[Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]

Fractional exhaled nitric oxide in a respiratory healthy general population through the lifespan

INTRODUCTION AND OBJECTIVES

The fractional exhaled fraction of nitric oxide (FeNO) is used in clinical practice for asthma diagnosis, phenotyping, and therapeutic management. Therefore, accurate thresholds are crucial. The normal FeNO values over lifespan in a respiratory healthy population and the factors related to them remain unclear.

MATERIALS AND METHODS

We determined FeNO levels in 2,251 respiratory healthy, non-atopic, and non-smoking participants from the Lung, hEart, sociAl, boDy (LEAD) cohort, a general population, observational cohort study of participants aged 6-82 years in Austria.

RESULTS

The median FeNO value in the total study population was 13.0 [interquartile range: 9.0, 20.0] ppb, increases with age, and, except in young participants (<18 years: 9.0 [7.0, 12.0], ≥18 years: 15.0 [11.0, 22.0]), it was significantly lower in females versus males. Multiple regression analyses showed that body height and blood eosinophil counts were associated with higher FeNO levels, both in children/adolescents and adults. In children/adolescents, FeNO values were positively associated with total IgE levels, FEV1/FVC ratio, and urban living. In adults, FeNO was positively associated with age and negatively associated with the presence of cardiovascular and ischaemic vascular disease.

CONCLUSIONS

We identified the normal FeNO ranges within a respiratory healthy population at different age ranges and associated factors. Collectively, they serve as a reference to frame FeNO values in clinical practice.

Blood Eosinophil Count in Asthma Is Associated With Increased Abdominal Aortic Diameter and Increased Vascular Stiffness

Background

Asthma is associated with atherosclerosis and abdominal aortic aneurysm (AAA). However, the underlying pathomechanisms remain elusive. Blood eosinophil count (BEC) is implicated in both eosinophilic asthma and arterial wall inflammation.

Objective

To explore the possible association of BEC in asthma and abdominal aortic artery changes.

Methods

112 outpatients were prospectively enrolled in this exploratory study. Abdominal aortic diameter was measured using ultrasonography imaging, while vascular speckle tracking was utilized to evaluate vascular strains. Patients were stratified into two groups, with n=66 patients with a BEC of ≥300 n/µL and n=46 patients with <300 n/µL. Both groups exhibited no significant disparities in cardiovascular risk factors; however, the high BEC group was more frequently male.

Results

The aortic diameter was wider in patients with a BEC ≥300 n/µL (1.46 ± 0.25 cm vs 1.67 ± 0.63 cm, p=0.018). Three patients were diagnosed with an AAA, all had a BEC ≥300 n/µL. Patients with a BEC ≥300 n/µL exhibited lower strain values, indicative of higher vascular stiffness, including radial strain (2.65 ± 1.38% vs 4.46 ± 2.59%; p<0.001). BEC exhibited a positive correlation with abdominal aortic diameter (R²=0.131, b=0.000, p<0.001), and a negative correlation with radial strain values (R²=0.131, b=-0.002, p=0.001) in sex-adjusted linear regression.

Conclusion

In patients with asthma, blood eosinophil count (BEC) is correlated with a wider aortic diameter and heightened vascular stiffness in the abdominal aorta. Hence, they may be at an elevated risk of developing an AAA.

SANI clinical remission definition: a useful tool in severe asthma management

In the field of severe asthma, the concept of disease control has recently been integrated by the one of clinical remission. With this new concept, we move on to analyze the efficacy of therapy on multiple parameters simultaneously, starting with the mandatory discontinuation of the systemic glucocorticoids, to which is added the effect on exacerbations, respiratory function, and symptoms control. The Italian severe asthma registry SANI (Severe Asthma Network Italy) drafted criteria for the definition of disease remission, allowing patients to be classified into two groups, partial and complete remission. The greater dynamism of the definition, provided by SANI, allows us to hypothesize its practical use, concerning therapy management of severe asthma patients, starting from the level of remission, with the aim to facilitate the clinical decision on replacement, continuation or modulation of patients' therapy.

