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This review offers readers new aspects for the guideline-compliant care of asthma patients. Here, attention is focused on illustrating the bottlenecks in the administration of good and practicable therapeutic care and listing these as "major challenges for GPs". The interdisciplinary team of authors - consisting of three hospital-based pulmonologists, one pulmonologist in private practice, one internist in general practice, one pharmacist and one health economist discussed aspects of asthma therapy relevant in clinical practice.Practicable results for the reader included an asthma pentagram, a graphic depicting the links and interactions between diagnosis, symptom management, communication, application and costs. From this emerged a consensus on four recommendations that can help GPs improve their care of their patients: (1) Whenever possible, have a specialist verifythe diagnosis. (2) Practice inhalation techniques with the patient and check up on their technique at regular intervals. (3) Monitor and fine-tune the therapeutic goals set down together with the patient. (4) Clearly define the (patient's) responsibilities and who is organizing care (communication between GP-specialist-patient-pharmacist-family members).

This is an updated overview of indications, contraindications, performance and interpretation of bronchial challenge tests. As speciality, the diagnostic step by step scheme comprises in addition to the clinical case history a detailed exposure (occupational) history, lung function testing, assessment of nonspecific bronchial hyperresponsiveness, allergological diagnostics (skin prick test, measurement of specific IgE antibodies), privation and reexposure test and as gold standard specific bronchial challenge tests. The last mentioned tests are of particular importance in the framework of a diagnostic backup with regard to specific therapeutic and preventive measures and insurance regulations (occupational disease?). Specific bronchial challenge tests and their variant, the workplace-related challenge test, serve to objectify or exclude the clinical relevance and the current state of a respiratory sensitization. They require a comprehensive experience of the physician performing the tests. The majority of diseases does not necessitate these tests, especially if case history, lung function testing, allergy tests, privation and reexposure test provide unanimously positive results. If allergic symptoms of conjunctiva or the upper respiratory tract are of prime importance the performance of a specific conjunctival or nasal challenge test is recommended.

The antileukotrienes (anti-LT), consisting of synthesis inhibitors and leukotriene receptor antagonists, represent a new direction in targeted drug therapy for asthma. In the present article, the anti-inflammatory properties of anti-LT are briefly summarized. Orally administered anti-LT inhibit the allergen-induced early and late asthmatic reactions and may attenuate the allergen-associated hyperresponsiveness. They also have a remarkable inhaled steroid-sparing effect. In chronic asthma, anti-LT may exert significant therapeutic benefit. In addition to their properties as relievers, anti-LT may have properties as controllers of asthma.

Genetic association studies have related the tumour necrosis factor-alpha gene (TNFA) guanine to adenine substitution of nucleotide -308 (-308G>A) polymorphism to increased risk of asthma, but results are inconsistent. The aim of the present study was to test whether two single-nucleotide polymorphisms, of TNFA and of the lymphotoxin-alpha gene (LTA), are associated with asthma, bronchial hyperresponsiveness and atopy in adults, by combining the results of two large population-based multicentric studies and conducting a meta-analysis of previously published studies. The European Community Respiratory Health Survey (ECRHS) and Swiss Cohort Study on Air Pollution and Lung and Heart Diseases in Adults (SAPALDIA) used comparable protocols, including questionnaires for respiratory symptoms and measures of lung function and atopy. DNA samples from 11,136 participants were genotyped at TNFA -308 and LTA 252. Logistic regression employing fixed and random effects models and nonparametric techniques were used. The prevalence of asthma was 6%. The TNFA -308G>A polymorphism was associated with increased asthma prevalence and with bronchial hyperresponsiveness. No consistent association was found for atopy. The LTA 252A>G polymorphism was not associated with any of the outcomes. A meta-analysis of 17 studies showed an increased asthma risk for the TNFA -308 adenine allele. The tumour necrosis factor-alpha gene nucleotide -308 polymorphism is associated with a moderately increased risk of asthma and bronchial hyperresponsiveness, but not with atopy. These results are supported by a meta-analysis of previously published studies.

