Asthma attacks: should we nail our colours to the mast (cell)?

Many common airway diseases are characterised by chronic symptoms with interspersed acute and unpredictable deteriorations, conventionally called “pulmonary exacerbations”. Until relatively recently, these so-called exacerbations were a rather Cinderella subject, relatively neglected in favour of treating day-to-day problems. This may in part be because in asthma, for example, we have treatments such as inhaled corticosteroids (ICS) which are enormously effective in treating chronic symptoms, but prevention of exacerbations is much less successful. However, it is becoming increasingly clear that pulmonary exacerbations carry much more sinister overtones than once we thought, to the extent that the term “lung attacks” has been proposed to describe them [1, 2]. In cystic fibrosis (CF), treatment of lung attacks even with intravenous antibiotics may fail to restore spirometry to baseline [3], and are associated with an accelerated decline in lung function [4] and a worse prognosis [5]. Failure of response is also described in primary ciliary dyskinesia [6]. Lung attacks, as we shall continue to describe them, have been used as clinical trial end-points in CF [7] and bronchiectasis [8], and may be a more sensitive marker of response than spirometry [9]. They are very far from being a minor and reversible inconvenience to the patient with airways disease. Why do only some asthmatic children exacerbate, what is the underlying pathology, and how should we treat them?