Disease Modification in Asthma: Are We on the Right Way? A Multidisciplinary Expert Delphi Consensus (MODIASTHMA Consensus)

Purpose

With the advent of biological therapies, emerging concepts regarding establishing new targets in asthma management, such as disease modification, have entered the debate among the scientific community. The definitions that form the conceptual basis of this goal need to be agreed upon.

Methods

A multidisciplinary expert group was assembled as the steering committee. A systematic literature review was conducted to identify the scientific background for constructing appropriate definitions. Based on the literature review and the clinical experience of the experts, the committee built a list of statements that could be applied to establish the definition of disease modification in asthma. After that, a Delphi validation was performed to assess the appropriateness of the list of statements. The questionnaire included a total of 22 statements, divided into "Essential criteria for disease modification in asthma" (5 statements) and "Disease modification indicators and other considerations" (17 statements). Panelists used a 9-point Likert scale to measure agreement on each statement. The cut-off point for high consensus was defined as a minimum score of 7 and had to be reached by at least two-thirds of the experts.

Results

A total of 192 asthma experts voted on statements anonymously. Of those, 104 (54%) were Pneumologists, 65 (34%) were allergologists, and 23 (12%) were Pediatricians. An interim analysis of round 1 data was performed. All statements reached consensus on the first round, with a median score above 7 in all cases.

Conclusion

In conclusion, in this Delphi study, a large number of experts in the management of severe asthma from different specialties agreed on the clinical-functional and pathophysiological aspects to be considered in order to try to achieve disease modification.

The Influence of Emphysema on Treatment Response to Biologic Therapy in Severe Asthma

Background

Patients with severe asthma (SA) benefit from biologic therapy substantially. However, the impact of smoking-related comorbidities remains unclear due to the exclusion of patients with ≥10 pack-years from asthma studies. Our aim was to examine the effects of emphysema on biologic treatment response in SA in this retrospective cohort study.

Methods

Pulmonary emphysema was examined using computed tomography. Patients with SA were included and divided into two groups based on emphysema quantity (≥5% or <5%). They received either anti-IgE (22.1%), anti-IL-5-(receptor) (52.3%), or anti-IL-4/IL-13 (25.6%) biologic therapy. Treatment response was assessed after 7.8 ± 2.5 months based on acute exacerbations (AE), oral corticosteroid (OCS) therapy, Asthma Control Test (ACT), forced expiratory volume in 1 second (FEV1) and using the Biologics Asthma Response Score (BARS).

Results

This study comprised 86 patients (mean age 56.1 ± 12.8 years; 54% female). Half (43, 50.0%) were never-smokers, half ex-smokers with an average of 26.9 ± 18.2 pack-years. Patients with ≥5% emphysema were more often ex-smokers (80% vs 41%, p=0.002), had poorer lung function (FEV1 median 1.3 [interquartile range: 1.0;1.6] vs 1.8[1-2;2.4] L, p=0.037), and more comorbid COPD (50% vs 21%, p=0.012). However, no significant differences were noted in treatment response regarding annualized AE rate (-2.5[-5;-1] vs -3.0[-5;-2] n/year, p=0.295) and OCS reduction (-4[-10;0] vs -5[-10;0] mg, p=0.691), ACT score (5[3;9] vs 4[0;9] points, p=0.579) or FEV1 improvement (0.03[-0.15;0.25] vs 0.23[-0.5;0.49] L, p=0.052), BARS (p=0.312), and remission rates (15.0% vs 19.7%, p=0.753).

Conclusion

In patients with severe asthma, those with comorbid emphysema show similar treatment response to biologic therapy. Therefore, suitable patients should not be denied biologics due to the presence of emphysema.

Blood eosinophil count is associated with early atherosclerotic artery changes in asthma

OBJECTIVE

Asthma is linked to atherosclerosis, yet the underlying mediators remain elusive. Eosinophils may contribute to both asthmatic and atherosclerotic inflammation. Hence, this study aimed to explore the potential associations of eosinophils with artery changes among patients with asthma.

METHODS

We assessed strain values of the common carotid arteries (CCAs) via vascular speckle tracking and compared asthma patients with low (< 300/µl) and high (≥ 300/µl) blood eosinophil counts (BEC).

