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The role of small airway disease in asthma

Bjermer, Leif

Current Opinion in Pulmonary Medicine: January 2014 - Volume 20 - Issue 1 - p 23–30
doi: 10.1097/MCP.0000000000000018
ASTHMA: Edited by Nicola A. Hanania and Zuzana Diamant

Purpose of review This review provides an update on the importance of the peripheral ‘small’ airways in asthma. As the small airways account for less than 10% of total airway resistance, thus having little impact on standard lung function measures such as forced expiratory volume and peak flow, they have been referred to as the ‘silent zone’.

Recent findings The study has revealed that small airway involvement is present in all stages of asthmatic disease, being related to important clinical phenotypes such as nocturnal asthma, exercise-induced asthma, and difficult-to-control asthma, including those with the risk of repeated asthma exacerbations. Uncontrolled small airway inflammation is related to airway remodeling and progression of the disease, with a more rapid decline in the lung function. Moreover, studies on both children and adults have shown that the involvement of the small airways represents a crucial step in asthma development. New tools have been developed and old tools have been refined, providing an opportunity to better understand small airway inflammation and dysfunction.

Summary Small airway inflammation is present in all stages of asthmatic disease and plays an important role in many key clinical conditions/phenotypes. In order to control the disease, we need to target small airway inflammation, which is not only difficult to reach by standard inhaled medications but also to some extent different. A better understanding of the important role small airways are playing in asthma will show that the ‘silent zone’ is by far not silent at all.

Department of Respiratory Medicine & Allergology, Skane University Hospital, Lund University, Lund, Sweden

Correspondence to Professor Leif Bjermer, MD, Department of Respiratory Medicine & Allergology, Skane University Hospital, Lund University, 221 85 Lund, Sweden. Tel: +46 70 2126845; e-mail:

© 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins