Editorials Diagnosing airflow obstruction in general practice

A decade ago several research studies highlighted the underdiagnosis of asthma, particularly in children 1–3 but also in the elderly, 4 5 and most general practitioners felt an increased pressure on them to diagnose this common chronic respiratory disorder. It was implied that asthma should be considered whenever a patient presented with a persistent cough and that far more people " deserved " to be on eVective treatment with inhaled steroids. Undoubtedly, as a consequence of this message, many with asthma gained treatment which otherwise would not have been provided and, presumably, improved their morbidity and quality of life. However, there has emerged a down side to this campaign in that some subjects with other respiratory conditions and some with no lung disease at all have been labelled as having asthma, leading not only to years of receiving unnecessary medication but also to the development of psychological dependence on the asthma label and its associated quest for improvements in symptom control. Most of such subjects have chronic obstructive pulmonary disease (COPD), but in my clinical practice I have also found cases of hyperventila-tion, recrudescent tuberculosis, and severe sleep apnoea syndrome. The records of the asthma diagnosis in one subject (now correctly labelled as having COPD) read merely: " Cough. Wheeze. Ventolin. Becotide ". It is now clear that, whenever possible, diagnoses of obstructive airways diseases—whether asthma, COPD, or other rarer conditions—should be supported by objective evidence from measures of lung function. Within the last decade in the UK, and similarly elsewhere, there have been consensus publications on the management of asthma 6 7 and COPD. 8 Much is written in these documents about the management of these conditions but less on diagnosis. The 1995 review and position statement on asthma management 6 said only that " If the variable nature of airway narrowing which is characteristic of asthma cannot be demonstrated by any other means, then in adults and older children a trial of high dose oral steroids with peak flow monitoring for a minimum of two weeks is essential ". The COPD guidelines are more specific, grading the condition into mild, moderate, and severe categories on the basis of forced expiratory volume in one second (FEV 1) as a percentage of predicted as well as symptoms and signs. 8 General practitioners in the UK have been able to prescribe peak flow meters on the National Health Service since 1990 …