How to set up a severe asthma service

Multidisciplinary care in pediatric severe asthma: A comparative outcomes analysis

Background

There are limited data comparing the effectiveness of multidisciplinary severe asthma clinics (SACs) with that of conventional single-discipline clinics (SDCs) for pediatric severe asthma.

Objective

Our aim was to compare asthma outcomes between SACs and SDCs clinics and examine longitudinal health outcomes for patients with severe asthma who were followed in SACs.

Methods

We conducted a retrospective cohort study comparing pediatric asthma outcomes among patients with severe asthma between 2018 and 2022 who were treated at the multidisciplinary Arkansas Children's SAC with those of patients with severe asthma treated at SDCs. The primary outcome was acute health care utilization, including hospitalizations and emergency department visits. Secondary outcomes included systemic corticosteroid prescriptions and controller medications. For SAC enrollees, longitudinal outcomes including health care utilization, symptom control, and spirometry were evaluated 12 months before and after enrollment. Data sources included the electronic health record and SAC patient registry.

Results

The study population included 280 patients with severe asthma, aged 5 to 18 years, from the SAC (n = 56) and SDCs (n = 224). The SAC patients were more likely to be Black (79% vs 52% [P = .0002]), be non-Hispanic (100% vs 88% [P = .01]), have had at least 1 hospitalization (21% vs 10% [P = .04]), and have received at least 2 prescriptions for a systemic corticosteroid (34% vs 17% [P = .01]). Longitudinal outcomes among patients for the 12 months before SAC enrollment versus 12 months after SAC enrollment demonstrated significant reductions in acute exacerbations (from 35 to 8 [P < .001]), hospitalizations (from 21 to 1 [P < .001]), and intensive care unit admissions (from 8 to 1 [P = .02]).

Conclusions

The study highlights significant morbidity among predominately Black pediatric patients with severe asthma, particularly those followed in a SAC versus in SDCs at a tertiary care referral center. The findings demonstrate the value of targeted multidisciplinary approaches to reduce asthma utilization and improve outcomes among high-risk patients.

'Stuck in catch-22': a qualitative study of perceived work ability and decision-making about employment in severe asthma

BACKGROUND

Severe asthma (SA) is characterised by persistent asthma symptomatology despite adherence to intensive treatment and control of asthma triggers. It is estimated that approximately 50% of individuals with SA have current employment, considerably less than rates in the general population. Poor physical and mental health status have been suggested as a potential explanation for this, but the relationship has not been investigated in depth. We investigated how bio-psycho-social and cultural factors influence work ability and employment in SA patients.

METHODS

Participants were recruited from the Birmingham Regional NHS Severe Asthma Service via opportunity sampling, with the exclusion criteria being individuals who had never been employed, currently in full-time education, or non-English speakers. Subsequently, men and those with minority-ethnic backgrounds were purposefully selected to gain a balanced sample. Interviews were performed either face-to-face, online or via telephone, transcribed using software and edited manually. Data were analysed using Reflexive Thematic Analysis.

RESULTS

The study included 12 participants (9 females and 3 males). Four major themes were constructed: impact of patients' asthma control on work, psychological burden of living with SA, costs and benefits of being in employment, and adaptations and strategies for remaining in employment.

CONCLUSIONS

Our findings highlight the potential for physical, occupational, psychological, and social support to address the diverse job-related difficulties experienced by people with SA. Additionally, national policy reforms should be considered to improve work capacity and promote employment opportunities.

Integrating hot topics and implementation of treatable traits in asthma

People with asthma experience many different problems related to their illness. The number and type of problems differ between patients. This results in asthma being a complex and heterogeneous disorder which mandates a personalised approach to management. These features pose very significant challenges for the effective implementation of evidence-based management. "Treatable traits" is a model of care that has been specifically designed to address these issues. Traits are identified in the pulmonary, extrapulmonary (comorbidity) and behavioural/risk factor domains. Traits are clinically relevant, recognisable with validated trait identification markers and treatable using evidence-based therapies. The clinician and patient agree on a personalised management plan that addresses the relevant traits, and trials show superiority of this approach with significant improvements in asthma control and quality of life. A number of tools have now been developed to assist the clinician in the implementation of this approach. The success of the treatable traits model of care is now being realised in other disease areas.

The treatable traits approach to adults with obstructive airways disease in primary and secondary care

The treatable traits approach is based on the recognition that the different clinical phenotypes of asthma and chronic obstructive airways disease (COPD) are a heterogeneous group of conditions with different underlying mechanisms and clinical manifestations, and that the identification and treatment of the specific clinical features or traits facilitates a personalised approach to management. Fundamentally, it recognises two important concepts. Firstly, that treatment for obstructive lung disease can achieve better outcomes if guided by specific clinical characteristics. Secondly, that in patients with a diagnosis of asthma, and/or COPD, poor respiratory health may also be due to numerous overlapping disorders that can present with symptoms that may be indistinguishable from asthma and/or COPD, comorbidities that might require treatment in their own right, and lifestyle or environmental factors that, if addressed, might lead to better control rather than simply increasing airways directed treatment. While these concepts are well accepted, how best to implement this personalised medicine approach in primary and secondary care within existing resource constraints remains uncertain. In this review, we consider the evidence base for this management approach and propose that the priority now is to assess different prototype templates for the identification and management of treatable traits in both asthma and COPD, in primary, secondary and tertiary care, to provide the evidence that will guide their use in clinical practice in different health care systems.