Airway smooth muscle cells (ASMC) play a key role in bronchial hyperresponsiveness (BHR). A major component of the signalling cascade leading to ASMC contraction is calcium. T-bet knock-out (KO) mice show the key features of allergic asthma such as a shift towards T (H2)-lymphocytes and display a broad spectrum of asthma-like histological and functional characteristics. In this study, we aimed at investigating whether Ca (2+)-homeostasis of ASMC is altered in T-bet KO-mice as an experimental model of asthma.Lung slices of 100 to 200 microm thickness were obtained from T-bet KO- and wild-type mice. Airway contractions in response to acetylcholine (ACH) were measured by video-microscopy and Ca (2+)-signaling in single ASMC of lung slices was assessed using two-photon microscopy.Airways from T-bet KO-mice showed increased baseline airway tone (BAT) and BHR compared to those of wild-type mice. The increased BAT was correlated with an increased incidence of spontaneous changes in intracellular Ca (2+)-concentrations, whereas BHR correlated with higher ACH-induced Ca (2+)-transients and an increased proportion of ASMC showing Ca (2+)-oscillations. Emptying intracellular Ca (2+)-stores using caffeine or cyclopiazonic acid induced higher Ca (2+)-elevations in ASMC from T-bet KO compared to wild-type mice.Altered Ca (2+)-homeostasis of ASMC contributes to increased BAT and BHR in lung slices from T-bet KO mice as a murine asthma model. We propose that a higher Ca (2+)-content of the intracellular Ca (2+)-stores is involved in the pathophysiology of these changes.

In 2003 Baiardini et al. presented the RHINASTHMA questionnaire, which measures the impairment of quality of life in patients with rhinitis and asthma and takes the "united airway disease" model into its account. The aim of our study was to create a valid version of this questionnaire adapted for use with German-speaking subjects.Datasets recorded for 85 patients were analysed for sensitivity, reliability and validity of the new questionnaire. For this purpose, as well as the symptom scores, disease-specific and generic quality of life questionnaires were also used as a measure of validity.A correlation analysis and Cronbach's alpha indicated that the RHINASTHMA scale is satisfactory from the aspect of reliability. Good validity was also shown in terms of discrimination and agreement for all items and scores. In addition, all the observed parameters reacted sensitively to clinical improvements of the health status.The RHINASTHMA questionnaire makes it possible to determine how badly the quality of life is impaired by rhinitis and asthma, based on the paradigm of "united airway disease".

Bronchial asthma is a chronic disease underlying which is an inflammatory cascade. Allergic reactions have an important role to play, in particular in the case of children and adolescents. An allergological investigation is of great importance in the initial diagnostic work-up of an atopic diathesis, and for the identification of the allergen. Exhaustive history-taking is the essential first measure in the stepped diagnostic approach. In-vivo and in-vitro tests such as the prick test and total IgE can provide information about the extent of the atopy as well as support for the clinical suspicion, but they are not proof of the presence or absence of a clinically relevant sensitization. Further allergological tests (e.g. provocative test) are usually indicated only in specific problems, and should remain the domain of the allergologist or pneumologist.

The phenomenon of Multiple Chemical Sensitivity which generally cannot be explained organically is frequently associated with psychic impairment. This case series deals with the question if in addition to a standardized interview a routine psychiatric-psychosomatic examination alters the classification if a patient suffers from symptoms compatible with MCS or not.Nine consecutive outpatients (m = 3, f = 6, mean age 44 yrs) of the environmental medicine centre were investigated. Somatic diseases were evaluated by standard medical procedures and emotional disturbances were assessed by the Munich Composite International Diagnostic Interview (M-CIDI) and a psychiatric-psychosomatic examination.In all but one patients emotional disturbances (F-codes of the ICD-10) were diagnosed by the M-CIDI and the psychiatric-psychosomatic examination. The diagnoses of the M-CIDI and the psychiatric-psychosomatic examination often did not match. MCS was ruled out in seven patients.According to the criteria defined by Cullen (5), emotional disturbances must be ruled out before MCS is diagnosed. Therefore, an examination by a specialist in psychiatry or psychosomatics is mandatory because evaluation solely based on the M-CIDI is insufficient. Performing a routine psychiatric-psychosomatic examination, MCS could be ruled out much more often than previously.

