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Vocal cord dysfunction and asthma

Vocal cord dysfunction can occur independently or can co-exist with asthma. It often mimics asthma in presentation and can be challenging to diagnose, particularly in those with known asthma. Vocal cord dysfunction remains under-recognized, which may result in unnecessary adjustments to asthma medicines and increased patient morbidity. There is a need to review current literature to explore current theories regarding disease presentation, diagnosis, and treatment.

Recent findings: The underlying cause of vocal cord dysfunction is likely multifactorial but there has been increased interest in hyper-responsiveness of the larynx. Many intrinsic and extrinsic triggers have been identified which in part may explain asthma-like symptomatology. A variety of techniques have been reported to provoke vocal cord dysfunction during testing which may improve diagnosis. There is a significant gap in the literature regarding specific laryngeal control techniques, duration of therapy, and the effectiveness of laryngeal control as a treatment modality.

Summary: Those with vocal cord dysfunction and asthma report more symptoms on standardized asthma control questionnaires, which can result in increasing amounts of medication if vocal cord dysfunction is not identified and managed appropriately. Clinicians need to maintain a high index of suspicion to identify these patients. Videolaryngostroboscopy remains the diagnostic method of choice. Evidence-based guidelines are needed for the most effective diagnostic techniques. Laryngeal control taught by speech pathologists is the most common treatment. Effectiveness is supported in case reports and clinical experience, but not in larger randomized trials which are needed.

Can inhaled corticosteroids prevent asthma exacerbations?

Asthma exacerbations occur unpredictably, are a cause of morbidity and mortality, and contribute significantly to increased healthcare costs. Inhaled corticosteroids reduce exacerbations and improve quality of life.

Recent findings: The aetiopathology of asthma exacerbations is heterogeneous. Attempts to phenotype the heterogeneity of the pattern of airway inflammation by noninvasive monitoring of airway inflammation has identified a subgroup of patients with eosinophilic inflammation who are most likely to respond to steroid therapy. Strategies directed to normalize eosinophilic airway inflammation with corticosteroids have consistently led to a marked reduction in exacerbations. In contrast, their role in modulating the natural history of disease is less certain.

Summary: In the near future, improvements in our understanding of the mechanisms of exacerbations may identify therapeutic targets. While we await these developments, inhaled corticosteroids remain the first choice anti-inflammatory therapy for asthma.

The addition of long-acting beta-agonists to inhaled corticosteroids in asthma

Although long-acting beta-agonists (LABAs) have been used for two decades, with many studies showing benefit versus increasing inhaled corticosteroid (ICS), controversy regarding safety has resulted in the United States Food and Drug Administration (FDA) recently mandating label changes restricting LABA use. This review addresses these safety concerns together with clinical studies and meta-analyses assessing the appropriate use of LABAs.

Recent findings: Effective use of LABAs requires sufficient ICS to control inflammation. Underuse of ICS, which is often manifest by exacerbations, may reflect undue emphasis on alleged steroid-sparing effects of LABAs. The FDA meta-analysis found that LABA with mandatory ICS was not associated with increased risks of serious adverse events. The role of LABA with ICS as initial therapy in steroid-naïve patients is debated, as is LABA use in children, with data indicating less benefit than in adults. The FDA recommendation that LABA be withdrawn once control is achieved remains problematic, as greater ICS reduction can be achieved when LABA is continued.

Summary: The safe use of LABAs, which are clearly effective in many patients with moderate to severe asthma, requires high compliance with ICS therapy, which is best assured if ICS and LABA are provided in a single inhaler.

Bronchial thermoplasty for severe asthma

The present article will address the potential for bronchial thermoplasty to be used in addition to conventional medications to help us treat our patients with severe asthma.

Recent findings: Two recently published studies report on the use of bronchial thermoplasty in patients with severe asthma. Now that patients with a range of asthma severity have been treated with bronchial thermoplasty, we are better able to comment on the appropriate selection of patients for this therapy that should optimize benefits and limit complications. In addition, studies reporting longer term follow-up are now available indicating the persistence of benefit and the absence of late developing adverse events.

Summary: Bronchial thermoplasty represents a novel approach to asthma treatment that is complementary to anti-inflammatory and bronchodilating therapies. Criteria for selecting appropriate patients are established and experience with bronchial thermoplasty is expanding since US Food and Drug Administration approval was obtained in April 2010.

Immunology and pathogenesis of childhood TB

Tuberculosis (TB) in children most commonly results from exposure to a household contact with active TB, and represents ongoing transmission of Mycobacterium Tuberculosis (Mtb) in the community.

Infants and young children have an increased risk of infection following exposure and progress more readily from infection to active TB disease; in the absence of intervention, infants have a 50-60% risk of disease in the first year following infection. It could therefore be argued that the determining factor for the higher susceptibility to disease in children is prolonged, intimate contact between the child and the index case, which might lead to a larger inoculum of Mtb. However, there is little evidence to support this assumption, since the mycobacterial load in children is notoriously low, whi...

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