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Thomas M, Beasley R. The treatable traits approach to adults with obstructive airways disease in primary and secondary care. Respirology 2023; 28:1101-1116. [PMID: 37877554 DOI: 10.1111/resp.14610] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 10/02/2023] [Indexed: 10/26/2023]
Abstract
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.
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Affiliation(s)
- Mike Thomas
- Primary Care Research, School of Primary Care, Population Sciences and Medical Education (PPM), Faculty of Medicine, University of Southampton, Southampton, United Kingdom
| | - Richard Beasley
- Medicine, Medical Research Institute of New Zealand, Wellington, New Zealand
- Victoria University of Wellington, Wellington, New Zealand
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2
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Ludlow S, Daly R, Elsey L, Hope H, Sheehan R, Fowler SJ. Multidisciplinary management of inducible laryngeal obstruction and breathing pattern disorder. Breathe (Sheff) 2023; 19:230088. [PMID: 37830100 PMCID: PMC10567073 DOI: 10.1183/20734735.0088-2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Accepted: 08/13/2023] [Indexed: 10/14/2023] Open
Abstract
We provide an overview of the assessment and management of inducible laryngeal obstruction and breathing pattern disorder. We highlight the multidisciplinary team members involved and their essential roles within a complex breathlessness service. We discuss treatments initiated by physiotherapy and speech and language therapy, the importance of joint working, and discuss the high incidence of comorbidities and the association with other respiratory disorders. Educational aims Inducible laryngeal obstruction and breathing pattern disorder are common causes of breathlessness.Inducible laryngeal obstruction is an inappropriate, transient, reversible narrowing of the laryngeal area that causes breathlessness and laryngeal symptoms.Breathing pattern disorder is an alteration in the normal biomechanical patterns of breathing that results in intermittent or chronic symptoms, which may be respiratory and/or non-respiratory.People with inducible laryngeal obstruction or breathing pattern disorder often have other comorbidities that will also need addressing.Multidisciplinary assessment and treatment is essential for comprehensive workup and holistic care.Timely assessment and diagnosis can prevent unnecessary medication use and hospital admissions and facilitate effective management of the condition using reassurance, advice, education, breathing retraining and vocal exercises.
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Affiliation(s)
- Siobhan Ludlow
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Psychology and Mental Health, Medical Education, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Rachel Daly
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Lynn Elsey
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Pharmacy and Optometry, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
| | - Helen Hope
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Reyenna Sheehan
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
| | - Stephen J. Fowler
- Manchester University Hospitals NHS Foundation Trust, Manchester, UK
- Division of Immunology, Immunity to Infection and Respiratory Medicine, Faculty of Biology, Medicine and Health, University of Manchester, Manchester, UK
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3
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Lin T, Pham J, Denton E, Lee J, Hore-Lacy F, Sverrild A, Stojanovic S, Tay TR, Murthee KG, Radhakrishna N, Dols M, Bondarenko J, Mahoney J, O'Hehir RE, Dabscheck E, Hew M. Trait profiles in difficult-to-treat asthma: Clinical impact and response to systematic assessment. Allergy 2023; 78:2418-2427. [PMID: 36940306 DOI: 10.1111/all.15719] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/12/2023] [Accepted: 01/31/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND Multidisciplinary systematic assessment improves outcomes in difficult-to-treat asthma, but without clear response predictors. Using a treatable-traits framework, we stratified patients by trait profile, examining clinical impact and treatment responsiveness to systematic assessment. METHODS We performed latent class analysis using 12 traits on difficult-to-treat asthma patients undergoing systematic assessment at our institution. We examined Asthma Control Questionnaire (ACQ-6) and Asthma Quality of Life Questionnaire (AQLQ) scores, FEV1 , exacerbation frequency, and maintenance oral corticosteroid (mOCS) dose, at baseline and following systematic assessment. RESULTS Among 241 patients, two airway-centric profiles were characterized by early-onset with allergic rhinitis (n = 46) and adult onset with eosinophilia/chronic rhinosinusitis (n = 60), respectively, with minimal comorbid or psychosocial traits; three non-airway-centric profiles exhibited either comorbid (obesity, vocal cord dysfunction, dysfunctional breathing) dominance (n = 51), psychosocial (anxiety, depression, smoking, unemployment) dominance (n = 72), or multi-domain impairment (n = 12). Compared to airway-centric profiles, non-airway-centric profiles had worse baseline ACQ-6 (2.7 vs. 2.2, p < .001) and AQLQ (3.8 vs. 4.5, p < .001) scores. Following systematic assessment, the cohort showed overall improvements across all outcomes. However, airway-centric profiles had more FEV1 improvement (5.6% vs. 2.2% predicted, p < .05) while non-airway-centric profiles trended to greater exacerbation reduction (1.7 vs. 1.0, p = .07); mOCS dose reduction was similar (3.1 mg vs. 3.5 mg, p = .782). CONCLUSION Distinct trait profiles in difficult-to-treat asthma are associated with different clinical outcomes and treatment responsiveness to systematic assessment. These findings yield clinical and mechanistic insights into difficult-to-treat asthma, offer a conceptual framework to address disease heterogeneity, and highlight areas responsive to targeted intervention.
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Affiliation(s)
- Tiffany Lin
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Jonathan Pham
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joy Lee
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Asger Sverrild
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Stephanie Stojanovic
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore City, Singapore
| | | | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Monique Dols
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janine Mahoney
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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4
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Denton E, Hew M, Gibson PG, Vertigan A. Lone Ranger or Handpicked Posse? How Multidisciplinary Assessment Helps Evaluate Suspected Laryngeal Disorders. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:609-611. [PMID: 35144775 DOI: 10.1016/j.jaip.2021.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 12/27/2022]
Affiliation(s)
- Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Treatable Traits, the University of Newcastle, Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
| | - Anne Vertigan
- Speech Pathology, John Hunter Hospital, Newcastle, NSW, Australia; School of Medicine and Public Health, University of Newcastle, Newcastle, NSW, Australia
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Kwon JW, Kim MA, Sim DW, Lee HY, Rhee CK, Yang MS, Shim JS, Kim MH, Kim SR, Park CS, Kim BK, Kang SY, Choi GS, Lee H, Jang AS, Kim SH. Prescription Patterns of Oral Corticosteroids for Asthma Treatment and Related Asthma Phenotypes in University Hospitals in Korea. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:300-313. [PMID: 35557495 PMCID: PMC9110914 DOI: 10.4168/aair.2022.14.3.300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 03/31/2022] [Accepted: 04/04/2022] [Indexed: 11/20/2022]
Abstract
Purpose Oral corticosteroids (OCSs) are frequently prescribed for asthma management despite their adverse effects. An understanding of the pattern of OCS treatment is required to optimize asthma treatment and reduce OCS usage. This study evaluated the prescription patterns of OCSs in patients with asthma. Methods This is a retrospective multicenter observational study. We enrolled adult (≥18 years) patients with asthma who had been followed up by asthma specialists in 13 university hospitals for ≥3 years. Lung function tests, the number of asthma exacerbations, and prescription data, including the days of supply and OCS dosage, were collected. The clinical characteristics of OCS-dependent and exacerbation-prone asthmatic patients were evaluated. Results Of the 2,386 enrolled patients with asthma, 27.7% (n = 660) were OCS users (the median daily dose of OCS was 20 mg/day prednisolone equivalent to a median of 14 days/year). OCS users were more likely to be female, to be treated at higher asthma treatment steps, and to show poorer lung function and more frequent exacerbations in the previous year than non-OCS users. A total of 88.0% of OCS users were treated with OCS burst with a mean dose of 21.6 ± 10.2 mg per day prednisolone equivalent to 7.8 ± 3.2 days per event and 2.4 times per year. There were 2.1% (51/2,386) of patients with OCS-dependent asthma and 9.5% (227/2,386) with exacerbation-prone asthma. These asthma phenotypes were consistent over the 3 consecutive years in 47.1% of OCS-dependent asthmatic patients and 34.4% of exacerbation-prone asthmatic patients when assessed annually over the 3-year study period. Conclusions We used real-world data from university hospitals in Korea to describe the OCS prescription patterns and relievers in asthma. Novel strategies are required to reduce the burden of OCS use in patients with asthma.