GEMA 5.3. Spanish Guideline on the Management of Asthma

The Spanish Guideline on the Management of Asthma, better known by its acronym in Spanish GEMA, has been available for more than 20 years. Twenty-one scientific societies or related groups both from Spain and internationally have participated in the preparation and development of the updated edition of GEMA, which in fact has been currently positioned as the reference guide on asthma in the Spanish language worldwide. Its objective is to prevent and improve the clinical situation of people with asthma by increasing the knowledge of healthcare professionals involved in their care. Its purpose is to convert scientific evidence into simple and easy-to-follow practical recommendations. Therefore, it is not a monograph that brings together all the scientific knowledge about the disease, but rather a brief document with the essentials, designed to be applied quickly in routine clinical practice. The guidelines are necessarily multidisciplinary, developed to be useful and an indispensable tool for physicians of different specialties, as well as nurses and pharmacists. Probably the most outstanding aspects of the guide are the recommendations to: establish the diagnosis of asthma using a sequential algorithm based on objective diagnostic tests; the follow-up of patients, preferably based on the strategy of achieving and maintaining control of the disease; treatment according to the level of severity of asthma, using six steps from least to greatest need of pharmaceutical drugs, and the treatment algorithm for the indication of biologics in patients with severe uncontrolled asthma based on phenotypes. And now, in addition to that, there is a novelty for easy use and follow-up through a computer application based on the chatbot-type conversational artificial intelligence (ia-GEMA).

Randomised controlled trial for the titration of oral corticosteroids using markers of inflammation in severe asthma

INTRODUCTION

Biomarkers are used to select biologic therapies for patients with severe asthma, but not to regularly adjust therapy, especially oral corticosteroids (OCS).

OBJECTIVE

Our goal was to test the efficacy of an algorithm to guide the titration of OCS using blood eosinophil count and fraction of exhaled nitric oxide (FeNO) levels.

DESIGN, PARTICIPANTS, INTERVENTIONS AND SETTING

This proof-of-concept prospective randomised controlled trial assigned adult participants with severe uncontrolled asthma (n=32) to biomarker-based management (BBM) where OCS dose was adjusted based on a composite biomarker score comprised of blood eosinophil count and FeNO, or a standard best practice (SBP) arm. The study was conducted at the Hunter Medical Research Institute, Newcastle, Australia. Participants were recruited from the local Severe Asthma Clinic and were blinded to their study allocation.

MAIN OUTCOME

The coprimary outcomes were number of severe exacerbations and time to first severe exacerbation assessed over 12 months.

RESULTS

There was a longer median time to first severe exacerbation with BBM, although not significant (295 vs 123 days, Adj. HR: 0.714; 95% CI: 0.25 to 2.06; p=0.533). The relative risk of a severe exacerbation in BBM (n=17) vs SBP (n=15) was 0.88 (Adj.; 95% CI: 0.47 to 1.62; p=0.675) with a mean exacerbation rate per year of 1.2 and 2.0, respectively. There was a significant reduction in the proportion of patients requiring an emergency department (ED) visit using BBM (OR 0.09, 95% CI: 0.01 to 0.91; p=0.041). There was no difference in the cumulative OCS dose used between the two groups.

CONCLUSION

A treatment algorithm to adjust OCS using blood eosinophil count and FeNO is feasible in a clinical setting and resulted in a reduced odds of an ED visit. This warrants further study to optimise the use of OCS in the future.

TRIAL REGISTRATION NUMBER

This trial was registered with the Australia and New Zealand Clinical Trials Registry (ACTRN12616001015437).

Treatable traits, combination inhaler therapy and the future of asthma management

The landscape of asthma has considerably changed in the last decade. Effective medications and inhaler devices have been developed and integrated into the asthma pharmacopoeia, but unfortunately, the proportion of uncontrolled patients remains unacceptably high. This is now recognized to be mainly due to the inappropriate use of medications or inhaler devices, heterogeneity of the disease or other factors contributing to the disease. Currently, inhaled corticosteroids (ICS), with or without long-acting beta agonists (LABA), are the cornerstone of asthma management, and recently international guidelines recognized the importance of combination inhaler therapy (ICS/LABA) even in mild asthma. In future, ultra-long-acting personalized medications and smart inhalers will complement combination inhaler therapy in order to effectively addresses issues such as adherence, inhaler technique and polypharmacy (both of drugs and devices). Asthma is now acknowledged as a multifaceted cluster of disorders and the treatment model has evolved from one-size-fits-all to precision medicine approaches such as treatable traits (TTs, defined as measurable and treatable clinically important factors) which encourages the quality use of medications and identification and management of all underlying behavioural and biological treatable risk factors. TT requires research and validation in a clinical context and the implementation strategies and efficacy in various settings (primary/secondary/tertiary care, low-middle income countries) and populations (mild/moderate/severe asthma) are currently evolving. Combination inhaler therapy and the TTs approach are complementary treatment approaches. This review examines the current status of personalized medicine and combination inhaler therapy, and describes futuristic views for these two strategies.

