The impact of bronchiectasis in clinical presentation of asthma

Clinical outcomes of long-term inhaled combination therapies in patients with bronchiectasis and airflow obstruction

BACKGROUND AND OBJECTIVES

Few studies have reported which inhaled combination therapy, either bronchodilators and/or inhaled corticosteroids (ICSs), is beneficial in patients with bronchiectasis and airflow obstruction. Our study compared the efficacy and safety among different inhaled combination therapies in patients with bronchiectasis and airflow obstruction.

METHODS

Our retrospective study analyzed the patients with forced expiratory volume in 1 s (FEV1)/forced vital capacity < 0.7 and radiologically confirmed bronchiectasis in chest computed tomography between January 2005 and December 2021. The eligible patients underwent baseline and follow-up spirometric assessments. The primary endpoint was the development of a moderate-to-severe exacerbation. The secondary endpoints were the change in the annual FEV1 and the adverse events. Subgroup analyses were performed according to the blood eosinophil count (BEC).

RESULTS

Among 179 patients, the ICS/long-acting beta-agonist (LABA)/long-acting muscarinic antagonist (LAMA), ICS/LABA, and LABA/LAMA groups were comprised of 58 (32.4%), 52 (29.1%), and 69 (38.5%) patients, respectively. ICS/LABA/LAMA group had a higher severity of bronchiectasis and airflow obstruction, than other groups. In the subgroup with BEC ≥ 300/uL, the risk of moderate-to-severe exacerbation was lower in the ICS/LABA/LAMA group (adjusted HR = 0.137 [95% CI = 0.034-0.553]) and the ICS/LABA group (adjusted HR = 0.196 [95% CI = 0.045-0.861]) compared with the LABA/LAMA group. The annual FEV1 decline rate was significantly worsened in the ICS/LABA group compared to the LABA/LAMA group (adjusted β-coefficient=-197 [95% CI=-307--87]) in the subgroup with BEC < 200/uL.

CONCLUSION

In patients with bronchiectasis and airflow obstruction, the use of ICS/LABA/LAMA and ICS/LABA demonstrated a reduced risk of exacerbation compared to LABA/LAMA therapy in those with BEC ≥ 300/uL. Conversely, for those with BEC < 200/uL, the use of ICS/LABA was associated with an accelerated decline in FEV1 in comparison to LABA/LAMA therapy. Further assessment of BEC is necessary as a potential biomarker for the use of ICS in patients with bronchiectasis and airflow obstruction.

The Role of Inflammatory Phenotype in Patients With Exacerbation-prone Asthma and Ongoing Therapy

INTRODUCTION

The risk factors for having frequent exacerbations are not well documented in cohort studies of patients with asthma on existing therapy. The objective of the present study was to compare the clinical and inflammatory characteristics of patients with exacerbation-prone asthma (EPA) with a history of two or more exacerbations in the previous year with those who had presented just one or no exacerbation.

METHODS

An ambispective observational study was conducted in a tertiary hospital. Patients diagnosed with moderate or severe asthma and ongoing therapy, whose inflammatory profile was determined by means of allergy and atopy status, blood eosinophilia and induced sputum were included. Patients were classified according to the number of asthma exacerbations in EPA (≥2 exacerbations in the previous year) vs. non-exacerbators (≤1 exacerbation in the previous year). Clinical, lung function and inflammatory characteristics of the two groups were compared.

RESULTS

Three hundred ten patients were visited in the Asthma Unit in 2018 and the combination of atopy and allergy status, blood eosinophilia and induced sputum was obtained in 96 (31%) patients. Of this latter group, 46 patients (47%) presented EPA compared to 50 (53%) non-exacerbators. Airway and blood eosinophilic inflammation did not differ between EPA and non-exacerbators in patients with asthma and ongoing therapy, and it was not a risk factor for EPA in our cohort.

CONCLUSION

Airway or blood type 2 inflammation status is not a valid tool for recognizing EPA or predicting asthma exacerbations in asthma patients following controller therapy.

Impacts of Asthma in Patients With Bronchiectasis: Findings From the KMBARC Registry

PURPOSE

Although the coexistence of asthma and bronchiectasis is common, the impacts of asthma on bronchiectastic patients (BE) have not been well evaluated because this issue using bronchiectasis cohorts has been investigated in only a few studies.

METHODS

In the present study, 598 patients who were prospectively enrolled in the Korean bronchiectasis registry were evaluated. The clinical characteristics between BE with asthma and those without asthma were compared.

RESULTS

Asthma was found in 22.4% of BE. BE with asthma had a higher body mass index (BMI) (P = 0.020), more dyspnea (P < 0.001), larger sputum volume (P = 0.015), and lower forced expiratory volume in 1 second (FEV1) (P < 0.001) than those without asthma. BE with asthma had a higher rate of previous pneumonia (P = 0.017) or measles (P = 0.037) than those without asthma. Regarding treatment, BE with asthma used inhaled corticosteroids, long-acting muscarinic antagonists, and leukotriene receptor antagonists more frequently than those without asthma. Although intergroup differences were not observed in disease severity of bronchiectasis (P = 0.230 for Bronchiectasis Severity Index and P = 0.089 for FACED), the Bronchiectasis Health Questionnaire (BHQ) scores indicating the quality of life, were significantly lower in BE with asthma than in those without asthma (61.6 vs. 64.8, P < 0.001). In a multivariable model adjusting for age, sex, body mass index, forced expiratory volume in 1 second %predicted, sputum volume, modified Medical Research Council dyspnea scale ≥ 2, and the number of involved lobes, asthma was associated with lower BHQ scores (β-coefficient = -2.579, P = 0.014).

CONCLUSIONS

BE with asthma have more respiratory symptoms, worse lung function, and poorer quality of life than those without asthma. A better understanding of the impacts of asthma in BE will guide appropriate management in this population.

Clinical Deterioration and Lung Function Change in Patients With Concomitant Asthma and Bronchiectasis

BACKGROUND

Only limited data are available regarding the effects of bronchiectasis on the clinical course of asthma.

OBJECTIVE

This study evaluated longitudinal clinical outcomes according to bronchiectasis status in patients with asthma.

METHODS

This retrospective study included patients with asthma who underwent chest computed tomography and pulmonary function tests between January 2013 and December 2019. The annual incidence of episodes of moderate-to-severe acute clinical deterioration (exacerbations) and longitudinal changes in lung function were evaluated.

RESULTS

Of 667 patients with asthma, 251 had bronchiectasis. Patients with bronchiectasis had significantly more history of tuberculosis and nontuberculous mycobacterial lung disease, and lower forced expiratory volume in 1 second and forced vital capacity, compared with patients without bronchiectasis, although there was no difference in smoking intensity and inhaled corticosteroid treatment. Bronchiectasis was significantly associated with higher annual rates of severe and moderate-to-severe acute exacerbations; it was also associated with greater risk of acute exacerbation during follow-up. The severity and progression of bronchiectasis were independent risk factors for acute exacerbation. There were no significant differences in annual decline of lung function according to bronchiectasis status or bronchiectasis progression.