RESULTS

We enrolled 100 patients, 42 with a BEC of < 300 and 58 with a BEC of ≥ 300 n/µl. Patients with high BEC exhibited more severe disease, characterized, e.g., by a higher frequency of acute exacerbations (1.3 ± 2.1 vs. 2.6 ± 2.4 n/year, p = 0.005). Both groups presented similar profiles in terms of conventional cardiovascular risk. The high BEC group demonstrated elevated arterial stiffness, reflected by reduced radial strain (mean radial strain of the right CCA: 2.7 ± 1.4% for BEC ≥ 300 n/µl vs. 3.5 ± 1.7% for BEC < 300 n/µl, p = 0.008; left CCA: 2.6 ± 1.4% vs. 4.1 ± 2.2%, p < 0.001). A weak yet statistically significant negative correlation was observed between BEC and radial strain for the right CCA (R2 = 0.131, b=-0.001, p = 0.001) and left CCA (R2 = 0.086, b=-0.001, p = 0.015). However, the prevalence of cerebrovascular disease was similar in both groups (31,0% vs. 50,0%, p = 0.057).

CONCLUSION

We identified a correlation between BEC and vascular stiffness, which supports the hypothesis that eosinophils may promote atherosclerosis.

CLINICAL TRIAL NUMBER

Due to the exploratory and predominantly retrospective nature of the study, trial registration was not conducted. The only prospective procedure conducted was the angiological sonography to evaluate the current state. No ensuing health-related interventions were performed specifically for this study.

Clinical remission and control in severe asthma: agreements and disagreements

Over the last two decades, we have witnessed great advancements in our understanding of the immunological pathways of asthma, leading to the development of targeted therapies, such as biologic drugs, that have radically and definitively changed the clinical outcomes of severe asthma. Despite the numerous therapeutic options available, ~4-10% of all people with asthma have severe or uncontrolled asthma, associated with an increased risk of developing chronic oral corticosteroid use, fixed airflow limitation, exacerbations, hospitalization and, finally, increased healthcare costs. The new concept of disease modification in asthma comes from the evolution of asthma management, which encompasses phenotyping patients with different inflammatory endotypes characterizing the disease, followed by the advent of more effective therapies capable of targeting the proximal factors of airway inflammation. This treat-to-target approach aims to achieve remission of the disease. Because the novel treatment paradigm for severe asthma with the advent of biologic therapies is no longer clinical control but rather clinical remission - a step closer to the concept of cure - a deeper and more accurate understanding of the critical causal mechanisms and endotypes of asthma is necessary to achieve the goal of clinical remission, which has the potential to generate real life-changing benefits for patients. This review aims to frame the evolution of the debated concept of clinical remission and provide clinicians with insights that may be helpful in achieving remission in the greatest number of patients.

The Diagnosis and Treatment of Chronic Rhinosinusitis

BACKGROUND

Chronic rhinosinusitis (CRS) is a heterogeneous condition characterized by local chronic inflammation of the mucous membranes of the nose and paranasal sinuses. It affects approximately 5% of the population.

METHODS

This review is based on relevant publications retrieved by a selective search of the literature, with particular attention to current national and international guidelines.

RESULTS

CRS is defined by, and diagnosed on the basis of, a combination of symptoms and objective findings of nasal endoscopy and imaging studies. It markedly impairs quality of life and gives rise to both direct and indirect health care costs. In 20-45% of cases, CRS is associated with comorbid bronchial asthma and a significantly elevated risk of further diseases (e.g., COPD, OR 1.73; depression, HR 1.50; obstructive sleep apnea, OR 1.91; carcinoma, OR 1.14-5.30). CRS is primarily treated medically with topical steroids (standardized mean difference of nasal symptoms, -0.63 (95% confidence interval [-0.89; -0.37]; standardized mean difference of quality of life as measured by SNOT -22, -5.46 [-8.08; -2.84]), as well as with nasal lavage and, as an option, systemic steroids (and antibiotics where appropriate). If appropriate medical treatment fails to bring about adequate and sustained improvement, endoscopic sinus surgery is indicated. This improves the individual symptoms, the overall symptom score, and patients' quality of life. Severe refractory CRS with nasal polyposis can be treated with biological agents.

