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  • Published on: 22 June 2019
    A Bird in the Hand is worht (literally) Two in the Bush
    • Andrew Bush, Professpr of Paediatrics Imperial College and Royal Brompton Hospital
    • Other Contributors:
      • Ian D Pavord, Professor of Respiratory Medicine

    We thank Professor Connett for his ornithological expertise, the extent of which we had not previously realised. There is indeed a wealth of literature about psychological stress to mothers affecting foetal outcomes [1], and stress being associated with asthma attacks [2] and worsening the effects of allergen challenge [3], and the importance of addressing this is emphasised by ourselves and many others [4]. Acknowledging this in no way contradicts the need also to address refractory airway pathology by the reductionist approach we advocate [5]. A holistic approach to severe asthma deploying the skills of a multidisciplinary team is essential. Render unto Caesar the things that are Caeser’s.

    Andrew Bush
    Ian Pavord

    References
    1. Wright RJ, Visness CM, Calatroni A, Grayson MH, Gold DR, Sandel MT, et al. Prenatal maternal stress and cord blood innate and adaptive cytokine responses in an inner-city cohort. Am J Respir Crit Care Med. 2010; 182: 25-33.
    2. Sandberg S, Paton JY, Ahola S, McCann DC, McGuinness D, Hillary CR, Oja H. The role of acute and chronic stress in asthma attacks in children. Lancet. 2000; 356: 982-7.
    3. Liu LY, Coe CL, Swenson CA, Kelly EA, Kita H, Busse WW. School examinations enhance airway inflammation to antigen challenge. Am J Respir Crit Care Med. 2002; 165: 1062-7.
    4. Cook J, Beresford F, Fainardi V, Hall P, Housley G, Jamalzadeh A, Nightingale M, Winch D, Bush A, Fleming L, Saglani S. Managing the paediatr...

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    Conflict of Interest:
    None declared.
  • Published on: 29 March 2019
    The canary might once have been a very stressed chick

    Professors Bush and Parvord usefully highlight key recommendations from their Lancet commission on asthma and acknowledge they are deliberately controversial. They accept the benefits of inhaled corticosteroids, but cite current shortcomings in meeting the needs of asthma sufferers as a reason to shift from a reductionist to a more detailed phenotyic approach to drive the development and use of new biological ‘precision medicines’.
    We do have a problem with our current approach and especially in the UK, which like the US, Australia and New Zealand, has an asthma death rate amongst adolescents at least three times higher than other European countries for which there is reliable data.1 However, emphasizing a need for basic science to focus on developing new drugs for specific patient groups, risks underestimating and misunderstanding the importance of psycho-social factors in determining all asthma phenotypes and especially those at risk of fatal asthma.
    Social and environmental factors are more than co-morbidities causing dysfunctional breathing and poor adherence to prescribed therapies. Systematic reviews and meta-analyses consistently show that pre-natal stress and stress in early childhood significantly increase the risk of subsequent wheeze and asthma.2 In prospective studies, depression in adults is associated with developing asthma and there are many studies demonstrating that anxiety can cause bronchoconstriction and lung inflammation.3,4 Mechanistic st...

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    Conflict of Interest:
    None declared.