CONCLUSIONS

In patients with asthma, the presence and progression of bronchiectasis were significantly associated with increased risk of moderate-to-severe acute exacerbation, but they were not associated with longitudinal changes in lung function.

Risk factors for the development of bronchiectasis in patients with asthma

Though asthma and bronchiectasis are two different diseases, their coexistence has been demonstrated in many patients. The aim of the present study is to compare the characteristics of asthmatic patients with and without bronchiectasis and to assess risk factors for the development of this condition. Two hundred and twenty-four moderate-severe asthmatic patients were included. The severity of bronchiectasis was assessed by Reiff and FACED parameters. Logistic regression was used to identify independent factors associated with bronchiectasis. Bronchiectasis was identified in 78 asthma patients. In severe asthma patients, its prevalence was 56.9%. Bronchiectasis was defined as mild in81% of patients using modified Reiff criteria and in 74% using FACED criteria. Asthmatic patients with bronchiectasis had decreasing FEV1, FVC and FEV1/FVC (p = 0.002, 0.005 and 0.014 respectively), presented more frequent asthma exacerbations (p < 0.001) and worse asthma control (ACT 21 vs 16pts, p < 0.001). Factors independently associated with bronchiectasis were older age (42-65 years: OR, 3.99; 95% CI 1.60 to 9.95, P = 0.003; ≥ 65 years: OR, 2.91; 95% CI 1.06 to 8.04, P = 0.039), severe asthma grade (OR, 8.91; 95% CI 3.69 to 21.49; P < 0.001) and frequency of asthma exacerbations (OR, 4.43; 95% CI 1.78 to 11.05; P < 0.001). In patients with severe asthma, age of asthma onset (OR, 1.02; 95% CI 1.01 to 1.04; P = 0.015) and asthma exacerbations (OR, 4.88; 95% CI 1.98 to 12.03; P = 0.001) were independently associated with the development of bronchiectasis. The prevalence of bronchiectasis in severe asthmatic patients is high. Age of asthma onset and exacerbations were independent factors associated with the occurrence of bronchiectasis.

Mepolizumab effectiveness in patients with severe eosinophilic asthma and co-presence of bronchiectasis: A real-world retrospective pilot study

BACKGROUND

The association of bronchiectasis (BE) in patients with severe eosinophilic asthma (SEA) is quite frequent. Mepolizumab is a well-recognized treatment for SEA; we aim to evaluate its effectiveness in SEA patients with and without BE in real-life.

METHODS

We performed a single-center retrospective pilot study, including patients with SEA treated with mepolizumab for one year. Asthma control test (ACT), lung function, annual exacerbations rate, oral corticosteroid dosage, FeNO, chronic mucous secretions, blood and sputum eosinophils were recorded at baseline and after 6 and 12 months.

RESULTS

we included 32 patients (mean age: 52.3 ± 10, 59% female). 50% showed co-presence of bronchiectasis, (SEA + BE). Significant improvements were found in ACT [(13.8 ± 4.6 to 20.7 ± 4.1, p = 0.0009) and (13 ± 4.8 to 20.7 ± 4.6, p = 0.0003)], annual exacerbations rate [from 7 (4-12) to 0 (0.00-0.75) and from 8 (4-12) to 0 (0-1), p < 0.0001], and blood eosinophils count [748 cells/μL (400-1250) vs. 84 cells/μL (52.5-100), and from 691 cells/μL (405-798) vs. 60 cells/μL (41-105), p < 0.0001] in SEA and SEA + BE group respectively, already after 6 months of treatment. A reduction in daily oral corticosteroids intake at 12 months was shown [from 15 mg (0-25) to 0 mg (0-0), p = 0.003 and from 8.8 mg (0-25) to 0 mg (0-0) (p = 0.01)] in both SEA and SEA + BE, respectively. Similar results were found, comparing SEA + BE patients based on the severity of bronchiectasis.

CONCLUSIONS

Mepolizumab effectively improves asthma symptoms control, reducing annual exacerbations and corticosteroid intake in all patients with SEA, even in the subgroup with coexisting bronchiectasis, independently of their severity.

The impact of comorbidities on severe asthma

PURPOSE OF REVIEW

Severe asthma is often associated with numerous comorbidities that complicate disease management and affect patient's outcomes. They contribute to poor disease control and mimic asthma symptoms. Although some comorbidities such as obstructive sleep apnea, bronchiectasis, and chronic obstructive pulmonary disease are generally well recognized, many other may remain undiagnosed but may be detected in an expert specialist setting. The management of comorbidities seems to improve asthma outcomes, and optimizes therapy by avoiding overtreatment. The present review provides recent knowledge regarding the most common comorbidities which are associated with severe asthma.

RECENT FINDINGS

Comorbidities are more prevalent in severe asthma than in mild-to-moderate disease or in the general population. They can be grouped into two large domains: the pulmonary domain and the extrapulmonary domain. Pulmonary comorbidities include upper respiratory tract disorders (obstructive sleep apnea, allergic and nonallergic rhinitis, chronic rhinosinusitis, nasal polyposis) and middle/lower respiratory tract disorders (chronic obstructive pulmonary disease, allergic bronchopulmonary aspergillosis and fungal sensitization, bronchiectasis, dysfunctional breathing). Extrapulmonary comorbidities include anxiety, depression, gastro-esophageal reflux disease, obesity, cardiovascular, and metabolic diseases.

SUMMARY

The identification of comorbidities via multidimensional approach is needed to initiate appropriate multidisciplinary management of patients with severe asthma.

Impact of asthma on bronchiectasis severity and risk of exacerbations

OBJECTIVE

Asthma is a frequent comorbidity of bronchiectasis, with possible implications for exacerbation and severity. We investigated the clinical impact of asthma on bronchiectasis in terms of disease severity and exacerbation risk.

METHODS

We collected demographic, clinical, and functional characteristics of patients with a confirmed diagnosis of bronchiectasis. All patients were investigated for concomitant diagnosis of asthma. The Bhalla score was used to assess radiological severity of bronchiectasis, and the Bronchiectasis Severity Index (BSI) was used to assess the clinical severity. Blood and sputum samples were collected to assess blood cell count, erythrocyte sedimentation rate, c-reactive protein, immunological status (IgA, IgE, IgM, IgG, and IgG subclasses), and microbiological analysis.

RESULTS

A total of 106 patients were enrolled in the study; 30.2% had concomitant asthma and were characterized by higher frequency of bronchiectasis exacerbation, despite higher Bhalla score and lower BSI compared to patients without asthma. Pseudomonas aeruginosa was more frequently isolated from the sputum of bronchiectasis patients without asthma. Total serum IgG, IgG1, and IgG3 were lower in patients with asthma. Blood eosinophils and exhaled nitric oxide were higher in patients with associated asthma. The presence of asthma and presence of Pseudomonas in sputum were the only significant determinants of frequent exacerbations in a binary logistic regression analysis.

CONCLUSION

The coexistence of asthma and bronchiectasis is associated with an independent increase in the risk of bronchiectasis exacerbation despite lower radiological and clinical severity indexes. Asthmatic airway inflammation could promote an enhanced "Cole's Cycle" that is responsible for a higher frequency of exacerbations.