CONCLUSION

CRS calls for individually adapted medical and/or surgical treatment.

Response to Biologic Therapy in Patients with Asthma and Reduced Pulmonary Diffusion Capacity

INTRODUCTION

Asthma patients with a smoking history are usually excluded from asthma trials to exclude smoking-related comorbidities like chronic obstructive pulmonary disease (COPD). Therefore, little is known about the efficacy of biologic therapy in asthma patients with reduced diffusing capacity of the lungs for carbon monoxide (DLCO).

METHODS

This study aimed to assess the response to biologic therapy in asthma patients with reduced DLCO. A total of 77 consecutive patients undergoing biologic therapy in a routine clinical setting were included in the analysis and divided into three groups: DLCO ≥60%, DLCO <60% and <10 pack-years, and DLCO <60% and ≥10 pack-years = asthma and COPD comorbidity. Follow-up evaluations were conducted after a minimum of 6 months of therapy.

RESULTS

After 34.0 ± 10.2 weeks, comparable therapeutic responses were observed between the three groups. There were no differences between the groups in terms of reduction in the annual acute exacerbation rate (AE median -3 [25th percentile -5; 75th percentile -1] vs. -6.1 [-11.3;-2.2] vs. -3 [-6;-2], p = 0.067), oral corticosteroid (OCS) doses (-5 [-10;0] vs. -1 [-7.5;0] vs. -7.5 [-10;-4] mg, p = 0.136), improvement in Asthma Control Test (ACT) scores (4 [0;9.3] vs. 3 [-1;6] vs. 4 [3;10], p = 0.276) or forced expiratory volume in 1 s (FEV1) improvement (5.5 [-2;21.5] vs. 0.5 [-2.8;9.3] vs. 5 [0;16] % predicted, p = 0.328). Linear regression analysis revealed no significant correlation between DLCO levels and changes in OCS dosage or AE rate, nor between DLCO and improvements in ACT scores or FEV1. Notably, a smaller proportion of patients exhibited a reduced transfer coefficient (DLCO/VA) (n = 13, 16.9%). This parameter did not significantly impact therapy response either.

CONCLUSION

Our findings suggest that biologic therapy can effectively manage asthma irrespective of DLCO measurements. Thus, reduced DLCO values should not preclude thorough asthma diagnosis and treatment. Further investigation into the utility of DLCO/VA assessment in this context is warranted.

[Advances in the management of asthma]

Asthma is a heterogeneous inflammatory airway disease that causes relevant morbidity across individuals of all age cohorts. In recent years, advances in the understanding of asthma pathophysiology have led to the development of treatments tailored to specific pheno- and endotypes of the disease. This has significantly changed asthma management, especially for patients with severe disease. These new treatment options offer individuals with asthma access to personalized and disease-modifying therapies. The present paper is a comprehensive overview of recent clinical studies and of German and international guideline updates on asthma management.

[Modern asthma management]

Symptom prevention and remission are the goals of asthma treatment. Precise phenotyping of the patients, including history, lung function, allergology and measurement of type 2 biomarkers, is the essential prerequisite for treatment success. Basic measures, treatment with DMAADs ("disease-modifying anti-asthmatic drugs": predominantly inhaled corticosteroids, biologics, and allergen immunotherapy) and treatment of comorbidities are the cornerstones of modern asthma management. The treatment of upper airway diseases such as allergic rhinitis (often associated with early-onset asthma) or chronic rhinosinusitis (often associated with adult-onset asthma, with 2 forms: either with nasal polyps, CRSwNP, or without nasal polyps, CRSsNP) is of major importance in this regard.

Fetal lung growth predicts the risk for early-life respiratory infections and childhood asthma

BACKGROUND

Early-life respiratory infections and asthma are major health burdens during childhood. Markers predicting an increased risk for early-life respiratory diseases are sparse. Here, we identified the predictive value of ultrasound-monitored fetal lung growth for the risk of early-life respiratory infections and asthma.

