The wide and ever-increasing prevalence of asthma makes the care of patients by specialists (allergists, pneumologists) difficult. In addition, because of the apparent simplification of treatments based on inhaled corticosteroids and beta2-agonists, many patients are managed by non-specialists. A third, additional factor is the recent idea that prolonged or recurrent cough is a manifestation of asthma ("cough variant asthma")1-3, which has erroneously contributed to simplifying diagnosis and therefore to inappropriate treatment.
Because many of these patients will inevitably be managed by primary care physicians, these should receive appropriate training that includes accurate information on the differential diagnosis of cough symptoms, the indications for each of the commonly used drugs, doses, and different inhalation systems, when required4. Above all, general practitioners should know how to evaluate severity and when to refer patients to specialist care for etiopathogenic and functional investigations to establish individualized treatment. The relationship between primary care physicians and specialists is essential for the correct management of these patients.
Persistent cough is common to many other diseases of the respiratory tract and, when severe, is exacerbated by a reflex mechanism; hence the improvement produced by inhaled bronchodilator therapy5. Nocturnal cough has various causes, such as maxillary sinusitis, in which case inhaled corticosteroids produce no improvement. For Russell6, the lack of efficacy of inhaled corticosteroids may be due to "excessive enthusiasm for the diagnosis of cough variant asthma", indicating the need to confirm the diagnosis before initiating a treatment that is not without adverse effects, especially when patients exceed the recommended dose or when more potent corticosteroids are used7,8.
Under no circumstances should pediatricians make a diagnosis of asthma based purely on history-taking since parents frequently have difficulty in interpreting the characteristics of cough, respiratory sounds or breathing difficulties, as demonstrated by Cane et al9 and Elphick et al10, among others.
In this issue of Allergología et Immunopathología, the study by de Cunha et al11 reveals that primary care physicians in the city of Río de Janeiro have limited knowledge of the use of inhalation systems, the concept of inflammation as a cause of asthma and how to classify the severity of the disease, all of which affects treatment efficacy. By way of conclusion, these authors stress the need for training programs for the care of asthmatic children.
This conclusion could be applied to many other countries, including Spain, since we can frequently verify similar deficiencies when patients reach specialized services.
