Book Review

Fatal Asthma

N Engl J Med 1998; 339:1864-1865December 17, 1998

Article

Fatal Asthma
Edited by Albert L. Sheffer, with William W. Busse, Peyton A. Eggleston, Thomas A.E. Platt-Mills, Malcolm R. Sears, and Kevin B. Weiss. 607 pp. New York, Marcel Dekker, 1998. $195. ISBN: 0-8247-0155-0

Asthma is one of the commonest chronic diseases. It causes great disability and presumably shortens life. Asthma-related mortality has not been fully assessed, however, and mercifully, the disease rarely kills. Deaths due to asthma have only recently been identified. In 1860, Salter, a pioneer in asthma research, said that “asthma never kills,” a view supported later by Osler. The message of this book is that asthma does kill, but that with appropriate therapy no one should die of it.

This book addresses several questions. How does asthma kill? Can the patients at risk be identified? And can death be prevented? The first two questions lead to a truism: that if asthma is sufficiently severe, it will kill by causing respiratory failure. Much of the book therefore discusses severe asthma, its features, and its diagnosis. Patients with severe asthma are at risk, but death can be prevented by adequate treatment before and during hospitalization. Fixed airway obstruction or a previous hospital admission for asthma is an ominous sign. The possibility that the patient may be unaware of the sensations and severity of asthma (and the doctor unaware of the latter) is an important consideration that needs further study. Once the patient has been admitted, prompt treatment of respiratory failure (for example, by oxygen) is, according to some clinicians, almost invariably successful. Others, however, probably realistically, believe that “unpreventable death” is more common for patients whose respiratory function has been too severely compromised.

Of particular interest are some forms of asthma that are related to therapy. Steroid-resistant asthma is an important example, as is asthma resulting from overdosage of β-adrenoceptor agonists, the latter perhaps in relation to genetic abnormalities in receptor populations. We do not know whether genetic factors played a part in the “epidemics” of asthma-related deaths in New Zealand. In this case there were clear correlations between increasing dosages of fenoterol and deaths due to asthma and between withdrawal of the drug and a decrease in the number of deaths.

The one category of asthma-related mortality that does not seem to fit into the rule that death follows the severity of asthma is sudden death in patients with moderate or even mild asthma. Inevitably, these patients are little studied, because they usually die before reaching an intensive care unit. The single clue to the cause of death in these cases is the infiltration of neutrophils into the airway walls; patients dying of severe asthma usually have an infiltration of eosinophils. Sudden death related to asthma could be due to an acute respiratory tract infection or a surge of pollution with allergens, but we do not know. Aspects of asthma that have received too little study are its instability and variability. It seems possible that the intrinsic variability of lung function in even mild asthma might tip the balance of health into an irreversible downhill slide, but this is speculation.

I have given a superficial summary of only some parts of what is an admirable book. Overall, it deals with geographic, racial, socioeconomic, and community influences on asthma; with genetics (perhaps too briefly); with allergens and pollution; and with the immunopathology and pathophysiology of the disease. These topics point to causes of death in people with asthma but have been dealt with in more detail elsewhere. With regard to asthma-related death, this book offers detailed assessments of its epidemiologic features, risk factors for its occurrence and their identification, and the prevention of death both before and after hospitalization (although the book is not meant to be a treatment manual). Almost all the chapters are detailed and informative factual accounts of distinguished scientists.

Some chapters also introduce an element of wisdom not always seen in books by multiple authors. I shall be invidious and select three. Altman discusses the public perception of asthma — how often do we think of that? — and his journalistic style is an encouragement to scientists to think more of their readers. Boushey, on the relation of asthma severity to fatalities, combines thought and fact in a way that almost justifies the expense of the book for his chapter alone. McFadden, with whom I have sometimes disagreed, writes on the prevention of asthma fatalities; if you are dying of asthma, call him in. Without these three chapters the book would be excellent. With them it is exceptional.

John Widdicombe, D.M., D.Phil.
St. Thomas' Hospital, London SE1 7EH, United Kingdom