Severe exacerbations predict excess lung function decline in asthma

Managing older patients with coexistent asthma and chronic obstructive pulmonary disease: diagnostic and therapeutic challenges

Asthma and chronic obstructive pulmonary disease (COPD) are common obstructive airway diseases, especially among older people. These conditions are associated with a significant and increasing disease burden. The diagnosis and management of asthma and COPD in older populations are complex, and consequently clinicians are faced with many therapeutic and diagnostic challenges. Both aging and obstructive airway diseases are associated with complex co-morbidities and these coexisting illnesses confound management. Moreover, the age-related physiological changes that occur in the lungs may lead to airflow limitation, and this may be difficult to distinguish from an active disease state. In practice, management of asthma and COPD is informed by disease-specific clinical practice guidelines; however, most older people with these conditions are excluded from clinical trials that are designed to inform practice, creating major evidence gaps. Furthermore, seldom do clinical practice guidelines consider the complexities of management in older populations. The problems experienced by older people are complex and multifactorial and our approach to management must reflect these challenges. Opportunities exist to improve the management and outcomes for older people with obstructive airway disease and there is an urgent need for clinical trials to test management approaches in this population; current research must consider the challenges and evidence gaps that exist.

Short and long-term quality of life and asthma control with omalizumab therapy in a real life setting in Portugal

BACKGROUND

The impact of severe asthma on patients' quality of life (QoL) has been previously demonstrated, as well the difficulties in controlling the disease. We aimed to evaluate the effect of omalizumab on QoL and asthma control, and its safety and tolerability in real-life conditions in Portugal.

METHODS

Prospective and open-label study in 15 adult patients with uncontrolled severe persistent allergic asthma on omalizumab treatment ≥16 weeks (w). The short (at 16w) and long-term (at 1 and 2 years) (y) effects of omalizumab were assessed through the Asthma Life Questionnaire (ALQ) and the Asthma Control Test (ACT). Other secondary outcomes were evaluated.

RESULTS

A significant reduction in ALQ total score (at 16w, p=0.002; at 1y, p=0.033 and at 2y, p=0.024), as well as in the 'non-scheduled medical visits' and the 'medication use' domains in both the short and long terms was observed. Regarding ACT, we verified a significant improvement in total score (at 16w, p=0.004; at 1y, p=0.004 and at 2y, p=0.008) and in almost all of the five individual questions. Asthma exacerbations and unscheduled health care visits were significantly decreased. There was a significant rise in lung function and a decrease in daily inhaled steroids dose. The most frequent adverse effects were headaches and nausea.

CONCLUSIONS

Omalizumab promoted a global benefit on QoL and asthma control outcomes. It also yielded a reduction in asthma exacerbations and unscheduled health care visits, a steroid-sparing effect, and an improvement in lung function. The drug was found to be generally safe and well-tolerated.

Cluster analysis identifies characteristic phenotypes of asthma with accelerated lung function decline

OBJECTIVE

While the majority of individuals with asthma retain normal lung function over time, some exhibit accelerated lung function decline. Preservation of lung function is an important aspect of asthma management. Whether the asthma guidelines can prevent lung function decline remains controversial. This study was performed to determine the distribution of asthmatic subjects with greater lung function decline and to identify characteristic clinical features of such subjects treated in accordance with clinical guidelines by using hierarchical cluster analysis.

METHODS

Eighty-six asthmatic subjects without a history of smoking were assessed with respect to eight variables selected from clinical phenotypes by using step-wise multiple regression analysis. Hierarchical cluster analysis using Ward's method generated a dendrogram for estimation of the number of clusters within the population and the differences between them.

RESULTS

Three distinct clusters were identified. Cluster 1 (n = 40) comprised women with late-onset asthma. Cluster 2 (n = 17) comprised subjects with early-onset asthma, atopy and long disease duration. Cluster 3 (n = 29) predominantly comprised older men who had late-onset asthma, a lower prevalence of exacerbation and a lower predicted % forced expiratory volume in 1 s (FEV1) at baseline. Subjects in cluster 3 showed a mean decline in FEV1 of 69 mL/year, which was the greatest lung function decline among the three clusters.

CONCLUSION

We identified a subgroup of patients with accelerated lung function decline despite appropriate asthma treatment based on guidelines constructed by using subjective symptoms.

Impact of inhaled corticosteroid treatment on 15-year longitudinal respiratory function changes in adult patients with bronchial asthma

BACKGROUND

Bronchial asthma is mainly controlled by inhaled corticosteroid (ICS) treatment, and discontinuation of ICS treatment can worsen asthma symptoms and reduce respiratory function. However, the longitudinal impact of ICS on lung function in adult patients is unknown.

METHODS

To determine whether regular ICS treatment can prevent long-term lung function deterioration in adults with bronchial asthma, we recruited 167 adult asthma patients who first visited Fukuoka National Hospital in 1995 and underwent lung function tests in 1995, 1996 and 2010. Regular ICS treatment was continued in 102 patients (regular group), while 39 patients received irregular ICS treatment (irregular group). Changes in lung function were compared retrospectively between the groups. The influences of smoking, disease severity and disease duration were also analyzed.

RESULTS

The forced expiratory volume in 1 s (FEV₁) values increased in the regular group 1 year after the initiation of therapy, but they decreased in the irregular group. At year 15, the predicted FEV₁% had decreased significantly more in the irregular group than in the regular group (p < 0.05); FEV₁ decreased by 28.2 ml/year (SD 24.5) in the regular group and by 44.6 ml/year (32.5) in the irregular group (p < 0.05). The decrease in FEV₁ was greater in smokers than in nonsmokers, despite regular ICS treatment, and it was significantly greater in patients with severe asthma than in those with mild or intermittent disease. Delay in ICS initiation also affected the annual FEV₁ decrease.

CONCLUSIONS

Regular ICS, introduced early when symptoms are mild, could prevent lung function from worsening significantly. Smoking should be strongly discouraged in asthma patients.

Asthma

Asthma is a heterogeneous group of conditions that result in recurrent, reversible bronchial obstruction. Although the disease can start at any age, the first symptoms occur during childhood in most cases. Asthma has a strong genetic component, and genome-wide association studies have identified variations in several genes that slightly increase the risk of disease. Asthma is often associated with increased susceptibility to infection with rhinoviruses and with changes in the composition of microbial communities colonising the airways, but whether these changes are a cause or consequence of the disease is unknown. There is currently no proven prevention strategy; however, the finding that exposure to microbial products in early life, particularly in farming environments, seems to be protective against asthma offers hope that surrogates of such exposure could be used to prevent the disease. Genetic and immunological studies point to defective responses of lung resident cells, especially those associated with the mucosal epithelium, as crucial elements in the pathogenesis of asthma. Inhaled corticosteroids continue to be the mainstay for the treatment of mild and moderate asthma, but limited adherence to daily inhaled medication is a major obstacle to the success of such therapy. Severe asthma that is refractory to usual treatment continues to be a challenge, but new biological therapies, such as humanised antibodies against IgE, interleukin 5, and interleukin 13, offer hope to improve the quality of life and long-term prognosis of severe asthmatics with specific molecular phenotypes.

Could FEV₁ decline have a role in daily clinical practice for asthma monitoring?

OBJECTIVE

The aim of this review was to understand whether FEV1 decline measured during the follow-up of asthmatic subjects (FEV1 variation between two different measurements at a distance of at least 5 years) may have a role in their management.

METHODS

Articles, commentaries and reviews relating to the topic were searched in PubMed.