Management of eosinophil-associated inflammatory diseases: the importance of a multidisciplinary approach

Elevated eosinophil counts in blood and tissue are a feature of many pathological processes. Eosinophils can migrate and accumulate in a wide variety of tissues and, by infiltrating a target organ, can mediate the development of several inflammatory diseases. The normalization of eosinophilia is a common biomarker of a treatable trait and can also be used as a prognostic and predictive biomarker since it implies a reduction in type 2 inflammation that contributes to disease pathogenesis. Biological therapies targeting this cell type and its proinflammatory mediators have been shown to be effective in the management of a number of eosinophilic diseases, and for this reason they constitute a potential common strategy in the treatment of patients with various multimorbidities that present with type 2 inflammation. Various biological options are available that could be used to simultaneously treat multiple target organs with a single drug, bearing in mind the need to offer personalized treatments under the umbrella of precision medicine in all patients with eosinophil-associated diseases (EADs). In addition to reviewing these issues, we also discuss a series of perspectives addressing the management of EAD patients from a multidisciplinary approach, with the collaboration of health professionals from different specialties who manage the different multimorbidities that frequently occur in these patients. We examine the basic principles of care that this multidisciplinary approach must cover and present a multidisciplinary expert opinion regarding the ideal management of patients with EADs, from diagnosis to therapeutic approach and follow-up.

Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome

Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.

Documento de consenso de asma grave en adultos. Actualización 2022

Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.

Multidisciplinary care in chronic airway diseases: the Newcastle model

Chronic airway diseases including, asthma and chronic obstructive pulmonary disease (COPD) are prevalent and high burden conditions with the majority of patients successfully managed in the primary care setting. However, some patients with more complex disease such as difficult-to-treat or severe asthma, or complex COPD, tertiary care is required. This review provides an overview of the successful tertiary care multidisciplinary respiratory service that operates in Newcastle, New South Wales, Australia, which has been integrated into the tertiary care outpatient clinics for almost three decades. The service is multifaceted in terms of the clinical care it provides, and includes an “Inpatient service”, “Asthma Management Service”, “Difficult Airway Clinic”, “Drug Administration Clinic”, “Rapid Access Clinic”, “Pulmonary Rehabilitation” and has an integrated research programme. The core of the multidisciplinary approach to airway diseases is a person-centred model of care, the “Treatable Traits” approach. The staffing of this service comprises of consultant physicians, respiratory advanced trainees, respiratory scientists, physiotherapists, speech pathologists, nurse specialists and a nurse consultant. Patients that present to this service undergo an initial assessment and clinical review by team members, synthesis of relevant data, and development of a diagnosis and management plan. Based on this review specific interventions are determined according to the traits identified. Overtime the service has evolved to accommodate the increasing numbers of patients requiring access to the “Difficult Airways Clinic” assessment and therapies. This has been facilitated by partnered with the Centres of Excellence in Severe Asthma and Treatable Traits to develop educational and practice management tools.

Using a knowledge translation framework to identify health care professionals’ perceived barriers and enablers for personalised severe asthma care

Background

Whilst multidimensional assessment enables the detection of treatable traits in severe asthma and has the potential to improve patient outcomes, healthcare disparities exist, and little is known about the factors influencing optimal management in severe asthma. This study aimed to explore perceived barriers, and enablers to implementing personalised care in severe asthma, from the healthcare professionals’ perspective.

Methods

A descriptive, qualitative study involving a single focus group (n = 7) and semi-structured interviews (n = 33) with multidisciplinary healthcare professionals involved in severe asthma care was conducted. A hybrid thematic and content analysis was undertaken to identify themes, which were then deductively mapped to the Theoretical Domains Framework (TDF).

Results

Overall, three emergent themes were identified: (1) Barriers- (2) Enablers- to optimal management; (3) Desired model of care. Across all TDF domains, 6 constructs influenced development and implementation of optimal care: (1) belief about consequences, (2) environmental context and resources, (3) belief about capabilities, (4) social/professional role and identity, (5) goals and (6) knowledge.

Conclusion

Implementation of personalised care in severe asthma is complex and non-linear. The use of a theory-based approach effectively demonstrated how a variety of behaviours could be targeted to optimise and promote personalised care in different clinical setting.

The Korean Severe Asthma Registry (KoSAR): real world research in severe asthma

Severe asthma constitutes a serious health burden with significant morbidity and socioeconomic costs. The development and introduction of new biologics targeting type 2 inflammation changed the paradigm for management of severe asthma and initiated a biological era. These changes impose a challenge to clinicians in managing difficult-to-treat and severe asthma. To understand the characteristics and heterogeneity of severe asthma and to develop a better strategy to manage it, the Korean Academy of Asthma, Allergy and Clinical Immunology, Working Group on Severe Asthma, has organized the Korean Severe Asthma Registry (KoSAR). In this review, we describe the challenges of severe asthma management regarding diagnosis, disease burden, heterogeneity, guidelines, and organization of severe asthma clinics. This review also examines the current global activities of national and regional registries and study groups. In addition, we present the KoSAR vision and organization and describe the findings of KoSAR in comparison with those of other countries.

