Asthma and chronic obstructive pulmonary disease (COPD) are currently diagnosed and treated after demonstration of variable airflow limitation and symptoms. Under this framework, undiagnosed and unchecked airway inflammation is associated with recurrent acute attacks, airway remodeling, airflow limitation, adverse effects of corticosteroids, and impaired quality of life, ultimately leading to the collection of side-effects termed ‘people remodeling’. This one-size-fits-all, damage control approach aims to control symptoms and treat exacerbations rather than modify the underlying disease process. The advent of highly effective therapies targeting proximal drivers of airways inflammation calls for a paradigm shift; upstream-acting therapies offer potential to alter the disease course and achieve clinical remission. We propose moving away from downstream firefighting and towards a predict and prevent model, measuring inflammation and providing anti-inflammatory therapy early, without waiting for further clinical deterioration. Much in the same way that high blood pressure and cholesterol are used to predict and prevent heart attacks, in asthma elevated blood eosinophils and/or exhaled nitric oxide (FeNO) can be used to predict and prevent asthma attacks. We advocate also moving research further upstream by identifying patients with subclinical airways inflammation or disease who may be at risk of progressing to airflow limitation and associated morbidities and intervening early to prevent them. In summary, we call for a ‘predict and prevent’ approach in obstructive airways disease.
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