To characterize parenchymal lung affections morphologically in patients with asthma and healthy subjects by high -resolution computed tomography (HRCT) subsequent to histamine-triggered inhalation bronchoprovocation and salbutamol-induced broncholysis, and to compare the results with pulmonary function tests.Fifteen asthmatics with bronchial hyperreactivity, with a20% decrease in FEV1 and a10 mmHg decrease in PaO(2) after bronchoprovocation (PC20%+), twelve asthmatics with a20% decrease in FEV1 and a10 mmHg decrease in PaO(2) after bronchoprovocation (PC20%-), and eight healthy persons without bronchial hyperreactivity underwent inhalation bronchoprovocation and broncholysis. Spirometer-triggered HRCT at high lung volumes was performed, and total and peripheral lung densities and the amount of solid lung structures, representing predominantly vessels, were measured.After bronchoprovocation, we observed significant decreases in total and peripheral lung densities in all groups (p0.0005), and a significant increase in lung densities subsequent to bronchodilation (p0.0002). The morphological alterations in solid lung structure were not significantly different after bronchoprovocation or broncholysis (p0.05), as compared to the baseline measurements. In hyperreactive patients, PaO(2) significantly decreased after provocation and significantly increased after lysis (p0.05). In PC20%+ asthmatics, a mean reduction of 27.8% in FEV1 was observed, which was20% in the other groups. No significant correlations were observed between radiological data and the results of pulmonary function tests. In healthy persons, we demonstrated highly significant parenchymal response to bronchoprovocation and broncholysis, which was not otherwise documented by pulmonary function tests.In both PC20%+ and PC20%- patients as well as in healthy individuals, HRCT was efficient in the evaluation of pathoanatomical alterations of the lung parenchyma subsequent to inhalation provocation. In healthy individuals, these parenchymal alterations were not documented by pulmonary function tests.

Epidemiological and clinical data are discussed dealing with a possible influence of inflammatory changes of the nasal and especially the paranasal tissue on lower airway disease like asthma, the so-called "sinobronchial syndrome". Even though there is clear evidence of an association of the upper with the lower airway diseases, a causal relationship and a possible work of action are still up for discussion. The literature has been reviewed, and different theories are discussed. Generally speaking, a branch of differently accentuated mechanisms seems to play a role.

The European Community Respiratory Health Survey (ECRHS) was the first study to assess the geographical variation in asthma, allergy, and allergic sensitization in adults using the same instruments and definitions. The database of the ECRHS includes information from approximately 140 000 individuals aged 20 - 44 years from 22 countries. The aim of this review is to summarize the results of the ECRHS and to present the specific contribution of the German centers in Hamburg and Erfurt. The prevalence ranged from 2.0 - 11.9 % for asthma, 9.5 - 40.9 % for allergic rhinitis, 4.0 - 32.0 % for wheeze, 3.4 - 27.9 % for bronchial hyperreactivity, and 16.2 - 44.5 % for allergic sensitisation against common aeroallergens. Although the prevalence of these atopic disorders were found to be consistently higher for the Hamburg center compared to the Erfurt center, strong regional differences in the prevalences were also found within several other European countries. Overall Europe, the lowest prevalences were seen in the Eastern and Middle European countries with the center Erfurt, followed by the Mediterranean region. The highest prevalences were reported for all English speaking centers. Strong geographic variation was reported for medication for asthma. Asthma seems to be undertreated in several countries. Environmental exposures and in particular indoor factors, and exposures at the workplace are playing a major role for asthma in adulthood. Furthermore, protective effects on atopy were found for exposures to pets (dogs) and a large number of siblings in early childhood. In conclusion, the ECRHS has shown that the prevalence of asthma varies widely. The fact that the geographical pattern is consistent with the distribution of atopy and bronchial responsiveness supports the conclusion that the geographical variations in the prevalence of asthma are true and likely due to environmental factors.

