Year‐in‐review 2010: Asthma, COPD, cystic fibrosis and airway biology

Respiratory diseases are estimated to affect a billion people around the world, and account for 12 million deaths a year. In order to raise awareness of respiratory conditions, the Forum of International Respiratory Societies (FIRS), which includes the Asia Pacific Society of Respirology, declared 2010 the Year of the Lung.1 One of the highlight events of the year was World Spirometry Day on October 14, when over 100 000 free spirometry tests were performed at 412 events worldwide. The Year of the Lung also involved intense lobbying of legislative bodies to promote issues such as air quality and anti-tobacco initiatives, and to encourage direction of research funding towards respiratory conditions. One of the important goals of the Year of the Lung was to focus awareness on respiratory research. In this review, we describe important global advances in 2010 in asthma, COPD, cystic fibrosis and airway biology, and highlight the contribution of research in these areas from Respirology. Helen Reddel In 2010, in a series of thought-provoking editorials, pro/con debates and reviews, Respirology provided a forum for discussion about important issues in asthma management. The discussion commenced with a Think Tank Review by Hancox and colleagues,2 which focussed on several ‘inconvenient truths’ about asthma, and linked these to current controversies in areas such as epidemiology, safety of long-acting β2-agonists (LABA) and clinical practice guidelines. Subsequently, in the first of several pro/con debates, O'Byrne and Colice argued, respectively, for and against the proposition that the current stepwise approach to asthma pharmacotherapy in guidelines encourages over-treatment.3 The discussion focussed on factors which currently encourage clinicians to increase medication doses when asthma is not completely controlled rather than considering more basic factors such as poor adherence or poor inhaler technique. The authors emphasized the importance of treating medication changes as therapeutic trials, to avoid an inevitable upward progression of medication use. Discussion about the safety of LABA continued unabated in 2010, with a robust pro/con debate in Respirology about whether more evidence on this topic is needed.4 On the pro side, Drazen, Kazani and Ware argued that the current level of uncertainty about safety was unacceptable, and proposed a randomized controlled trial of 50 000 patients. On the con side, Sears argued that no safety signal was seen when concomitant inhaled corticosteroid use was mandatory. As moderator, Taylor commented that it was unlikely that the outcomes of any further safety study would be regarded as final, and recommended ongoing vigilance for adverse effects of β2-agonists.4 In a third pro/con debate,5 Bardin, as moderator, asked whether allergy still had a role in asthma exacerbations, reminding readers that for much of the 20th century, they were mostly assumed to be caused by allergens. On the pro side, Custovic and Simpson provided evidence of synergistic effects between viruses, atopy and allergen exposure, and argued that previous evidence may have been diluted by the phenotypic heterogeneity of asthma. On the con side, Le Souëf argued that allergy, rather than being causally related to asthma, was a marker for more important deficits in the immune system that allowed respiratory viruses to induce exacerbations. The complexity of the relationships between socioeconomic factors and the prevalence of asthma was demonstrated in a population-based study published in Respirology, in which Chittleborough and colleagues reported that gender interactions varied according to which socioeconomic variable, for example employment, educational status or income, was considered.6 Recent years have seen increasing awareness of the need for use of objective measures in epidemiological studies. The Tennessee Children's Respiratory Initiative, the design of which was reported in Respirology,7 recruited over 650 families during acute viral respiratory illness of infancy. These children will be followed to age 6 years with standardized assessments, to identify modifiable factors important in the development of asthma. One of the challenges in such studies is in the way asthma should be defined. The scale of this issue for paediatric epidemiological studies was highlighted by Van Wonderen and colleagues in a systematic review8 which identified no fewer than 60 definitions of childhood asthma; the choice of definition had a major impact on predictive models for asthma prevalence. Paediatric epidemiological studies often depend on parent-reported wheezing, but wheezing is poorly defined, and the range of human hearing varies among individuals. In Respirology, Habukawa and colleagues9 demonstrated a lack of correlation between airway hyperresponsiveness, spirometry and wheezing sounds, using sound spectography during methacholine challenge. The frequency of both inspiratory and expiratory breath sounds increased during challenge testing and decreased following administration of salbutamol. The importance of objective measures for asthma studies in adults was also highlighted in 2010 by Luks and colleagues;10 following their earlier demonstration that 30% of doctor diagnoses of asthma were incorrect,11 the authors demonstrated that a correct diagnosis could be confirmed in over 90% of patients with a simple bronchodilator reversibility test or single methacholine challenge, even in those taking regular controller medications. For patients presenting primarily with cough, a standard objective measure has been capsaicin challenge,12 which stimulates C-fibre cough receptors. As cough may also be stimulated via rapidly adapting mechanoreceptors, Kamimura and colleagues13 investigated three modes of mechanical stimulation (tracheal compression, neck retroflexion, tuning fork). Induction of an itchy sensation and cough with all tests was significantly more likely in patients reporting phonation-induced cough. Further major work on asthma phenotypes was published in 2010, including a cluster analysis of 726 patients with mild, moderate and severe asthma, published from the Severe Asthma Research Program.14 Eighty per cent of patients were able to be classified into one of five clusters on the basis of just three clinical variables—pre- and post-bronchodilator FEV1% predicted, and age of onset of asthma. Even more interesting will be future work from this programme on predictors of clinical course and response to treatment. The interaction between asthma and obesity is complex. In Respirology, Arshi and colleagues15 studied the relationship between obesity and asthma in children, finding insulin resistance in almost half of the children with allergic asthma but none of the BMI-matched healthy controls, with some interesting patterns emerging in the relationships between insulin resistance and blood levels of several adipokines. With increasing awareness of phenotypic differences in asthma, increasing importance is placed on the identification of predictors of response to different asthma medications, and, as a corollary, on phenotype-based approaches to asthma management. In a novel triple cross-over study, Lemanske and colleagues16 investigated the predictors of response to add-on therapy with LABA, montelukast or higher dose inhaled corticosteroid, for children with persistent asthma who were uncontrolled on inhaled corticosteroids alone. Almost all of the children demonstrated a differential response between treatments, but, contrary to prior assumptions, baseline characteristics mostly failed to predict the most effective treatment for individual patients. Polymorphisms of the β2-adrenoceptor not predict response to add-on LABA in this In Respirology, and the impact for β2-adrenoceptor studies of reporting response as a of the reversibility administration of both and rather than as the administration of alone. 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