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Affiliation(s)
- Jae-Woo Kwon
- Division of Allergy and Clinical Immunology, Department of Internal Medicine, Kangwon National University School of Medicine, Chuncheon, Korea
| | - Mi-Ae Kim
- Department of Pulmonology, Allergy and Critical Care Medicine, CHA Bundang Medical Center, CHA University, Seongnam, Korea
| | - Da Woon Sim
- Division of Allergy, Asthma, and Clinical Immunology, Department of Internal Medicine, Chonnam National University Medical School & Chonnam National University Hospital, Gwangju, Korea
| | - Hwa Young Lee
- Division of Allergy, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Seoul St. Mary’s Hospital, The Catholic University of Korea, Seoul, Korea
| | - Min-Suk Yang
- Department of Internal Medicine, Seoul Metropolitan Government - Seoul National University Boramae Medical Center, Seoul, Korea
| | - Ji-Su Shim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - Min-Hye Kim
- Department of Internal Medicine, Ewha Womans University College of Medicine, Seoul, Korea
| | - So Ri Kim
- Division of Respiratory Medicine and Allergy, Department of Internal Medicine, Jeonbuk National University Medical School, Jeonju, Korea
| | - Chan Sun Park
- Department of Internal Medicine, Inje University Haeundae Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Byung-Keun Kim
- Division of Pulmonology, Allergy and Critical Care Medicine, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
| | - Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Gil-Soon Choi
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hyun Lee
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
| | - An-Soo Jang
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Sang-Heon Kim
- Department of Internal Medicine, Hanyang University College of Medicine, Seoul, Korea
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de Carvalho-Pinto RM, Cançado JED, Pizzichini MMM, Fiterman J, Rubin AS, Cerci A, Cruz ÁA, Fernandes ALG, Araujo AMS, Blanco DC, Cordeiro G, Caetano LSB, Rabahi MF, de Menezes MB, de Oliveira MA, Lima MA, Pitrez PM. 2021 Brazilian Thoracic Association recommendations for the management of severe asthma. J Bras Pneumol 2021; 47:e20210273. [PMID: 34932721 PMCID: PMC8836628 DOI: 10.36416/1806-3756/e20210273] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 08/05/2021] [Indexed: 12/20/2022] Open
Abstract
Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.
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Affiliation(s)
- Regina Maria de Carvalho-Pinto
- . Divisão de Pneumologia, Instituto do Coração − InCor − Hospital das Clínicas, Faculdade de Medicina, Universidade de São Paulo, São Paulo (SP) Brasil
| | | | | | - Jussara Fiterman
- . Hospital São Lucas, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS) Brasil
| | - Adalberto Sperb Rubin
- . Universidade Federal de Ciências da Saúde de Porto Alegre − UFCSPA − Porto Alegre (RS) Brasil
- . Santa Casa de Misericórdia de Porto Alegre, Porto Alegre (RS) Brasil
| | - Alcindo Cerci
- . Universidade Estadual de Londrina − UEL − Londrina (PR) Brasil
- . Pontifícia Universidade Católica do Paraná − PUCPR − Londrina (PR) Brasil
| | - Álvaro Augusto Cruz
- . Universidade Federal da Bahia − UFBA − Salvador (BA) Brasil
- . Fundação ProAR, Salvador (BA) Brasil
| | | | - Ana Maria Silva Araujo
- . Instituto de Doenças do Tórax, Universidade Federal do Rio de Janeiro − IDT/UFRJ − Rio de Janeiro (RJ) Brasil
| | - Daniela Cavalet Blanco
- . Escola de Medicina, Pontifícia Universidade Católica do Rio Grande do Sul − PUCRS − Porto Alegre (RS), Brasil
| | - Gediel Cordeiro
- . Hospital Júlia Kubitschek, Fundação Hospitalar do Estado de Minas Gerais - FHEMIG - Belo Horizonte (MG) Brasil
- . Hospital Madre Teresa, Belo Horizonte (MG) Brasil
| | | | - Marcelo Fouad Rabahi
- . Faculdade de Medicina, Universidade Federal de Goiás − UFG − Goiânia (GO) Brasil
| | - Marcelo Bezerra de Menezes
- . Departamento de Clínica Médica, Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto (SP) Brasil
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Luo L, Yu X, Yong Z, Li C, Gu Y. Design Comorbidity Portfolios to Improve Treatment Cost Prediction of Asthma Using Machine Learning. IEEE J Biomed Health Inform 2021; 25:2237-2247. [PMID: 33108300 DOI: 10.1109/jbhi.2020.3034092] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Comorbidity is an important factor to consider when trying to predict the cost of treating asthma patients. When an asthmatic patient suffered from comorbidity, the cost of treating such a patient becomes dependent on the nature of the comorbidity. Therefore, lack of recognition of comorbidity on asthmatic patient poses a challenge in predicting the cost of treatment. In this study, we proposed a comorbidity portfolio design that improves the prediction cost of treating asthmatic patients by regrouping frequently occurred comorbidities in different cost groups. In the experiment, predictive models, including logistic regression, random forest, support vector machine, classification regression tree, and backpropagation neural network were trained with real-world data of asthmatic patients from 2012 to 2014 in a large city of China. The 10-fold cross validation and random search algorithm were employed to optimize the hyper-parameters. We recorded significant improvements using our model, which are attributed to comorbidity portfolios in area under curve (AUC) and sensitivity increase of 46.89% (standard deviation: 4.45%) and 101.07% (standard deviation: 44.94%), respectively. In risk analysis of comorbidity on cost, respiratory diseases with a cumulative proportion in the adjusted odds ratio of 36.38% (95%CI: 27.61%, 47.86%) and circulatory diseases with a cumulative proportion in the adjusted odds ratio of 23.83% (95%CI: 15.95%, 35.22%) are the dominant risks of asthmatic patients that affects the treatment cost. It is found that the comorbidity portfolio is robust, and provides a better prediction of the high-cost of treating asthmatic patients. The preliminary characterization of the joint risk of multiple comorbidities posed on cost are also reported. This study will be of great help in improving cost prediction and comorbidity management.
