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1.1
chapter 1: The burden of respiratory disease in New znaland
Introduction
This opening chapter will set the scene as to why I felt that this area of research was of
importance and of interest. The burden of respiratory disease in New Tnaland is high, and
clearly apparent to anyone who trains or works here in the field of medicine. It was an
obvious problem as I came through the Auckland School of Medicine, it was obvious when I
chose a rural setting to do my first house year, and it remained obvious when I commenced
training in paediatrics. The burden appeared to be borne disproportionately by children, and
by children of two specific community groups - Maori and Pacific Island. In the l9g0s and
1990s, New Zealand was leading the world in both the incidence of asthma and, more
appallingly, asthma mortality. Although the diagnosis of asthma in children was not always
clear, we embarked on anti-inflammatory drug treatment, possibly for years. While asthma
was thought to be a reversible disease, it has since transpired that an element of irreversibility
could develop which has been termed 'airway remodelling'.
This thesis commenced ten years ago and is based on work I conducted while employed as a
fellow and senior registrar and lecturer at the Royal Brompton Hospital in london. My
interest, then as now' was in paediatric respiratory disease. I was concerned that we seemed to
be making treatment decisions regarding the use of potential toxic anti-inflammatory agents,
specifically the use of steroids, without measuring any inflammatory parameter. Rather, we
were using history, examination and other surrogate measures such as x-rays and lung
function (where possible and where children were old enough) to determine correct diagnosis
and response to treatment. So for the individual child; was the diagnosis correct? Was the
child on too much or unnecessary medication? - a treatment with potentially significant side
effects, such as adrenal suppression and growth failure. Or was the child on too little
medication? - suffering symptoms daily with the possible development of irreversible
disease, or even death. I saw many children in the clinic that were in both categories; on ..too
much" steroid therapy for too long incorrectly, on "too little" with unnecessary morbidity, and
so very few seemed'Just right". I planned and conducted the research outlined in this thesis,
which I saw as a unique opportunity to investigate a possible solution to this quandary. The
research presented is thus now historical. It has already contributed to medical literature,
including the formulation by the European Respiratory Society and American Thoracic
Society of standardized procedures for the measurement of exhaled nitric oxide (NO), the
marker I chose to explore to indicate airway inflammation. I have continued to research this