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A SMART exchange of views
“The General was essentially a man of peace, except in his domestic life” (Lady Bracknell, The Importance of Being Earnest). Other than in domesticity, there can be few better opportunities for open warfare than the correspondence columns of an academic journal. In this issue we publish a sometimes heated correspondence arising from Chapman et al's recent review article on the SMART regime for asthma (Thorax 2010;65:747–52), the authors' reply, and the Editor in Chiefs' attempts to pour petrol on the flames. We want to encourage vigorous debate and controversy; where do you stand on SMART? Either way, the Journal should be a place of cut and thrust scholarship, not somnolent like the smoking room of a London Club; please join in on this and other issues. See pages 86–88
Not a personal choice
No-one would dispute the right of an adult to poison him- or herself, even in particularly terrible ways. But this right does not extend to poisoning those around themselves, in particular children. For years the tobacco industry has tried to defend the indefensible, first that cigarettes do not harm the smoker, and then that passive smoking is not a real health hazard. Every time, as they fight resolutely under the banner that ‘red is green’, they have been pushed back kicking and screaming. We know that if you smoke this is not good for your chest. We also know about the reduction of admissions of pre-school and school age asthmatic children to hospital after smoke free legislation in Scotland (N Engl J Med 2010;363:1139–54). This month we publish a report showing an independent and long term effect of maternal smoking on symptoms of asthma, irrespective of whether the young adults smoked themselves. Surely we need to re-focus on the rights of the individual NOT to be exposed to smoke, rather than the right of the individual to smoke. It is incumbent on those who wish to preserve smokehavens like private cars to show that this is not damaging to others; and while they are doing it, we will work on proving that Miss Piggy beat Sir Isaac Newton to the discovery of the laws of motion. See page 20
A flat feeling
Worsening spirometry on exercise is not always due to exercise induced asthma. Look at these old-fashioned spirograms, form your own conclusions and then turn to this month's Pulmonary Puzzle to find out why this case of exercise induced asthma failed to respond to medications. See pages 54 and 74
Management plans in COPD
Use of written management plans has been shown to substantially reduce the risk of exacerbations of asthma but uptake by clinicians and patients is poor. The study by Biscoff et al (page…) suggests the same story in COPD. Only 40% of a cohort of patients with moderate to severe COPD adhered to their management plan. Adherence was associated with a reduction in the recovery time but not in the number of unscheduled healthcare visits. However, non-adherent patients differed in other aspects of patient behaviour making it difficult to be sure of a specific beneficial effect of the management plan. New and imaginative ways of reaching these hard to help patients are needed. See page 26
Rational use of oxygen
There is no strong physiological rationale for the use of supplementary oxygen in patients who are not hypoxic but we all know that this is widely done in hospital and at home. Might this treatment have a useful palliative effect? Moore et al have tested this hypothesis in a blinded controlled study comparing the effect of supplementary oxygen and air on symptoms, quality of life and functional status in patients with COPD and a resting PaO2>7.3 kPa. Both supplementary air and oxygen produced modest palliative effects but there was no evidence of an oxygen specific effect, even in the subgroup of patients with exercise-induced desaturation. This data adds to growing evidence (see Lancet 2010;376:784–93) that supplementary oxygen is overused in hospitals and in the community. How should we tackle this? See page 32
Small is NOT beautiful? (Editors' choice)
The strong and independent association between FEV1 and survival is widely assumed to reflect a link between airflow obstruction and cardiovascular disease but how sure are we of this link? Burney et al highlight an equally strong association between vital capacity and survival in a reanalysis of a large American population sample. In their analysis neither FEV1 nor FEV1/FVC were independent predictors of survival after vital capacity was accounted for. This analysis suggests that it is small rather than obstructed lungs that are associated with survival. In a linked editorial Peter Lange reminds us that vital capacity was so named because of its close links with survival, first identified by Hutchinson more than 150 years ago; as usual, just when you think you have discovered something novel, you find that our great predecessors knew about it all along! See page 49
Linked Articles
- Miscellanea
- Chronic obstructive pulmonary disease
- PostScript
- Epidemiology
- Chronic obstructive pulmonary disease
- Asthma