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Hew M, Denton E. Prioritizing Treatable Traits in Airways Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1265-1266. [PMID: 33685609 DOI: 10.1016/j.jaip.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
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Vertigan AE, Kapela SL, Gibson PG. Laryngeal Dysfunction in Severe Asthma: A Cross-Sectional Observational Study. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 9:897-905. [PMID: 33011304 DOI: 10.1016/j.jaip.2020.09.034] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Revised: 08/20/2020] [Accepted: 09/21/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laryngeal disorders can contribute to disease burden in severe asthma yet the nature of laryngeal disorders in severe asthma is poorly understood. OBJECTIVE The aim of this study was to examine laryngeal function in patients with severe asthma. METHOD A cross-sectional observational study involving 97 participants compared laryngeal function in patients with severe asthma (n = 53) with patients with laryngeal disorders of vocal cord dysfunction/inducible laryngeal obstruction (n = 16) and muscle tension dysphonia (n = 14), and with healthy controls (n = 13). A pre-post pilot study of speech pathology intervention for laryngeal symptoms was then provided to 11 participants with severe asthma and laryngeal dysfunction. RESULTS Laryngeal dysfunction was common in severe asthma. The majority of participants with severe asthma (87%) had laryngeal dysfunction, which affected respiration, phonation, or both. Three distinct patterns of laryngeal dysfunction in severe asthma were identified: (1) phonatory laryngeal dysfunction, (2) respiratory laryngeal dysfunction, and (3) combined laryngeal dysfunction. Laryngeal hypersensitivity and impaired voice measures were common in severe asthma. Patient-reported outcome measures improved after therapy, and laryngeal dysfunction improved in 7 (64%) participants. CONCLUSION Laryngeal dysfunction affects respiration and phonation in severe asthma. It requires identification and treatment to minimize its impact on asthma symptoms.
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Affiliation(s)
- Anne E Vertigan
- Speech Pathology Department, John Hunter Hospital, Newcastle, NSW, Australia; Hunter Medical Research Institute, Newcastle, NSW, Australia; University of Newcastle, Newcastle, NSW, Australia.
| | - Sarah L Kapela
- Speech Pathology Department, John Hunter Hospital, Newcastle, NSW, Australia
| | - Peter G Gibson
- Hunter Medical Research Institute, Newcastle, NSW, Australia; University of Newcastle, Newcastle, NSW, Australia; Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, NSW, Australia
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10
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Scichilone N, Barnes PJ, Battaglia S, Benfante A, Brown R, Canonica GW, Caramori G, Cazzola M, Centanni S, Cianferoni A, Corsico A, De Carlo G, Di Marco F, Gaga M, Hawrylowicz C, Heffler E, Matera MG, Matucci A, Paggiaro P, Papi A, Popov T, Rogliani P, Santus P, Solidoro P, Togias A, Boulet LP. The Hidden Burden of Severe Asthma: From Patient Perspective to New Opportunities for Clinicians. J Clin Med 2020; 9:jcm9082397. [PMID: 32727032 PMCID: PMC7463666 DOI: 10.3390/jcm9082397] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2020] [Revised: 07/15/2020] [Accepted: 07/20/2020] [Indexed: 12/17/2022] Open
Abstract
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.
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Affiliation(s)
- Nicola Scichilone
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
- Correspondence: ; Tel.: +39-091-655-2146
| | - Peter John Barnes
- Airway Disease Section, National Heart & Lung Institute, Imperial College London, Dovehouse Street, London SW3 6LY, UK;
| | - Salvatore Battaglia
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Alida Benfante
- Division of Respiratory Diseases, Department of Health Promotion Sciences, Maternal and Infant Care, Internal Medicine and Medical Specialties (PROMISE), University of Palermo, Piazza delle Cliniche 2, 90143 Palermo, Italy; (S.B.); (A.B.)
| | - Robert Brown
- Department of Anesthesiology and Critical Care Medicine, Medicine, Department of Medicine, Division of Pulmonary Medicine, Department of Environmental Health and Engineering, Johns Hopkins University, Baltimore, MD 21287, USA;
| | - Giorgio Walter Canonica
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Gaetano Caramori
- Respiratory Medicine Unit, Department of Biomedical Sciences, Dentistry and Morphological and Functional Imaging (BIOMORF), University of Messina, 98122 Messina, Italy;
| | - Mario Cazzola
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Stefano Centanni
- Respiratory Unit, ASST Santi Paolo e Carlo, San Paolo Hospital, Department of Health Sciences, University of Milan, 20142 Milan, Italy;
| | - Antonella Cianferoni
- Pediatrics Department, Perlman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - Angelo Corsico
- Division of Respiratory Diseases, IRCCS Policlinico San Matteo Foundation and Department of Internal Medicine and Therapeutics – University of Pavia, 27100 Pavia, Italy;
| | - Giuseppe De Carlo
- The European Federation of Allergy and Airways Diseases Patients Associations (EFA), 1000 Brussels, Belgium;
| | - Fabiano Di Marco
- Respiratory Unit, ASST - Papa Giovanni XXIII Hospital, Bergamo, University of Milan, 24127 Milan, Italy;
| | - Mina Gaga
- 7th Respiratory Medicine Dept, Asthma Cen, Athens Chest Hospital, 11527 Athens, Greece;
| | - Catherine Hawrylowicz
- Division of Asthma, Allergy and Lung Biology, King’s College London, Guy’s Hospital, London SE1 9RT, UK;
| | - Enrico Heffler
- Personalised Medicine Clinic Asthma & Allergy, Humanitas University, Department of Biomedical Sciences, IRCCS Humanitas Research Hospital, Rozzano, 20089 Milan, Italy; (G.W.C.); (E.H.)
