The natural history of asthma in adults: the problem of irreversibility

Asthma is common, affecting 5% to 10% of adults; asthma is progressive, leading to irreversible obstruction in 80% of elderly patients; and asthma is complex, often complicated by coexisting lung diseases. This loss of lung function results from 4 independent pathologic conditions: (1) airway remodeling, especially in the small airways, from the lymphocytic-eosinophilic inflammation that characterizes asthma; (2) bronchiectasis; (3) postinfectious pulmonary fibrosis; and (4) emphysema and chronic bronchitis from tobacco smoke. Deterioration in lung function develops faster in nonallergic patients with intrinsic asthma during the period shortly after onset of asthma and in older patients. About 4% of patients die of asthma, and most are elderly. Death most often results from complications of irreversible obstruction or cardiotoxicity of bronchodilator therapy. More research is needed to improve therapy for preventing remodeling of small airways, to confirm the frequency of bronchiectasis and postinfectious fibrosis and to determine their causes, and to develop diagnostic criteria to identify these complications. Meanwhile, clinicians treating adult asthmatic patients need to be aggressive in preventing the damage from cigarette smoke; in immunizing for influenza and pneumococcus infection and identifying and treating respiratory infections, particularly at times of acute exacerbations; in diagnosing and managing bronchiectasis; and in objectively confirming the efficacy of asthma therapy to prevent illness from overtreatment with glucocorticoids and bronchodilators.