Clinical features associated with a doctor-diagnosis of bronchiectasis in the Severe Asthma Network in Italy (SANI) registry

BACKGROUND

Several severe asthma comorbidities have been identified: an emerging one is bronchiectasis. We evaluated the frequency of bronchiectasis on severe asthma in a real-life setting, through the 'Severe Asthma Network Italy' (SANI) registry.

METHODS

SANI registry encompasses demographic, clinical, functional and inflammatory data of Italian severe asthmatics. Data obtained by the enrolled patients were analyzed, focusing the attention on those patients with concomitant clinically relevant bronchiectasis.

RESULTS

About 15.5% patients have bronchiectasis. Bronchiectasis diagnosis was associated with a higher prevalence of chronic rhinosinusitis with nasal polyps (54.6% vs. 38%, p = 0.001) and higher serum IgE levels (673.4 vs. 412.1 kUI/L, p = 0.013). Patients with bronchiectasis had worse asthma control (ACT: 16.7 vs 18.2, p = 0.013), worse quality of life (AQLQ: 4.08 vs. 4.60, p = 0.02) and lower lung function (FEV₁% predicted 67.3 vs. 75.0, p = 0.002). A higher rate of severe asthma exacerbations in the previous 12 months (85.2% vs. 61.5%, p < 0.001) was found in patients with bronchiectasis.

CONCLUSION

severe asthma associated with bronchiectasis represents a particularly severe asthma variant, possibly driven by an eosinophilic endotype. We, therefore, suggest that bronchiectasis should necessarily be assessed in severe asthmatic patients.

How does comorbid bronchiectasis affect asthmatic patients? A meta-analysis

OBJECTIVE

Asthma and bronchiectasis are known to be two distinct diseases with different etiology, pathophysiology, management, and prognosis. However, a high prevalence of bronchiectasis has been reported in patients with severe asthma. Thus, it is of great importance to identify the impact of bronchiectasis on asthmatic patients.Data sources: Databases including PubMed, Embase, Cochrane, Web of Science were searched comprehensively to identify relevant human clinical studies published until February 2020.Study selections: Two investigators (Gelei Lan and Guochao Shi) independently obtained the potentially eligible articles based on their titles and abstracts. When opinions differed between the investigators, discussions were made to reach an agreement. The authors of the included studies were contacted for inquiry when necessary.

RESULTS

Six observational studies with 1004 patients were included in the meta-analysis. The mean prevalence of bronchiectasis in patients with asthma was 35.2% (ranging from 2.2% to 47%). Asthmatic patients with bronchiectasis were older, had a longer disease duration, exhibited greater severity, and showed more frequent exacerbations and hospitalization, and poorer lung function, compared with the patients without bronchiectasis.

CONCLUSION

Despite of the heterogeneity between included studies and detectable publication bias, this meta-analysis demonstrated the impact of comorbid bronchiectasis on asthmatic patients. Thus, coexistence of bronchiectasis should be considered a clinical phenotype of asthma, which may have associations with exacerbation and hospitalization.

The Link between Asthma and Bronchiectasis: State of the Art

The nonrecognition of asthma-associated comorbidities is often responsible for the therapeutic failure and the worsening of symptoms, and it is associated with frequent exacerbations, higher disease severity, and increased health costs. Bronchiectasis, one of the most frequent asthma-associated comorbidities, can increase airways inflammation and exacerbation rates and cause respiratory functional impairment. The aim of this article is to review the interactions between bronchiectasis and asthma, in order to better identify patients in the overlap between the 2 diseases and to select an "ad hoc" therapy. A literature search on PubMed/MEDLINE was performed using the following search terms: bronchiectasis in asthma, the association between asthma and bronchiectasis, comorbidities in asthma, and severe asthma. This review analyzed the following items: incorrect or underestimated diagnosis of asthma and bronchiectasis, prevalence of bronchiectasis in asthma, the impact of bronchiectasis in asthma, radiological imaging features of the 2 diseases, etiopathogenesis, and common causes (such as gastroesophageal reflux disease, immune deficits, chronic rhinosinusitis and allergic bronchopulmonary aspergillosis, and treatment of asthma and bronchiectasis). The concomitant presence of bronchiectasis and asthma should be suspected and investigated in patients with severe asthma, frequent exacerbations, and not responding to standard therapy. This clinical phenotype, characterized by a more severe disease, worse outcomes, and functional decline, must be readily recognized in order to choose the most appropriate therapeutic approach, able to potentially improve the management of bronchial asthma, to prevent the onset of exacerbations as well the functional decline, and to reduce health costs.

Trend from 2001 to 2015 in the prevalence of bronchiectasis among patients hospitalized for asthma and effect of bronchiectasis on the in-hospital mortality

OBJECTIVE

We aimed to analyze the prevalence of bronchiectasis among patients hospitalized with asthma and to assess the effect of suffering bronchiectasis on in-hospital mortality (IHM).

METHODS

We used the Spanish National Hospital Discharge Database from 2000 to 2015 to evaluate all admissions for asthma exacerbation as the main diagnosis, dividing them according to the presence or absence of associated bronchiectasis. We assessed time trends in the prevalence, clinical characteristics, length of hospital stay, costs, and IHM.

RESULTS

Of 342,644 admissions for asthma, 10,377 (3.02%) had bronchiectasis. The prevalence of bronchiectasis increased from 2.16% in 2001 to 4.47% in 2015 (p < 0.001). Compared to patients without bronchiectasis, those with bronchiectasis were more frequently women (77.06% vs. 22.94%, p < 0.001), were older (68.87 ± 15.16 vs. 47.05 ± 30.66 years, p < 0.001) and had more comorbid conditions (Charlson comorbidity index ≥ 2: 9.45% vs. 6.58%, p < 0.001). Pseudomonas (8% vs. 0.66%, p < 0.001), Aspergillus (0.93% vs. 0.15%, p < 0.001), eosinophilia (0.29% vs. 0.17%, p = 0.005) and IHM (2.07% vs. 1.2%, p < 0.001) were more frequent in patients with bronchiectasis. After multivariable adjustments, IHM was not associated with bronchiectasis. The presence of bronchiectasis was associated with a longer length of hospital stay and higher costs.

CONCLUSIONS

Admissions for asthma with bronchiectasis have increased over time in Spain. In our investigation, the presence of bronchiectasis was not associated with higher IHM, but it increased the length of hospital stay and costs.

Bronchiectasis in severe asthma: a distinct phenotype?

PURPOSE OF REVIEW

The presence of bronchiectasis has been described in about 30% of severe asthma patients. The coexistence of these two respiratory conditions poses new challenges from both clinical and research perspectives. We will review the available literature on this topic to discuss the existance of a specific clinical phenotype of asthma.

RECENT FINDINGS

Despite the paucity of literature, the presence of bronchiectasis with severe asthma is associated with older age, chronic bronchial expectoration, rhinosinusitis, more frequent and severe exacerbations, neutrophilic airway inflammation and poor response to usual treatment. Conversely, asthma features are also described in bronchiectasis patients even in the absence of an appropriate diagnosis of asthma. In both cases, there is some evidence supporting the use of bronchodilators, macrolides and respiratory physiotherapy, while the use of inhaled corticosteroids and antibiotics is controversial.

