[Fatal asthma: who, when, why and how to prevent?]

Despite our understanding of the inflammatory nature of asthma, mortality from the disease has been on the rise. Most deaths follow a protracted course, but some occur abruptly. Many of those who die or who have experienced a near fatal episode share common characteristics (giving hope that many deaths are preventable), such as insufficient steroid therapy, reliance on inhaled bronchodilators, marked peak flow fluctuations, psychiatric disorders and attenuated dyspnea in response to stimuli. No genetic marker has been identified for the at-risk group, but the fall in lung function in response to methacholine dose is high and the ventilatory response to hypoxia is blunted. The last 3 characteristics may be causative. The patient at risk needs to be identified and treated with the goal to normalize lung function (as is usually recommended). However, in this group it may be desirable (though not yet proven) to up-titrate therapy further, with the added goal to minimize peak flow fluctuations and bronchial reactivity. Patients (and families) need to be taught to monitor peak flow and as the disease worsens, by clinical and by written peak flow criteria, to increase inhaled steroids, to use oral steroids, to self inject subcutaneous epinephrine or to sick (urgent) medical attention. This mode of therapy depends on tight patient-physician relation, a pattern of behavior that is not easy to achieve with this group.