Introduction

‘It was the best of times, it was the worst of times.’ This well-known quote opens Charles Dickens’ popular novel ‘A Tale of Two Cities.’ Charles Dickens characterized the bleak times of an industrializing country having personally experienced many trials and tribulations while growing up and then reflecting on the bad and good times as an adult. While painting a very depressing picture of strife and struggle, there are threads of optimism throughout his work and even glimmers of humor. His writing and public speaking brought attention to the problems and ultimately had impact on changing society. However, he did not live long enough to see the changes that followed.

In many ways analogies can be made between the situation described by Dickens and the healthcare system. The poor seek help. The system is complicated. There is a growing concern that two levels of care are emerging. This situation is of great concern worldwide, but especially in the USA, where the economy is strong yet the healthcare system is in apparent disarray. A careful examination of various national healthcare systems reveals that each has its benefits and limitations.

Certainly, asthma provides a good model for the healthcare situation generally. There continues to be a high burden of asthma among the poor. On the other hand, scientific advancements are being made regarding the use of patient characteristics, biomarkers and genetics to assist in individualizing care. New medications are being developed but there are financial limits to their application.

The review on new directions in asthma management in the previous edition of this book concentrated on the understanding of the therapeutic interventions at the time and the possibilities for improving asthma management and perhaps halting the progression of the disease. It also emphasized an integrated approach to patient care. At the time, there were serious deficiencies in the healthcare system that influenced access to health care. The reported decline in asthma mortality and morbidity was encouraging, but it was pointed out that this could be deceptive since the decline did not encompass all racial/ethnic groups. Recent statistics have shown that asthma deaths and hospitalizations are indeed decreasing, but there are still health disparities in that the African American/black population bears a heavier burden of the disease ( Figure 39-1 ).

Asthma hospitalization rates and asthma death rates (population-based) by race: United States, 1980–2009.

(From Moorman JE, Akinbami LJ, Bailey CM, National Surveillance of Asthma, et al. )

Concerted efforts are now being directed toward understanding this phenomenon and recommendations are being made to integrate the various national resources available to improve outcomes of asthma care for children in the USA. The application of electronic medical records and additional methods of surveying disease management should prompt improvements in medical care.

This chapter will describe the current state of asthma care, using some quotes from Dickens’ writing to highlight the important points. Perhaps this will inspire a reflection on the past to help set a vision for the future. The key message is that there is a need to standardize and harmonize our approach to asthma care; a continuing need for communication among the various stakeholders; and a need for collaboration in order to address health disparities in asthma care.

Asthma: Past, Present and Future

In the Christmas Carol, Dickens wrote ‘It is a fair, even-handed, noble adjustment of things, that while there is infection in disease and sorrow, there is nothing in the world so irresistibly contagious as laughter and good humor.’ In the past, asthma was treated as an episodic disease, primarily with bronchodilators ( Figure 39-2 ). As it began to be realized that asthma has an inflammatory component, inhaled corticosteroids became the cornerstone of asthma management. Advances in extending the duration and specificity of the bronchodilator led to the development of the long-acting ß-adrenergic agonists and their combination with inhaled corticosteroids. Additional medications introduced in the last 20 years included leukotriene modifiers and anti-IgE therapy. Asthma guidelines were also introduced and revised over the past 30 years and helped to standardize and harmonize asthma care.

Timeline of advances in asthma care showing the interaction of research focus and development of new medications.

Currently, we have the Global Initiative for Asthma as a template global strategy for managing asthma. This strategy is updated regularly and the latest version was released in May 2014. Many countries have their own specific guidelines, such as the National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma in the USA. These guidelines were last released in 2007 and placed an emphasis on asthma control. They are currently being reviewed for revision and there are several areas that need to be updated to integrate recent studies that impact asthma management. The importance of guidelines in asthma management is addressed by Allan Becker in Chapter 29 .

In managing asthma today the focus is on achieving asthma control through an effort to minimize asthma impairment, specifically factors that affect day-to-day symptoms, and risk for future asthma events, such as asthma exacerbations, progression and adverse effects of medications. The issues for current management in young and older children include asthma worsening due to exercise, infection and living in the inner city, as well as severe asthma are comprehensively addressed in Chapter 31 , Chapter 32 , Chapter 33 , Chapter 34 , Chapter 36 , Chapter 37 . Up to date information related to immunology and pulmonary physiology have been summarized (see Chapters 28 and 30 ). Information is also provided on methods to improve asthma management by improving medication adherence (see Chapter 38 ), as well as supporting students with asthma through school-centered asthma programs (see Chapter 35 ).

Some key observations have been made that can be useful in designing strategies for future asthma management, including the variability in response to medications, the association of a positive response to certain biomarkers and patient characteristics, and the potential to utilize intermittent inhaled corticosteroid therapy in place of or in addition to daily administration of inhaled corticosteroids. There is growing concern about the management of patients with difficult-to-control asthma. Of interest, new medications have been developed and the positive response to them have been linked to certain biomarkers, e.g. sputum or blood eosinophil count with anti-IL 4 therapy and serum periostin with anti-IL13 therapy.

For the future, there is emerging concern regarding the potential for overlap of asthma and chronic obstructive pulmonary disease (COPD) in certain patients, called the ‘asthma-COPD overlap syndrome’, and growing interest in preventing this phenomenon. There is also a growing need to address the special needs of children and asthma management must be viewed across the ages. Of great interest is the development of strategies to prevent asthma.