Difficult Asthma

Eds Stephen T Holgate, Homer Boushey, Romain Pauwels

Martin Dunitz, £65, pp 304

ISBN 1 85317 556 0

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Rating: ★★★★

“Difficult asthma” means very different things to different people. As Abisheganaden and Boushey point out in the first chapter, asthma is by definition “difficult” if you happen to suffer from it. The remainder of this multiauthor text focuses on another perspective—that of the clinician-scientist—and on asthma that is difficult for that person to manage. This is a good time for such a book. Research over the past two decades has placed inflammation at the centre of our understanding of the pathophysiology of the disease, and a new class of antiasthma drug, the antileukotrienes, is now available and is expected to find a major role in treatment.

An aside. Not so long ago, treatment by inhalation was triumphed as a major boon in asthma management as the drug is delivered direct to the target organ, with minimal delivery to other tissues. Now, the antileukotrienes are promoted as a major advance precisely because they are taken orally, and hence are more convenient for the user. Are we really becoming more patient centred, or have we changed our tune to suit the latest development?

Back to the book, and it makes fascinating reading. Here is an update on the role of the bronchial epithelium, the potential contribution of endogenous nitric oxide, and the influence of socioeconomic factors in severe asthma. The relations with gastrooesophageal reflux and vocal cord dysfunction are explored. Syndromes of brittle, nocturnal, glucocorticoid resistant, and drug induced asthma are discussed. The implications for prevention and treatment are rightly emphasised. And the epidemiology of “difficult asthma” is not forgotten.

Most people with asthma do not, however, have severe, massively disabling, or life threatening disease. Usually their symptoms are readily controlled with fairly simple regimens of inhaled drugs. To the generalist clinician, a book such as this offers insight into current understanding of disease processes, glimpses of the future, and a reminder that not all small brown birds are sparrows. However, it should not distract us too much from remembering that applying what we already know, systematically and carefully, will prevent many more patients' asthma from being “difficult.”