Harvard Medical School Guide to Taking Control of Asthma A Comprehensive Prevention and Treatment Plan for You and Your Family

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Preface Here, at the start of the twenty-first century, we find ourselves witnessing two seemingly contradictory trends in the world of asthma care. We find asthma becoming more common and more severe in our country and in many of the Westernized nations of the world. More people are developing asthma. More people are being hospitalized for treatment of severe flare-ups of asthma, and more fatal episodes of severe asthma are occurring. At the same time, our understanding of the underlying processes that make asthmatic air passageways behave the way they do has grown enormously, and better, easier-to-take treatments have made their way to our pharmacies. New, highly effective, and convenient therapies for asthma are widely available.It wasn't very long ago -- 20 to 30 years ago -- that asthma was conceived of primarily as a disease of episodic spasm of the involuntary muscles that surround the breathing tubes, a concept understood by the Roman physician Galen nearly 2,000 years earlier. Many physicians didn't consider asthma to be a terribly serious disease. A famous physician, Sir William Osler (1849-1919), commented: "Asthmatics don't die, they just pant into old age." We sometimes still hear of the asthmatic tendency being attributed, erroneously, to emotional stresses and difficult child-parent relationships. Our treatments have focused on medications that cause the bronchial muscles to relax -- "bronchodilators." Even today, our schools and playgrounds are filled with asthmatic children who carry medication inhalers to deliver bronchodilator treatments when they are feeling short of breath or tight in the chest.Our medical understanding of asthma has advanced dramatically over these past 20 to 30 years. We now understand asthma to be a chronic inflammatory condition of the bronchial tubes. The type of inflammation characteristic of asthma has the appearance of an allergic response. Great strides have been made in identifying what cells and chemicals in the body participate in this allergic-type reaction, and what stimuli produce it, in susceptible individuals. We now see that contraction of the muscles surrounding the breathing tubes is a manifestation of chronically inflamed asthmatic airways. The inflammation and the susceptibility to spasmodic narrowing of the breathing tubes persist even when someone with asthma feels well -- that is, totally free of symptoms.In people with more than very mild asthma, treatment now focuses on suppressing the allergic inflammation of the breathing tubes. Safe and effective medicines, taken once or twice daily, can reduce asthmatic inflammation, inhibit contraction of the bronchial muscles, and prevent narrowing of the air passageways. For a time, the best medicines available to treat asthma included theophylline, a not-so-distant relative of caffeine. Imagine taking -- or giving to your asthmatic child -- a caffeine-like substance just before bedtime to maintain comfortable breathing overnight! There was also a time, as we started to focus on treating inflammation of the bronchial tubes, when we asked some of our patients to inhale anti-inflammatory medicines in doses of 6 to 12 sprays at a time. Now it is a rare patient who needs more than two inhalations twice daily to keep asthma under good control.Because of the tremendous advances in understanding and treating asthma, our book has good news to share, and also carries a message of great optimism for the future. The vast majority of people with asthma can achieve good control of their illness with currently available medications. Only a small minority cannot.But a small part of a very large number -- say, for example, 1 percent of the estimated 15 million Americans with asthma -- is still a large number of people with persistent, difficult-to-control asthma. For this group there is also reason for optimism, because we stand on the threshold of a new age of asthma therapies