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INTRODUCTION

One of the main recommendations to improve chronic asthmatic patients' adhesion to their treatment is the implementation of a coordinated care pathway aiming at facilitating disease management by the patient while meeting his needs and expectations.

PURPOSE OF RESEARCH

To study through a critical literature review and a short survey how this care pathway can be set up and adapted to the Belgian context.

RESULTS

A model including the three healthcare levels in Belgium was developed. The first level is mainly formed by general practitioners while the second and third are centralized around a structure called asthma clinic. This latter would provide a full asthma assessment, its chronic follow-up and treatment for severe asthma. Roles of healthcare professionals working with the asthmatic patient were identified and described. This model is discussed in the light of the present Belgian situation according to different plans: asthma management, effective interdisciplinary communication, advanced nurse practitioner's role implementation.

CONCLUSION

Although the Belgian context is currently not suitable enough for allowing this new nursing function to arise, our model lays the foundations of a system which is adapted to complexity of Belgium, follows from validated experiences on international scene, and offers an answer to chronic asthmatic patient's needs and expectations.

Severe asthma assessment, management and the organisation of care in Australia and New Zealand: expert forum roundtable meetings

Severe asthma imposes a significant burden on individuals, families and the healthcare system. Treatment is complex, due to disease heterogeneity, comorbidities and complexity in care pathways. New approaches and treatments improve health outcomes for people with severe asthma. However, emerging multidimensional and targeted treatment strategies require a reorganisation of asthma care. Consensus is required on how reorganisation should occur and what areas require further research. The Centre of Excellence in Severe Asthma convened three forums between 2015 and 2018, hosting experts from Australia, New Zealand and the UK. The forums were complemented by a survey of clinicians involved in the management of people with severe asthma. We sought to: (i) identify areas of consensus among experts; (ii) define activities and resources required for the implementation of findings into practice; and (iii) identify specific priority areas for future research. Discussions identified areas of unmet need including assessment and diagnosis of severe asthma, models of care and treatment pathways, add-on treatment approaches and patient perspectives. We recommend development of education and training activities, clinical resources and standards of care documents, increased stakeholder engagement and public awareness campaigns and improved access to infrastructure and funding. Further, we propose specific future research to inform clinical decision-making and develop novel therapies. A concerted effort is required from all stakeholders (including patients, healthcare professionals and organisations and government) to integrate new evidence-based practices into clinical care and to advance research to resolve questions relevant to improving outcomes for people with severe asthma.

Continuous positive airway pressure acutely increases exercise duration in children with severe therapy-resistant asthma: a randomized crossover trial

BACKGROUND

Lower exercise tolerance is an important component of asthma and the possible effects of non-invasive ventilation on exercise capacity in individuals with severe therapy-resistant asthma (STRA) are unknown. This study aimed to evaluate the immediate effect of continuous positive airway pressure (CPAP) on exercise tolerance in children with STRA.

METHODS

We performed a controlled, randomized, crossover clinical trial including subjects aged 6 to 18 years old diagnosed with STRA. Clinical, anthropometric and lung function data were collected. The participants in the intervention group (IG) used CPAP (PEEP 10cmH₂O and FiO₂ 0.21) for a period of 40 min. Subjects in the control group (CG) used CPAP with minimum PEEP at 1 cmH₂0 also for 40 min. Afterwards, subjects from both groups underwent cardiopulmonary exercise testing (CPET). After a 15-day washout period, on a subsequent visit, subjects participated in the opposite group to the initial one.

RESULTS

Thirteen subjects with a mean age of 12.30 ± 1.7 years were included. The variables of peak expiratory flow (PEF) and forced expiratory volume in the first second (FEV₁) before using CPAP and after performing CPET did not show significant differences. Regarding CPET results, there was no significant difference (P = 0.59) between groups at peak exercise for oxygen consumption-VO₂ (CG: 33.4 ± 6.3 and IG: 34.5 ± 5.9, mL kg^-1 min^-1). However, the IG (12.4 ± 2.1) presented a total test time (min) significantly (P = 0.01) longer than the CG (11.5 ± 1.3).

CONCLUSION

The results suggest that the use of CPAP before physical exercise increases exercise duration in children and adolescents with STRA.

Multidisciplinary Care for Severe or Uncontrolled Chronic Upper Airway Diseases

PURPOSE OF REVIEW

A multidisciplinary approach is regarded as the best practice for many chronic diseases, such as cancer and asthma, with well-documented value. There is also evidence that it may be beneficial to patients with chronic rhinosinusitis (CRS) and/or allergic airway disease presenting to tertiary referral centres. We discuss here whether and how organizing this kind of healthcare transition into a more integrated care pathway would benefit severe chronic upper airways disease (SCUAD) management.

RECENT FINDINGS

Based on a recent related EUFOREA panel discussion, literature search, and review of the best overseas practices, an appropriate implementation strategy of multidisciplinary care and its potential results are presented. Organizational principles, hurdles, and challenges of the process, as well as envisaged solutions and results, are being reported. The efficiency of care and the quality control assessment are concepts that are currently gaining importance. At the same time, novel treatment options based on molecular and precision medicine advancements, such as biologics, are being increasingly prescribed. Appropriately organized multidisciplinary care teams can adapt to new demands, data, and discoveries to assure maximum benefit for both patients and healthcare professionals.