To compare the validity of different methods for the assessment of bronchial hyperresponsiveness used by different centers.Case series of 648 subjects referred to six pulmonary centers, all with a history of shortness of breath without airway obstruction, without use of medication that might influence the tests and without viral infections during the previous two weeks. All subjects answered a questionnaire of recent symptoms and underwent bronchial challenge with a chemical stimulus according to each center's protocol. Analysis was performed by receiver operating characteristic (ROC) plots using the questionnaire's answers as the gold standard. Diagnostic test sensitivities at the cut-offs for bronchial hyperresponsiveness indicated by each center were compared.ROC plots showed poor validity of all tests, i.e. both acceptable sensitivity and specificity were not observed with any test. There was no obvious difference of the slope of the ROC plots between the different centers. However, maximal sensitivity differed considerably: for "wheeze during the previous 12 months", sensitivity at each center's cut-off for the definition of bronchial hyperresponsiveness varied between 0.35 and 0.73. The choice of the question used as the standard had little influence on test validity.Although some of the differences between centers may be explained by subject characteristics, the large differences of the test sensitivities are unacceptable and underscore the need for standardization of these tests, primarily with respect to sufficient sensitivity.

Since the 1960s an increasing number of occupational allergies against natural, and against modified recombinant enzymes were observed. Subtilisin, a frequently used enzyme often has been shown to cause airway sensitization. The present evaluation of clinical literature data confirms the sensitization potential of subtilisin. Several cases of specific airway hyperresponsiveness caused by subtilisin are verified by a number of studies. As symptoms, results of skin prick tests, detection of specific IgE-antibodies and results of specific bronchoprovocation tests are consistent, an immunologic mechanism is confirmed.

Asthma and COPD (chronic obstructive pulmonary disease) are the most important obstructive pulmonary diseases. Patient's history and physical evaluation give major hints of the underlying disease. Further diagnostic measures comprise lung function analysis including spirometry, plethysmography and--in severe cases--blood gas analysis. Bronchial hyperreactivity may be quantified with an unspecific inhalative provocation test. In many cases allergic diseases are accompanied by asthma. Thus, allergy tests--particularly skin prick tests--have to be carried out. To further define an underlying allergy, in some cases even specific inhalative provocation tests have to be performed. X-ray of the thorax and other imaging techniques, detailed blood analysis, further diagnosis of the upper respiratory tract and the cardiac system may have to be carried out a) to quantify the effects of a severe form of asthma or COPD on other organs, and b) for differential diagnostic examinations.

Twenty-four patients with bronchial hyperreactivity due to asthma (8 patients), COPD (13) and of unknown origin (3) entered and completed a randomized double-blind intraindividual cross-over study. Thirteen patients first received the highly selective vasodilatating beta 1-blocker Nebivolol (5 mg) and 11 patients first placebo with a wash-out period of at least 2 days. Before the controlled oral intake of the tablets, the patients were challenged with increasing inhalative doses of carbachol between 8 and 9 a.m. according to the recommendation of the German Society of Pneumology. At 10, 11 and 12 a.m. and 1 and 2 p.m. control measurements of airway patency (Raw, FEV1) were performed in the body box. At the same time intervals, oxygen saturation and pulse rate (pulsoximetry) including systolic and diastolic blood pressure were monitored. From 2-3 p.m. the carbachol provocation was repeated as in the morning to assess the changes in hyperreactivity due to Nebivolol.During the Nebivolol phase, blood pressure values and pulse rates were significantly reduced compared to the placebo phase. At the same time intervals, no significant changes of the measured body box variables to assess airway obstruction were observed during therapy with Nebivolol compared to placebo. Comparing the measured variables (maximal deviation from base-line values of Raw and FEV1) during carbachol provocation in the afternoon under Nebivolol and placebo with the values in the morning before any medication (base-line values), there were also no significant detectable differences indicating an increase of bronchial hyperreactivity under Nebivolol treatment.It seems that Nebivolol in these hyperreactive patients is as safe as placebo despite its significant effect on blood pressure and pulse rate.