METHODS

Fetal lung size was serially assessed at standardized time points by transabdominal ultrasound in pregnant women participating in a pregnancy cohort. Correlations between fetal lung growth and respiratory infections in infancy or early-onset asthma at five years were examined. Machine-learning models relying on extreme gradient boosting regressor or classifier algorithms were developed to predict respiratory infection or asthma risk based on fetal lung growth. For model development and validation, study participants were randomly divided into a training and a testing group, respectively, by the employed algorithm.

RESULTS

Enhanced fetal lung growth throughout pregnancy predicted a lower early-life respiratory infection risk. Male sex was associated with a higher risk for respiratory infections in infancy. Fetal lung growth could also predict the risk of asthma at five years of age. We designed three machine-learning models to predict the risk and number of infections in infancy as well as the risk of early-onset asthma. The models' R2 values were 0.92, 0.90 and 0.93, respectively, underscoring a high accuracy and agreement between the actual and predicted values. Influential variables included known risk factors and novel predictors, such as ultrasound-monitored fetal lung growth.

CONCLUSION

Sonographic monitoring of fetal lung growth allows to predict the risk for early-life respiratory infections and asthma.

Barriers to clinical remission in severe asthma

Severe asthma is associated with an increased risk for exacerbations, reduced lung function, fixed airflow obstruction, and substantial morbidity and mortality. The concept of remission in severe asthma as a new treatment goal has recently gained attention due to the growing use of monoclonal antibody therapies, which target specific pathologic pathways of inflammation. This review evaluates the current definitions of asthma remission and unveils some of the barriers for achieving this state in the severe asthma population. Although there is no unified definition, the concept of clinical remission in asthma should be based on a sustained period of symptom control, elimination of oral corticosteroid exposure and exacerbations, and stabilization of pulmonary function. The conjugation of these criteria seems a realistic treatment target in a minority of asthmatic patients. Some unmet needs in severe asthma may affect the achievement of clinical remission. Late intervention with targeted therapies in the severe asthma population may increase the risk of corticosteroid exposure and the development of irreversible structural airway changes. Moreover, airway infection is an important component in persistent exacerbations in patients on biologic therapies. Phenotyping exacerbations may be useful to guide therapy decisions and to avoid the liberal use of oral corticosteroids. Another challenge associated with the aim of clinical remission in severe asthma is the multifaceted interaction between the disease and its associated comorbidities. Behavioural factors should be evaluated in case of persistent symptoms despite optimised treatment, and assessing biomarkers and targeting treatable traits may allow for a more objective way of reaching remission. The concept of clinical remission will benefit from an international consensus to establish unifying criteria for its assessment, and it should be addressed in the future management guidelines.

[Diagnosis and therapy of patients with asthma in Germany. Results of the care study RELEVANT]

BACKGROUND

Diagnostic and therapeutic options for asthma have improved with asthma control and remission being of central importance. The RELEVANT study aimed for a nationwide snapshot of current asthma diagnosis and treatment in general practice and specialty care for identification of further aspects for optimization.

METHOD

RELEVANT is a nationwide cross-sectional study using a structured questionnaire. This comprised 14 questions on asthma-related topics covering diagnostics and therapy. Participants were general practitioners/internal medicine specialists and pulmonologists.

RESULTS

A total of 1,558 persons took part in the survey. Regarding relevant specific diagnostic procedures for asthma, GPs/internists almost exclusively mentioned pulse oximetry. Among the pulmonologists, fractional exhaled nitric oxide (FeNO) measurement was mentioned, among others. FeNO and blood eosinophils were only mentioned by the pulmonologists as diagnostic and treatment-relevant markers. A total of more than 60% of the GPs/internists surveyed stated that only around 25% or fewer of their patients would voluntarily report restrictions in their everyday lives. Regarding drug treatment, the majority stated that they recognized differences between various ICS/LABA combination therapies.

CONCLUSIONS

The results indicate a need for optimization, particularly regarding asthma control. This involves both a better assessment by patients' everyday life restrictions and modern ways of assessing asthma control in cooperation between GPs/internal medicine specialists and pulmonologists. One fifth of respondents do not see any differences between various ICS/LABA combinations in daily practice, although there are pharmacodynamic and pharmacokinetic differences.

