Asthma therapy in the United States in 1996

ABSTRACT Asthma is defined as a lung disease characterized by airway obstruction and/or narrowing. This condition is usually reversible, either spontaneously or with treatment. In addition, an important feature of the disease is airway inflammation. Attention to this is a major focus of therapy. Somewhat related to the inflammatory condition and somewhat to hereditary and environmental factors is the feature of airways hyper-responsiveness. Much of what is currently taught in the United States today concerning asthma pathophysiology and treatment emanates from guidelines that were issued in 1991 and that are currently being revised. This guideline initiative has been sponsored by the National Heart, Lung and Blood Institute (NHLBI) of the National Institutes of Health. As a large and influential government agency, the NHLBI has provided the financial and human resources to distribute important information to patients, their families and doctors. There are several aspects that should be stressed concerning these guidelines. The importance given to the concept of airway inflammation in contrast to the idea of simple bronchospasm being the main feature of asthma has already been highlighted. Related to this is the idea of early intervention with anti-inflammatory therapy rather than use of beta-agonist bronchodilators alone. It has been difficult to achieve acceptance of this concept by patients and physicians, because chronic use of a medication is foreign to many and is also costly. A great deal of the time of American asthma specialists is devoted to educating their patients on the importance of chronic anti-inflammatory therapy. Another important focus is the environment. The role of the housedust mite, indoor pets, molds and cock-roaches in increasing airway inflammation in allergic asthmatic patients is receiving growing attention. Diagnosing the allergic component of the disorder with allergy skin tests or RAST and then acting on the environment to remove major allergens is now considered to be of paramount importance. Another important aspect of care that has been overlooked in the past is the need to monitor pulmonary function with some regularity. This should be done at visits to both the asthma specialist and family doctor. Some patients require daily home monitoring with the use of a peak flow meter. Both patients and physicians have failed to recognize that significant airway obstruction can occur before there are symptoms. Pulmonary function monitoring is the only way that this situation can be tracked and recognized early in the development of an attack. American physicians are trained to believe that the success of their treatment plan depends on communication with patients and families. They generally recognize the need to simplify the regimen, to provide written information reinforcing their instructions, to repeat these at each visit, and to observe the patient who uses metered dose inhalers. Many communities in the US have support groups for patients and families with asthma, which allow people to come together to share their concerns and frustrations. This seems to enhance compliance with medical therapy, as patients feel they are more involved in their disease than if they were passive recipients of information. Federal programs are ongoing to assess the outcome of these support interventions.