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• W2054858074 abstract "How should asthma be defined in population studies? The question is deceptively simple, and its answer remains elusive. Since questionnaires are the most practical tools to use in screening populations for asthma, much attention has focused on developing survey definitions of asthma based on questionnaires. In general, the approach to validating such definitions has been to assess the ability of individual questions and combinations of questions to predict which individuals in a population have either clinical diagnoses of asthma or nonspecific bronchial hyperreactivity (BHR) to agents such as histamine or methacholine.1Toren K Brisman J Jarvholm B Asthma and asthma-like symptoms in adults assessed by questionnaires: a literature review.Chest. 1993; 104: 600-608Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar Unfortunately, physicians' diagnoses of asthma and BHR are not particularly good “gold standards” for identification of asthma. It is likely that a physician's diagnosis of asthma underdetects subclinical mild asthma. Thus, using it as a“ gold standard” will tend to underestimate the specificity of a questionnaire. In contrast, BHR is present in many people without asthma.1Toren K Brisman J Jarvholm B Asthma and asthma-like symptoms in adults assessed by questionnaires: a literature review.Chest. 1993; 104: 600-608Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar2Pekkanen J Pearce N Defining asthma in epidemiological studies.Eur Respir J. 1999; 14: 951-957Crossref PubMed Scopus (224) Google Scholar3Peat JK Toelle BG Marks GB et al.Continuing the debate about measuring asthma in population studies.Thorax. 2001; 56: 406-411Crossref PubMed Scopus (92) Google Scholar Therefore, use of BHR as a “gold standard” will underestimate sensitivity. Recognizing these limitations, many studies1Toren K Brisman J Jarvholm B Asthma and asthma-like symptoms in adults assessed by questionnaires: a literature review.Chest. 1993; 104: 600-608Abstract Full Text Full Text PDF PubMed Scopus (525) Google Scholar4Burney PGJ Chinn S Britton JR et al.What symptoms predict bronchial response to histamine? Evaluation in a community survey of the bronchial symptoms questionnaire (1984) of the International Union Against Tuberculosis and Lung Disease.Int J Epidemiol. 1989; 18: 165-173Crossref PubMed Scopus (157) Google Scholar5Jenkins MA Clarke JR Carlin JB et al.Validation of questionnaire and bronchial hyperresponsiveness against respiratory physician assessment in the diagnosis of asthma.Int J Epidemiol. 1996; 25: 609-616Crossref PubMed Scopus (386) Google Scholar6Sistek D Tschopp JM Schindler C et al.Clinical diagnosis of current asthma: predictive value of respiratory symptoms in the SAPALDIA study.Eur Respir J. 2001; 17: 214-219Crossref PubMed Scopus (73) Google Scholar have assessed the ability of questionnaires to predict a physician's diagnosis of asthma and/or BHR. In general, questions about ever having asthma, ever having asthma diagnosed by a physician, and having wheezing during the previous 12 months have been the questions with best sensitivity and specificity for prediction of the flawed “gold standards.” Thus, responses to these questions are often used in survey definitions of asthma. In this issue of CHEST (see page 135), Ponsonby et al report a study suggesting that evaluation of severity can be used to classify into subsets individuals identified by questionnaire to have symptoms of asthma or the disease itself. The study is a cross-sectional survey for asthma conducted in 1999, evaluating children aged 8 to 10 years from randomly selected schools in the Australian Capital Territory. Children of the same age presenting in 1999 to the only three hospitals in the Australian Capital Territory able to manage acute pediatric asthma were also evaluated. For all of these children, asthma was identified using a questionnaire and atopy by a panel of allergy skin tests. Among those reporting wheezing in the previous 12 months, a stronger relationship was noted with atopy for those reporting > 12 episodes of wheezing in the last 12 months than for those reporting 1 to 3 episodes in the last 12 months (odds