[Prevention of progression of allergic bronchial asthma as an occupational disease]

Since January 1st, 2021, termination of a harmful activity as a requirement for its recognition as an occupational disease (OD) has been abolished in Germany. This also includes the OD No. 4301 in accordance with Appendix 1 of the Occupational Diseases Ordinance (ODO) (obstructive respiratory diseases caused by allergenic substances). There has already been a significant increase in the number of diseases recognized under this OD. In this article, we present two patients with allergic (in the second case report mixed-form) bronchial asthma, in whom a medically easily preventable disease progression occurred as a result of continued occupational exposure to allergens as a farmer. According to § 3 (1) ODO, if there is a "risk that an occupational disease will develop, recur or worsen", the statutory accident insurance institutions are obliged to "counteract this danger with all suitable means". These individual preventive measures are compulsory by law and medically sensible, even under circumstances where only the risk of the genesis of an OD is given. Nonetheless, they are likely to be indicated and offered more frequently in the future due to an increased recognition of ODs. Unfavorable clinical courses such as those described in the two case reports presented here should therefore occur less frequently in the future.

Long-term multicenter comparison shows equivalent efficacy of monoclonal antibodies in severe asthma therapy

BACKGROUND

Monoclonal antibodies (biologics) drastically changed severe asthma therapy. Mepolizumab (anti-interleukin (IL) 5), benralizumab (anti-IL5 receptor alpha), and dupilumab (anti-IL4/13) are the most used biologics in this context. While all biologics are efficient individually, the choice of biologic is complicated by insufficient data on their comparative long-term treatment efficacy. Here, we compare the real-life efficacy of these biologics in asthma therapy over 12 months.

METHODS

280 severe asthma patients treated with mepolizumab (129/280, 46%), benralizumab (83/280, 30%) or dupilumab (68/280, 24%) for one year were analyzed retrospectively. Data were collected at baseline and after 6 and 12 months of therapy. Endpoints were changes pulmonary function (PF), exacerbation rate, oral corticosteroid (OCS) use and dose, asthma control test (ACT) score and fractional exhaled nitric oxide (FeNO) levels as well as responder status measured by the recently published "Biologic Asthma Response Score" (BARS).

RESULTS

All biologics led to significant improvements in PF, ACT and OCS dose. Only Mepolizumab and Benralizumab significantly decreased the exacerbation rate, while only Mepolizumab and Dupilumab significantly decreased FeNO. Responder rates measured by BARS were high across all groups: roughly half of all patients achieved full response and most of the remainder achieved at least partial responder status. Overall, outcomes were similar between groups after both 6 and 12 months.

CONCLUSIONS

All biologics showed great efficacy in individual parameters and high responder rates measured by BARS without a clinically relevant advantage for any antibody. Response was usually achieved after 6 months and retained at 12 months, emphasizing the utility of early response assessment.

The pharmacological management of asthma in adults: 2023 update

INTRODUCTION

The pharmacotherapy of asthma is a dynamic process that changes as our knowledge of the underlying pathophysiology and treatment of this disease continues to evolve. This implies the need for continuous revision of the recommendations of asthma guidelines and strategies.

AREAS COVERED

This review summarizes the latest key practical information on the pharmacological management of asthma in adults. We provide the background to the 2023 update of the GINA strategy report, focusing on changes and discussing areas of uncertainty. We review current and emerging pharmacotherapy for uncontrolled asthma, including synthetic agents and new biologics, and provide expert perspectives and opinions on the treatment of uncontrolled asthma.

EXPERT OPINION

The current pharmacological treatment of asthma, based on a step-by-step, control-based approach, with ICSs, LABAs and LAMAs being the mainstay generally provides good symptom control. Biologic therapies are often effective in treating T2high severe asthma. However, there is still room for improvement, such as the discovery of new molecules that specifically target chronic inflammation and, most importantly, the ability to provide solutions to the various areas of uncertainty that still exist. Also finding solutions to improve the accessibility and affordability of rescue ICS in resource-constrained settings is critical.

