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CLINICAL REVIEW: J Townshend, S Hails, and M Mckean Diagnosis of asthma in children BMJ 2007; 335: 198-202 [Full text]

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Asthma control instead of asthma severity

Lotte van den Nieuwenhof, Lisette van den Bemt   (1 August 2007)

Editorial blue pencil

Gabriel Symonds   (5 August 2007)

Asthma control instead of asthma severity 1 August 2007
Lotte van den Nieuwenhof, GP registrar Dpt of General Practice, Radboud University Nijmegen Medical Centre,P.OBox 9101,Nijmegen,Netherlands, Lisette van den Bemt Send response to journal: Re: Asthma control instead of asthma severity	In 28th July 2007 issue of the Journal, Dr. Townshend and colleagues review diagnostic procedures to diagnose asthma in children with wheeze and do recommendations to assess disease severity when children do not adequetely respond to initial treatment. (1) We agree with the authors that the listed investigations could contribute to more insight in securing the diagnosis and the disease severity of children. However, we would like to add that insufficient adherence to preventive measures, poor medical compliance and poor inhaler technique can also result in non adequate response to initial treatment.(2;3) Since, the suggested additional diagnostic procedures not only result in information, but also are inconvenient for the child (and parent), and cause economic burden for the society at large, unnecessary tests should be avoided. Furthermore, recent guidelines like the Global Initiative for Asthma (GINA) guidelines(4) have begun placing greater emphasis on the concept asthma control in stead of asthma severity. Although there is no universal definition for asthma control, it is generally considered to reflect disease activity expressed as fluctuations in symptoms and the degree to which these symptoms limit activities, disturb sleep or require the use of a rescue inhaler (eg short-acting ß agonist). As the goal for all patients with asthma is to achieve and maintain optimal asthma control, the diagnostic investigations of children with asthma should not only be focused on assessing asthma severity but also on assessing asthma control(4). The previously mentioned factors for treatment non-response (insufficient adherence to preventive measures, poor medical compliance and poor inhaler technique) are common in pediatric asthma and are related to poor asthma control.(5) Therefore during the diagnostic process of children with wheeze that do not respond to initial treatment, there is also need to collect information on these factors. Lotte van den Nieuwenhof, MD Lisette van den Bemt, MSc L.vandennieuwenhof@hag.umcn.nl Reference List (1) Townshend J, Hails S, McKean M. Diagnosis of asthma in children. BMJ 2007 Jul 28;335(7612):198-202. (2) van Schayck CP, Der Heijden FM, van den BG, Tirimanna PR, van Herwaarden CL. Underdiagnosis of asthma: is the doctor or the patient to blame? The DIMCA project. Thorax 2000 Aug;55(7):562-5. (3) Boulet LP. Perception of the role and potential side effects of inhaled corticosteroids among asthmatic patients. Chest 1998 Apr;113(3):587-92. (4) GINA Report. Global strategy for asthma management and prevention. National Institutes of Healt, National Heart, Lung, and Blood Institute. Revised 2006. www.ginasthma.com (5) Kuehni CE, Frey U. Age-related differences in perceived asthma control in childhood: guidelines and reality. Eur Respir J 2002 Oct;20(4):880-9. Competing interests: None declared
Editorial blue pencil 5 August 2007
Gabriel Symonds, General Practitioner Tokyo Send response to journal: Re: Editorial blue pencil	Never use a simple word when you can use a complicated one. The word "phenotype(s)" in relation to asthma occurs no less than eight times in this article. A phenotype is the entire physical, biochemical, and physiological makeup of an organism produced by the interaction of genes and the environment, or the expression of a single gene or gene pair. It cannot properly be applied to a symptom, physical sign, or diagnosis. I wonder what meaning the authors intend to convey by, for example, "Different phenotypes of wheeze are seen in childhood." which would not be more clearly put as "Different types of wheeze are seen in childhood."? Competing interests: None declared