ratios [ORs], 8.70 vs 3.27, respectively). Atopy was also found to be more strongly associated with 1999 hospital attendance for asthma than with ever having had asthma (ORs, 16.95 vs 2.09, respectively). The proportion of “asthma-ever” attributable to atopy was 33%, while for hospital attendance in 1999, this proportion was 89%. Based on these findings, the authors suggest that atopy contributes more to frequent or severe asthma than to infrequent or mild asthma. These findings are consistent with those of other studies. The important association of atopy with childhood asthma is well accepted.7Host A Halken S The role of allergy in childhood asthma.Allergy. 2000; 55: 600-608Crossref PubMed Scopus (56) Google Scholar A review8Pearce N Pekkanen J Beasley R How much asthma is really attributable to atopy?.Thorax. 1999; 54: 268-272Crossref PubMed Scopus (544) Google Scholar of studies relating atopy to asthma notes that in cross-sectional studies conducted exclusively or predominantly in children, the proportion of cases attributable to atopy varied from 25 to 63%, with a weighted mean of about 38%. Previous studies8Pearce N Pekkanen J Beasley R How much asthma is really attributable to atopy?.Thorax. 1999; 54: 268-272Crossref PubMed Scopus (544) Google Scholar have also suggested a relationship between atopy and asthma severity. Atopy is also related to degree of BHR.9Burrows B Sears MR Flannery EM et al.Relations of bronchial responsiveness to allergy skin test reactivity, lung function, respiratory symptoms, and diagnoses in thirteen-year-old New Zealand children.J Allergy Clin Immunol. 1995; 95: 548-556Abstract Full Text Full Text PDF PubMed Scopus (105) Google Scholar10Soriano JB Anto JM Sunyer J et al.Risk of asthma in the general Spanish population attributable to specific immunoresponse.Int J Epidemiol. 1999; 28: 728-734Crossref PubMed Scopus (17) Google Scholar Conversely, in patients having wheeze in the previous 12 months, BHR is related to both atopy and measures of disease severity such as peak flow variability.11Toelle BG Peat JK Salome CM et al.Toward a definition of asthma for epidemiology.Am Rev Respir Dis. 1992; 146: 633-637Crossref PubMed Scopus (255) Google Scholar Thus, it has become increasingly apparent that populations identified by survey definitions of asthma based on self-report of asthma or asthma symptoms are a heterogeneous population. This population can be further subdivided into more homogenous subsets. Those with mild or inactive disease are less likely to be atopic or exhibit BHR. In contrast, those with more severe disease are more likely to be atopic and exhibit BHR. It has already been proposed that measurement of BHR can be used in combination with questionnaire responses to define subpopulations of asthmatics.3Peat JK Toelle BG Marks GB et al.Continuing the debate about measuring asthma in population studies.Thorax. 2001; 56: 406-411Crossref PubMed Scopus (92) Google Scholar11Toelle BG Peat JK Salome CM et al.Toward a definition of asthma for epidemiology.Am Rev Respir Dis. 1992; 146: 633-637Crossref PubMed Scopus (255) Google Scholar Perhaps it will also prove useful to define subpopulations based on severity of disease using questions such as those in the wheezing module of the International Study of Asthma and Allergies in Childhood questionnaire.12Asher MI Keil U Anderson HR et al.International study of asthma and allergies in childhood (ISAAC): rationale and methods.Eur Respir J. 1995; 8: 483-491Crossref PubMed Scopus (2888) Google Scholar This approach has already been applied to evaluation of asthma prevalence, documenting that increases in the prevalence of asthma diagnosis and symptoms in Sheffield, UK, between 1991 and 1999 were confined to mild symptoms.13Kwong GNM Proctor A Billings C et al.Increasing prevalence of asthma diagnosis and symptoms in children is confined to mild symptoms.Thorax. 2001; 56: 312-314Crossref PubMed Scopus (84) Google Scholar Identification of more homogeneous asthmatic subpopulations should also facilitate population studies addressing issues such as asthma pathogenesis and effectiveness of preventive interventions such as allergen avoidance." @default.
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