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Asthma
asthma. Although immunotherapy certainly reduces allergen- measurements while at home and at work, preferably with the aid of
induced bronchospasm in atopic asthmatics,
28–30
there are no data a criterion-based expert system (www.occupational asthma.com),
showing that immunotherapy is additive to or sparing of may suggest the diagnosis. Patients are best managed by an
conventional therapy. Furthermore, life-threatening anaphylactic occupational physician. The prognosis is worse for workers who
reactions, while very rare, are much more common in asthmatics. remain exposed to the offending agent for more than one year after
Studies suggesting that immunotherapy may alter the natural symptoms develop.
36
history of asthma by reducing new allergic sensitisations,
31
if
ratified, might result in its more widespread use in the future for Alternative and Complementary Medicine
patients with mild or moderate, carefully stabilised disease. Currently, there is no clear evidence-based confirmation that herbal
medicine, acupuncture, air ionisers, homoeopathy and chiropractic or
Drugs breathing exercises (including yoga and buteyko) improve asthma
Beta-blockers, including eye drops, are contraindicated in asthmatics objectively, although some may discourage inappropriate over-
since they may cause acute, severe bronchospasm. Aspirin-sensitive breathing associated with anxiety. This is discussed in more detail in
asthmatics may develop one or more of a constellation of symptoms the BTS/SIGN guidelines.
1
(bronchospasm, rhinitis, gastrointestinal upset and urticaria) acutely
following aspirin ingestion. Aspirin sensitivity affects about 10% of Conclusion
adult asthmatics, and is usually diagnosed by a careful clinical Most asthmatics have mild to moderate disease requiring steps one
history. It reflects the ability of aspirin and related NSAIDs to inhibit to three of treatment and can be managed almost entirely in the
the cyclo-oxygenase (COX) isoenzyme COX-1. Affected asthmatics community. For these patients, total disease control is a realistic aim
should avoid aspirin and other COX-1 inhibitors, but it is not logical and therapy is relatively cheap and safe. Successful therapy requires
automatically to ban all asthmatics from using these drugs. In cases a correct diagnosis, matching of therapy to disease severity and
of doubt the patient should be referred to an allergist for formal recognition and elimination, wherever possible, of factors that
aspirin challenge. confound therapy (in particular, poor inhaler technique and
compliance). Patients with more severe disease are best managed in
Smoking collaboration with a respiratory specialist. Total disease control in all
Maternal smoking in pregnancy impedes foetal lung development
32
of these patients is not a realistic aim, and quality of life must be
and increases the risk of allergic sensitisation of the offspring.
33
balanced against the risks of therapy. Attention to psychosocial
Exposure to environmental tobacco smoke (passive smoking) factors may assume a prominent role in the management of chronic,
increases the risk of asthma exacerbation in children.
34
Smoking as a severe disease. New approaches to therapy are urgently needed for
teenager increases the risk of persisting asthma.
35
It is unclear patients who continue to suffer symptoms despite reliably taking
whether smoking increases symptoms or exacerbations in adult maximal conventional therapy. ■
asthmatic patients; nevertheless, for all of these reasons smoking
should be discouraged.
Christopher John Corrigan is a Professor of Asthma,
Allergy and Respiratory Science at King’s College
Occupational Asthma
London School of Medicine, the Medical Research
Occupational asthma may now account for up to 10% of cases of Council (MRC) Centre for Allergic Mechanisms of
adult-onset asthma. The diagnosis should be suspected in all cases
Asthma and Guy’s Hospital, London. His research
interests include immunopathological mechanisms of
of adult-onset asthma, particularly in high-risk occupations (paint
asthma and allergic inflammation and phenotypes of
sprayers, bakers, nurses, chemical workers, animal handlers, welders, severe asthma. He runs a severe asthma clinic and a
food-processing workers and timber workers). Patients should be
large allergen immunotherapy service.
asked whether symptoms improve away from work. Serial PEF
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24 EUROPEAN RESPIRATORY DISEASE
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