Correspondence

Environment and Asthma

N Engl J Med 2004; 351:2654-2655December 16, 2004

Article

To the Editor:

Morgan et al. (Sept. 9 issue)1 demonstrate the efficacy of environmental measures in the management of atopic asthma in children. Their discussion and the accompanying editorial by Sheffer2 state that this environmental program has an efficacy similar to that of corticosteroid treatment. Morgan et al. cite a large study3 of budesonide treatment in childhood asthma as evidence of this. Their conclusion is not supported by the data. Direct comparison of these two studies (Table 1Table 1Effects of Inhaled Budesonide and Environmental Control Measures in Two Populations of Children with Asthma.) demonstrates that both interventions do have similar efficacy in the control of daily symptoms. However, budesonide has much greater efficacy in the prevention of both emergency hospital or clinic visits and hospital admissions for asthma than do environmental control measures. For example, the number of patients who would need to be treated for a year in order to prevent one emergency hospital or clinic visit is 2.85 with environmental measures and 0.85 with budesonide. Although Morgan et al. have shown that intensive environmental control measures can improve symptoms in urban children with asthma, inhaled corticosteroids remain the most effective treatment for childhood asthma.

Robert J. Boyle, M.B., Ch.B.
Mimi L.K. Tang, M.B., B.S., Ph.D.
Royal Children's Hospital, Parkville, Victoria 3052, Australia

3 References

1. 1

   Morgan WJ, Crain EF, Gruchalla RS, et al. Results of a home-based environmental intervention among urban children with asthma. N Engl J Med 2004;351:1068-1080
   Full Text | Web of Science | Medline

2. 2

   Sheffer AL. Allergen avoidance to reduce asthma-related morbidity. N Engl J Med 2004;351:1134-1136
   Full Text | Web of Science | Medline

3. 3

   The Childhood Asthma Management Program Research Group. Long-term effects of budesonide or nedocromil in children with asthma. N Engl J Med 2000;343:1054-1063
   Full Text | Web of Science | Medline

Author/Editor Response

The Childhood Asthma Management Program study did indeed show a significantly lower frequency of urgent care visits for asthma (0.12 per 100 person-years for the budesonide group vs. 0.22 for the control group), a larger decline than resulted from our environmental intervention. Although a percent change for low-frequency events, such as these urgent care visits for asthma in the Childhood Asthma Management Program, must be interpreted with some caution, we agree with Drs. Boyle and Tang that inhaled corticosteroids should be considered the mainstay therapy for persistent asthma. Our intent in making a comparison to the Childhood Asthma Management Program study's data on symptom-free days was simply to put in perspective the magnitude of the response that can be achieved with a tailored, comprehensive environmental intervention. Our environmental intervention lasted only one year, as compared with the four to five years of corticosteroid intervention of the Childhood Asthma Management Program. Whether urgent care visits for asthma would continue to decline after a comparable period of environmental control remains an unanswered question.

Wayne J. Morgan, M.D., C.M.
University of Arizona College of Medicine, Tucson, AZ 85724

Marshall Plaut, M.D.
National Institute of Allergy and Infectious Diseases, Bethesda, MD 20817

Herman Mitchell, Ph.D.
Rho, Chapel Hill, NC 27514

Author/Editor Response

The purpose of the editorial was to comment on the statistically significant improvement in asthma symptoms that occurred with adequate environmental control. In neither the original article nor the editorial was there any direct comparison with the efficacy of inhaled steroids — only a reference to a similar salutary response. Corticosteroid therapy is the most effective therapeutic intervention for asthma of any severity. Removal of any offending allergen is central to the successful management of asthma resulting from antigen exposure.

Albert L. Sheffer, M.D.
Brigham and Women's Hospital, Boston, MA 02115

Citing Articles (1)

Citing Articles

1. 1

   Coleen Kumar, MaryAnn Edelman, Carmel Ficorelli. (2005) Children With Asthma. MCN, The American Journal of Maternal/Child Nursing 30:5, 305-311
   CrossRef