SUMMARY

Based on available evidence on the association between (severe) asthma and bronchiectasis, its pathophysiology, certain clinical aspects and prognosis are largely unclear. Although specific management appears to be required in most cases, in our opinion there is still insufficient evidence to consider it a distinct phenotype of severe asthma. Hopefully, future research will shed more light on this topic and define the best therapeutic approach.

Managing comorbid conditions in severe asthma

Asthma care has increasingly focused on personalised management for severe asthma, and recognition of the role and importance of comorbid conditions has increased. Severe asthma can be crippling; associated comorbid conditions often play a key role in the significant disease morbidity and frequently contribute to a severe and difficult-to-treat asthma phenotype. Comorbid conditions can be broadly grouped as being either airway-related or airway-unrelated. Airway-related comorbid conditions with the greatest impact are allergic rhinitis, chronic rhinosinusitis, vocal cord dysfunction, lung fungal sensitisation and underlying structural lung disease. The most important airway-unrelated comorbid conditions are obesity, obstructive sleep apnoea, gastro-oesophageal reflux disease and anxiety and depression. A diagnostic and management algorithm for comorbid conditions in severe asthma is outlined. It concentrates initially on the group with common comorbid conditions that can be managed in primary care. If asthma remains troublesome, emphasis can shift to identifying uncommon and more complex factors. The algorithm allows for personalised diagnostic and management pathways to be implemented. Personalised diagnosis and management of comorbid conditions are essential to achieving effective and improved outcomes for patients with severe asthma.

Severe uncontrolled asthma with bronchiectasis: a pilot study of an emerging phenotype that responds to mepolizumab

Background

Asthma and bronchiectasis are different conditions that frequently coexist. The prevalence of bronchiectasis rises considerably in subjects with severe asthma (25%–51%).

Objective

We evaluated the clinical and biological efficacy of mepolizumab on our pilot population of severe uncontrolled asthmatics with bronchiectasis not related to other pathologies.

Patients and methods

Four patients with severe uncontrolled asthma and diagnosed as bronchiectasis were recruited and started biological treatment with mepolizumab. Standard investigations were performed in all four patients at baseline (T0), after 3 months (T1) and after 1 year (T2) of treatment.

Results

After 1 year (T2) of therapy with mepolizumab, patients showed a significant increment of asthma control test value (12±1.1 vs 24.5±0.3, P<0.01), a reduction of the number of exacerbations/year (5±0.7 vs 0.75±0.75, P<0.01), an increase of pre-bronchodilator FEV₁ (1,680±500 vs 1,860±550 mL, P<0.01) and a reduction of eosinophils in blood (0.75±0.14 vs 0.12±0.02 cells/µL, P<0.01), in the sputum (9.6%±2.1% vs 5.6%±2.7%, P<0.05) and in nasal cytology (++ vs +).

Conclusion

The efficacy of mepolizumab in terms of reduction of inflammation and increase of control that we observed in our patients might suggest that targeting the IL-5 in severe eosinophilic asthma with bronchiectasis may be a good therapeutic strategy.

Severe asthma and bronchiectasis

Objective: The aim of our study was to determine the tomographic findings and prevalence of bronchiectasis in our population of patients with severe asthma, and to identify factors associated with the presence of bronchiectasis in these patients. Materials and methods: We retrospectively collected data from the medical histories of patients referred to the asthma unit of our hospital, with a diagnosis of severe asthma between 2015 and 2017. Patients with ABPA, cystic fibrosis, immunodeficiency or systemic disease were excluded. High-resolution thorax-computed tomodensitography (HRCT) was performed in all patients. A standardized protocol was applied in data collection. Results: A total of 108 patients comprising 50 men (46%) and 58 women (54%) were included in the study. Of the 108 patients, 59 (55%) had at least one abnormality detected by HRCT, the most commonly reported abnormalities being bronchiectasis (35%), bronchial wall thickening (33%), emphysema (7%), atelectasis area (6%), mosaic attenuation due to air trapping (4%), and "tree in bud" image (2%). Subjects with bronchiectasis were older (p = 0.001), had a longer asthma history (p = 0.048), had poorer pulmonary function tests with lower FVC (p = 0.031), had more severe bronchial obstruction with lower FEV1 (p = 0.008) and had lower FEV1/FVC (p = 0.003). They also experienced more frequent hospitalizations in the previous year (p = 0.019) and received treatment with omalizumab more frequently (p = 0.049). Plasma eosinophil count and IgE levels were comparable in both groups. In the multivariate analysis, the presence of bronchiectasis was associated with ages older than 40 (OR: 8.3; 95% CI: 1.7-41.2) and chronic airflow obstruction (OR: 5.4; 95% CI: 1.9-15.3). Conclusions: We found that in patients with severe asthma, the prevalence of bronchiectasis is high and that bronchiectasis is associated with a longer asthma history, greater severity and, more importantly, chronic airflow obstruction. These findings are still insufficient evidence to considere features of asthma-bronchiectasis overlap syndrome, a distinct phenotype of severe asthma, but bronchiectasis is a frequent phenomenon leading to a more severe disease with frequent exacerbations. The performance of thorax HRCT on patients with severe asthma can help to evaluate management strategies for the disease in order to improve treatment and prognosis.

The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions

Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.

The MEGA Project: A Study of the Mechanisms Involved in the Genesis and Disease Course of Asthma. Asthma Cohort Creation and Long-Term Follow-Up

The general aim of this study is to create a cohort of asthma patients with varying grades of severity in order to gain greater insight into the mechanisms underlying the genesis and course of this disease. The specific objectives focus on various studies, including imaging, lung function, inflammation, and bronchial hyperresponsiveness, to determine the relevant events that characterize the asthma population, the long-term parameters that can determine changes in the severity of patients, and the treatments that influence disease progression. The study will also seek to identify the causes of exacerbations and how this affects the course of the disease. Patients will be contacted via the outpatient clinics of the 8 participating institutions under the auspices of the Spanish Respiratory Diseases Networking System (CIBER). In the inclusion visit, a standardized clinical history will be obtained, a clinical examination, including blood pressure, body mass index, complete respiratory function tests, and FENO will be performed, and the Asthma Control Test (ACT), Morisky-Green test, Asthma Quality of Life Questionnaire (Mini AQLQ), the Sino-Nasal Outcome Test 22 (SNOT-22), and the Hospital Anxiety and Depression scale (HADS) will be administered. A specific electronic database has been designed for data collection. Exhaled breath condensate, urine and blood samples will also be collected. Non-specific bronchial hyperresponsiveness testing with methacholine will be performed and an induced sputum sample will be collected at the beginning of the study and every 24 months. A skin prick test for airborne allergens and a chest CT will be performed at the beginning of the study and repeated every 5 years.

Factors associated with bronchiectasis in patients with uncontrolled asthma; the NOPES score: a study in 398 patients

Background

Some studies have reported a high prevalence of bronchiectasis in patients with uncontrolled asthma, but the factors associated with this condition are unknown. The objective of this study was to determine the prevalence of bronchiectasis in uncontrolled moderate-to-severe asthma and to identify risk factors and their correlation with bronchiectasis in these patients.