| | - Maria Gabriella Matera
- Unit of Pharmacology, Dept. Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80138 Naples, Italy;
| | - Andrea Matucci
- Immunoallergology Unit, Careggi University Hospital, 50139 Florence, Italy;
| | - Pierluigi Paggiaro
- Department of Surgery, Medicine, Molecular Biology and Critical Care, University of Pisa, 56126 Pisa, Italy;
| | - Alberto Papi
- Research Center on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, 44121 Ferrara, Italy;
| | - Todor Popov
- Clinic of Occupational Diseases, University Hospital Sv. Ivan Rilski, 1431 Sofia, Bulgaria;
| | - Paola Rogliani
- Unit of Respiratory Medicine, Dept. Experimental Medicine, University of Rome “Tor Vergata”, 00133 Rome, Italy; (M.C.); (P.R.)
| | - Pierachille Santus
- Division of Respiratory Diseases, Department of Biomedical and Clinical Sciences (DIBIC), Università degli Studi di Milano, Ospedale L. Sacco, ASST Fatebenefratelli-Sacco, 20157 Milan, Italy;
| | - Paolo Solidoro
- Pneumology Unit U, Cardiovascular and Thoracic Department, AOU Città della Salute e della Scienza di Torino, University of Turin, 10126 Turin, Italy;
| | - Alkis Togias
- National Institute of Allergy and Infectious Diseases, Bethesda, MD 20814, USA;
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11
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
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.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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12
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Lee J, Denton E, Hoy R, Tay TR, Bondarenko J, Hore-Lacy F, Radhakrishna N, O'Hehir RE, Dabscheck E, Abramson MJ, Hew M. Paradoxical Vocal Fold Motion in Difficult Asthma Is Associated with Dysfunctional Breathing and Preserved Lung Function. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2256-2262. [PMID: 32173506 DOI: 10.1016/j.jaip.2020.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/13/2020] [Accepted: 02/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many patients with difficult asthma also have coexisting vocal cord dysfunction (VCD), evident by paradoxical vocal fold motion (PVFM) on laryngoscopy. OBJECTIVE Among patients with difficult asthma, we sought to identify clinical features associated with laryngoscopy-diagnosed PVFM. METHODS Consecutive patients with "difficult asthma" referred by respiratory specialists underwent systematic assessment in this observational study. Those with a high clinical suspicion for VCD were referred for laryngoscopy, either at rest or after mannitol provocation. Statistical analyses were performed to identify clinical factors associated with PVFM, and a multivariate logistic regression model was fitted to control for confounders. RESULTS Of 169 patients with difficult asthma, 63 (37.3%) had a high clinical probability of VCD. Of 42 who underwent laryngoscopy, 32 had PVFM confirmed. Patients with PVFM more likely had preserved lung function (prebronchodilator forced expiratory ratio 74% ± 11 vs 62% ± 16, P < .001); physiotherapist-confirmed dysfunctional breathing (odds ratio [OR] = 5.52, 95% confidence interval [CI]: 2.4-12.7, P < .001), gastro-oesophageal reflux (OR = 2.6, 95% CI: 1.16-5.8, P = .02), and a lower peripheral eosinophil count (0.09 vs 0.23, P = .004). On multivariate logistic regression, independent predictors for PVFM were dysfunctional breathing (OR = 4.93, 95% CI: 2-12, P < .001) and preserved lung function (OR = 1.07, 95% CI: 1.028-1.106, P < .001). CONCLUSION Among specialist-referred patients with difficult asthma, VCD pathogenesis may overlap with dysfunctional breathing but is not associated with severe airflow obstruction. Dysfunctional breathing and preserved lung function may serve as clinical clues for the presence of VCD.
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Affiliation(s)
- Joy Lee
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ryan Hoy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tunn Ren Tay
- Department of Respiratory & Critical Care Medicine, Changi General Hospital, Singapore
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Respiratory Medicine, Allergy and Clinical Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael J Abramson
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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13
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Systematic Assessment for Difficult and Severe Asthma Improves Outcomes and Halves Oral Corticosteroid Burden Independent of Monoclonal Biologic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1616-1624. [PMID: 31954193 DOI: 10.1016/j.jaip.2019.12.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/22/2019] [Accepted: 12/28/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Guidelines endorse systematic assessment for severe asthma, with data indicating benefit across multiple outcome domains. OBJECTIVE We examined which patients respond to systematic assessment and whether oral corticosteroid burden can be decreased independent of monoclonal biologic use. METHODS Specialist-referred patients are assessed systematically for difficult asthma at our center. We undertook a responder analysis for improvements in the domains of symptom control, quality of life, exacerbations, and airflow obstruction, assessed 6 months after initial assessment. Multivariate analyses were performed for each domain to identify predictors of response. Changes in oral corticosteroid burden were also measured, stratified by monoclonal biologics commenced during assessment. RESULTS Among 161 patients assessed systematically, 64% had a reduction in exacerbations, 54% achieved minimum clinically important differences for both symptom control and quality of life, and 40% increased their forced expiratory volume in 1 second by ≥100 mL. Altogether, 87% of patients with asthma improved in at least 1 domain. The most consistent predictor of response across domains was poorer baseline asthma status. There was a substantial reduction in mean chronic oral corticosteroid dose (11-5 mg, n = 46, P < .001), even after excluding 7 patients commenced on monoclonal biologics (11-5.6 mg, n = 39, P < .001). CONCLUSIONS Almost 90% of patients undergoing systematic assessment for difficult asthma improve significantly in at least 1 key asthma outcome, with few reliable predictors of response. The halving of oral corticosteroid burden during systematic assessment is independent of, and comparable in magnitude with, that achieved by monoclonal biologics.
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14
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Abstract
Background: Severe asthma can be a challenging disease to manage by the provider and by the patient, supported by evidence of increased health-care utilization by this population. Patients with severe asthma should be screened for comorbidities because these often contribute to poorly controlled asthma. The impact of comorbidities, however, are not completely understood. Objective: To review common comorbidities and their impact on severe asthma. Methods: A review of relevant clinical research studies that examined comorbidities in severe or difficult-to-treat asthma. Results: A number of comorbid diseases, including rhinitis, rhinosinusitis, gastroesophageal reflux, and obstructive sleep apnea, are associated with severe or difficult-to-treat asthma. If present and untreated, these conditions may adversely affect asthma control, quality of life, and/or lung function, despite adequate treatment with step-up asthma controller therapy. Conclusion: Treatable comorbidities are associated with severe and difficult-to-control asthma. Failure to recognize these comorbidities may divert appropriate care and increase disease burden. Assessment and management of these risk factors may contribute to improved asthma outcome; however, more investigation is needed to understand the relationship of comorbidities and asthma due to inconsistency in the findings.