RESULTS

Patients with an accelerated FEV1 decline (>30 ml/year) may be either steroid-resistant/difficult-to-treat asthmatics or not adequately treated because they are either under-perceivers or poorly adherent to their therapy. Sometimes they may be unable to use devices correctly. Untreated rhinitis and incorrect lifestyle (obesity status, a high-fat diet and lack of exercise) must be considered when facing a pulmonary function decline. Identifying asthmatics with an accelerated FEV1 decline, even with well controlled symptoms, may allow us to make possible treatment adjustments or to remove potentially harmful environmental exposure and suggest a correct lifestyle. Depending on FEV1 decline severity, we may detect different asthma phenotypes. One type is characterized by no/low lung function reduction. Among moderate/severe 'declining' subjects, there may be a group that might be responsive to treatment and a second one with a quicker loss in lung function that may be unresponsive to therapy.

CONCLUSION

FEV1 decline calculation should be assessed early in clinical practice over the course of time in order to make all possible variations in treatment, environmental exposure and lifestyle more efficacious overall for declining subjects responsive to anti-inflammatory therapy. Further studies are necessary to validate this approach to asthma.

Lost to follow-up in asthmatics does not mean treatment failure: causes and clinical outcomes of non-adherence to outpatient treatment in adult asthma

Purpose

Long-term asthma management is recommended to asthmatics; however, many patients do not adhere to follow-up treatment. It is unclear why many asthmatics do not adhere to follow-up treatment and long-term clinical course after discontinuation of asthma management. This study investigates the factors associated with loss to follow-up and observes the clinical course in asthmatics who discontinued asthma treatment.

Methods

A retrospective investigation was conducted after reviewing medical records of adult patients who were newly diagnosed with asthma at a university hospital in Seoul, South Korea from January 2005 to March 2007. We compared baseline demographics and the clinical and laboratory profiles of patients to see if they successfully adhered to the treatment at an outpatient clinic for at least 3 years. The clinical course and asthma control status were surveyed by telephone for patients who were lost to follow-up within 3 years.

Results

A total of 351 (73.9%) out of 475 patients were lost to follow-up within 3 years of asthma diagnosis. Patients lost to follow-up were younger and had clinical features of less severe asthma at time of diagnosis (higher FEV1 and PC20, and lower grade treatments) compared to patients who adhered to the follow-up for longer than 3 years (all P<0.05). Among the 198 responders to the telephone survey, 124 responders (62.6%) answered that they eventually discontinued asthma medication. A significantly higher proportion of the 124 responders who discontinued asthma treatment maintained symptom improvement compared to the 74 responders who continued asthma medication (77.4% vs. 55.4%, P=0.003).

Conclusions

Almost three quarters of newly diagnosed asthmatics discontinued asthma medication within 3 years despite a medical recommendation. There are considerable numbers of asthmatics who can maintain long-term asthma control status without medication.

Assessing the risk of attack in the management of asthma: a review and proposal for revision of the current control-centred paradigm

Asthma guidelines focus on day-to-day control of symptoms. However, asthma attacks remain common. They continue to cause mortality and considerable morbidity, and are a major financial burden to the UK National Health Service (NHS) and the wider community. Asthma attacks have chronic consequences, being associated with loss of lung function and significant psychological morbidity. In this article we argue that addressing daily symptom control is only one aspect of asthma treatment, and that there should be a more explicit focus on reducing the risk of asthma attacks. Management of future risk by general practitioners is already central to other conditions such as ischaemic heart disease and chronic renal impairment. We therefore propose a revised approach that separately considers the related domains of daily control and future risk of asthma attack. We believe this approach will have advantages over the current 'stepwise' approach to asthma management. It should encourage individualised treatment, including non-pharmacological measures, and thus may lead to more efficacious and less harmful management strategies. We speculate that this type of approach has the potential to reduce morbidity and healthcare costs related to asthma attacks.

Remodeling, inflammation and airway responsiveness in early childhood asthma

PURPOSE OF REVIEW

Remodeling and inflammation together with airway hyperresponsiveness are essential components of asthma but their role in development of the disease is still obscure.

RECENT FINDINGS

Recent data imply that remodeling can occur early in childhood, not necessarily subsequent to but rather, in parallel with inflammation. The assumption of thickening of the reticular basement membrane being a prerequirement for chronic asthma is questioned but development of airway responsiveness is a significant factor. Airway responsiveness is at least partially linked to bronchial inflammation but there are several other genes and pathways regulating airway responsiveness. Increased airway smooth muscle in early childhood is associated with later development of asthma and may be one link between inflammation and airway responsiveness. Novel findings on genetic variation in genes regulating lung growth and remodeling in early childhood shed light on the pathophysiological mechanisms leading to chronic asthma.

SUMMARY

Even young children with chronic asthma have detectable elements of airway remodeling, inflammation and increased airway responsiveness, which all contribute to impaired lung function.

Bronchial thermoplasty: a novel therapy for severe asthma

This article presents an overview of bronchial thermoplasty, a novel treatment for severe asthma. Within, the authors discuss the rationale for bronchial thermoplasty in severe asthma, current clinical evidence for the use of this procedure, clinical recommendations, and future directions.

Assessing asthma control: An evidence-based approach to improve skills and outcomes

The goal of asthma therapy is to achieve and maintain good asthma control. By utilizing evidence-based guidelines recommended by the National Asthma Education Prevention Program Expert Panel-3 Report, nurse practitioners can improve assessment of asthma control, and ultimately improve asthma outcomes.

Increased periostin associates with greater airflow limitation in patients receiving inhaled corticosteroids

BACKGROUND

Periostin, an extracellular matrix protein, contributes to subepithelial thickening in asthmatic airways, and its serum levels reflect airway eosinophilic inflammation. However, the relationship between periostin and the development of airflow limitation, a functional consequence of airway remodeling, remains unknown.

OBJECTIVE

We aimed to determine the relationship between serum periostin levels and pulmonary function decline in asthmatic patients on inhaled corticosteroid (ICS) treatment.

METHODS

Two hundred twenty-four asthmatic patients (average age, 62.3 years) treated with ICS for at least 4 years were enrolled. Annual changes in FEV1, from at least 1 year after the initiation of ICS treatment to the time of enrollment or later (average, 16.2 measurements over 8 years per individual), were assessed. At enrollment, clinical indices, biomarkers that included serum periostin, and periostin gene polymorphisms were examined. Associations between clinical indices or biomarkers and a decline in FEV1 of 30 mL or greater per year were analyzed.

RESULTS

High serum periostin levels (≥ 95 ng/mL) at enrollment, the highest treatment step, higher ICS daily doses, a history of admission due to asthma exacerbation, comorbid or a history of sinusitis, and ex-smoking were associated with a decline in FEV1 of 30 mL or greater per year. Multivariate analysis showed that high serum periostin, the highest treatment step, and ex-smoking were independent risk factors for the decline. Polymorphisms of periostin gene were related to higher serum periostin levels (rs3829365) and a decline in FEV1 of 30 mL or greater per year (rs9603226).

CONCLUSIONS

Serum periostin appears to be a useful biomarker for the development of airflow limitation in asthmatic patients on ICS.

Impact of Schizophyllum sensitization on decline of lung function in asthma

OBJECTIVE

There is increasing interest in the association between the severity of asthma and fungal sensitization, and lung function decline in relation to mold and dampness in the home has recently been reported. This study was performed to determine the correlation between sensitization to Schizophyllum commune and decline of lung function, and to elucidate the outcomes and risk factors, especially from Schizophyllum allergy.