Methods

This is a prospective study of data from consecutive patients with uncontrolled moderate-to-severe asthma. Diagnosis of bronchiectasis was based on high-resolution computed tomography. A prognostic score was developed using a logistic regression model, which was used to determine the factors associated with bronchiectasis.

Results

A total of 398 patients (60% with severe asthma) were included. The prevalence of bronchiectasis was 28.4%. The presence of bronchiectasis was associated with a higher frequency of chronic expectoration (OR, 2.95; 95% CI, 1.49–5.84; p = 0.002), greater severity of asthma (OR, 2.43; 95% CI, 1.29–4.57; p = 0.006), at least one previous episode of pneumonia (OR, 2.42; 95% CI, 1.03–5.69; p = 0.044), and lower levels of FeNO (OR, 0.98; 95% CI, 0.97–0.99; p = 0.016). The NOPES score was developed on the basis of these variables (FeNO[cut off point 20.5 ppb], Pneumonia, Expectoration and asthma Severity), and it ranges from 0 to 4 points, where 0 means “no risk” and 4 corresponds to “high risk”. The NOPES score yielded an AUC-ROC of 70% for the diagnosis of bronchiectasis, with a specificity of 95%.

Conclusions

Almost a third of the patients with uncontrolled moderate-to-severe asthma had bronchiectasis. Bronchiectasis was related to the severity of asthma, the presence of chronic expectoration, a previous history of pneumonia, and lower levels of FeNO. The NOPES score is an easy-to-use scoring system with a high prognostic value for bronchiectasis in patients with uncontrolled moderate-to-severe asthma.

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

Although a minority of asthma patients suffer from severe asthma, they represent a major clinical challenge in terms of poor symptom control despite high-dose treatment, risk of exacerbations, and side effects. Novel biological treatments may benefit patients with severe asthma, but are expensive, and are only effective in appropriately targeted patients. In some patients, symptoms are driven by other factors than asthma, and all patients with suspected severe asthma ('difficult asthma') should undergo systematic assessment, in order to differentiate between true severe asthma, and 'difficult-to-treat' patients, in whom poor control is related to factors such as poor adherence or co-morbidities. The Nordic Consensus Statement on severe asthma was developed by the Nordic Severe Asthma Network, consisting of members from Norway, Sweden, Finland, Denmark, Iceland and Estonia, including representatives from the respective national respiratory scientific societies with the aim to provide an overview and recommendations regarding the diagnosis, systematic assessment and management of severe asthma. Furthermore, the Consensus Statement proposes recommendations for the organization of severe asthma management in primary, secondary, and tertiary care.

Bronchiectasis in severe asthma: Clinical features and outcomes

BACKGROUND

Bronchiectasis is increasingly being identified in patients with severe asthma and could contribute to disease severity.

OBJECTIVE

To determine the prevalence of bronchiectasis in a population of patients with severe asthma and to better characterize the clinical features of these patients and their outcomes.

METHODS

We retrospectively reviewed the medical files of 184 subjects with confirmed severe asthma who had undergone high-resolution thoracic computed tomography and compared the characteristics and outcomes of subjects with and without bronchiectasis.

RESULTS

Bronchiectasis was identified in 86 patients (47%). These patients had concomitant hypersensitivity to nonsteroidal anti-inflammatory drugs (odds ratio [OR] 2.24, 95% confidence interval [CI] 1.00-5.03) and gastroesophageal reflux disease (OR 1.89, 95% CI 1.05-3.41) more frequently than subjects without bronchiectasis, but had less atopic dermatitis (OR 0.188, 95% CI 0.04-0.88). Subjects with bronchiectasis were more frequently hospitalized for asthma exacerbations (OR 2.09, 95% CI 1.08-4.05) and had higher blood eosinophil levels (464 vs 338; P = .005) than subjects without bronchiectasis.

CONCLUSION

Our study suggests that in subjects with severe asthma, the presence of bronchiectasis is associated with more frequent hospitalizations, concomitant gastroesophageal reflux disease, hypersensitivity to nonsteroidal anti-inflammatory drugs, and higher blood eosinophil counts. Bronchiectasis could represent an additional phenotypic feature of severe eosinophilic asthma.

An Official American Thoracic Society Workshop Report: Evaluation and Management of Asthma in the Elderly

Asthma in the elderly (>65 yr old) is common and associated with higher morbidity and mortality than asthma in younger patients. The poor outcomes in this group are due, in part, to underdiagnosis and undertreatment. There are a variety of factors related to aging itself that affect the presentation of asthma in the elderly and influence diagnosis and management. Structural changes in the aging lung superimposed on structural changes due to asthma itself can worsen the disease and physiologic function. Changes in the aging immune system influence the cellular composition and function in asthmatic airways. These processes and differences from younger individuals with asthma are not well understood. Phenotypes of asthma in the elderly have not been clearly delineated, but it is likely that age of onset and overlap with chronic obstructive pulmonary disease impact disease characteristics. Physiologic tests and biomarkers used to diagnose and follow asthma in the elderly are generally similar to testing in younger individuals; however, whether they should be modified in aging has not been established. Confounding influences, such as comorbidities (increasing the risk of polypharmacy), impaired cognition and motor skills, psychosocial effects of aging, and age-related adverse effects of medications, impact both diagnosis and treatment of asthma in the elderly. Future efforts to understand asthma in the elderly must include geriatric-specific methodology to diagnose, characterize, monitor, and treat their disease.

The therapeutic potential of CFTR modulators for COPD and other airway diseases

Airways diseases, especially chronic obstructive pulmonary disease (COPD) and asthma, are common causes of morbidity and mortality worldwide. There is an ongoing unmet need for novel and effective therapies. There is an established pathophysiological link and phenotypic similarity between the chronic bronchitis phenotype of COPD and cystic fibrosis (CF). New evidence suggests that CFTR dysfunction may play a role in other common airways diseases such as COPD, non-atopic asthma and non-CF bronchiectasis. Newly approved and investigational drugs that target both mutant and wild-type CFTR channels have provided a new treatment opportunity addressing the mucus defect in pulmonary diseases that share the same pathophysiology with CF.

Investigation of bronchiectasis in severe uncontrolled asthma

INTRODUCTION

The presence of bronchiectasis in patients with asthma varies in different reports, while a clear aetiological relation has not been precisely established.

OBJECTIVES

To investigate the presence of bronchiectasis in patients with severe uncontrolled asthma and examine whether they contribute to the severity of asthma.

METHODS

Patients with severe asthma were prospectively recruited. HRCT of the chest was performed to identify and grade bronchiectasis using the 'Smith' radiology scale. Investigation of the underlying cause was carried out for patients with bronchiectasis in order to exclude aetiologies other than asthma. The Statistical Package for the Social Sciences (SPSS), version 21, was used.

