Fatal asthma: where did we go wrong?

Vivid descriptions of life-threatening asthma attacks have persisted into modern medicine since antiquity. Asthma is characterized by airway hyperresponsiveness--a condition of an exaggerated bronchoconstriction in response to a variety of stimuli (irritants and triggers). Over the past decade it has become clear that in asthma significant inflammation occurs in the airways. Airway hyperresponsiveness and the clinical asthma symptomatology may be at least in part dependent on the inflammation generated by cell mediated immune mechanisms, including T cells, macrophages as well as mast cells and eosinophils in the airways. However, the recent advances in the understanding of the pathogenesis and pathophysiology of asthma, new modes for the diagnosis of the disease and the development of various therapeutic options have not been accompanied by increased survival rate. On the contrary, a gradually rising death rate from asthma has been reported worldwide. The reasons for this are not completely understood. Controversy exists whether an increase in the prevalence or the case fatality rate or both are the main cause of the reported rise in asthma death rate. Genetic, environmental and psychological factors have also been implicated. One has to consider the poorly controlled state in which some patients arrive at emergency wards, the possible delay in adequate therapy due to psychological and socioeconomic factors and also the information implicating iatrogenic factors among the possible explanations for increased asthma mortality. It is imperative to improve patient and family education to increase awareness. Conflicting results in the medical literature regarding the medical therapy of asthma impose a great responsibility on the practising physician. It is necessary to improve physician knowledge of the modern therapeutic strategies in asthma to gain better control of the disease. Pending further clarification as to optimal management of asthma, and forthcoming new and novel treatment, management should rely on current guidelines, emphasizing the role of antiinflammatory therapy in severe asthma. It is desirable to improve emergency services to deliver expert care in life-threatening conditions as soon as possible.