METHODS

The medical records of 50 patients with asthma who satisfied the following inclusion criteria were collected and reviewed retrospectively: (1) at least 5 years of follow-up with five evaluations; (2) intradermal skin tests including S. commune performed at the initial assessment; and (3) severity ranging from mild-to-moderate. Lung function decline (evaluated as adjusted delta FEV1/year) was compared in a cross-sectional manner with regard to gender, age, BMI, smoking habit, allergological characteristics and exacerbation frequency.

RESULTS AND CONCLUSIONS

There were significant differences in lung function decline between females and males (p < 0.05), positive and negative results of late-phase skin reaction to S. commune (p < 0.001), and positive and negative late-phase skin reaction to Aspergillus (p < 0.05). Lung function decline was correlated with exacerbation frequency (r = 0.428, p = 0.002). On multiple regression analysis, the probability of lung function decline in asthma was found to be significantly associated with female gender and positive late-phase skin reaction against S. commune. Our results suggested that sensitization to S. commune may be one of the risk factors involved in lung function decline in asthmatic patients.

Daily vs. intermittent inhaled corticosteroids for recurrent wheezing and mild persistent asthma: a systematic review with meta-analysis

BACKGROUND

Intermittent ICS treatment with SABA in response to symptoms, is an emerging strategy for control of mild-to-moderate asthma, and recurrent wheezing. This systematic revue compares the efficacy of daily vs. intermittent ICS among preschoolers, children and adults with persistent wheezing and mild to moderate stable persistent asthma.

METHODS

Systematic review of randomized, placebo-controlled trials with a minimum of 8 weeks of daily (daily ICS with rescue SABA during exacerbations) vs. intermittent ICS (ICS plus SABA at the onset of symptoms), were retrieved through different databases. Primary outcome was asthma exacerbations; secondary outcomes were pulmonary function tests, symptoms, days without symptoms, SABA use, corticosteroids use, days without rescue medication use, expired nitric oxide and serious adverse events.

RESULTS

Seven trials (1367 participants) met inclusion criteria there was no statistically significant difference in the rate of asthma exacerbations between those with daily vs. intermittent ICS (0.96; 95% CI: 0.86, 1.06, I(2) = 0%). In the sub-group analysis, no differences were seen in duration of studies, step-up strategy or age. However, compared to intermittent ICS, the daily ICS group had a significant increase in asthma-free days and non-significant decreases in rescue SABA use and exhaled nitric oxide measurement.

CONCLUSIONS

No significant differences between daily and intermittent ICS in reducing the incidence of asthma exacerbations was found. However, the daily ICS strategy was superior in many secondary outcomes. Therefore, this study suggests to not change daily for intermittent ICS use among preschoolers, children with persistent wheezing and adults with mild-to-moderate stable persistent asthma. International prospective register of systematic reviews http://www.crd.york.ac.uk/PROSPERO/ (CRD42012003228).

Safety of bronchial thermoplasty in patients with severe refractory asthma

BACKGROUND

Patients with severe refractory asthma treated with bronchial thermoplasty (BT), a bronchoscopic procedure that improves asthma control by reducing excess airway smooth muscle, were followed up for 5 years to evaluate long-term safety of this procedure.

OBJECTIVES

To assess long-term safety of BT for 5 years.

METHODS

Patients with asthma aged 18 to 65 years requiring high-dose inhaled corticosteroids (ICSs) (>750 μg/d of fluticasone propionate or equivalent) and long-acting β2-agonists (LABAs) (at least 100 μg/d of salmeterol or equivalent), with or without oral prednisone (≤30 mg/d), leukotriene modifiers, theophylline, or other asthma controller medications were enrolled in the Research in Severe Asthma (RISA) Trial. Patients had a prebronchodilator forced expiratory volume in 1 second of 50% or more of predicted, demonstrated methacholine airway hyperresponsiveness, had uncontrolled symptoms despite taking maintenance medication, abstained from smoking for 1 year or greater, and had a smoking history of less than 10 pack-years.

RESULTS

Fourteen patients (of the 15 who received active treatment in the RISA Trial) participated in the long-term follow-up study for 5 years. The rate of respiratory adverse events (AEs per patient per year) was 1.4, 2.4, 1.7, and 2.4, respectively, in years 2 to 5 after BT. There was a decrease in hospitalizations and emergency department visits for respiratory symptoms in each of years 1, 2, 3, 4, and 5 compared with the year before BT treatment. Measures of lung function showed no deterioration for 5 years.

CONCLUSION

Our findings suggest that BT is safe for 5 years after BT in patients with severe refractory asthma.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT00401986.

Atopy is important in the management of asthma

Allergic diseases are a public health problem in industrialized countries due to the increasing number of allergies related to Western lifestyle. The multiplicity of organs affected by allergy (skin (atopic dermatitis), airway epithelium (respiratory allergy), and digestive tract (food allergy)) worsens the prognosis of each of the allergic diseases and specially asthma. The importance of allergy in management of asthma is also underlined by the risk of fatal or near fatal acute asthma attacks due to multiple allergic sensitizations. Preliminary studies suggest that specific treatment of allergy could change the asthma course.

CD8(+) T cells characterize early smoking-related airway pathology in patients with asthma

BACKGROUND

Smoking in asthma occurs frequently and is associated with increased symptom severity, an impaired response to corticosteroids, and accelerated lung function decline. Airway pathology in smoking asthmatics is characterized by neutrophilia and epithelial changes such as goblet cell hyperplasia and increased proliferation. Bronchial CD8(+) T cells are implicated in lung function decline in asthma and COPD. We hypothesized that smoking modifies airway inflammation in asthma by increasing the number of CD8(+) T cells at an early stage.

OBJECTIVES & METHODS

To study effects of smoking on airway pathology in bronchial biopsies from atopic patients with controlled intermittent or mild persistent asthma (12 smokers, 9.7 py and 11 never-smokers, 0.0 py; 20-50 yrs; FEV1 > 70% predicted; PC20MCh < 8 mg/mL, no ICS) using immunohistochemistry.

RESULTS

Smoking asthmatics showed higher numbers of bronchial CD8(+) T cells (55.8 vs 23.9 cells/0.1 mm(2); p = 0.001) and CD68(+) macrophages (7.5 vs 4.6 cells/0.1 mm(2), p = 0.012), and a lower CD4(+)/CD8(+) cell ratio (0.16 vs 0.40; p = 0.007) compared with non-smoking asthmatics, but no difference in neutrophils. Furthermore, the % intact epithelium was higher in smoking asthmatics (49.3 vs 23.3, p = 0.001).

CONCLUSION

Smoking asthmatics with a limited smoking history show a distinct pattern of airway pathology characterized by a bronchial infiltrate of CD8(+) T cells and CD68(+) macrophages, and epithelial remodelling resembling COPD-like features. This raises the hypothesis that early presence of CD8(+) T cells contributes to disease progression in smoking asthmatics.

Beclometasone-formoterol as maintenance and reliever treatment in patients with asthma: a double-blind, randomised controlled trial

BACKGROUND

According to international treatment guidelines, inhaled rapid-acting β2 agonists should be used for the control of symptoms in patients with asthma. We compared the efficacy and safety of an extrafine combination inhaler containing a corticosteroid (beclometasone) plus a rapid-onset, long-acting β2 agonist (formoterol) with a short-acting β2 agonist (salbutamol) as reliever strategies in patients taking beclometasone-formoterol combination as maintenance treatment.