RESULTS

Forty patients were studied, 28 women, mean age (±SD) 57.9 years (±12.4). Mean ACT score was 14.2(±4.9). Main symptoms were: wheezing (95%), cough (92%), dysponea (92%) and sputum production (72%). Mean duration of asthma was 16.5(±11.5) years, exacerbations: 4.4(±2.7)/year. In 27 patients (67.5%) bronchiectasis was diagnosed. In nine patients (22.5%) pathogens were cultured in sputum (mainly Pseudomonas aeruginosa, Haemophilus influenzae). Patients with sputum production and pathogens in sputum cultures had a higher Smith score compared to those without expectoration and without pathogens, respectively (P = .005, P < .0001). No correlation was found between the extent of bronchiectasis and lung function. The radiological severity of bronchiectasis was correlated with the antibiotic courses/year (P = .002).

CONCLUSION

Bronchiectasis is common in patients with severe asthma. Sputum production and pathogen isolation in sputum may indicate the presence of bronchiectasis which seems to contribute to the severity of asthma.

A morphologic study of the airway structure abnormalities in patients with asthma by high-resolution computed tomography

BACKGROUND

Airway structure changes, termed as airway remodeling, are common in asthma patients due to chronic inflammation, which can be assessed by high-resolution computed tomography (HRCT). Considering the controversial conclusions in the correlation of morphologic abnormalities with clinical feature and outcome, we aimed to further specify and evaluate the structural abnormalities of Chinese asthmatics by HRCT.

METHODS

From August 2012 to February 2015, outpatients with asthma were recruited consecutively in the Asthma Center of West China Hospital, Sichuan University. Standard HRCT and pulmonary function test (PFT) were performed to collect information of bronchial wall thickening, bronchial dilatation, mucus impaction, emphysema, mosaic perfusion, atelectasis, and spirometric parameters. We reported the incidence of each structural abnormality in HRCT and compared it among different asthmatic severities.

RESULTS

A total of 123 asthmatics were enrolled, among which 84 (68.3%) were female and 39 (31.7%) were male. At least one structural abnormality was detected by HRCT in 85.4% asthmatics, and the incidence of bronchial wall thickening, bronchial dilatation, mucus impaction, emphysema, mosaic perfusion, and atelectasis was 57.7%, 51.2%, 22%, 24.4%, 5.7% and 1.6%, respectively. The incidences of bronchial wall thickening, bronchial dilation and emphysema were significantly increased by asthma severity (P<0.05), while incidences of mucus impaction (26/27, 96.30%), mosaic perfusion (6/7, 85.71%) and atelectasis (2/2, 100%) were mainly found in severe asthma. We found a longer asthma history (28.13±18.55 years, P<0.001, P=0.003), older age (51.30±10.70 years, P=0.022, P=0.006) and lower predicted percentage of forced expiratory volume in one second (FEV₁%) (41.97±15.19, P<0.001, P<0.001) and ratio of forced expiratory volume to forced vital capacity (FEV₁/FVC) (48.01±9.55, P<0.001, P<0.001) in patients with severe bronchial dilation compared with those in none and mild bronchial dilation. A negative correlation was also found between the extent of bronchial dilation and FEV₁% as well as FEV₁/FVC (r=-0.359, P=0.004; r=-0.266, P=0.035, respectively).

CONCLUSIONS

The incidences of structural abnormalities detected by HRCT are fairly high in Chinese asthma populations, especially the bronchial wall thickening and bronchial dilation, which are significantly increased in severe asthma, and are potential risk factors of pulmonary function decline in asthmatics.

Chronic suppurative lung disease in adults

Chronic suppurative lung disease (CSLD), characterized by a bronchiectasis-like syndrome in the absence of bronchial dilatation, is well described in the pediatric literature. In some patients, it may be a precursor of bronchiectasis. In adults, this syndrome has not been well described. We present four adult patients without obvious causative exposures who presented with prolonged cough and purulent sputum. Sputum cultures revealed a variety of Gram negative bacteria, fungi and mycobacteria. High resolution CT scanning did not reveal bronchiectasis. Evaluation revealed underlying causes including immunodeficiency in two, and Mycobacterium avium infection. One patient subsequently developed bronchiectasis. All patients improved with therapy. CSLD occurs in adults and has characteristics that distinguish it from typical chronic bronchitis. These include the lack of causative environmental exposures and infection with unusual pathogens. Evaluation and treatment of these patients similar to bronchiectasis patients may lead to clinical improvement.

Asthma and bronchiectasis exacerbation

Bronchiectasis and asthma are common respiratory diseases worldwide. However, the influence of asthma on bronchiectasis remains unclear. The objective of this study is to analyse the effects of asthma on bronchiectasis exacerbation.Data from inpatients diagnosed with bronchiectasis with or without asthma at Shanghai Pulmonary Hospital (Shanghai, China) between January 2013 and December 2014 were retrospectively collected and analysed. 249 patients with only bronchiectasis and 214 patients with both bronchiectasis and asthma were included in the study. Follow-up records were used to evaluate the effect of asthma on bronchiectasis exacerbation.The variables found to be independently associated with bronchiectasis exacerbations were age (OR 1.07, 95% CI 1.03-1.11; p<0.001), duration of symptoms (OR 1.06, 95% CI 1.03-1.09; p<0.001), the presence of asthma (OR 2.6, 95% CI 1.15-5.88; p=0.021), forced expiratory volume in 1 s <50% predicted (OR 4.03, 95% CI 1.75-9.26; p=0.001), isolation of Pseudomonas aeruginosa in sputum (OR 2.41, 95% CI 1.00-5.79; p=0.05) and lung lesion extension to more than two lobes (OR 2.73, 95% CI 1.16-6.45; p=0.022).The existence of asthma was associated with an independent increase in risk of bronchiectasis exacerbation.

Acquired Cystic Fibrosis Transmembrane Conductance Regulator Dysfunction in Chronic Bronchitis and Other Diseases of Mucus Clearance

Chronic obstructive pulmonary disease (COPD) is a major public health problem. No therapies alter the natural history of the disease. Chronic bronchitis is perhaps the most clinically troublesome phenotype. Emerging data strongly suggest that cigarette smoke and its components can lead to acquired cystic fibrosis transmembrane conductance regulator (CFTR) dysfunction. Findings in vitro, in animal models, and in smokers with and without COPD also show acquired CFTR dysfunction, which is associated with chronic bronchitis. This abnormality is also present in extrapulmonary organs, suggesting that CFTR dysfunction may contribute to smoking-related systemic diseases.

Novel imaging approaches in adult asthma and their clinical potential

Currently, imaging in asthma is confined to chest radiography and CT. The emergence of new imaging techniques and tremendous improvement of existing imaging methods, primarily due to technological advancement, has completely changed its research and clinical prospects. In research, imaging in asthma is now being employed to provide quantitative assessment of morphology, function and pathogenic processes at the molecular level. The unique ability of imaging for non-invasive, repeated, quantitative, and in vivo assessment of structure and function in asthma could lead to identification of 'imaging biomarkers' with potential as outcome measures in future clinical trials. Emerging imaging techniques and their utility in the research and clinical setting is discussed in this review.

The effects of bronchiectasis on asthma exacerbation

BACKGROUND

Bronchiectasis and asthma are different in many respects, but some patients have both conditions. Studies assessing the effect of bronchiectasis on asthma exacerbation are rare. The aim of this study is to investigate the effect of bronchiectasis on asthma exacerbation.

