Hidden factors in asthma.

The importance of discovering and treating hidden factors that exacerbate asthma as specified in component 2 of the 1997 National Heart Lung and Blood Institute (NHLBI) expert panel report guidelines has been overshadowed by a disproportionate emphasis on component 3 (pharmacologic therapy). This has resulted in disease management models that consist of a two-step classification-treatment system in which little regard is given to the evaluation of underlying contributing factors. In addition to the identification of environmental allergens, an aggressive evaluation of other potential factors that may contribute to asthma is essential to optimal, efficient, and cost-effective asthma care. These factors include sinusitis, allergic rhinitis, and gastroesophageal reflux. Diagnostic testing for sinusitis and/or gastroesophageal reflux is warranted even in the absence of suggestive signs or symptoms for many patients with asthma classified in the moderate and severe ranges by NHLBI guidelines. A disease management algorithm for gastroesophageal reflux disease in the patient with asthma is proposed.