Dear Sir,

We would like to thank Dr Yaxley for his comments on our article.(1) We strongly agree with his comments and reflections on the current treatment of childhood asthma.(2) However, the main objective of our study was not to find causes, but mainly to report on the current practices (and malpractices) of childhood asthma treatment in 2009. We would like to clarify some of the important issues raised by the author.

Our study focused entirely on childhood asthma. Therefore, diagnoses such as cardiogenic pulmonary oedema or bronchiectasis are of less relevance, especially in the local setting. We agree that a major weakness of our study was the low response rate (8.6%). However, it was likely that the responders were doctors with a greater interest in childhood asthma and who have a better knowledge of childhood asthma. Therefore, it can be speculated that in reality, asthma treatment practices could be even worse.

We agree that bronchodilators are mainly effective in patients with bronchoconstriction, which usually presents as shortness of breath or wheezing (sometimes only detectable with a stethoscope). However, mild bronchoconstriction can present as an isolated dry cough, without wheezing or shortness of breath. Therefore, in patients with cough (especially in children previously diagnosed as asthmatic), the use of bronchodilators may be trialled. Furthermore, in a study by Higenbottam, it was shown that beta-agonists may cause an important antitussive effect through the isolation of cough receptors, even in nonasthmatic patients.(3)

We also agree that nebulisers have few advantages, although they may be useful in specific cases, such as in children with extreme breathlessness or who refuse a spacer. We strongly agree that most children with acute asthma should be treated with a metered dose inhaler and spacer, which is more cost-effective and results in better compliance at home. We also concur that nebulisers continue to be overused.

Yours sincerely,

Tan C, Wong B, Goh DY, Van Bever HP. Monitoring treatment practices of childhood asthma in Singapore: a questionnaire study. Singapore Med J. 2009;50:54-61.
Yaxley J. Bronchodilators and nebulisers in obstructive lung diseases. Singapore Med J. 2016;57:103.
Higenbottam T. Chronic cough and the cough reflex in common lung diseases. Pulm Pharmacol Ther. 2002;15:241-7.