The present edition of the Portuguese Journal of Pulmonology brings to our knowledge the study of Pegas et al,1 in wich were identified the risk factors for respiratory problems in school children (5–12 years) in Lisboa.
Besides them it states a very high prevalence of wheezing (43,3 %) and a allergic rhinitis (43.0 %) amongst these children. And that this prevalence increased, in relation to previous studies.
In a recently published article2 we called the attention to the asthma's problem. Why?
Because it is our conviction that bronchial asthma(s) has not had, in a recent past, which we should place since the mid 90s of the last century, the interest and the attention it deserves -and it needs- by the several groups of health professionals.
This evidence has raised, in us, a question about the reason of the loss of interest in this disease.
Was it because the number of asthmatics, nowadays, is so low that it does not justify our attention?
Or they continue to be over 300 million worldwide -and about 700,000 with active asthma in Portugal -but they have already reached control levels that please everyone- and specially the patients?
Was the rising prevalence in developed countries, which in some, exceeds 50 % per decade, reversed or stopped?
Do the populations -in particular the patients and their families- have already reached levels of knowledge that enables them the quality of life and well being they wish and they have the right to have?
Were the costs of the illness, considerably, reduced?
The answer to these questions, which are only a brief example of the many that asthma continues to rise, it is always… no!
In our opinion two words summarize the answer: the fashion!
The word fashion is, usually, associated with clothing and all the several elements that can compose it.
But we can also use it when referred to a certain way of acting, or to a behaviour model, accepted and shared by a group of people in a given time.
The acceptance of the mode, or of the behaviour model, can have multiple and diverse reasons and motivations. Some as simple as the desire, or the enjoyment, for what is new, or for becoming different.
But, as we know quite well, sometimes the wills and the wishes can be induced and formed, in a relatively easy way.
The fact is that the chronic obstructive pulmonary disease (COPD), until then an “obscured” entity acquired, over the past 10–15 years, a status of prima donna, relegating bronchial asthma to a secondary place.
One must only read the Revista Portuguesa de Pneumologia (Portuguese Journal of Pulmonology) or flip through the pages of our congresses and meetings, to be fully aware of the reality.
The negative discrimination of bronchial asthma goes as far as new drugs, an ultra long acting β2 agonist, being only recommended in COPD. On the accompanying information it is expressly mentioned that it has no indication in bronchial asthma!
The history of adrenergic drugs in asthma, that have several millennia,3 was sponged out.
And the same happened to the “recent” end of the 60's of the 20th century,2 when there existed the isoprenaline and the orciprenaline -both being an important advance, but still with such a selectivity to the β-receptor that so many problems induced in our asthmatic patients. And to the benefit to these patients of the introduction, into the therapeutic armamentarium, of salbutamol and terbutaline in the beginning of the 70s.
The change of concepts, in the 80s, considering asthma as an inflammatory disease of the airways, underplay the role of these drugs compared to the inhaled corticosteroids. But it did not take off importance of the former on the control of bronchial obstruction of the asthmatic, either the permanent or the episodic one.
Interestingly, over several decades, it was considered, and scientifically justified, that the first line bronchodilators in COPD were the anticholinergics.
This new position, or this new fashion or behaviour, could have an underlying issue, related to the evolutionary perspectives of the diseases, notwithstanding the appropriate treatment.
In asthma what is expected is that the vast majority of the patients can achieve control of the disease over a short period of time –some months.
And, from the control, the maintenance treatment can only be an inhaled corticosteroid and a β2 agonist for relief that, ideally, will not be used.
It means that the majority for the asthmatic patients can have a quality of life and wellbeing -as it they would not suffer from any disease- with a minimal therapy.
Unfortunately this is not true for a very high percentage of patients with COPD. This disease must be prevented. But once established, the prevention of its progression is a major objective.
And its therapy is an add-on one. One must add anticholinergics, β-agonists, inhaled corticosteroids, methylxanthines, or, in a very near future, an phosphodiesterase 4 inhibitor. Besides all the other necessary measures.
And the treatment will be prolonged ad perpetuam. Do these perspectives “set the trends”?!
