Inflammation and airway function in the lung periphery of patients with stable asthma

Small airway disease in asthma and COPD: clinical implications

Asthma and COPD have a high personal, societal, and economic impact. Both diseases are characterized by airway obstruction and an inflammatory process. The inflammatory process affects the whole respiratory tract, from central to peripheral airways that are <2 mm in internal diameter, the so-called small airways. There is an increased interest in small airway disease, and some new insights have been gained about the contribution of these small airways to the clinical expression of asthma and COPD, as reviewed in this article. Newly developed devices enable drugs to target the small airways, and this may have implications for treatment of patients with asthma, particularly those not responding to large-particle inhaled corticosteroids or those with uncontrollable asthma. The first studies in COPD are promising, and results from new studies are eagerly awaited.

Targeting small airways in asthma: improvement in clinical benefit?

BACKGROUND AND AIM

Disease control is not achieved in a substantial proportion of patients with asthma. Recent advances in aerosol formulations and delivery devices may offer more effective therapy. This review will focus on the importance and potential clinical benefit of targeting the lung periphery in adult asthma by means of ultra-fine aerosols.

RESULTS

Ultra-fine formulations of inhaled corticosteroids (ICS) have improved lung deposition up to at least 50%, primarily in the peripheral airways. Ultra-fine formulations of ICS provide equivalent asthma control to non-ultra-fine ICS at approximately half the daily dose, with no increased risk of systemic effects. Clinical studies of adults with asthma have shown a greater effect of ultra-fine ICS, compared with non-ultra-fine ICS, on quality of life, small airway patency, and markers of pulmonary and systemic inflammation, but no difference with regard to conventional clinical indices of lung function and asthma control.

CONCLUSIONS

Asthma patients treated with ultra-fine ICS, compared with non-ultra-fine ICS, have at least similar chance of achieving asthma control at a lower daily dose. Further clinical studies are needed to explore whether treatment with ultra-fine formulations of ICS will change the natural history of asthma and prevent airway remodelling in both the large and small airways.