Asthma and Allergy or Just Allergies?

All during my training in allergy at Duke University and my first job as a member of the allergy section at Henry Ford Hospital in Detroit, Michigan asthma was always considered a large part of the realm of allergy. During my time in Detroit I was privileged to be the principal investigator (Detroit site) for a National Institute of Health funded research study (the National Cooperative Inner-City Asthma Study) which included an evaluation of the role of allergy in moderate to severe asthma. I have been in Indianapolis for the past 15 years and I have always been struck by the separation of asthma from the world of allergy. In my clinic when I ask about the reason for a visit, I will often hear ‘we are here for allergy and asthma’. This continues to take me aback. My perspective is that asthma is a significant manifestation of allergy. Yes, the differential diagnosis for asthma is lengthy and we will not find sensitization in some, however allergy and that tendency towards allergy called atopy are significant contributors to asthma. Now I have to back up these bold statements.

 

Your Indiana Joint Asthma Coalition (InJAC)  just put online a Continuing Medical Education (CME) offering on the most recent national asthma guidelines. As the chair of the Health Care Committee of InJAC it was my job to oversee the project. This gave me the opportunity to go over that 400+ document known as the “Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma”. The CME program can be viewed by anyone without registering for the credit. The online program is a slide set on the various sections of the guidelines. Each reviewer summarized the essential points and provided notes for each slide in the presentation. A shorter Summary report of the Asthma Guidelines (EPR-3) is also available.  This is the 3rd such report. The first came in 1991. Number two was 1997. There was a publication that dealt with 5 specific hot topics from the guidelines in 2002. In 2007 the most recent EPR was published.

 

As I reviewed the EPR-3 I noted how often allergy/atopy appears in the document. Consider a few of the following statements;

  1. Atopy, the genetic predisposition for the development of immunoglobulin E (IgE)-mediated response to common aeroallergens, is the strongest identifiable predisposing factor for developing asthma (Key Point- page 11).
  2. The onset of asthma for most patients begins early in life with the pattern of disease persistence determined by early, recognizable risk factors including atopic disease, recurrent wheezing, and a parental history of asthma (Key Point- page 12).
  3. This working definition (of asthma) and its recognition of key features of asthma have been derived from studying how airway changes in asthma relate to the various factors associated with the development of airway inflammation (e.g. allergens, respiratory viruses, and some occupational exposures) and recognition of genetic regulation of these processes (page 14).
  4. Sensitization and exposure to house-dust mites and Alternaria (mold) are important factors in the development of asthma in children (page 22).
  5. The asthma predictive index…..identifies the following risk factors for developing persistent asthma among children younger than 3 years of age who had four or more episodes of wheezing during the previous year: either (1) one of the following: parental history of asthma, a physician diagnosis of atopic dermatitis, or evidence of sensitization to aeroallergens, or (2) two of the following: evidence of sensitization to foods, > 4 percent peripheral blood eosinophilia, or wheezing apart from colds (page 25).
  6. Tests to consider in the differential diagnosis of asthma- allergy testing (page 45).
  7. Key Points in the Initial Assessment of Asthma- identify precipitating factors (inhalant allergens…) and identify co-morbid conditions that may aggravate asthma (rhinitis –nasal allergy…) page 47.
  8. Referral to an Asthma Specialist for Consultation and Co-management- ….for allergy skin testing (authors note- not RAST or blood specific IgE)…..for consideration of allergen immunotherapy (page 68).

The above excerpts came from section 2 (asthma definition, pathophysiology, pathogenesis, and natural history of asthma) and section 3 part one- Asthma Management- measures of asthma assessment and monitoring. These remaining sections comprise over 300 pages of material. 

The remaining sections of the EPR-3 cover education, environmental control, medications, long-term management, and managing exacerbations of asthma. These sections also include information on the significant role of allergy in asthma. These sections go over specifics on how to manage the allergens.

 Through the allergist’s eyes- Asthma is significantly intertwined with allergy. We should look at it as a manifestation of the allergic condition. It is not allergy and asthma anymore, in many children it is allergy showing itself as asthma! Asthma can be a manifestation of allergy.

FEL

October 1, 2009 · fleickly · 2 Comments
Posted in: Allergies, Asthma

2 Responses

  1. Stephen - October 1, 2009

    Dr. L

    I believe that ASTHMA is; Simply the Progression of Infant Allergy Disease MARCH; Which begins at BIRTH; Whcih has been allowed to migrate / exacerbate to ASTHMA because of non-Medical Action to ID / Neutralize the Source of Child’s Allergy Disease / Offending Allergens.

  2. fleickly - October 1, 2009

    Stephen,
    I love the avatar!
    I heard a variation on your theme from a former chief of pediatrics. The twist was that the lungs were not allowed to evolve completely from a hypertrophic and hyper-reactive baseline. There are a significant number of theories out there.
    Thanks,
    FEL

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