METHODS

We enrolled 2,270 asthma patients who were followed up in our hospital. Fifty patients had bronchiectasis and asthma. We selected fifty age- and sex-matched controls from the 2,220 asthma patients without bronchiectasis, and assessed asthma exacerbation and its severity based on the annual incidence of total asthma exacerbation, annual prevalence of steroid use, and frequency of emergency room visits and hospitalizations due to asthma exacerbation in each group.

RESULTS

Fifty patients (2.2%) had bronchiectasis and asthma. The annual incidence of asthma exacerbation was higher in patients with asthma and bronchiectasis than in patients with asthma alone (1.08±1.68 vs. 0.35±0.42, p=0.004). The annual prevalence of steroid use (0.9±1.54 vs. 0.26±0.36, p=0.006) and the frequency of emergency room visits (0.46±0.84 vs. 0.02±0.13, p=0.001) due to asthma exacerbation were also higher in patients with asthma and bronchiectasis than in patients with asthma alone.

CONCLUSION

Bronchiectasis is associated with difficult asthma control.

Diagnosis and management of asthma in the elderly

Bronchial asthma is one of the most common chronic diseases worldwide, and by definition not expected to recover with aging. However, the concept that asthma can affect older individuals has been largely denied in the past. In clinical practice, asthma that occurs in the most advanced ages is often diagnosed as COPD, thus leading to undertreatment or improper treatment. The heterogeneity of clinical and functional presentation of geriatric asthma, including the partial loss of reversibility and of the allergic component, contributes to this misconception. A large body of evidence has accumulated demonstrating that the prevalence of asthma in the most advanced ages is similar to that in younger ages. The frequent coexistence of comorbid conditions in older patients compared to younger asthmatics, together with age-associated changes of the human lung, may render the management of asthma a complicated task. The article addresses the main issues related to the diagnosis and treatment of asthma in the geriatric age.

Prevalence of bronchiectasis in asthma according to oral steroid requirement: influence of immunoglobulin levels

PURPOSE

To establish the prevalence of bronchiectasis in asthma in relation to patients' oral corticosteroid requirements and to explore whether the increased risk is due to blood immunoglobulin (Ig) concentration.

METHODS

Case-control cross-sectional study, including 100 sex- and age-matched patients, 50 with non-steroid-dependent asthma (NSDA) and 50 with steroid-dependent asthma (SDA).

STUDY PROTOCOL

(a) measurement of Ig and gG subclass concentration; (b) forced spirometry; and (c) high-resolution thoracic computed tomography. When bronchiectasis was detected, a specific etiological protocol was applied to establish its etiology.

RESULTS

The overall prevalence of bronchiectasis was 12/50 in the SDA group and 6/50 in the NSDA group (p = ns). The etiology was documented in six patients (four NSDA and two SDA). After excluding these patients, the prevalence of bronchiectasis was 20% (10/50) in the SDA group and 2/50 (4%) in the NSDA group (P < 0.05). Patients with asthma-associated bronchiectasis presented lower FEV1 values than patients without bronchiectasis, but the levels of Ig and subclasses of IgG did not present differences.

CONCLUSIONS

Steroid-dependent asthma seems to be associated with a greater risk of developing bronchiectasis than non-steroid-dependent asthma. This is probably due to the disease itself rather than to other influencing factors such as immunoglobulin levels.

Gastroesophageal reflux in bronchiectasis and the effect of anti-reflux treatment

BACKGROUND

Bronchiectasis is a progressive and fatal disease despite the available treatment regimens. Gastroesophageal reflux (GER) may play an important role in the progression of bronchiectasis. However, active anti-reflux intervention such as Stretta radiofrequency (SRF) and/or laparoscopic fundoplication (LF) have rarely been used to treat Bronchiectasis.

CASE PRESENTATION

Seven patients' clinical outcomes for treating GER-related deteriorated bronchiectasis were retrospective reviewed. All patients were treated by SRF and/or LF, and had follow-up periods ranging from one to five years. Typical GER symptoms, respiratory symptoms, medication consumption and general health status were assessed during the follow-ups. At the latest follow-up all patients were alive. The typical GER symptoms disappeared in five people and were significantly improved in the other two. Two had complete remissions of both respiratory symptoms and bronchiectasis exacerbations; four had significantly improved respiratory symptoms to mild/moderate degrees as well as reduced or zero bronchiectasis exacerbations, which allowed them to resume the physical and social functions; one's respiratory symptoms and bronchiectasis exacerbations were not much improved, yet she was in stable condition and satisfied with the results.

CONCLUSIONS

Potentially, GER plays an important role in some patients with bronchiectasis, and active anti-reflux treatments can be beneficial. Future clinical studies are suggested to clarify GER's role in bronchiectasis and to further determine whether anti-reflux interventions for GER can improve the outcomes of patients with bronchiectasis.

The overlap of bronchiectasis and immunodeficiency with asthma

Bronchiectasis should be considered as a differential diagnosis for, as well as a comorbidity in, patients with asthma, especially severe or long-standing asthma. Chronic airway inflammation is thought to be the primary cause, as with chronic or recurrent pulmonary infection and autoimmune conditions that involve the airways. Consequently, immunodeficiencies with associated increased susceptibility to respiratory tract infections or chronic inflammatory airways also increase the risk of developing bronchiectasis. Chronic bronchiectasis is associated with impaired mucociliary clearance and increased bronchial secretions, leading to airway obstruction and airflow limitation, which can lead to exacerbation of underlying asthma or increased asthma symptoms.

Effect of radiological extent and severity of bronchiectasis on pulmonary function

Background

The aim of this study was to ascertain the effect of the extent and severity of bronchiectasis as determined with high-resolution computed tomography (HRCT) on lung function in patients with pure bronchiectasis, bronchiectasis and asthma, and bronchiectasis and chronic obstructive pulmonary disease (COPD).

Methods

One hundred nineteen patients (71 with pure bronchiectasis, 25 asthmatic patients with bronchiectasis, and 23 COPD patients with bronchiectasis) underwent HRCT and pulmonary function tests. Computed tomography features were scored by the consensus of 2 radiologists.

Results

There were no statistically significant differences among the 3 patient groups regarding the extent of bronchiectasis, bronchial dilatation degree, bronchial wall thickening, decreased attenuation in the lung parenchyma, or presence of mucus in the large and small airways. In the pure bronchiectasis group, a negative correlation was found between forced vital capacity (FVC) % of predicted, forced expiratory volume in 1 sec (FEV₁) % of predicted, the FEV₁/FVC ratio and the extent of bronchiectasis, bronchial wall thickening, bronchial wall dilatation, and decreased attenuation. At multivariate analysis the main morphologic changes associated with impairment of FVC and FEV₁ were the extent of bronchiectasis and a decreased attenuation in the lung parenchyma. The decrease in the FEV₁/FVC ratio was associated with bronchial wall dilatation. No correlation was found between morphologic changes and indices of pulmonary function in the asthma and COPD patients.