Fungal sensitization and positive fungal culture from sputum in children with asthma are associated with reduced lung function and acute asthma attacks respectively

BACKGROUND

Sensitization to thermotolerant fungi, including filamentous fungi and Candida albicans, is associated with poor lung function in adults with severe asthma. Data in children are lacking. Environmental exposure to fungi is linked with acute severe asthma attacks, but there are few studies reporting the presence of fungi in the airways during asthma attacks.

METHODS

We investigated the association between fungal sensitization and/or positive fungal sputum culture and markers of asthma severity in children with chronic and acute asthma. Sensitization was determined using serum-specific IgE and skin prick testing against a panel of five fungi. Fungal culture was focused towards detection of filamentous fungi from sputum samples.

RESULTS

We obtained sensitization data and/or sputum from 175 children: 99 with chronic asthma, 39 with acute asthma and 37 controls. 34.1% of children with chronic asthma were sensitized to thermotolerant fungi compared with no children without asthma (p =< 0.001). These children had worse pre-bronchodilator lung function compared with asthmatics without sensitization including a lower FEV₁ /FVC ratio (p < .05). The isolation rate of filamentous fungi from sputum was higher in children with acute compared with chronic asthma.

CONCLUSIONS

Fungal sensitization is a feature of children with chronic asthma. Children sensitized to thermotolerant fungi have worse lung function, require more courses of systemic corticosteroids and have greater limitation of activities due to asthma. Asthma attacks in children were associated with the presence of filamentous fungi positive sputum culture. Mechanistic studies are required to establish whether fungi contribute directly to the development of acute asthma.

Treatable Traits That Predict Health Status and Treatment Response in Airway Disease

BACKGROUND

A strategy based on the assessment and management of treatable traits (TTs) has been proposed as a new paradigm in airway disease. There is a potentially long list of TTs with likely different clinical impact.

OBJECTIVE

To identify TTs most strongly associated with poorer health-related quality of life (HRQOL) and treatments that most substantially improved HRQOL.

METHODS

We pooled data from 2 parallel-group clinical trials of multidimensional assessment and individualized management targeted to TTs versus usual care in patients with chronic obstructive pulmonary disease or severe asthma (intervention N = 45; control N = 46). Following multidimensional assessment, 22 TTs were identified and the intervention group received treatments tailored to their identified TT. We used Bayesian Model Averaging to examine associations between TTs and HRQOL (St George's Respiratory Questionnaire) at baseline, as well as between each TT treatment and the observed change in HRQOL postintervention.

RESULTS

TTs most substantially associated with poorer baseline HRQOL were frequent chest infections, breathing pattern disorder, inadequate inhaler technique, systemic inflammation (C-reactive protein >3 mg/L), and depression. In both trials, TT treatment led to a large, significant improvement in HRQOL compared with usual care (Cohen's d = 1.19; P < .001). Receiving a statin for systemic inflammation and oral corticosteroid for eosinophilic airway inflammation was associated with the largest HRQOL improvements. Treatments for exercise intolerance, anxiety, and obesity were associated with smaller improvements in HRQOL.

CONCLUSIONS

This study contributes to identifying clinically impactful TTs by showing that TTs across pulmonary, extrapulmonary, and behavioral domains were associated with HRQOL impairment and treatment response.

Impact of psychological impairment on quality of life and work impairment in severe asthma

BACKGROUND

Psychological impairment, such as anxiety and depression, is common in severe asthma. However, the impact of psychological impairment on asthma-specific quality of life (ASQOL) and work impairment has not been assessed within Southeast-Asia. Furthermore, previous ASQOL questionnaires contained items overlapping with asthma control, making it challenging to isolate the relationship between psychological impairment with ASQOL and asthma control, respectively.

OBJECTIVE

To evaluate the relationship between psychological impairment with ASQOL and work impairment in severe asthma.

METHODS

This is a cross-sectional study of severe asthma at Singapore General Hospital. We assessed ASQOL, psychological impairment, work impairment and asthma control using validated questionnaires. An ASQOL questionnaire not containing items evaluating asthma symptoms was selected to reduce overlap with asthma control. Medical records were used to obtain other asthma characteristics and healthcare utilization patterns.

RESULTS

Amongst 111 patients, 37% had psychological impairment based on Hospital Anxiety and Depression Scale. Poorer ASQOL was associated with anxiety (p = .013) after controlling for demographic characteristics, asthma control and comorbidities. Anxiety symptoms were associated with greater health concerns while depression symptoms were associated with sleep difficulty and physical limitations. Having depressive symptoms was associated with an additional 16% impairment of total work hours (p = .038). Psychological impairment was not associated with spirometry results or healthcare utilization. Ethnicity significantly predicted both ASQOL and work impairment.

CONCLUSIONS

In severe asthma, patients with psychological impairment have poorer ASQOL and greater work impairment than those without psychological impairment. There is an urgent need to mitigate this problem.

