Book Review

Asthma and Rhinitis

N Engl J Med 1995; 332:1042April 13, 1995

Article

Asthma and Rhinitis
Edited by William W. Busse and Stephen T. Holgate. 1488 pp., illustrated. Cambridge, Mass., Blackwell Science, 1994. $225. ISBN: 0-86542-246-X

Our understanding of the pathogenesis of asthma has changed dramatically over the past decade. An unprecedented research effort has shown that asthma is a complex chronic inflammatory process rather than merely an acute bronchospastic process. As a direct result of this work, our philosophy of treatment has shifted, and we now place the primary emphasis on inhaled corticosteroids. Many other antiinflammatory therapeutic strategies appear to be on the horizon. Thus, the time is ripe for publication of this comprehensive textbook on asthma and its bedfellow, rhinitis.

The initial chapters of this encyclopedic work deal with epidemiology, including important discussions of occupational asthma and the increase in asthma-related mortality. The substantial middle section (accounting for approximately 70 percent of the book) describes the biology of the major cellular players in asthma: mast cells, eosinophils, neutrophils, lymphocytes, the epithelium, airway neurons, and the endothelium. Great emphasis is placed on the interaction between these cellular elements and the scores of mediators and proinflammatory products identified in the asthmatic lung and rhinitic nose. There is an extensive review of the influence of these interactions on the traditional aspects of asthma research: airway and smooth-muscle physiology. Along the way, there are ample descriptions of animal models and emerging techniques, particularly bronchoalveolar lavage and endobronchial biopsy, used to study allergic diseases of the airways. The final part of the book, building on the pathophysiologic foundations laid in the middle, addresses important clinical issues, such as exercise-induced asthma, nocturnal asthma, and established and investigational treatments.

What are the strengths of this book? Most of the chapters are well written and well organized, typically concluding with a useful summary. Though much of the material is scientifically complex, it can be reasonably well digested by an immunologically addled reader like me. My comprehension was substantially aided by the many superb electron micrographs in the chapters on the various cellular elements. I also benefited from the overlap of material between chapters. Although this feature may seem less attractive to the well-versed reader, it does allow each chapter to stand on its own, without the need for extensive cross-referencing.

What is missing? The aspects of asthma in which the interface between basic science and clinical observation is less clear are not exhaustively explored. Most notably, the psychological effect of asthma, the perioperative care of the patient with asthma, and the care of the pregnant patient with asthma are treated superficially at best. The brief section on critical care management does not cover continuous nebulization of bronchodilators, use of inhalational anesthetics, or the emerging problem of prolonged neuromuscular weakness in patients receiving mechanical ventilation who are treated with corticosteroids and paralytic agents. The well-publicized recommendations of the National Heart, Lung, and Blood Institute's National Asthma Education Program are mentioned only briefly, though management strategies employed in the United Kingdom and New Zealand are extensively outlined.

These points aside, there is a wealth of practical clinical and therapeutic information in this book. More important, for readers who are interested in asthma, this book skillfully presents a comprehensive review of the revolution in asthma research. The inquisitive reader wishing to understand the scientific basis for our clinical and therapeutic observations will be richly rewarded.

Scott K. Epstein, M.D.
New England Medical Center, Boston, MA 02111