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Affiliation(s)
- Gayatri B Patel
- Division of Allergy and Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Anju T Peters
- Division of Allergy and Immunology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
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15
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Chung LP, Upham JW, Bardin PG, Hew M. Rational oral corticosteroid use in adult severe asthma: A narrative review. Respirology 2019; 25:161-172. [PMID: 31713955 PMCID: PMC7027745 DOI: 10.1111/resp.13730] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 08/05/2019] [Accepted: 10/22/2019] [Indexed: 12/17/2022]
Abstract
OCS play an important role in the management of asthma. However, steroid‐related AE are common and represent a leading cause of morbidity. Limited published studies suggest OCS usage varies across countries and recent registry data indicate that at least 25–60% of patients with severe asthma in developed countries may at some stage be prescribed OCS. Recent evidence indicate that many patients do not receive optimal therapy for asthma and are often prescribed maintenance OCS or repeated steroid bursts to treat exacerbations. Given the recent progress in adult severe asthma and new treatment options, judicious appraisal of steroid use is merited. A number of strategies and add‐on therapies are now available to treat severe asthma. These include increasing specialist referral for multidisciplinary assessments and implementing OCS‐sparing interventions, such as improving guideline adherence and add‐on tiotropium and macrolides. Biologics have recently become available for severe asthma; these agents reduce asthma exacerbations and lower OCS exposure. Further research, collaboration and consensus are necessary to develop a structured stewardship approach including realistic OCS‐weaning programmes for patients with severe asthma on regular OCS; education and public health campaigns to improve timely access to specialized severe asthma services for treatment optimization; and implementing targeted strategies to identify patients who warrant OCS use using objective biomarker‐based strategies.
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Affiliation(s)
- Li Ping Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Perth, WA, Australia
| | - John W Upham
- Department of Respiratory Medicine, Princess Alexandra Hospital and University of Queensland, Brisbane, QLD, Australia
| | - Philip G Bardin
- Department of Respiratory and Sleep Medicine, Monash Medical Centre, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Hospital, Melbourne, VIC, Australia
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16
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Hains I, Meyers J, Sterling K, Yoo J, Reddel H, Weston C. Difficult-to-treat and severe asthma in general practice: delivery and evaluation of an educational program. BMC FAMILY PRACTICE 2019; 20:99. [PMID: 31301742 PMCID: PMC6626400 DOI: 10.1186/s12875-019-0991-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Accepted: 07/08/2019] [Indexed: 11/25/2022]
Abstract
Background Asthma, a common yet complex airway disorder affecting about 11% of Australians, is well-controlled in only 54% of people with asthma. Those with difficult-to-treat and severe asthma are more likely to experience recurrent and potentially life-threatening exacerbations. It is therefore important that GPs can initiate a systematic approach for the management of patients with difficult-to-treat asthma to identify those whose condition may improve by addressing contributory factors and those who require specialist input. We therefore aimed to develop and deliver an educational program for GPs on the systematic management of patients with difficult-to-treat and severe asthma and evaluate the effectiveness of this program. Methods We developed an educational program on the management of difficult-to-treat and severe asthma in primary care that was delivered to GPs and other health professionals between January and June 2018. We evaluated the effectiveness of the program using a retrospective pre-test with post-survey, administered to GPs directly after program participation. Results Over 1000 general practice health professionals participated in the educational program, including 890 GPs of whom 226 (25%) completed the survey. Following program participation, a greater proportion of GPs identified factors they would assess in managing a patient with poor asthma control, particularly for considering the risk of future adverse outcomes (+ 51%), changes in lifestyle (+ 38%), and self-management strategies (+ 35%). GPs indicated a greater awareness of the biologic therapies that specialists could consider prescribing to their patients with severe asthma (+ 75%), of the requirements for a patient to be prescribed a biologic therapy (+ 73%) and that patients with different phenotypic characteristics can respond differently to standard therapy (+ 67%). The proportion of GPs who would refer appropriate patients to a specialist also significantly increased. Conclusions This study suggests that an evidence-based educational program can improve GP knowledge, confidence and intended practice in managing patients with difficult-to-treat and severe asthma. Electronic supplementary material The online version of this article (10.1186/s12875-019-0991-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Isla Hains
- NPS MedicineWise, PO Box 1147, Strawberry Hills, NSW, 2012, Australia.
| | - Josh Meyers
- NPS MedicineWise, PO Box 1147, Strawberry Hills, NSW, 2012, Australia
| | - Kirsten Sterling
- NPS MedicineWise, PO Box 1147, Strawberry Hills, NSW, 2012, Australia
| | - Jeannie Yoo
- NPS MedicineWise, PO Box 1147, Strawberry Hills, NSW, 2012, Australia
| | - Helen Reddel
- Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, 2006, Australia
| | - Clare Weston
- NPS MedicineWise, PO Box 1147, Strawberry Hills, NSW, 2012, Australia
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Tay TR, Lee JWY, Hew M. Diagnosis of severe asthma. Med J Aust 2019; 209:S3-S10. [PMID: 30453866 DOI: 10.5694/mja18.00125] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2018] [Accepted: 05/21/2018] [Indexed: 02/01/2023]
Abstract
Patients with asthma that is uncontrolled despite high intensity medication can present in both primary and specialist care. An increasing number of novel (and expensive) treatments are available for patients who fail conventional asthma therapy, but these may not be appropriate for all such patients. It is essential that a rigorous evaluation process be undertaken for these patients to identify those with biologically severe asthma who will require novel therapies, and those who may improve with control of contributory factors. In this article, we describe three key steps in the diagnostic evaluation process for severe asthma. The first step is confirmation of asthma diagnosis with objective evidence of variable airflow obstruction. The second involves management of contributory factors such as non-adherence, poor inhaler technique, ongoing asthma triggers, and comorbidities. The third step involves phenotyping and endotyping of patients with severe asthma. We provide a practical approach to implementing these measures in both primary and secondary care.
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Affiliation(s)
| | | | - Mark Hew
- The Alfred Hospital, Melbourne, VIC
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18
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Severe Asthma Global Evaluation (SAGE): An Electronic Platform for Severe Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2019; 7:1440-1449. [PMID: 30954467 DOI: 10.1016/j.jaip.2019.02.042] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 12/16/2018] [Revised: 02/22/2019] [Accepted: 02/27/2019] [Indexed: 01/26/2023]
Abstract
Severe asthma is complex and heterogeneous; ad hoc outpatient assessment can be suboptimal. Systematic evaluation improves outcomes and is recommended by international guidelines. Electronic templates improve physician performance and clinical processes, and may be useful in severe asthma systematic evaluation. We developed the Severe Asthma Global Evaluation (SAGE) electronic platform to streamline this process, via Research Electronic Data Capture (REDCap). It incorporates: a questionnaire battery for patient completion before clinical consultation; asthma and comorbidity modules; a clinical summary page in an asthma management module; a nurse educator module; a structured panel discussion record; and an automatically generated report incorporating all key data. SAGE incorporates 282 clinician input fields, with a typical consultation requiring completion of 169. To streamline the process SAGE contains 34 autocalculations and 20 decision support tools. It incorporates all 95 core variables of the International Severe Asthma Registry, with which it is directly compatible. SAGE improves symptom control and exacerbations in patients with difficult asthma. In conclusion, we developed and validated an electronic platform that facilitates a comprehensive but streamlined systematic evaluation of severe asthma that is available for free download via REDCap. Its use enhances management of patients with severe asthma and facilitates audit and international research collaboration.
