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Editor,—Professor Silverman and Dr Wilson propose to use the diagnosis ‘asthma’ in children only when it is accompanied by a description of qualifying features such as the pattern and severity of the disease and possible causative or aggravating factors.1 As much as their suggestion deserves endorsement, both from a clinical and a scientific point of view, history has taught that getting physicians to accept such an approach may be very difficult, or even impossible.
In 1961, Professor Orie in Groningen considered that it is often very difficult to separate asthma from chronic obstructive pulmonary disease (COPD) in adults. Moreover, the two diagnoses could be encountered in the same patient over time. Finally, the approach to treatment to both disorders was often the same.2 He, therefore, proposed to use an umbrella term, chronic non-specific lung disease (or CARA in Dutch) for patients with asthma or COPD, provided it was accompanied by defining criteria (at that time considered to be allergy, airways hyper-responsiveness, and reversibility of airways obstruction). He hoped that this approach would improve communication between doctors and, eventually, patient care.
Unfortunately, he was wrong. The ‘Dutch hypothesis’ was strongly opposed, especially from the UK and the USA, by physicians who found it incomprehensible that the Dutch would lump together two diseases so obviously different as atopic asthma and chronic bronchitis.3 In practice, it turned out to be impossible to get doctors to use comprehensive defining criteria to describe individual patients, simply because doctors want simple diagnostic labels that can be communicated quickly.4 This has led to the unfortunate practice of giving a diagnosis of ‘CARA’ to any patient with cough and/or wheeze in our country for a number of years. Over the past five years or so the Dutch have learned their lesson and the term ‘CARA’ is being abandoned now, being replaced by more traditional diagnoses such as asthma and COPD.
The parallel to childhood asthma as illustrated by Silverman and Wilson is obvious. Their suggestion of using ‘asthma’ as an umbrella term only when accompanied by a description of the disease in more detail, logical and balanced as it is, is going to be difficult to implement in practice. It requires extra work and discipline from busy practising physicians who prefer economic communication in short labels.
Only if practitioners can be convinced that the approach proposed by Silverman and Wilson is going to be useful and meaningful in patient care will it have a chance of succeeding.
I sincerely hope that the time is more right for asthma with descriptive features in 1997 than it was in 1961. I wish Silverman and Wilson much support from paediatricians. They can count on the Dutch!
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