METHODS

In a double-blind trial undertaken in 183 centres in 14 European countries over 48 weeks, patients (aged ≥18 years) with asthma that was not fully controlled, with a forced expiratory volume in 1 s (FEV1) of at least 60% predicted, had a 2-week run in. During this period, patients were treated with a combination of beclometasone 100 μg and formoterol 6 μg per one inhalation twice daily plus salbutamol 100 μg as required delivered by use of a pressurised metered-dose inhaler. They were then randomly assigned in a 1:1 ratio with a computer-generated randomisation list to receive beclometasone 100 μg plus formoterol 6 μg or salbutamol 100 μg as reliever in addition to maintenance with beclometasone 100 μg plus formoterol 6 μg twice daily. Primary outcome was the time to first severe exacerbation (admission to hospital or visit to emergency department, or use of systemic steroids for ≥3 consecutive days). Secondary outcomes were number of severe exacerbations (events per 100 patients per year), time to and number of mild exacerbations, additional exacerbation variables, lung function, symptom scores, and asthma control. Analysis was by intention to treat. The study is registered with ClinicalTrials.gov, number NCT00861926.

FINDINGS

1714 patients were randomly assigned to the as-needed beclometasone-formoterol (n=857) and as-needed salbutamol groups (n=857), and 1701 were analysed (852 and 849, respectively). 326 severe exacerbations were reported by 251 patients during the study, and 99 versus 152 patients had at least one exacerbation during the 48 weeks, respectively. Compared with beclometasone-formoterol plus salbutamol as needed, beclometasone-formoterol for both maintenance and reliever treatment significantly increased the time to first exacerbation (209 days vs 134 days) by 75 days, with a 36% reduction in risk (hazard ratio 0·64 [95% CI 0·49 to 0·82]; p=0·0005), and the estimated probability was 12% and 18%, respectively (p=0·0003). The number of days with mild asthma exacerbations was also lower with as-needed beclometasone-formoterol than with as-needed salbutamol (56·04 days per patient per year vs 65·11 days per patient per year; 0·86 [0·76 to 0·98]; p=0·021). From the run-in period to week 48, both treatments improved symptoms (mean change -1·59 [-1·94 to -1·25] in the as-needed beclometasone-formoterol group vs -1·44 [-1·78 to -1·10] in the as-needed salbutamol group, difference -0·15 [-0·60 to 0·30]; p=0·507), percentage of asthma control days (9·5% [7·3 to 11·8] vs 10·9% [8·7 to 13·1], respectively, -1·4 [-4·3 to 1·6]; p=0·359), use of reliever (-0·29 [-0·38 to -0·20] vs -0·27 [-0·36 to -0·19], respectively, -0·02 [-0·13 to 0·10]; p=0·794), and lung function (FEV1, 0·090 [0·060 to 0·120] vs 0·090 [0·060-0·120], respectively, 0·001 [-0·040 to 0·040]; p=0·969), and were well tolerated (patients with serious adverse events, 32 [4%] and 41 [5%], respectively).

INTERPRETATION

Our results lend support to the use of the combination of a single inhaled corticosteroid plus a rapid-onset, long-acting β2 agonist for maintenance and relief in patients with moderate to severe asthma and provide encouraging data for the formulation of beclometasone-formoterol for this use.

FUNDING

Chiesi Farmaceutici.

Hypoxia potentiates allergen induction of HIF-1α, chemokines, airway inflammation, TGF-β1, and airway remodeling in a mouse model

Whether hypoxia contributes to airway inflammation and remodeling in asthma is unknown. In this study we used mice exposed to a hypoxic environment during allergen challenge (simulating hypoxia during an asthma exacerbation) to investigate the contribution of hypoxia to airway inflammation and remodeling. Although neither hypoxia alone, nor OVA allergen alone, induced significant neutrophil influx into the lung, the combination of OVA and hypoxia induced a synergistic 27 fold increase in peribronchial neutrophils, enhanced expression of HIF-1α and one of its target genes, the CXC-family neutrophil chemokine KC. The combination of hypoxia and OVA allergen increased eotaxin-1, peribronchial eosinophils, lung TGB-β1 expression, and indices of airway remodeling (fibrosis and smooth muscle) compared to either stimulus alone. As hypoxia is present in >90% of severe asthma exacerbations, these findings underscore the potential of hypoxia to potentiate the airway inflammatory response, remodeling, and accelerate the decline of lung function in asthma exacerbations.

Clinical phenotypes of chronic obstructive pulmonary disease and asthma: recent advances

Asthma and chronic obstructive pulmonary disease (COPD) are prevalent obstructive lung diseases, both of which are characterized by airflow limitation. Although both represent distinct pathogenic entities, there can be significant clinical and physiologic overlap between the 2 disorders, creating potential management difficulties for clinicians. Although practice guidelines for both conditions outline diagnostic and management strategies, asthma and COPD are highly heterogeneous, and the symptoms of many patients remain poorly controlled despite adherence to current guidelines. Recent advances in phenotyping studies have elucidated heterogeneity in these airway diseases and might represent the best opportunity to enhance diagnosis, predict outcomes, and personalize treatments in patients with asthma and those with COPD. This review will focus on recent advances in describing phenotypic heterogeneity in asthma and COPD, including the evaluation of multiple clinical variables, molecular biomarkers, physiologic and radiologic data, and factors associated with disease progression and frequent exacerbations.

Natural history and risk factors of obstructive changes over a 10-year period in severe asthma

BACKGROUND

The clinical features, physiology, and pathology of severe asthma are poorly understood. Recently, the forced vital capacity (FVC) has been shown to be reduced in severe asthma compared to mild asthma, possibly due to air trapping. However, the natural history and risk factors of obstructive change for such asthmatic patients have not been fully elucidated.

METHODS

We examined the data of a retrospective analysis of lung function changes over a 10-year period in 54 severe asthma patients.

RESULTS

The faster obstructive changes detected by FEV(1) (forced expiratory volume in one second) were accompanied by excessive loss of FVC (r = 0.85, p < 0.0001) and the reduction in FVC was 1.2 times larger than the FEV(1) change. Age, baseline FVC, exacerbation rate and oral corticosteroids use showed significantly negative correlations with the rate of annual change in FVC.

CONCLUSIONS

These data indicate that the decline in FVC is more evident than FEV(1) in severe asthma, suggesting that small airway susceptibility may be the cause of rapid disease progression. Aging, exacerbations of asthma, and use of systemic corticosteroids are related to excess FVC decline, particularly if FVC is still normal.

Comparison between two methods of asthma control evaluation based on individual perception

OBJECTIVE

To compare the subjective perception of asthma control reported by the patient with that measured by the score obtained on the Asthma Control Questionnaire 6-item version (ACQ-6) in patients with severe asthma and to determine whether asthma control is associated with the number of emergency room visits in the previous month.

METHODS

This was a cross-sectional study involving 528 patients treated at the Bahia State Asthma and Allergic Rhinitis Control Program Central Referral Clinic between August of 2008 and March of 2010, in the city of Salvador, Brazil. The patients completed the ACQ-6 and answered a specific additional question in order to evaluate their own perception of asthma control in the previous week.

RESULTS

We evaluated 423 patients who met the inclusion criteria. The sample was predominantly female (81.3%), and 64.3% had an income lower than two times the national minimum wage. The mean age was 49.85 ± 13.71 years, and the duration of asthma symptoms was 32.11 ± 16.35 years. The patients had been regularly treated via the program for 36.65 ± 18.10 months. Based on the subjective perception of asthma control, only 8% of the patients considered their asthma to be uncontrolled, whereas 38.8% had an ACQ-6 score > 1.5, which indicates poor control. The kappa statistic revealed poor concordance between the two methods. There was a direct association between uncontrolled asthma and the number of emergency room visits in the previous month (p < 0.001).