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Denton E, Bondarenko J, O'Hehir RE, Hew M. Breathing pattern disorder in difficult asthma: Characteristics and improvement in asthma control and quality of life after breathing re-training. Allergy 2019; 74:201-203. [PMID: 30243028 DOI: 10.1111/all.13611] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Eve Denton
- Allergy, Asthma & Clinical Immunology The Alfred Hospital Melbourne Victoria Australia
- Public Health & Preventive Medicine Monash University Melbourne Victoria Australia
| | - Janet Bondarenko
- Physiotherapy Department The Alfred Hospital Melbourne Victoria Australia
| | - Robyn E. O'Hehir
- Allergy, Asthma & Clinical Immunology The Alfred Hospital Melbourne Victoria Australia
- Central Clinical School Monash University Melbourne Victoria Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology The Alfred Hospital Melbourne Victoria Australia
- Public Health & Preventive Medicine Monash University Melbourne Victoria Australia
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20
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Denton E, Bondarenko J, Tay T, Lee J, Radhakrishna N, Hore-Lacy F, Martin C, Hoy R, O'Hehir R, Dabscheck E, Hew M. Factors Associated with Dysfunctional Breathing in Patients with Difficult to Treat Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2018; 7:1471-1476. [PMID: 30529061 DOI: 10.1016/j.jaip.2018.11.037] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 11/01/2018] [Accepted: 11/19/2018] [Indexed: 01/08/2023]
Abstract
BACKGROUND Understanding of dysfunctional breathing in patients with difficult asthma who remain symptomatic despite maximal inhaler therapy is limited. OBJECTIVE We characterized the pattern of dysfunctional breathing in patients with difficult asthma and identified possible contributory factors. METHODS Dysfunctional breathing was identified in patients with difficult asthma using the Nijmegen Questionnaire (score >23). Demographic characteristics, asthma variables, and comorbidities were assessed. Multivariate logistic regression was performed for dysfunctional breathing, adjusted for age, sex, body mass index, and airflow obstruction. RESULTS Of 157 patients with difficult asthma, 73 (47%) had dysfunctional breathing. Compared with patients without dysfunctional breathing, those with dysfunctional breathing experienced poorer asthma status (symptom control, quality of life, and exacerbation rates) and greater unemployment. In addition, more frequently they had elevated sino-nasal outcome test scores, anxiety, depression, sleep apnea, and gastroesophageal reflux. On multivariate analysis, anxiety (odds ratio [OR], 3.26; 95% CI, 1.18-9.01; P = .02), depression (OR, 2.8; 95% CI, 1.14-6.9; P = .03), and 22-item sino-nasal outcome test score (OR, 1.03; 95% CI, 1.003-1.05; P = .03) were independent risk factors for dysfunctional breathing. CONCLUSIONS Dysfunctional breathing is common in difficult asthma and associated with worse asthma status and unemployment. The independent association with psychological disorders and nasal obstruction highlight an important interaction between comorbid treatable traits in difficult asthma.
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Affiliation(s)
- Eve Denton
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia.
| | - Janet Bondarenko
- Physiotherapy Department, The Alfred Hospital, Melbourne, Victoria, Australia
| | - TunnRen Tay
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Joy Lee
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Catherine Martin
- Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ryan Hoy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robyn O'Hehir
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Victoria, Australia; Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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21
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Tay TR, Hew M. Comorbid "treatable traits" in difficult asthma: Current evidence and clinical evaluation. Allergy 2018; 73:1369-1382. [PMID: 29178130 DOI: 10.1111/all.13370] [Citation(s) in RCA: 99] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/21/2017] [Indexed: 01/07/2023]
Abstract
The care of patients with difficult-to-control asthma ("difficult asthma") is challenging and costly. Despite high-intensity asthma treatment, these patients experience poor asthma control and face the greatest risk of asthma morbidity and mortality. Poor asthma control is often driven by severe asthma biology, which has appropriately been the focus of intense research and phenotype-driven therapies. However, it is increasingly apparent that extra-pulmonary comorbidities also contribute substantially to poor asthma control and a heightened disease burden. These comorbidities have been proposed as "treatable traits" in chronic airways disease, adding impetus to their evaluation and management in difficult asthma. In this review, eight major asthma-related comorbidities are discussed: rhinitis, chronic rhinosinusitis, gastroesophageal reflux, obstructive sleep apnoea, vocal cord dysfunction, obesity, dysfunctional breathing and anxiety/depression. We describe the prevalence, impact and treatment effects of these comorbidities in the difficult asthma population, emphasizing gaps in the current literature. We examine the associations between individual comorbidities and highlight the potential for comorbidity clusters to exert combined effects on asthma outcomes. We conclude by outlining a pragmatic clinical approach to assess comorbidities in difficult asthma.