According to national and international recommendations the bronchial sensitivity should be determined based on the decrease of the FEV1 by 20 % (FEV1 - 20) or the increase of the airway resistance by means of body plethysmography by 100 % (Raw + 100). Measurement of airway resistance by interrupter technique (Rint) is a simple method and needs no active cooperation of the patient, but is not recommended in airway challenge testing. We investigated the role of the increase of Rint by 100 % (Rint + 100) compared to Raw + 100 and FEV1 - 20 during carbachol airway challenge testing by means of dosimetry. We examined 123 patients with following symptoms: 85 x coughing, 31 x coughing and dyspnea, 7 x medical opinion. Significant correlations between Rint and Raw were found before and after the challenge tests (Rint before/after 0,3 +/- 0,13/0,36 +/- 0,25 kPa*s/l; Raw before/after 0,24 +/- 0,09/0,50 +/- 0,41 kPa*s/l; r = 0,504/0,672; p0,001 [Pearson]). The median values of Rint and Raw were significantly different (p0,001 [Wilcoxon]). Moreover Rint systematically overestimated airway resistance in the normal range and underestimated the increase of airway resistance during challenge testing (r = 0,783; p0,001 [Pearson]). In 58 patients an increased airway responsiveness was found. In 21 oft these patients there was no increase of Rint above the initial value. Sensitivity/specificity/positive predictive value/negative predictive value in % to the detection of airway hyperresponsiveness were in Rint + 100 9/95/63/54, in FEV1 - 20 61/100/100/66 and in Raw + 100 98/100/100/98. In conclusion we found significant correlations between Rint and Raw, but the median values were systematically and significantly different. Rint + 100 had a low sensitivity to detect airway hyperresponsiveness and is not comparable with FEV1 - 20 or Raw + 100.

In non-smokers the underlying causes for chronic persistent cough (CPC) e.g. chronic cough without diagnostic chest X-ray or pulmonary function test--are usually as follows: several common upper airways diseases, bronchial (cough type) asthma, gastrooesophageal reflux or treatment with an ACE (angiotensin converting enzyme)--inhibitor. In 10% of CPC however the cause remains uncertain. We report a 30 year old non-smoker with severe coughing and repeated vomiting for two months. No laboratory or technical data could be collected suggestive of a common cause of CPC: Upper airways disease, bronchial flow limitation or hyperresponsiveness, ACE inhibitor medication, B. pertussis infection, gastrooesophageal reflux disease (by 24 hours pH-probe) were ruled out. Fiberbronchoscopic findings remained unremarkable, except for the bronchial biopsy specimen, which showed moderate eosinophilic inflammation of the mucosa and marked thickening of the subepithelial layer. Since the cough was non-productive, sputum induction with 3 ml nebulised 3% NaCl solution was performed. 28% of the granulocytes were eosinophil stained. A low quality morning sputum (1 ml) showed 21% eosinophilia. Thus, the diagnosis of eosinophilic bronchitis was established. 400 micrograms budesonide dry powder inhalations b.i.d. for one week resolved the cough, treatment was stopped after three weeks. No recurrence was seen two months later. Both the cough type asthma and the eosinophilic bronchitis could represent a form fruste of classical bronchial asthma beyond wheezing or dyspnoea, but with the common main symptom: cough. Since hyperresponsiveness and cough are phenotypic hallmarks of cough variant asthma, in eosinophilic bronchitis--beside cough--another two features of asthma are present: eosinophilic inflammation of the mucosa along with sputum eosinophilia and subepithelial layer thickening. Not surprisingly, eosinophilic bronchial inflammation could be shown in patients with cough variant asthma as well, who--up to 56% during a four year-period--develop classic asthma. The long-term outcome of eosinophilic bronchitis is not known, however. Thus, asthma, cough variant asthma and cough due to eosinophilic bronchitis can mirror different phenotypes or phases of the same entity. CPC due to either the cough type asthma or the eosinophilic bronchitis is like asthma fast responding to inhalative steroids. (Induced) sputum staining should be added to the diagnostic armamentarium of CPC.