The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians

Severe asthma is an important topic in respiratory diseases, due to its high impact on morbidity and mortality as well as on health-care resources. The many challenges that still exist in the management of the most difficult-to-treat forms of the disease, and the acknowledgement of the existence of unexplored areas in the pathophysiological mechanisms and the therapeutic targets represent an opportunity to gather experts in the field with the immediate goals to summarize current understanding about the natural history of severe asthma and to identify gaps in knowledge and research opportunities, with the aim to contribute to improved medical care and health outcomes. This article is a consensus document from the “International Course on Severe Asthma” that took place in Palermo, Italy, on May 10–11, 2019. Emerging topics in severe asthma were addressed and discussed among experts, with special focus on patient’s needs and research opportunities, with the aim to highlight the unanswered questions in the diagnostic process and therapeutic approach.

The management of severe asthma in 2020

Asthma is a chronic inflammatory disease of the airways affecting more than 300 million patients worldwide. The disease can be of various severity ranging from very mild to severe. The severe form of the disease only affects about 5% of patients but is responsible for a large component of the overall disease burden and results in about half of direct asthma-related costs. This led to important investments in research, which allowed better understanding of its pathophysiology and the development of new therapeutic strategies. Despite those breakthroughs, recent guidelines still emphasize the need to distinguish uncontrolled or difficult-to-control asthma from severe asthma. Indeed, a significant number of patients referred to severe asthma clinics are non-severe uncontrolled patients. However, the basics of asthma management such as ensuring that the patient has the right diagnosis, recognition of contributing comorbidities, avoidance of exposure to sensitizing agents in allergic individuals, regular assessment of control, and patient education should not be forgotten. The major improvements in pathophysiology arose from the evidences that asthma is of heterogeneous nature. Such heterogeneity has been particularly studied in severe asthma, leading to the recognition of more homogeneous groups referred to as phenotypes. Appropriate phenotyping of individual patients allows enforcing more specific treatment plans for patients, which is a step toward precision medicine. The high morbidity and socioeconomic burden of severe asthma has led to the development of optimized therapeutic strategies in addition to the commercialization of new drugs. Many of these have targeted the eosinophilic component of inflammatory asthma phenotypes while there is still a need to develop new therapies for non-eosinophilic asthma. When asthma is not controlled by optimal therapy, including a high-dose of inhaled corticosteroid (ICS) and a long-acting beta-agonist (LABA), a long acting anticholinergic agent can be added and if insufficient, a variety of biologic agents is now available in many countries. When biologics are not an option, thermoplasty and macrolides have also become available. Despite many recent breakthroughs in severe asthma, much research needs to be done. Improvement in availability of targeted asthma medications and asthma prevention should be top priorities.

Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives

Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.

Targeting treatable traits in severe asthma: a randomised controlled trial

RATIONALE

Treatable traits have been proposed as a new paradigm for airway disease management.

OBJECTIVES

To characterise treatable traits in a severe asthma population and to determine the efficacy of targeting treatments to these treatable traits in severe asthma.

METHODS

Participants (n=140) with severe asthma were recruited to a cross-sectional study and underwent a multidimensional assessment to characterise treatable traits. Eligible participants with severe asthma (n=55) participated in a 16-week parallel-group randomised controlled trial to determine the feasibility and efficacy of management targeted to predefined treatable traits, compared to usual care in a severe asthma clinic. The patient-reported outcome of health-related quality of life was the trial's primary end-point.

MAIN RESULTS

Participants with severe asthma had a mean±sd of 10.44±3.03 traits per person, comprising 3.01±1.54 pulmonary and 4.85±1.86 extrapulmonary traits and 2.58±1.31 behavioural/risk factors. Individualised treatment that targeted the traits was feasible and led to significantly improved health-related quality of life (0.86 units, p<0.001) and asthma control (0.73, p=0.01).

CONCLUSIONS

Multidimensional assessment enables detection of treatable traits and identifies a significant trait burden in severe asthma. Targeting these treatable traits using a personalised-medicine approach in severe asthma leads to improvements in health-related quality of life, asthma control and reduced primary care acute visits. Treatable traits may be an effective way to address the complexity of severe asthma.

Approaches to the assessment of severe asthma: barriers and strategies

Asthma is a chronic condition with great variability. It is characterized by intermittent episodes of wheeze, cough, chest tightness, dyspnea and backed by variable airflow limitation, airway inflammation and airway hyper-responsiveness. Asthma severity varies uniquely between individuals and may change over time. Stratification of asthma severity is an integral part of asthma management linking appropriate treatment to establish asthma control. Precision assessment of severe asthma is crucial for monitoring the health of people with this disease. The literature suggests multiple factors that impede the assessment of severe asthma, these can be grouped into health care professional, patient and organizational related barriers. These barriers do not exist in isolation but interact and influence one another. Recognition of these barriers is necessary to promote precision in the assessment and management of severe asthma in the era of targeted therapy. In this review, we discuss the current knowledge of the barriers that impede assessment in severe asthma and recommend potential strategies for overcoming these barriers. We highlight the relevance of multidimensional assessment as an ideal approach to the assessment and management of severe asthma.