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Affiliation(s)
- T. R. Tay
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- Department of Respiratory and Critical Care Medicine; Changi General Hospital; Singapore
| | - M. Hew
- Allergy, Asthma and Clinical Immunology; The Alfred Hospital; Melbourne Vic. Australia
- School of Public Health & Preventive Medicine; Monash University; Melbourne Vic. Australia
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22
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Lee JW, Tay TR, Paddle P, Richards AL, Pointon L, Voortman M, Abramson MJ, Hoy R, Hew M. Diagnosis of concomitant inducible laryngeal obstruction and asthma. Clin Exp Allergy 2018; 48:1622-1630. [PMID: 29870077 DOI: 10.1111/cea.13185] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2018] [Revised: 05/09/2018] [Accepted: 05/31/2018] [Indexed: 01/20/2023]
Abstract
BACKGROUND Inducible laryngeal obstruction, an induced, inappropriate narrowing of the larynx, leading to symptomatic upper airway obstruction, can coexist with asthma. Accurate classification has been challenging because of overlapping symptoms and the absence of sensitive diagnostic criteria for either condition. OBJECTIVE To evaluate patients with concomitant clinical suspicion for inducible laryngeal obstruction and asthma. We used a multidisciplinary protocol incorporating objective diagnostic criteria to determine whether asthma, inducible laryngeal obstruction, both, or neither diagnosis was present. METHODS Consecutive patients were prospectively assessed by a laryngologist, speech pathologist and respiratory physician. Inducible laryngeal obstruction was diagnosed by visualizing paradoxical vocal fold motion either at baseline or following mannitol provocation. Asthma was diagnosed by physician assessment with objective variable airflow obstruction. Validated questionnaires for laryngeal dysfunction and relevant comorbidities were administered. RESULTS Of 69 patients, 15 had asthma alone, 11 had inducible laryngeal obstruction alone and 14 had neither objectively demonstrated. Twenty-nine patients had both diagnoses. In 19 patients, inducible laryngeal obstruction was only seen following provocation. Among patients with inducible laryngeal obstruction, chest tightness was more frequent with concurrent asthma. Among patients with asthma, stridor was more frequent with concurrent inducible laryngeal obstruction. Cough was more frequently found in asthma alone, whereas difficulty with inspiration and symptoms triggered by psychological stress were more frequently found in inducible laryngeal obstruction alone. Patients with asthma alone had greater airflow obstruction. Relevant comorbidities were frequent (rhinitis in 85%, gastro-oesophageal reflux in 65%), and questionnaire scores for laryngeal dysfunction were abnormal. However, neither comorbidities nor questionnaires differentiated patients with or without inducible laryngeal obstruction. CONCLUSIONS AND CLINICAL RELEVANCE In this cohort with suspected inducible laryngeal obstruction and asthma, 42% had objective evidence of both conditions. Clinical assessment, questionnaire scores and comorbidity burden were not sufficiently discriminatory for diagnosis, highlighting the necessity of objective diagnostic testing.
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Affiliation(s)
- Joy W Lee
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Vic., Australia
| | - Tunn Ren Tay
- Department of Respiratory Medicine, Changi General Hospital, Singapore, Singapore
| | - Paul Paddle
- Department of Otolaryngology, Head and Neck Surgery, Monash Health, Melbourne, Vic., Australia.,Department of Surgery, Monash University, Melbourne, Vic., Australia
| | - Amanda L Richards
- Department of Otolaryngology, Head and Neck Surgery, The Royal Melbourne Hospital, Melbourne, Vic., Australia
| | - Lisa Pointon
- Department of Speech Pathology, The Alfred Hospital, Melbourne, Vic., Australia
| | - Miriam Voortman
- Department of Speech Pathology, The Alfred Hospital, Melbourne, Vic., Australia
| | - Michael J Abramson
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia
| | - Ryan Hoy
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Vic., Australia
| | - Mark Hew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Vic., Australia.,Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, Vic., Australia
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Calabrese C, Costigliola A, Maffei M, Simeon V, Perna F, Tremante E, Merola E, Leone CA, Bianco A. Clinical impact of nasal budesonide treatment on COPD patients with coexistent rhinitis. Int J Chron Obstruct Pulmon Dis 2018; 13:2025-2032. [PMID: 29988687 PMCID: PMC6029594 DOI: 10.2147/copd.s165857] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background A high percentage of patients with COPD report chronic nasal symptoms. The study aims to evaluate the clinical impact of a 2-month treatment with inhaled nasal budesonide (100 µg per nostril twice daily) in patients affected by COPD with chronic rhinitis comorbidity. Patients and methods Fifty-three stable COPD patients in therapy according to the Global initiative for chronic Obstructive Lung Disease recommendations were enrolled; 49 completed the study. At enrollment (visit 0), patients underwent skin prick test and rhinoscopy. At visit 0 and after 1 month (visit 1) and 2 months (visit 2) of therapy with nasal budesonide, patients underwent spirometry, and COPD assessment test (CAT), Sinonasal Outcome Test (SNOT 22), and modified Medical Research Council dyspnea scale were administered. Differences in continuous variables, after 2 months of treatment with nasal budesonide, were evaluated using a paired t-test or Wilcoxon matched-pairs signed-ranks test. Results Two months of treatment with nasal budesonide showed a significant statistical improvement in the total scores of CAT, SNOT 22, and modified Medical Research Council (p<0.001). A significant relationship between CAT and SNOT 22 total scores at baseline and after treatment was observed. Conclusion The results of the present study indicate the importance of careful evaluation of the presence of chronic nasal symptoms in all COPD patients and suggest beneficial clinical effect from treatment with nasal budesonide in terms of COPD symptoms and quality of life.
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Affiliation(s)
- Cecilia Calabrese
- Department of Cardio-Thoracic and Respiratory Sciences, Monaldi Hospital, University of Campania "Luigi Vanvitelli", Naples, Italy,
| | - Adriano Costigliola
- Department of Cardio-Thoracic and Respiratory Sciences, Monaldi Hospital, University of Campania "Luigi Vanvitelli", Naples, Italy,
| | - Marianna Maffei
- Ear Nose and Throat Unit and Neck Surgery, Monaldi Hospital, Naples, Italy
| | - Vittorio Simeon
- Medical Statistics Unit, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Francesco Perna
- Department of Clinical Medicine and Surgery, Monaldi Hospital, University "Federico II", Naples, Italy
| | - Eugenio Tremante
- Ear Nose and Throat Unit and Neck Surgery, Monaldi Hospital, Naples, Italy
| | - Elena Merola
- Bronchoscopic Unit, Public Hospital, Eboli, Italy
| | | | - Andrea Bianco
- Department of Cardio-Thoracic and Respiratory Sciences, Monaldi Hospital, University of Campania "Luigi Vanvitelli", Naples, Italy,
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Lee J, Tay TR, Radhakrishna N, Hore-Lacy F, Mackay A, Hoy R, Dabscheck E, O'Hehir R, Hew M. Nonadherence in the era of severe asthma biologics and thermoplasty. Eur Respir J 2018. [PMID: 29519922 PMCID: PMC5884695 DOI: 10.1183/13993003.01836-2017] [Citation(s) in RCA: 73] [Impact Index Per Article: 12.2] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Nonadherence to inhaled preventers impairs asthma control. Electronic monitoring devices (EMDs) can objectively measure adherence. Their use has not been reported in difficult asthma patients potentially suitable for novel therapies, i.e. biologics and bronchial thermoplasty.Consecutive patients with difficult asthma were assessed for eligibility for novel therapies. Medication adherence, defined as taking >75% of prescribed doses, was assessed by EMD and compared with standardised clinician assessment over an 8-week period.Among 69 difficult asthma patients, adherence could not be analysed in 13, due to device incompatibility or malfunction. Nonadherence was confirmed in 20 out of 45 (44.4%) patients. Clinical assessment of nonadherence was insensitive (physician 15%, nurse 28%). Serum eosinophils were higher in nonadherent patients. Including 11 patients with possible nonadherence (device refused or not returned) increased the nonadherence rate to 31 out of 56 (55%) patients. Severe asthma criteria were fulfilled by 59 out of 69 patients. 47 were eligible for novel therapies, with confirmed nonadherence in 16 out of 32 (50%) patients with EMD data; including seven patients with possible nonadherence increased the nonadherence rate to 23 out of 39 (59%).At least half the patients eligible for novel therapies were nonadherent to preventers. Nonadherence was often undetectable by clinical assessments. Preventer adherence must be confirmed objectively before employing novel severe asthma therapies.
