g, Oxhoj H. Evaluation of peak expiratory flow variability in an adolescent population. Am J Respir Crit Care Med 1994; 149:598-60 4 Higgins BG, Britton JR, Chinn S, Cooper S, Burney PGJ, Tattersfield AK. Comparison of bronchial reactivity and peak expiratory flow variability for epidemiologic studies. Am Rev Respir Dis 1992; 145:588-93. 5 ID ID Pavord, MMM Pizzichini, E Pizzichini, FE Hargreave. The use of induced sputum to measure airway inflammation. Thorax 1997;52:498-501 measure airway inflammation. Thorax 1997;52:498-501
epidemiological versus clinical assessment of asthma 3 September 1998
Henk Thiadens, general practitioner Amersfoort The Netherlands Send response to journal: Re: epidemiological versus clinical assessment of asthma	Editor, We read with interest the editorial by Britton and Lewis about objective measures and the diagnosis of asthma.1 The editorial nicely illustrates the essential lack of one single parameter to diagnose asthma. However, most of the statements in their paper are based upon and refer to epidemiological research. The authors state that the value of measuring the degree of airways responsiveness and peak expiratory flow variability in assessing a diagnosis of asthma must be questionned, since these objective markers are also found in other diseases and even healthy people. Although we agree with the statement that measuring diurnal peakflow variability is not sensitive in primary care patients, evidence remains that almost all asthmatics show airways hyperresponsiveness especially when they present with symptoms. 2 For general practitioners diagnosing asthma is important to avoid overuse of antibiotics and underuse of adequate anti inflammatory treatment in order to improve the clinical state in an early phase. In many cases identifying (or excluding)asthma is possible by symptoms and physical examination only.3 Furthermore, GPs should perform spirometry (including bronchodilator response) and/or a provocation test in case of doubt, sometimes followed by a course of steroids. 3 Britton and Lewis state that longterm risk of airway hyperresponsiveness is unknown, although several papers have unambigeously shown its prognostic significance both in epidemiological and clinical setting.4,5 We would like to stress that this nihilistic attitude towards diagnosing asthma should not be advocated as a guideline for practical doctors treating patients presenting with respiratory symptoms, which are often non-specific. Henk Thiadens, general practitioner Plompstraat 3, 3815MV,Amersfoort. Dirkje Postma, professor, department of pulmonology, University of Groningen, the Netherlands References 1. Britton J, Lewis S. Objective measures and the diagnosis of asthma BMJ 1998;317:227-228 2. Cockcroft DW, Hargreave FE. Airway hyperresponsiveness. Relevance of random population data to clinical usefulness. Am Rev Respir Dis 1990;142:497-500 3. Thiadens HA, De Bock GH, Dekker FW, Huysman JAN, Van Houwelingen JC, Springer MP, Postma DS. Identifying asthma and chronic obstructive pulmonary disease in patients with persistent cough presenting to general practitioners: descriptive study. BMJ 1998;316:1286-1290 4. Xu X, Rijcken B, Schouten JP, Weiss ST. Airway responsiveness and development and remission of chronic respiratory symptoms in adults. Lancet 1997;350:1431-34 5. O Connor GT, Sparrow D, Weiss ST. A prospective longitudinal study of methacholine airway responsiveness as a predictor of pulmonary function decline: the normative aging study. Am J Respir Crit Care Med 152:1377-82