Bronchial asthma is a chronic inflammatory disease of the lower respiratory tract. It is characterized by nonspecific bronchial hyperresponsiveness, which may lead to variable, reversible airflow obstruction in affected patients. Despite therapeutic improvements, the worldwide prevalence and morbidity of asthma have risen during the past decades. An improved understanding of underlying pathological features and mechanisms of asthmatic inflammation is essential to achieve an enhanced asthma symptom control and may lead to prevention in the future.Besides the impact of genetic and environmental factors, scientific interest has especially been focused on the molecular and cellular biology of the asthmatic response. Mucosal inflammation in asthmatics is mainly orchestrated by T cells and derived cytokines. Immunoglobulin E and mast cells play a pivotal role in the initiation and pathogenesis of the early asthmatic reaction, while recruitment and activation of eosinophils seem to be crucial for the persistent asthma phenotype with chronic airflow obstruction. Additionally, smooth muscle cells, parasympathetic nerve fibers, bronchial epithelial cells and a vast amount of mediators may either promote or inhibit the inflammatory pathology of bronchial asthma.The recent insights from molecular biology have found their correlate in actual therapeutic guidelines, and have further led to the development of new innovative asthma drugs such as monoclonal antibodies against IgE or IL-5. Hopefully, future progress in revealing pathogenetic mechanisms of asthma may lead to further therapeutic improvement and eventually reverse the trend of rising asthma morbidity in western societies.

For more than 30 years the ascarid Toxocara canis, a parasite of the dog, has been considered a possible cause of allergic-pulmonal irritations (i.e. asthma bronchial) in man. According to a British study thousands of people are presumably suffering from asthma bronchial as a consequence of Toxocara infestations. The aim of our recent study was the assessment of the Toxocara seroprevalence in patients of varying bronchial reactivity and status of atopy suffering from respiratory disturbances. 191 serum samples from 59 male (mean age: 31.7 years) and 132 female patients (mean age: 36.6 years) with varying atopy status and degree of bronchial reactivity, living in or near Vienna, were examined for specific IgG antibodies against excretory-secretory (E/S) Toxocara canis antigen with enzyme-linked immunosorbent assay (TES-ELISA) and Western blot (TES-WB). In total a Toxocara seroprevalence of 9.4% could be assessed among these patients. 10% of the patients with and 7.8% of the patients without bronchial hyperreactivity were Toxocara-positive. Atopic patients were serologically positive in 7.1% of the cases tested whereas non-atopics showed an antibody prevalence of 14.3%. A comparison of Toxocara seroprevalence assessed within the recent study and in an earlier study among healthy pregnant women in Vienna did not show significant differences. The results of this study carried out in Vienna indicate that patients with bronchial hyper-reactivity or atopy show no higher seroprevalence than the normal population.

Several studies note that bronchial hyperresponsiveness has increased in the past years. There is a connection between allergen exposition during childhood and the development of asthma bronchiale. 1988 a questionnaire was sent to the parents of 281 Viennese school children. The children were tested for bronchial hyperresponsiveness as well as for sensitization to airborne allergens like Alternaria alternata (A. alternat) and Dermatophagoides pteronyssinus (D. pter.). The same test with the same methodology was repeated in 390 children at the same school in 1997. In the period from 1988 to 1997 the number of children with bronchial hyperresponsiveness increased significantly from 20 to 27 percent. The prevalence of sensitization increased from 24 to 34 percent. The report of asthmatic symptoms and allergic reactions is increasing as well.