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Affiliation(s)
- Joy Lee
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Tunn Ren Tay
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Anna Mackay
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia
| | - Ryan Hoy
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
| | - Eli Dabscheck
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Robyn O'Hehir
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,Allergy, Immunology and Respiratory Medicine, Central Clinical School, Monash University, Melbourne, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology, The Alfred Hospital, Melbourne, Australia.,School of Public Health and Preventive Medicine, Monash University, Melbourne, Australia
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Colodenco D, Palomares O, Celis C, Kaplan A, Domingo C. Moving toward consensus on diagnosis and management of severe asthma in adults. Curr Med Res Opin 2018; 34:387-399. [PMID: 28906154 DOI: 10.1080/03007995.2017.1380617] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
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.
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Affiliation(s)
- Daniel Colodenco
- a Pulmonology , Hospital De Rehabilitación Respiratoria María Ferrer , Buenos Aires , Argentina
| | - Oscar Palomares
- b Department of Biochemistry and Molecular Biology , School of Chemistry, Complutense University of Madrid , Madrid , Spain
| | - Carlos Celis
- c Pulmonary Unit, Internal Medicine Department , Hospital Universitario San Ignacio , Bogota , Colombia
| | - Alan Kaplan
- d University of Toronto , Thornhill , Ontario , Canada
| | - Christian Domingo
- e Servei de Pneumologia , Corporació Sanitària Parc Taulí , Barcelona , Spain
- f Department of Medicine , Universitat Autònoma de Barcelona (UAB) , Barcelona , Spain
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Dysfunctional breathing is more frequent in chronic obstructive pulmonary disease than in asthma and in health. Respir Physiol Neurobiol 2017; 247:20-23. [PMID: 28870869 DOI: 10.1016/j.resp.2017.08.011] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 08/13/2017] [Accepted: 08/16/2017] [Indexed: 11/21/2022]
Abstract
Involuntary adaptations of breathing patterns to counter breathlessness may lead to dysfunctional breathing in obstructive lung diseases. However, no studies examining dysfunctional breathing in Chronic Obstructive Pulmonary Disease (COPD) have been reported. Patients with verified COPD (n=34), asthma (n=37) and a healthy control group (n=41) were recruited. All participants completed the Nijmegen questionnaire for dysfunctional breathing as well as measures of disease activity. Comparisons between groups employed analysis of variance with post-hoc Bonferroni analyses and Pearson correlation for associations. Patients with COPD had significantly higher Nijmegen questionnaire scores than asthmatics (COPD: 23.4±10.6 versus 17.3±10.6, p=0.016) and healthy individuals (14.3±9.6, p=0.002). Significantly more patients with COPD had severe dysfunctional breathing with Nijmegen scores >23 (47%; 16/34) compared to asthma (27%; 10/37) and healthy controls (17%; 7/41) respectively (p=0.019). Dysfunctional breathing was detected in ∼50% of patients with COPD, more so than in asthma or health. Strategies to reduce abnormal breathing behaviours may have important benefits for treatment of breathlessness in COPD.
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Affiliation(s)
- Elliot Israel
- From the Pulmonary and Critical Care Medicine Division-Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (E.I.); and the Clinical Management Group and Centre for Research Excellence in Severe Asthma, Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
| | - Helen K Reddel
- From the Pulmonary and Critical Care Medicine Division-Division of Rheumatology, Immunology, and Allergy, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (E.I.); and the Clinical Management Group and Centre for Research Excellence in Severe Asthma, Woolcock Institute of Medical Research, University of Sydney, Sydney (H.K.R.)
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Tay TR, Lee J, Radhakrishna N, Hore-Lacy F, Stirling R, Hoy R, Dabscheck E, O'Hehir R, Hew M. A Structured Approach to Specialist-referred Difficult Asthma Patients Improves Control of Comorbidities and Enhances Asthma Outcomes. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 5:956-964.e3. [PMID: 28284780 DOI: 10.1016/j.jaip.2016.12.030] [Citation(s) in RCA: 45] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/13/2016] [Revised: 12/05/2016] [Accepted: 12/20/2016] [Indexed: 12/15/2022]
Abstract
BACKGROUND Systematic evaluation is advocated for difficult asthma, but how best to deliver such care is unclear and outcome data are scarce. OBJECTIVE We describe our institution's structured approach to difficult asthma management and report on the outcomes of such an approach. METHODS Eighty-two consecutive patients with difficult asthma referred to our clinic from respiratory specialists were evaluated in 3 key areas: diagnostic confirmation, comorbidity detection, and inflammatory phenotyping. We then optimized treatment including relevant comorbidity interventions. The outpatient protocol was supported by comorbidity questionnaires, an electronic clinic template, and standardized panel discussion. Asthma outcomes were assessed at 6 months. RESULTS Sixty-eight patients completed follow-up. Asthma diagnosis was refuted in 3 patients and the remaining 65 patients were included in the study analysis. There was no overall escalation of inhaled or oral corticosteroids. Patients had a median of 3 comorbidities, and a median of 3 comorbidity interventions. Control of chronic rhinosinusitis and dysfunctional breathing improved among patients with these diagnoses (22-item Sino-Nasal Outcome Test score from 47 ± 20 to 37 ± 22, P = .017; Nijmegen score from 32 ± 6 to 25 ± 9, P = .003). There were overall improvements in the Asthma Control Test score (from 14 ± 5 to 16 ± 6, P < .001), the Asthma Quality of Life Questionnaire (from 4.29 ± 1.4 to 4.65 ± 1.5, P = .073), and the frequency of exacerbations over 6 months (from 2 [interquartile range, 0-4] to 0 [interquartile range, 0-2], P < .001). CONCLUSIONS In patients referred with difficult asthma from respiratory specialists, a structured approach coupled with targeted comorbidity interventions improved control of key comorbidities and enhanced asthma outcomes.
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Affiliation(s)
- Tunn Ren Tay
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia.
| | - Joy Lee
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia
| | - Robert Stirling
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Ryan Hoy
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Robyn O'Hehir
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; Department of Medicine, Monash University, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma and Clinical Immunology Service, The Alfred Hospital, Melbourne, Victoria, Australia; School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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