CONCLUSIONS

In this sample of patients, the subjective perception of asthma control differed from that measured by the ACQ-6 score, and the patients overestimated their own level of asthma control, which puts them at risk of being undertreated.

Efficacy of anticholinergic drugs in asthma

Although bronchial hyperresponsiveness to cholinergic agents is a main feature of asthma, the role of anticholinergic drugs in chronic asthma management has been largely underestimated. Several single-dose studies comparing acute bronchodilation induced by ipratropium bromide with salbutamol have shown that salbutamol was more effective than ipratropium in asthma treatment. Recently, tiotropium has been studied in asthma, when added to low-dose inhaled corticosteroids in unselected moderate asthmatics or in patients with uncontrolled asthma, or patients with chronic obstructive pulmonary disease and history of asthma. Later, studies on patients with Arg/Arg β(2)-receptor polymorphism demonstrated a similar efficacy of tiotropium in comparison with salmeterol when both were added to low-dose inhaled corticosteroids. Further long-term studies are currently in progress, for the evaluation of the efficacy of tiotropium on clinical asthma control, and on the rate and severity of asthma exacerbations, as well as the potential modification of inflammatory mechanisms and varying efficacy in specific asthma phenotypes (such as smoking asthmatics).

Exacerbations of severe asthma

Exacerbations occur frequently in severe asthma. They result in significant morbidity and can lead to hospitalization and death. Severe exacerbations can also lead to an accelerated decline in lung function. Phenotyping severe asthma can aid with both prognostication of exacerbation risk and maintenance treatment selection to minimize future risks of exacerbations in severe asthma. The rate of exacerbations differs by phenotype, and is most frequent in refractory eosinophilic asthma and early onset allergic asthma. Phenotype specific therapy can reduce exacerbations in both these forms of severe asthma. Exacerbations are multi-component events. Each exacerbation represents an opportunity to assess and target treatment to the domains of airway pharmacotherapy, self-management behaviour, risk factors, and relevant co-morbidities.

What is severe asthma?

Asthma is common, and some individuals are severely affected by it. Learned institutions have sought to provide a definition of 'severe asthma' to facilitate research and clinical care. This is a challenging undertaking given the difficulty in defining asthma and the lack of supportive evidence for a distinct severe asthma phenotype. In this review, we discuss the rationale for a definition of severe asthma and the relative merits of the sequential attempts that have been made to produce such a definition. The difficulty in disentangling control and severity is highlighted, as is the heterogeneity of phenotype in severe asthma, and potential for misclassification. We conclude that the search for a singular definition of severe asthma is problematic, though likely to continue. We suggest the alternative strategy of using classifiers with a specific aim related to symptoms, pathophysiology or service provision.

Severe asthma in adults: an orphan disease?

Severe asthma affects fewer than 10% of patients with asthma, is associated with a severe risk of death and disability, has a great impact on health and quality of life, and represents a huge cost to patients and society. Given the poor response to treatment and the side effects associated with medications for severe asthma, more efficient, cost-effective, and phenotype-specific medications are needed. Considering severe asthma as an orphan disease could encourage the pharmaceutical industry to stratify studies based on a more detailed characterization of study subjects at baseline, resulting in the development of novel therapeutic approaches.

Budesonide/formoterol maintenance and reliever therapy in primary care asthma management: effects on bronchial hyperresponsiveness and asthma control

BACKGROUND

The management of asthma has changed since the introduction of budesonide/formoterol (Symbicort®) as both maintenance and reliever therapy (SMART). SMART and its effects on bronchial hyperresponsiveness (BHR) have not been studied in primary care.

AIMS

To compare the effects of SMART and guideline-driven usual care (UC) on BHR and clinical asthma severity in primary care practice.

METHODS

Patients with mild-to-moderate stable asthma were randomised to receive SMART treatment (n=54) (budesonide/formoterol 80/4.5 μg Turbuhaler®, two puffs once daily and extra inhalations as needed) or UC treatment (n=48) for 12 months. Diary data, Asthma Control Questionnaire scores, forced expiratory volume in 1 second (FEV1), and peak expiratory flow (PEF) measurements were collected during run-in and after 1, 3, 6, and 12 months of treatment. BHR, measured as the dose of histamine provoking a fall in FEV1 of 20% (PD20-histamine), was determined at randomisation and after 12 months.

RESULTS

One hundred and two patients with asthma participated in the study. The change in PD20-histamine during the study was not significantly different between the SMART and UC groups (p=0.26). The mean inhaled corticosteroid (ICS) dose was 326 μg beclomethasone dipropionate (BDP) equivalents/day (95% CI 254 to 399) with SMART, which was significantly lower (p<0.0001) than the mean ICS dose with UC treatment (798 μg BDP equivalents/day (95% CI 721 to 875). Morning and evening PEF values increased significantly with SMART treatment compared with UC; FEV1, symptoms and asthma control did not differ.

CONCLUSIONS

Despite a 59% lower dose of ICS, BHR and other clinical outcomes remained stable during SMART treatment while PEF values improved.

Asthma outcomes: exacerbations

BACKGROUND

The goals of asthma treatment include preventing recurrent exacerbations. Yet there is no consensus about the terminology for describing or defining "exacerbation" or about how to characterize an episode's severity.

OBJECTIVE

National Institutes of Health institutes and other federal agencies convened an expert group to propose how asthma exacerbation should be assessed as a standardized asthma outcome in future asthma clinical research studies.

METHODS

We used comprehensive literature reviews and expert opinion to compile a list of asthma exacerbation outcomes and classified them as either core (required in future studies), supplemental (used according to study aims and standardized), or emerging (requiring validation and standardization). This work was discussed at a National Institutes of Health-organized workshop in March 2010 and finalized in September 2011.

RESULTS

No dominant definition of "exacerbation" was found. The most widely used definitions included 3 components, all related to treatment, rather than symptoms: (1) systemic use of corticosteroids, (2) asthma-specific emergency department visits or hospitalizations, and (3) use of short-acting β-agonists as quick-relief (sometimes referred to as "rescue" or "reliever") medications.

CONCLUSIONS

The working group participants propose that the definition of "asthma exacerbation" be "a worsening of asthma requiring the use of systemic corticosteroids to prevent a serious outcome." As core outcomes, they propose inclusion and separate reporting of several essential variables of an exacerbation. Furthermore, they propose the development of a standardized, component-based definition of "exacerbation" with clear thresholds of severity for each component.

[Asthma exacerbations: pharmacological prevention]

Asthma exacerbations are responsible for many emergency medical interventions and account for a significant proportion of the health costs of the disease. Increased airway inflammation is a key feature of exacerbations in asthma and therefore inhaled corticosteroids (ICS) are considered as first-line therapy for long-term asthma control. ICS have been demonstrated to reduce the risk of asthma exacerbations, as well as improving lung function. Oral leukotriene receptor antagonists also reduce the incidence of asthma exacerbations but are less effective than ICS. In patients with inadequately controlled persistent asthma despite low-dose ICS, the addition of a long-acting inhaled beta-agonist (LABA) should be considered. LABA should not be given alone and should always be associated with ICS in asthma. The anti-immunoglobulin E antibody, omalizumab, reduces severe exacerbations and emergency visits in patients with severe allergic asthma. In clinical trials measurement of the inflammatory response in induced sputum could provide information concerning appropriate drug therapy. Asthma-associated comorbidities should be investigated and treated, particularly in severe asthma. Despite a high prevalence of both gastro-oesophageal reflux and allergic rhinitis among patients with asthma, treatment with proton-pump inhibitors or nasal corticosteroids does not reduce the rate of asthma exacerbations.