Conclusions

Morphologic changes associated with bronchiectasis do not influence lung function in patients with asthma and COPD directly, although they do play a role in impairing pulmonary function in patients with bronchiectasis alone.

Neomacrolides in the treatment of patients with severe asthma and/or bronchiectasis: a retrospective observational study

RATIONALE

Previous studies have demonstrated that long-term low-dose macrolides are efficacious in cystic fibrosis (CF) and diffuse panbronchiolitis, two chronic neutrophilic airway diseases.

AIMS

The aims of this study were to evaluate the efficacy and safety of low-dose neomacrolides as add-on therapy in patients with severe asthma and/or bronchiectasis and to identify predictors for therapeutic response.

METHODS

In a retrospective observational cohort study, we examined 131 adult, non-CF patients with severe asthma and/or bronchiectasis, receiving low-dose neomacrolides as add-on treatment. Pulmonary function tests and symptom scores were assessed at baseline and after 3 to 8 weeks of therapy.

RESULTS

After 3-8 weeks of treatment with low-dose neomacrolides, 108 patients were available for evaluation. In asthma patients (n = 47), pulmonary function tests and symptom scores improved significantly. Responders (≥7% forced expiratory volume in one second predicted [FEV(1)%] improvement) were older (55 vs. 47 years; p = 0.042) and had a longer duration of asthma (29 vs. 9 years; p = 0.052). In patients with bronchiectasis only (n = 61), symptom scores improved significantly. Responders (≥60% symptom score improvement) were older (61 vs. 53 years; p = 0.004), more frequently male (53% vs. 27%; p = 0.043), and there was a nonsignificant trend towards higher high-resolution CT (HRCT) score for bronchiectasis in responders (6.4 vs. 4.6; p = 0.053). In multivariate logistic regression analysis, age and male gender were independent predictors for improvement in this group.

CONCLUSION

The results of this retrospective study suggest that neomacrolides may be useful as an add-on therapy in patients with severe asthma and/or bronchiectasis. Older age may predict good response in patients with severe asthma, whereas older age, male gender and a higher HRCT score for bronchiectasis may predict therapeutic response in patients with bronchiectasis only. Prospective controlled trials of neomacrolides in patients with severe asthma are needed to confirm these observations.

Clinical, radiologic, and functional evaluation of 304 patients with bronchiectasis

BACKGROUND

Bronchiectasis continues to be one of the major causes of morbidity and mortality in developing countries, with a probably underestimated higher prevalence than in developed countries.

OBJECTIVE

To assess the clinical profile of adult patients with bronchiectasis.

METHODS

We retrospectively reviewed the clinical, radiologic, and physiologic findings of 304 patients with bronchiectasis confirmed by high-resolution computed tomography.

RESULTS

Mean age of participants (45.7% males, 54.3% females) was 56 ± 25 years and 65.8% of them were lifetime non-smokers. Most common identified causes of bronchiectasis were childhood disease (22.7%), tuberculosis (15.5%), and pneumonia (11.5%). The predominant symptoms were productive cough (83.6%), dyspnea (72%), and hemoptysis (21.1%). The most common findings on chest examination were crackles (71.1%) and rhonchi (28.3%). Types of bronchiectasis were cylindrical in 47%, varicose in 9.9%, cystic in 45.1%, and multiple types in 24.3%. Involvement was multilobar in 75.3% and bilateral in 62.5%. Of 274 patients, 20.8% displayed normal pulmonary function test results, whereas 47.4%, 8% and 23.7% showed obstructive, restrictive, and mixed pattern, respectively. Patients with cystic disease had a higher frequency of hemoptysis (42%) and a greater degree of functional impairment, compared to other types.

CONCLUSION

In patients with bronchiectasis from southern Turkey, generally presenting with recurrent productive cough, hemoptysis, dyspnea, and persistent bibasilar rales, the etiology remains mainly idiopathic. Post-infectious bronchial destruction is one of the major identified underlying pathological processes. The clinical picture and the deterioration of the pulmonary function test might be more severe in patients with cystic type bronchiectasis.

Should atopy be assessed in elderly patients with respiratory symptoms suggestive of asthma?

Aging is associated with modifications of the immune system and this could contribute to a reduced prevalence of allergic disease in the elderly. Atopy has rarely been considered in the clinical assessment of the geriatric respiratory patient. This article is a review of the available literature assessing the impact of age on atopy in the asthmatic patient. In the majority of papers, we found a lower prevalence of atopy in the most advanced ages, both in healthy subjects and in individuals affected by allergic respiratory diseases. No large, longitudinal studies performed in the general population have been conducted to confirm this observation. Although available data seem to favor the decline of allergen sensitization with age, the prevalence of allergic sensitizations in the elderly population with respiratory symptoms is substantial enough to warrant evaluation of the atopic condition. For this reason, the evaluation of the atopic condition in the geriatric patient is recommended. The role of atopy as regards diagnosis, therapy and prognosis of asthma in the elderly is addressed.

Asthma in the elderly

Asthma is frequent among older people. Nevertheless, under-recognition, misdiagnosis and under-treatment are still relevant issues. We aim to provide an overview of epidemiology of asthma in the elderly, and a thorough description of its pathology and clinical presentation, with special emphasis on the distinction of late versus early-onset asthma. We also discuss selected treatment topics of special interest for older patients, such as compliance with therapy and ability with the inhalers, which are basic to the success of the prescribed therapy. Finally, we suggest that multidimensional geriatric assessment of older asthmatics could help in tailoring the therapy to the individual needs and capacity.

Qualitative analysis of high-resolution CT scans in severe asthma

BACKGROUND

High-resolution CT (HRCT) scanning is part of the management of severe asthma, but its application varies between centers. We sought to describe the HRCT scan abnormalities of a large severe asthma cohort and to determine the utility of clinical features to direct the use of HRCT scanning in this group of patients.

METHODS

Subjects attending our Difficult Asthma Clinic (DAC) between February 2000 and November 2006 (n = 463) were extensively re-characterized and 185 underwent HRCT scan. The HRCT scans were analyzed qualitatively and the interobserver variability was assessed. Using logistic regression we defined clinical parameters that were associated with bronchiectasis (BE) and bronchial wall thickening (BWT) alone or in combination.

RESULTS

HRCT scan abnormalities were present in 80% of subjects and often coexisted with BWT (62%), BE (40%), and emphysema (8%). The interobserver agreement for BE (kappa = 0.76) and BWT (kappa = 0.63) was substantial. DAC patients who underwent HRCT scanning compared with those who did not were older, had longer disease duration, had poorer lung function, were receiving higher doses of corticosteroids, and had increased neutrophilic airway inflammation. The sensitivity and specificity of detecting BE clinically were 74% and 45%, respectively. FEV(1)/FVC ratio emerged as an important predictor for both BE and BWT but had poor discriminatory utility for subjects who did not have airway structural changes (FEV(1)/FVC ratio, >or= 75%; sensitivity, 67%; specificity, 65%).

CONCLUSION

HRCT scan abnormalities are common in patients with severe asthma. Nonradiologic assessments fail to reliably predict important bronchial wall changes; therefore, CT scan acquisition may be required in all patients with severe asthma.