Managing patients with severe asthma in Australia: Current challenges with the existing models of care

Severe asthma leads to debilitating symptoms for patients and excessive socioeconomic burden for the community. Comprehensive models of care are required to address complex issues, risk factors and comorbidities in patients with severe asthma, and to identify patients most appropriate for specialised treatments. Dedicated severe asthma services improve asthma control, reduce asthma exacerbations and hospital admissions, and improve quality of life. Currently, diverse models of care exist for managing severe asthma across Australia. Most referrals to severe asthma services are from respiratory physicians seeking a second opinion or from primary care for poorly controlled asthma. Despite benefits of specialised severe asthma services, many patients are not referred and resources are limited, often resulting in long waiting times. Patient referral is often unstructured and there are considerable variations in the management of severe asthma with limited access to other health care professionals such as speech pathologists and dieticians, and restricted scope to optimise patient work-up before referral. Ongoing communication between the specialist and referring clinician is essential for continuity of care but is often lacking. Referral pathways can be optimised by developing referral criteria and guidelines to triage patients with severe asthma and to improve resource efficiency. Additional education and tools for assessing and managing severe asthma are needed, and mechanisms should be developed for involving primary care in the management of stabilised patients. Strategies to increase patient access to multidisciplinary services are recommended.

Optimising treatment for severe asthma

The treatment landscape in severe asthma is changing rapidly, with multiple new therapies emerging that promise to transform patient outcomes. In a patient who is not responding to conventional therapy with inhaled corticosteroids and long-acting β2-agonists, it is important to first consider if the diagnosis of asthma is correct and, second, to reflect on whether readily modifiable factors are contributing to poor asthma control. In selected patients it may be appropriate to consider a modified n-of-1 trial of add-on therapies such as long-acting anti-muscarinic agents, leukotriene blockers, theophylline or low dose macrolide antibiotics. A number of monoclonal antibodies are now available that target the molecular pathways that contribute to asthma pathogenesis, and more such agents are likely to emerge in the near future. These biologicals can be transformative in selected patients, markedly reducing the frequency of asthma exacerbations, and allowing many patients to reduce or eliminate their use of long term oral corticosteroids. If the promise of personalised treatment is to be fully realised, it is important that better methods are developed to target these new and expensive treatments to patients most likely to respond. The ultimate goal of inducing remission or cure of asthma is still some distance away.

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.

Treatable traits: a new paradigm for 21st century management of chronic airway diseases: Treatable Traits Down Under International Workshop report

"Treatable traits" have been proposed as a new paradigm for the management of airway diseases, particularly complex disease, which aims to apply personalised medicine to each individual to improve outcomes. Moving new treatment approaches from concepts to practice is challenging, but necessary. In an effort to accelerate progress in research and practice relating to the treatable traits approach, the Treatable Traits Down Under International Workshop was convened in Melbourne, Australia in May 2018. Here, we report the key concepts and research questions that emerged in discussions during the meeting. We propose a programme of research that involves gaining international consensus on candidate traits, recognising the prevalence of traits, and identifying a potential hierarchy of traits based on their clinical impact and responsiveness to treatment. We also reflect on research methods and designs that can generate new knowledge related to efficacy of the treatable traits approach and consider multidisciplinary models of care that may aid its implementation into practice.

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.

Moving toward consensus on diagnosis and management of severe asthma in adults

Asthma is a considerable health problem with an increasing global prevalence. The burden of severe asthma is expected to notably increase in the following years. Some misleading concepts that sometimes appear in the literature can drive the physician responsible for a patient's management to make incorrect decisions. Furthermore, some of the concepts that appear in the literature and in the guidelines may not be clear to understand, follow or adapt to regional and local realities. This could again drive the physicians responsible for a patient's management to make incorrect clinical judgments. In this article, we review the definition, prevalence and immunopathology of severe asthma, describe the asthma phenotypes, clinical features and comorbidities, the diagnosis of severe asthma and personalized asthma treatment. At the end, we offer a treatment approach based on literature publications, personalized medicine and marketed biologic treatment options.

A 1-day visit in a severe asthma centre: effect on asthma control, quality of life and healthcare use

Patients with uncontrolled asthma report ongoing symptoms, poor quality-of-life and extensive healthcare use (HCU) and might benefit from management by a specialised severe asthma team. It is unknown whether a one-time evaluation by asthma experts, without long-term supervision by a specialised team, provides favourable outcomes. We evaluated asthma control (Asthma Control Questionnaire; ACQ), quality-of-life (Asthma-related Quality of Life Questionnaire; AQLQ) and HCU before and 1 year after a 1-day visit programme in a severe asthma centre, including a multidisciplinary assessment resulting in a personalised management plan to be implemented by patients own pulmonologists.40 uncontrolled asthma patients completed questionnaires (ACQ, AQLQ, HCU) at baseline, and 6 and 12 months follow-up.ACQ improved from 2.6 (interquartile range 1.7-3.2) to 1.8 (1.2-3.2) (p=0.003) and AQLQ from 4.8 (4.0-5.2) to 5.3 (4.4-6.0) (p<0.001). We found a reduction in patients with ≥2 exacerbations (95% versus 17%; p<0.001), ≥1 emergency room visit (78% versus 37%; p<0.001) and ≥1 hospitalisation (47% versus 10%; p=0.001).Evaluation of uncontrolled asthma patients in a 1-day visit programme in a severe asthma centre resulted in significant improvements in asthma control, quality-of-life and healthcare use after 1 year. This 1-day visit approach seems beneficial for uncontrolled asthma patients and might reduce their dependence on expensive treatment modalities and long-term management in specialised centres.

