Proactive asthma care in childhood: general practice based randomised controlled trial

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.

Barbara Rubin

New York, USA

Competing interests:  
None declared