An official american thoracic society statement: work-exacerbated asthma

RATIONALE

Occupational exposures can contribute to the exacerbation as well as the onset of asthma. However, work-exacerbated asthma (WEA) has received less attention than occupational asthma (OA) that is caused by work.

OBJECTIVES

The purpose of this Statement is to summarize current knowledge about the descriptive epidemiology, clinical characteristics, and management and treatment of WEA; propose a case definition for WEA; and discuss needs for prevention and research.

METHODS

Information about WEA was identified primarily by systematic searches of the medical literature. Statements about prevention and research needs were reached by consensus.

MEASUREMENTS AND MAIN RESULTS

WEA is defined as the worsening of asthma due to conditions at work. WEA is common, with a median prevalence of 21.5% among adults with asthma. Different types of agents or conditions at work may exacerbate asthma. WEA cases with persistent work-related symptoms can have clinical characteristics (level of severity, medication needs) and adverse socioeconomic outcomes (unemployment, reduction in income) similar to those of OA cases. Compared with adults with asthma unrelated to work, WEA cases report more days with symptoms, seek more medical care, and have a lower quality of life. WEA should be considered in any patient with asthma that is getting worse or who has work-related symptoms. Management of WEA should focus on reducing work exposures and optimizing standard medical management, with a change in jobs only if these measures are not successful.

CONCLUSIONS

WEA is a common and underrecognized adverse outcome resulting from conditions at work. Additional research is needed to improve the understanding of the risk factors for, and mechanisms and outcomes of, WEA, and to inform and evaluate preventive interventions.

Changes in clinical, pulmonary function, quality of life and costs in a cohort of asthmatic patients followed for 10 years

Few studies have comprehensively assessed the evolution asthma disease in recent years.

OBJECTIVES

To determine changes in morbidity, lung function and quality of life and to establish the impact in terms of cost in a cohort of patients with asthma.

METHODS

Prospective, descriptive and realistic study that included 220 asthma patients evaluated 10 years after their inclusion (1994-2004). For all the patients, data for symptoms, lung function, quality of life and financial cost were collected.

RESULTS

There was a decrease in the frequency of health service visits, including: emergency room visits for asthma exacerbations, 0.3 (0.9) versus 0.6 (1) visits per patient per year (P=.003); a reduction in the severity of the disease, with a greater proportion of patients with mild asthma, 121 (54.8%) versus 94 (42.7%) (P=.001); a decrease (improvement in quality of life) in the total SGRQ, 30.1 (16.5) versus 37 (19.6) (P<.001); and reduced total costs, 1,464€ (3,415.8) compared to 2,267€ (4.174) per patient/year (P<.001), mainly due to indirect costs, 617.50€ (2855.9) compared to 1,320.10€ (3,685.3) per patient/year (P=.001). When assessing the changes observed according to asthma severity, no differences were observed between groups.

CONCLUSIONS

The evolution of the morbidity and quality of life of asthma patients between 1994 and 2004 are clearly favorable. This improvement provided a significant reduction in the total costs of disease treatment.

Urinary bromotyrosine measures asthma control and predicts asthma exacerbations in children

OBJECTIVES

To determine the usefulness of urinary bromotyrosine, a noninvasive marker of eosinophil-catalyzed protein oxidation, in tracking with indexes of asthma control and in predicting future asthma exacerbations in children.

STUDY DESIGN

Children with asthma were recruited consecutively at the time of clinic visit. Urine was obtained, along with spirometry, exhaled nitric oxide, and Asthma Control Questionnaire data. Follow-up phone calls were made 6 weeks after enrollment.

RESULTS

Fifty-seven participants were enrolled. Urinary bromotyrosine levels tracked significantly with indexes of asthma control as assessed by Asthma Control Questionnaire scores at baseline (R = 0.38, P = .004) and follow-up (R = 0.39, P = .008). Participants with high baseline levels of bromotyrosine were 18.1-fold (95% CI 2.1-153.1, P = .0004) more likely to have inadequately controlled asthma and 4.0-fold more likely (95% CI 1.1-14.7, P = .03) to have an asthma exacerbation (unexpected emergency department visit; doctor's appointment or phone call; oral or parenteral corticosteroid burst; acute asthma-related respiratory symptoms) over the ensuing 6 weeks. Exhaled nitric oxide levels did not track with Asthma Control Questionnaire data; and immunoglobulin E, eosinophil count, spirometry, and exhaled nitric oxide levels failed to predict asthma exacerbations.

CONCLUSIONS

Urinary bromotyrosine tracks with asthma control and predicts the risk of future asthma exacerbations in children.

What effect does asthma treatment have on airway remodeling? Current perspectives

Airway remodeling, or structural changes of the airway wall arising from injury and repair, plays an important role in the pathophysiology of asthma. Remodeling is characterized as structural changes involving the composition, content, and organization of many of the cellular and molecular constituents of the bronchial wall. These structural changes can include epithelial injury, subepithelial thickening/fibrosis, airway smooth muscle hyperplasia, goblet cell hypertrophy and hyperplasia, and angiogenesis. Historically, these changes are considered a consequence of long-standing airway inflammation. Recent infant and child studies, however, suggest that remodeling occurs in parallel with inflammation in asthmatic subjects. Despite advancements in the recognition of key cellular and molecular mechanisms involved in remodeling, there remains a paucity of information about which treatments or interactions are most likely to regulate these processes. Furthermore, it is unclear as to when is the best time to initiate treatments to modify remodeling, which components to target, and how best to monitor interventions on remodeling. Indeed, inhaled corticosteroids, which are generally considered to have limited influence on remodeling, have been shown to be beneficial in studies in which the dose and duration of treatment were increased and prolonged, respectively. Moreover, several studies have identified the need to identify novel asthma indices and phenotypes that correlate with remodeling and, as a consequence, might specifically respond to new therapies, such as anti-IgE, anti-IL-5, and anti-TNF-α mAbs. Our review will evaluate the development of remodeling in asthmatic subjects and the effects of treatment on these processes.

Update on optimal use of omalizumab in management of asthma

Omalizumab is a humanized monoclonal anti-IgE antibody recently approved for the treatment of severe allergic asthma. This drug inhibits allergic responses by binding to serum IgE, thus preventing interaction with cellular IgE receptors. Omalizumab is also capable of downregulating the expression of high affinity IgE receptors on inflammatory cells, as well as the numbers of eosinophils in both blood and induced sputum. The clinical effects of omalizumab include improvements in respiratory symptoms and quality of life, paralleled by a reduction of asthma exacerbations, emergency room visits, and use of systemic corticosteroids and rescue bronchodilators. Omalizumab is relatively well-tolerated, and only rarely induces anaphylactic reactions. Therefore, this drug represents a valid option as add-on therapy for patients with severe persistent allergic asthma inadequately controlled by high doses of standard inhaled treatments.

The persistence of allergen exposure favors pulmonary function decline in workers with allergic occupational asthma

BACKGROUND

In asthmatics, a rapid decline in pulmonary function is observed, likely as a consequence of airways remodeling. Persistence of allergen exposure in patients with occupational asthma (OA) maintains chronic bronchial inflammation, resulting in a more severe lung function decline. Few studies were performed on the effects of allergen exposure cessation.

OBJECTIVE

This study aims at evaluating the influence of allergen exposure cessation on respiratory decline in allergic asthmatic workers.

