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Editor,—In his robust defence of the term asthma,1 Dr Speight has failed to grasp the significance of the changed definition of this term. The original definition of asthma was purely functional: “airway obstruction which varies over the course of time and with treatment”.2 In small infants in whom lung function measurements are not usually available, this was modified to “cough and/or wheeze in a setting where asthma is likely, and other rarer conditions have been excluded”.3 By this definition, few would quarrel with Dr Speight’s wish1 to retain the term for infant wheezing.
Unfortunately, to use Asher’s words,4 “an abominable semantic crime has been committed, a single term has knowingly been applied to two completely different things without making the slightest effort to determine if the one is the equal to the other, or even related to the other. A pathological process and a collection of symptoms have been given the same name”. Asthma is now defined as “a chronic inflammatory disorder of the airways in which many cells play a role, including mast cells and eosinophils”5 or “a common and chronic inflammatory condition of the airways whose cause is not completely understood”,6 and by these definitions many of the infants whom Dr Speight labels as asthmatic have no such condition. This is not merely of theoretical importance, because there is abundant evidence that earlier treatment of T lymphocyte driven, eosinophil mediated airway inflammation with inhaled corticosteroids is beneficial both in terms of immediate symptomatic benefit and long term preservation of lung function.7 8Confusedly labelling infants who wheeze with colds as asthmatic, with the implication of airway inflammation, will result in exactly the same treatment policy being advocated for them, despite evidence that there is no benefit either on acute symptoms9 or long term lung function.10 The safety record of inhaled steroids is impressive, but even in the short term, there is evidence that overtreatment causes harm which is not reversed on stopping therapy.11 Furthermore, the fiscal cost of the medications is not small and the long term effects are sufficiently imponderable as to make this not a subject for complacency.
The issues may be different if the sole concern is the laudable one of ensuring acutely ill children get ambulances quickly. Speed is of the essence, and accuracy less relevant. In this setting, the use of the term is justified, and has in the past been absolutely invaluable. In 1997, between consenting adults in the cold light of day, the use of the unqualified term asthma is indefensible, unless the clock be turned back and the old definition restored.
Dr Speight comments:
In his indignation Dr Bush attacks not only my position but that of Professor Silverman and Dr Wilson. In their article Professor Silverman and Dr Wilson argued that it is perfectly reasonable in clinical practice to both label and treat episodic viral wheeze as “asthma”.1-1 Crucially, they pointed out that in early childhood it may prove impossible to distinguish between a future moderately severe perennial atopic asthmatic and a mere episodic viral wheezer (and of course both may wheeze in response to viruses).
The sheer practical value of using “asthma” as an umbrella concept far outweighs Dr Bush’s academic objections. Just because successive committees have changed the definition of asthma from (a) a clinical definition to (b) one based on bronchial hyperactivity to (c) one which emphasises inflammation, does not mean that any doctor who objects on the grounds of common sense should be cast into outer darkness. Neither should we necessarily assume that no one will ever be allowed to revise the definition of asthma again as if the 1992 statement was written in tablets of stone. If Dr Bush is really losing sleep over his fears that some children may receive inhaled steroids unnecessarily, surely he should concentrate his efforts on arguing (as I would) against their use in mild episodic wheezing/asthma.
I personally lose far more sleep over the prospect of a return to the bad old days when children had to earn the diagnosis of “asthma” the hard way, with general practitioners and district paediatricians inhibited in their use of the word for fear of having their wrists slapped by someone in a teaching centre. In our survey of childhood asthma deaths,1-12 two of the children who died under the age of 5 years had an official diagnosis at the time of death of “wheezy bronchitis”, and only received a diagnosis of asthma at necropsy.
The early and confident use of the word asthma as a provisional clinical diagnosis allows doctors to give the families of all wheezing children a “crisis pack” for the management of future possibly severe attacks outside hospital.1-13 (This consists of high dose β2 agonist and a crash course of prednisolone plus written instructions.) If they never need to use it no harm has been done. Families of children labelled “viral induced wheeze” or “wheezy bronchitis” are left up the creek without a paddle.
I rest my case.
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