Proactive asthma care in childhood: general practice based randomised controlled trialBMJ 2003; 327 doi: https://doi.org/10.1136/bmj.327.7416.659 (Published 18 September 2003) Cite this as: BMJ 2003;327:659
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To the Editor,
Re: BMJ article, Sept '03
Proactive asthma care in childhood: general practice based randomised controlled trial by Glasgow, Ponsonby, Yates, Beilby and Dugdale.
It is gratifying to see heightened interest in chronic asthma, an increasingly prevalent illness throughout developed countries. Proactive strategies are undeniably the correct approach to take in all disease processes but are of particular importance in asthma, since so many attacks can be prevented through our awareness of triggers for bronchoconstriction.
This brings us to an inherent contradiction in the medical management of asthma, once we acknowledge the many environmentally induced attacks which occur daily in the lives of asthmatics and the medications used to respond to them. In the above referenced article, some benefits accrued to the experimental group. However, control and experimental groups did not show significant statistical differences in reports of ER visits, symptom-free days or continued symptoms of wheeze, night time symptoms, and restriction of activities. The authors did recommend the evaluation of patients for triggers as per allergy protocols (e.g. RAST testing).
The contradiction in this medical model is as follows: Most marketed personal care products, cleaning solvents, articles of clothing, air fresheners, construction materials etc., contain respiratory irritants either listed on the label or the MSDS sheet. Many products which do not offer disclosure of ingredients on their labels (e.g. synthetic "fragrances"), for reasons of "trade secrets", are nevertheless proven asthma triggers. The American Medical Association and the American Lung Association have published statements to that effect.
Introduction of such irritants to the lungs leads to bronchoconstriction, a natural protection mechanism. We then administer bronchodilators to relieve symptoms which permit the bronchi to open further and permit deeper penetration of offending substances into lung tissues. This results frequently in inflammation, which then calls for administration of steroids. The cycle repeats itself again and again but should not be regarded as a necessary component of asthma. In such a case, these extrinsically triggered asthma attacks are not preventable by medication, only mitigated by it.
True prevention in these mainly non-allergic, reactive asthma events must take place in the marketplace rather than the pharmaceutical laboratory. Medical groups must demand government regulatory agencies require safety testing of all chemicals prior to marketing (much as current EU legislation now requires). In the absence of such rigorous attention to the public health, the public must be entitled to full disclosure of the ingredients of all products being marketed. Choice depends upon disclosure. Most consumers do not know that fragrances may contain toluene or benzene derivatives; that air fresheners can contain naphthelene; that clothing may be treated with formaldehyde (released during ironing), that pesticides contain carrier solvents and synergists which were not part of registration testing etc.
Doctors can recommend patients familiarize themselves with these threats posed by the environment but change must be addressed at the source. Physician's groups may make their greatest contribution to the management and prevention of asthma by lobbying government and industry to alter manufacturing and labelling policies.
In the meantime, avoidance strategies recently investigated in the New England Journal of Medicine, must play a larger role in management plans. This can reduce reliance upon drugs which have deleterious short and long term side effects and basically profit the same companies which manufacture products inducing asthma. Studies of IgE mediated vs. non-allergic asthma conditions would also go far towards identifying these terrible threats to the public health at every stage of life.
New York, USA
Competing interests: No competing interests
Prompting GPs to provide the 3+ visit plan for children (reference 1)
results in children having more consultations, more written asthma plans,
but no important differences in outcomes.
Finding ‘effective ways to help people follow medical treatments
would have far larger effects on health than any treatment itself'
(reference 2). Conventional structured care that requires children to
attend on a regular basis is disease-centred and may suit only those
children and parents who regard asthma as a chronic disease (reference 3).
Most children and their parents with mild or moderate asthma manage their
asthma as an intermittent acute disorder, and may have no desire for a
written action plan, or a regular review. A proactive regular review of
care can help, but many patients only respond to prompts and help when
they realise they have a problem. They may learn most when they have the
A more patient-centred approach could be based on health behaviour
change(reference 4), learning (reference 5) and continuous quality
improvement theories (reference 6). Neglecting these principles delays
providing children with the structured care they need when they seek help.
Clinicians will be challenged to accept that patients reactive behaviour
is appropriate, and structure care so that whenever, wherever or whoever
the patients consult their immediate needs are met and a reactive regular
review of care provided. Proactive care does not suit reactive people.
1 Nicholas J Glasgow, Anne-Louise Ponsonby, Rachel Yates, Justin Beilby,
and Paul Dugdale. Proactive asthma care in childhood: general practice
based randomised controlled trial. BMJ 2003; 327: 659-0
2 Haynes RB, McKibbon KA, Kanani R, Brouwers MC, Okuver T. Interventions
to assist patients to follow prescriptions for medications (Cochrane
Review). In: The Cochrane Library, Issue 3. Oxford: Update Software. 1998.
3 Paterson C. Britten N. Organising primary health care for people with
asthma: the patient's perspective. British Journal of General Practice
2000; 50: 299-303.
4 Prochaska JO, Velicer WF. The transtheoretical model of health behavior
change. American Journal of Health Promotion 1997; 12: 38-48.
5 Slotnick H. How Doctors Learn: Education and Learning across the Medical
-school-to-practice Trajectory. Acad Med 2001; 76: 1013-1026.
6 Batalden PB, Stoltz PK. A framework for continual improvement of health
care. The Joint Commission Journal on Quality Improvement 1993;19;424-447.
Competing interests: No competing interests