METHODS

Two groups of workers with allergic OA were selected. The first group (30 workers) changed job after the diagnosis and was no more exposed to sensitizing allergens, and the second group (28 subjects) did not and, as a consequence of preventive measures in the work place, was exposed to a lower level of allergens. All were treated with conventional therapy, according to GINA protocols. FEV1 changes during a 12-year period were evaluated.

RESULTS

Despite pharmacological therapy, the pulmonary function decay slope was steeper in workers continuously exposed to the sensitizing agent (even at reduced level) than in those with a complete cessation of exposure: final FEV1 loss was 512.5 ± 180 ml versus 332.5 ± 108 ml, respectively. The difference became significant after 4 years from the cessation of the exposure.

CONCLUSIONS

The study shows that the cessation of the exposure to allergen in the work place appears the most effective measure in limiting pulmonary function decline in asthmatic workers and underlines the importance of allergic risk assessment and control in the management of occupational asthma.

Remodeling in asthma

Airway remodeling encompasses the structural alterations in asthmatic compared with normal airways. Airway remodeling in asthmatic patients involves a wide array of pathophysiologic features, including epithelial changes, increased smooth muscle mass, increased numbers of activated fibroblasts/myofibroblasts, subepithelial fibrosis, and vascular changes. Multiple cytokines, chemokines, and growth factors released from both inflammatory and structural cells in the airway tissue create a complex signaling environment that drives these structural changes. However, recent investigations have changed our understanding of asthma from a purely inflammatory disease to a disease in which both inflammatory and structural components are equally involved. Several reports have suggested that asthma primarily develops because of serious defects in the epithelial layer that allow environmental allergens, microorganisms, and toxins greater access to the airway tissue and that can also stimulate the release of mediators from the epithelium, thus contributing to tissue remodeling. Lung-resident fibroblasts and smooth muscle cells have also been implicated in the pathogenesis of airway remodeling. Remodeling is assumed to result in persistent airflow limitation, a decrease in lung function, and airway hyperresponsiveness. Asthmatic subjects experience an accelerated decrease in lung function compared with healthy subjects, which is proportionally related to the duration and severity of their disease.

Targeting small airways, a step further in asthma management

INTRODUCTION

During the last decade, small airway (SA) involvement in asthma and Chronic Obstructive Pulmonary Disease (COPD) have reached increasing attention. Originally referred to as the 'silent zone', SA may not be that silent after all. Important clinical correlates are asthma exacerbations and airways remodelling, exercise asthma and nocturnal asthma. Thus, to control pathology in the SA has become a desirable goal in asthma management.

OBJECTIVES

The scope of this review is to give a brief overview of the current status on SA in asthma, how to monitor and to diagnose SA inflammation and finally highlight some important treatment strategies.

RESULTS/CONCLUSION

New tools have been developed to monitor SA function; these implies the use of imaging techniques and respiratory physiology, targeting SA function. Fractional exhaled nitric oxide and the combined use of hyperresponsiveness testing with impulsoscillometry is another option. The introduction of ultrafine aerosols has provided new tools for to treat SA inflammation. The challenge for the future will be to define the optimal particle size and device for maximal deposition in entire lung, including the small airways. Moreover, we also need strategies for increasing the therapeutic ratio, i.e. increasing lung deposition without increasing systemic side effects. Another challenge is to design and to perform clinical trials, targeting effects in SA, proving the clinical importance of SA treatment in a large number of patients. The latter also imply education of our medical authorities, communicating that asthma is more than a beta-2 agonist responsive central airway disorder of the lungs.

Can inhaled corticosteroids prevent asthma exacerbations?

PURPOSE OF REVIEW

asthma exacerbations occur unpredictably, are a cause of morbidity and mortality, and contribute significantly to increased healthcare costs. Inhaled corticosteroids reduce exacerbations and improve quality of life.

RECENT FINDINGS

the aetiopathology of asthma exacerbations is heterogeneous. Attempts to phenotype the heterogeneity of the pattern of airway inflammation by noninvasive monitoring of airway inflammation has identified a subgroup of patients with eosinophilic inflammation who are most likely to respond to steroid therapy. Strategies directed to normalize eosinophilic airway inflammation with corticosteroids have consistently led to a marked reduction in exacerbations. In contrast, their role in modulating the natural history of disease is less certain.

SUMMARY

in the near future, improvements in our understanding of the mechanisms of exacerbations may identify therapeutic targets. While we await these developments, inhaled corticosteroids remain the first choice anti-inflammatory therapy for asthma.

Airway eosinophilia in remission and progression of asthma: accumulation with a fast decline of FEV(1)

BACKGROUND

As it is unknown whether complete asthma remission or progression of asthma is associated with airway inflammation and remodeling, we assessed these characteristics in bronchial biopsies of relevant subsets of asthma patients.

METHODS

Sputum and bronchial biopsies were obtained from asthma patients in remission (PC(20) histamine> 32 mg/ml, PC(20) AMP> 320 mg/ml) and from those with either a slow FEV(1) decline (< 30 ml/year) or fast decline (> 30 ml/year). Inflammatory cells and mediators were determined in sputum, inflammatory cells and aspects of airway remodeling in bronchial biopsies.

RESULTS

Asthmatics in remission and asthma patients with a slow FEV(1) decline had a similar extent of airway inflammation and remodeling in sputum and bronchial biopsies. Asthma patients with a fast FEV(1) decline had high sputum eosinophil numbers. Moreover, FEV(1) decline (ml/year) correlated with sputum eosinophil numbers (Rs=0.51, p=0.003) and ECP levels (Rs=0.57, p=0.001). Airway remodeling, i.e. basement membrane thickness, correlated with sputum eosinophils (Rs=0.69, p<0.001), sputum ECP (Rs=0.46, p=0.018) and airway wall eosinophil numbers (Rs=0.49, p=0.002).

CONCLUSIONS

Asthma, even when in remission, is accompanied by airway inflammation and remodeling. Data suggest that eosinophils are important in a subset of asthma patients by association to accelerated FEV(1) decline and change of basement membrane thickness.

Cough and Asthma

Cough is the most common complaint for which patients seek medical attention. Cough variant asthma (CVA) is a form of asthma, which presents solely with cough. CVA is one of the most common causes of chronic cough. More importantly, 30 to 40% of adult patients with CVA, unless adequately treated, may progress to classic asthma. CVA shares a number of pathophysiological features with classic asthma such as atopy, airway hyper-responsiveness, eosinophilic airway inflammation and various features of airway remodeling. Inhaled corticosteroids remain the most important form of treatment of CVA as they improve cough and reduce the risk of progression to classic asthma most likely through their prevention of airway remodeling and chronic airflow obstruction.

Smoking, longer disease duration and absence of rhinosinusitis are related to fixed airway obstruction in Koreans with severe asthma: findings from the COREA study

Background

The clinical manifestations of severe asthma are heterogeneous. Some individuals with severe asthma develop irreversible fixed airway obstruction, which is associated with poor outcomes. We therefore investigated the factors associated with fixed airway obstruction in Korean patients with severe asthma.

Methods

Severe asthma patients from a Korean adult asthma cohort were divided into two groups according to the results of serial pulmonary function tests. One group had fixed airway obstruction (FAO) [forced expiratory volume in 1 second (FEV1)/forced vital capacity (FVC) ratio < 0.7, n = 119] and the other had reversible airway obstruction (RAO) [FEV1/FVC ratio ≥ 0.7, n = 116]. Clinical and demographic parameters were compared between the two groups.