Diagnosis and investigation in the severe asthma clinic

Severe asthma is recognised as an important and emerging area of unmet need in asthma. The assessment of severe asthma should include three steps; (1) determining the diagnosis of asthma, including verification that the disease is severe asthma, (2) assessing comorbidities and contributing factors that will impact on clinical severity, as well as (3) assessing asthma phenotypes. These steps recognize the importance of heterogeneity in asthma as a key factor that determines the disease course and increasingly the choice of successful therapy. This assessment should be undertaken systematically and is best done by an expert multidisciplinary team. Here, we will outline the important aspects that should be included in the clinical assessment of the patient in the severe asthma clinic, including diagnosis, clinical history, the assessment of important comorbidities and the key investigations needed to support them.

Characteristics and prognosis of near-fatal asthma exacerbations

BACKGROUND

Asthma remains a major public health concern because of its high prevalence and the costs it generates. Near-fatal asthma (NFA) episodes represent the most severe forms of the disease after fatal asthma with significant variations in their incidence between different populations.

OBJECTIVE

To analyze the episodes of NFA over a period of 11 years in the hospital.

METHODS

The authors retrospectively reviewed all admissions due to asthma exacerbation in our hospital between 2000 and 2010 for patients over 18 years of age.

RESULTS

The study included 400 NFA episodes of 285 patients (74% women; mean age 66 years). Of these patients, 228 (80%) had a single episode of NFA and 57 had more than 1 episode during the study period. The authors observed no clear upward or downward trend during the study period. Readmitted patients had more comorbidities, poorer lung function, more severe forms of asthma and more admissions in the year before the index admission. There was a mortality rate of 3.1%. More than 20% of patients were not given controller treatment and more than 40% of patients were not treated with inhaled corticosteroids (ICS).

CONCLUSIONS

NFA episodes are still prevalent in the population of patients with asthma. Reasons for this could be related to improper management in the stable phase, as suggested by the low rate of patients treated with ICS. It also seems necessary to optimize patient management during hospitalization because stays appear prolonged in comparison with studies in other countries.

Adjusting prednisone using blood eosinophils reduces exacerbations and improves asthma control in difficult patients with asthma

Severe or therapy-resistant asthma represents a major problem, and despite advanced treatment, many patients require oral corticosteroids (OCS). We aimed to determine if patients with severe asthma and elevated peripheral blood eosinophils (PBE) could have treatment with OCS adjusted using an algorithm that controlled PBE (<0.2 × 10(9) /L). In 11 patients, the OCS dose was adjusted to suppress PBE, leading to a reduced exacerbation frequency and improvement in asthma symptoms with an overall lower OCS dose.

Distinguishing adult-onset asthma from COPD: a review and a new approach

Adult-onset asthma and chronic obstructive pulmonary disease (COPD) are major public health burdens. This review presents a comprehensive synopsis of their epidemiology, pathophysiology, and clinical presentations; describes how they can be distinguished; and considers both established and proposed new approaches to their management. Both adult-onset asthma and COPD are complex diseases arising from gene-environment interactions. Early life exposures such as childhood infections, smoke, obesity, and allergy influence adult-onset asthma. While the established environmental risk factors for COPD are adult tobacco and biomass smoke, there is emerging evidence that some childhood exposures such as maternal smoking and infections may cause COPD. Asthma has been characterized predominantly by Type 2 helper T cell (Th2) cytokine-mediated eosinophilic airway inflammation associated with airway hyperresponsiveness. In established COPD, the inflammatory cell infiltrate in small airways comprises predominantly neutrophils and cytotoxic T cells (CD8 positive lymphocytes). Parenchymal destruction (emphysema) in COPD is associated with loss of lung tissue elasticity, and small airways collapse during exhalation. The precise definition of chronic airflow limitation is affected by age; a fixed cut-off of forced expiratory volume in 1 second/forced vital capacity leads to overdiagnosis of COPD in the elderly. Traditional approaches to distinguishing between asthma and COPD have highlighted age of onset, variability of symptoms, reversibility of airflow limitation, and atopy. Each of these is associated with error due to overlap and convergence of clinical characteristics. The management of chronic stable asthma and COPD is similarly convergent. New approaches to the management of obstructive airway diseases in adults have been proposed based on inflammometry and also multidimensional assessment, which focuses on the four domains of the airways, comorbidity, self-management, and risk factors. Short-acting beta-agonists provide effective symptom relief in airway diseases. Inhalers combining a long-acting beta-agonist and corticosteroid are now widely used for both asthma and COPD. Written action plans are a cornerstone of asthma management although evidence for self-management in COPD is less compelling. The current management of chronic asthma in adults is based on achieving and maintaining control through step-up and step-down approaches, but further trials of back-titration in COPD are required before a similar approach can be endorsed. Long-acting inhaled anticholinergic medications are particularly useful in COPD. Other distinctive features of management include pulmonary rehabilitation, home oxygen, and end of life care.

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

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

Exacerbations of severe asthma

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