Cough, primary care and other matters.

The w ide 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” ), w hich has erroneously contributed to simplifying diagnosis and therefore to inappropriate treatment. Because many of these patients w ill 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 required. 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 therapy. Nocturnal cough has various causes, such as maxillary sinusitis, in which case inhaled corticosteroids produce no improvement. For Russell, 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 w ithout adverse effects, especially when patients exceed the recommended dose or when more potent corticosteroids are used. 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 al and Elphick et al, among others. In this issue of Allergología et Immunopathología, the study by de Cunha et al 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 con-