[Precision medicine in the diagnosis and treatment of asthma]

Due to the availability of disease-modifying anti-asthmatic drugs (DMAADs), especially inhaled steroids (alone or in combination with long-acting bronchodilators), biologics and modern allergen immunotherapy, the treatment of asthma has fundamentally changed. The aims of modern asthma precision medicine are prevention of symptoms and the induction and maintenance of asthma remission (long-term asthma control, freedom from exacerbations and stable lung function without the use of systemic steroids). A treat to target approach is used as for other chronic inflammatory diseases in internal medicine: the aim is to achieve remission by an individually tailored treatment with DMAADs; however, the prerequisite for modern asthma precision medicine is asthma phenotyping, including a detailed medical history, lung function testing, allergological diagnostics and measurement of type 2 markers (blood eosinophils and, if available, exhaled nitric oxide, FeNO).

[Update on asthma 2024 - what the ENT specialist needs to know]

The lifetime prevalence of 8.6% of asthma in Germany reflects the high medical and socioeconomic impact of the disease. Asthma treatment goals have changed during the last decades: from symptom control to symptom prevention, with highly effective, disease-modifying anti-asthmatic drugs (DMAADs) aiming at asthma remission. In order to achieve this goal, phenotyping of patients (including an evaluation of allergies and type 2 biomarkers) is crucial for personalized treatment. The identification and effective treatment of concomitant diseases, such as allergic rhinitis or chronic rhinosinusitis with nasal polyps (CRSwNP), plays a major role for successful treatment. This underlines the importance of interdisciplinary collaboration of otolaryngologists and respiratory physicians in the management of patients with asthma. This CME article informs the reader about current guidelines on the diagnosis and treatment of asthma, focusing on clinically relevant recommendations for ENT physicians.

[Pneumological Rehabilitation in Long COVID - A Comparative Exploratory Longitudinal Study of Long COVID and Asthma/COPD Rehabilitees]

BACKGROUND

For some COVID-19 patients, symptoms and health impairments persist for an extended period of time (long COVID). Long-term consequences of the disease can lead to permanent limitations in participatory life. In these cases, medical rehabilitation may be useful. Due to the novelty of the disease, little is known about the need for rehabilitation and therapy and the health benefits of specific rehabilitation interventions.

METHODS

A multicentre longitudinal observational study was conducted. Persons affected by long COVID (LC) between 18 and 65 years of age undergoing pulmonary rehabilitation were included. An age-matched comparison group (CG) consisted of rehabilitation patients with bronchial asthma and COPD. Written questionnaires were administered at the beginning and end of rehabilitation, as well as six and twelve months after rehabilitation. Outcomes included parameters of subjective health, occupational outcomes, contents of rehabilitation and rehabilitation aftercare.

RESULTS

The sample consisted of 305 participants, of whom 172 were classified as LC and 133 as CG. In the total sample, one third of the participants were male and the average age was 53 years. All rehabilitation participants had high health burdens, LC patients had statistically significantly higher impairments in almost all outcomes recorded. At the beginning of rehabilitation, one third of the respondents were on sick leave, more often in LC than in the CG. Twelve months after rehabilitation, both groups achieved significant health improvement, with LC showing greater improvements in most outcomes (interaction effect p<0.01). Despite success in most parameters, LC patients still showed persistent COVID symptoms at twelve months. One year after rehabilitation, 89% returned to work.

CONCLUSION

The majority of rehabilitation patients benefit greatly from pulmonary medical rehabilitation in terms of health and occupation. The content of pulmonary rehabilitation seems to be suitable for this indication group; however, there is an indication-specific use of therapy between CG and LC group. As a result, the LC group seems to need more and different therapies.

[Advances in the management of asthma]

Asthma is a heterogeneous inflammatory airway disease that causes relevant morbidity across individuals of all age cohorts. In recent years, advances in the understanding of asthma pathophysiology have led to the development of treatments tailored to specific pheno- and endotypes of the disease. This has significantly changed asthma management, especially for patients with severe disease. These new treatment options offer individuals with asthma access to personalized and disease-modifying therapies. The present paper is a comprehensive overview of recent clinical studies and of German and international guideline updates on asthma management.