Complementary and alternative medicine is a widespread phenomenon. On the one hand it is demanded by the patients. On the other, practising physicians want to know more about it. The common motive for their interest is the perception that conventional medicine has its limits. This is obvious in the case of bronchial asthma, whose underlying cause is largely unknown despite decades of research, and whose treatment is symptomatic. Furthermore, asthma mortality is not declining. In these circumstances it is legitimate to look for alternatives. One alternative therapy is acupuncture. Although there are many published studies on acupuncture and asthma, few meet the scientific tests necessary to prove the effectiveness of acupuncture. From these studies it emerges that short term effects of acupuncture are better documented than long term ones. Nor is it possible to predict what proportion of asthmatics will respond to acupuncture. Allergic eosinophilic inflammation of the respiratory tract is foremost among present day hypotheses concerning the pathogenesis and pathophysiology of asthma. It is interesting that there are no known clinical or experimental investigations into the effect of acupuncture on allergic inflammation of the asthmatic's bronchial mucosa. In view of these facts we are conducting a long term controlled study of the acute and chronic effects of acupuncture on both allergic inflammation of the bronchial mucosa and asthmatics' clinical symptoms, bronchial hyperreactivity and consumption of medication. To establish responders and non-responders, lung function tests and measurement of microcirculation and skin temperature are carried out before and after acupuncture treatment. If we can show that acupuncture has an effect on the allergic inflammation, this is not only a new pathophysiologic aspect and a further explanation of how the acupuncture effect on asthma comes about. The result also has far-reaching implications for the asthmatic by improving the disease, limiting consumption of medication, preventing side effects and lowering drug costs.

Increased reactions of the laryngeal mucosal membrane can appear after acetylcholine (ACH) inhalation. A red mucous membrane, vocal cord edema, mucus formation, changes in the glottic configuration and (rarely) subglottic edema are visible to laryngoscopic observations. The influence on various voice parameters in patients with and without laryngeal hyperreactivity was researched in order to decide the reliability of voice parameter measurements in clinical practice. Significant variations of the soft phonation index (SPI), the fundamental frequency variation (vFo), the noise-to-harmonic ratio (NHR) and the voice turbulence index (VTI) were examined for their correlations with the observable features of laryngeal hyperreactivity. A single diagnosis of hyperreactivity with voice parameter analysis failed in 50% of the patients examined because of functional voice instability and irregularities seen. Only with both laryngoscopy for reliable discrimination and voice parameter analysis for quantitative registration were findings sufficient for assessing laryngeal hyperreactivity.

Little is known about the prognosis of asthma. Disease remission in adolescence has been reported to vary between 20-80%, but bronchial hyperresponsiveness can still be detected in most subjects even if they are without symptoms. The relapse rate of asthmatics who were without symptoms during adolescence amounts to about 30%. Severe disease at an early stage or in adolescence, atopy, atopic dermatitis, a high degree of bronchial hyperresponsiveness, severely impaired lung function and both active and passive smoking are risk factors and closely associated with a poor prognosis. The relevance of gender, age at onset or recurrent viral infections has not been clarified yet. The effect of environmental factors on the increasing incidence and the prognosis of asthma remains to be quantified.

Airways of patients with bronchial hyperreactivity (BHR) are characterised by exaggerated bronchoconstriction in response to a variety of stimuli; bronchospasm may be elicited during induction and maintenance of anaesthesia. The prevalence of BHR in normal populations is approximately 10%. BHR is an important feature of clinical asthma, chronic obstructive pulmonary disease (COPD), allergic rhinitis, atopy, upper respiratory tract infections and smoking. This review will outline some important aspects of the pathophysiological basis of BHR, i.e., neural and inflammatory mechanisms. Furthermore, it should assist in identifying patients at risk and update perioperative anaesthetic considerations. Prophylaxis of airway reflex activation and an appropriate anaesthetic plan should prevent airway constriction. Since tracheal intubation is the major risk factor to induce bronchospasm intubation should be avoided whenever possible and regional anaesthesia preferred. If tracheal intubation is unavoidable, propofol and ketamine can be recommended as induction agents. Prophylaxis of intraoperative bronchospasm and initial therapy, such as deepening of anaesthesia, inhalational administration of sympathomimetics and anticholinergics, and i.v. use of local anaesthetics and corticosteroids are outlined. Despite its popularity theophylline offers little benefit during anaesthesia. Adequate preoperative evaluation and preparation of the patient with BHR will contribute to optimising anaesthetic management of patients with BHR.