Results

Multivariate analysis showed that longer duration of disease, greater amount of cigarette smoking and absence of rhinosinusitis were significantly related to the development of FAO in severe asthmatics. Other parameters, including atopic status, pattern of airway inflammatory cells in induced sputum, and frequency of asthma exacerbations did not differ between the FAO and RAO groups.

Conclusion

Severe asthma patients with longer disease duration and the absence of rhinosinusitis are more likely to develop FAO. This study also demonstrates the importance of quitting smoking in order to prevent irreversible airway obstruction. Further investigation is required to determine the mechanism by which these factors can modify the disease course in Korean patients with severe asthma.

Current recommendations for the treatment of mild asthma

Patients suffering from mild asthma are divided into intermittent or persistent classes based on frequency of symptoms and reliever medication usage. Although these terms are used as descriptors, it is important to recognize the approach of focusing on asthma control in managing asthma patients. Beta-agonists are considered first-line therapy for intermittent asthmatics. If frequent use of beta-agonists occurs more than twice a week, controller therapy should be considered. For persistent asthma, low-dose inhaled corticosteroids are recommended in addition to reliever medication. Compliance to regular therapy can pose problems for disease management, and while intermittent controller therapy regimens have been shown to be effective, it is imperative to stress the value of regular therapy especially if an exacerbation occurs. It is also important when such an approach is adopted that there is regular re-evaluations of asthma control. This is because regular anti-inflammatory therapy may become necessary if symptoms become more persistent. Other therapies are seldom needed. Antileukotrienes can be considered an option for mild asthma; however, studies have shown that they are not as effective as inhaled corticosteroids. Aside from therapy, patient education, which includes a written action plan, should be a component of the patient's strategy for disease management.

An official American Thoracic Society public policy statement: Novel risk factors and the global burden of chronic obstructive pulmonary disease

RATIONALE

Although cigarette smoking is the most important cause of chronic obstructive pulmonary disease (COPD), a substantial proportion of COPD cases cannot be explained by smoking alone.

OBJECTIVES

To evaluate the risk factors for COPD besides personal cigarette smoking.

METHODS

We constituted an ad hoc subcommittee of the American Thoracic Society Environmental and Occupational Health Assembly. An international group of members was invited, based on their scientific expertise in a specific risk factor for COPD. For each risk factor area, the committee reviewed the literature, summarized the evidence, and developed conclusions about the likelihood of it causing COPD. All conclusions were based on unanimous consensus.

MEASUREMENTS AND MAIN RESULTS

The population-attributable fraction for smoking as a cause of COPD ranged from 9.7 to 97.9%, but was less than 80% in most studies, indicating a substantial burden of disease attributable to nonsmoking risk factors. On the basis of our review, we concluded that specific genetic syndromes and occupational exposures were causally related to the development of COPD. Traffic and other outdoor pollution, secondhand smoke, biomass smoke, and dietary factors are associated with COPD, but sufficient criteria for causation were not met. Chronic asthma and tuberculosis are associated with irreversible loss of lung function, but there remains uncertainty about whether there are important phenotypic differences compared with COPD as it is typically encountered in clinical settings.

CONCLUSIONS

In public health terms, a substantive burden of COPD is attributable to risk factors other than smoking. To prevent COPD-related disability and mortality, efforts must focus on prevention and cessation of exposure to smoking and these other, less well-recognized risk factors.

The importance of airway remodelling in the natural course of asthma

INTRODUCTION

Asthma is associated with airflow limitation and increased decline in lung function. The underlying mechanism for this was probably that persisting inflammation leads to remodelling of the airways.

OBJECTIVES

To review the importance of different factors which are related to airflow limitation and lung function decline in asthma.

METHODS

Case report and literature review.

RESULTS

Asthma severity, smoking, bronchial hyperresponsiveness and eosinophil inflammation were the variables that were most convincingly related to decline in forced expiratory volume in 1 s (FEV(1)) in asthma. Treatment with inhaled corticosteroids probably decreased the rate of FEV(1) decline, although this was more uncertain because of the lack of randomised double blind studies that show such an effect. Progress in the field of the genetics of asthma may, in the near future, elucidate the role of gene-environment interaction in lung function decline in asthma.

CONCLUSION

Regular treatment with inhaled corticosteroids may partly have a beneficial effect on airway remodelling in asthma. Improved understanding of the processes leading to airway remodelling is, however, important in order to prevent a large number of asthmatics from developing irreversible airflow obstruction.

Recent advances in the pathophysiology of asthma

There has been an increased understanding, over the past 2 decades, that asthma is a chronic, immunologically mediated condition with a disturbance of the normal airway repair mechanism, which results in inflammatory changes and airway remodeling. The airway inflammation and remodeling together likely explain the clinical manifestations of asthma. The mechanisms by which the external environmental cues, together with the complex genetic actions, propagate the inflammatory process that characterize asthma are beginning to be understood. There is also an evolving awareness of the active participation of structural elements, such as the airway epithelium, airway smooth muscle, and endothelium, in this process. In tandem with this has come the realization that inflammatory cells respond in a coordinated, albeit dysfunctional manner, via an array of complex signaling pathways that facilitate communication between these cells; these structural elements within the lung and the bone marrow serve as reservoirs for and the source of inflammatory cells and their precursors. Although often viewed as separate mechanistic entities, so-called innate and acquired immunity often overlap in the propagation of the asthmatic response. This review examines the newer information on the pathophysiologic characteristics of asthma and focuses on papers published over the past 3 years that have helped to improve current levels of understanding.

Decreased activation of inflammatory networks during acute asthma exacerbations is associated with chronic airflow obstruction

Asthma exacerbations are associated with subsequent deficits in lung function. Here, we tested the hypothesis that a specific pattern of inflammatory responses during acute exacerbations may be associated with chronic airway obstruction. Gene coexpression networks were characterized in induced sputum obtained during an acute exacerbation, from asthmatic children with or without chronic airflow limitation. The data showed that activation of Th1-like/cytotoxic and interferon signaling pathways during acute exacerbations was decreased in asthmatic children with deficits in baseline lung function. These associations were independent of the identification of picornaviruses in nasal secretions or the use of medications at the time of the exacerbation. Th2-related pathways were also detected in the responses, but variations in these pathways were not related to chronic airways obstruction. Our findings show that decreased activation of Th1-like/cytotoxic and interferon pathways is a hallmark of acute exacerbation responses in asthmatic children with evidence of chronic airways obstruction.

Evidence for airway remodeling in chronic asthma

PURPOSE OF REVIEW

This review focuses on recent findings in relation to potential functional consequences of structural changes in the asthmatic airway.

RECENT FINDINGS

Increases in smooth muscle mass have been shown to be an early finding in childhood asthma, related to clinical severity and predictive of greater airflow obstruction. Both hyperplasia and hypertrophy contribute to the increase in smooth muscle mass. A phenotypic shift in the epithelium of asthmatic airways related to stress and injury is suggested by recent data, with likely direct transformation of epithelial cells into mesenchymal cells. Fibrocyte in-migration from the vasculature may be an additional source of increased smooth muscle mass. The increased smooth muscle may contribute to neovascularization via vascular endothelial growth factor. Computed tomography studies continue to show some correlations between wall thickness and airway physiology. Exacerbations are predictive of greater lung function decline and hence remodeling.

SUMMARY

On balance, recent evidence continues to show that structural changes contribute to asthma persistence, airflow obstruction, lung function decline, and clinical severity, though there is increased recognition of the heterogeneity of asthma and in some phenotypes inflammatory cell influx or vascular effects may be more important than structural effects.