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Siora A, Vontetsianos A, Chynkiamis N, Anagnostopoulou C, Bartziokas K, Anagnostopoulos N, Rovina N, Bakakos P, Papaioannou AI. Small airways in asthma: From inflammation and pathophysiology to treatment response. Respir Med 2024; 222:107532. [PMID: 38228215 DOI: 10.1016/j.rmed.2024.107532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2023] [Revised: 01/02/2024] [Accepted: 01/13/2024] [Indexed: 01/18/2024]
Abstract
Small airways are characterized as those with an inner diameter less than 2 mm and constitute a major site of pathology and inflammation in asthma disease. It is estimated that small airways dysfunction may occur before the emergence of noticeable symptoms, spirometric abnormalities and imaging findings, thus characterizing them as "the quiet or silent zone" of the lungs. Despite their importance, measuring and quantifying small airways dysfunction presents a considerable challenge due to their inaccessibility in usual functional measurements, primarily due to their size and peripheral localization. Several pulmonary function tests have been proposed for the assessment of the small airways, including impulse oscillometry, nitrogen washout, body plethysmography, as well as imaging methods. Nevertheless, none of these methods has been established as the definitive "gold standard," thus, a combination of them should be used for an effective assessment of the small airways. Widely used asthma treatments seem to also affect several parameters of the small airways. Emerging biologic treatments show promising results in reducing small airways inflammation and remodelling, providing evidence for potential alterations in the disease's progression and outcomes. These novel therapies have implications not only in the clinical aspects of asthma but also in its inflammatory and functional aspects.
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Affiliation(s)
- Anastasia Siora
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece.
| | - Angelos Vontetsianos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Nikolaos Chynkiamis
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Christina Anagnostopoulou
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | | | - Nektarios Anagnostopoulos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Nikoletta Rovina
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Petros Bakakos
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
| | - Andriana I Papaioannou
- 1st Department of Respiratory Medicine, National and Kapodistrian University of Athens, School of Medicine, Sotiria Chest Hospital, Athens, Greece
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2
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James AL, Donovan GM, Green FHY, Mauad T, Abramson MJ, Cairncross A, Noble PB, Elliot JG. Heterogeneity of Airway Smooth Muscle Remodeling in Asthma. Am J Respir Crit Care Med 2023; 207:452-460. [PMID: 36399661 DOI: 10.1164/rccm.202111-2634oc] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Rationale: Ventilatory defects in asthma are heterogeneous and may represent the distribution of airway smooth muscle (ASM) remodeling. Objectives: To determine the distribution of ASM remodeling in mild-severe asthma. Methods: The ASM area was measured in nine airway levels in three bronchial pathways in cases of nonfatal (n = 30) and fatal asthma (n = 20) and compared with control cases without asthma (n = 30). Correlations of ASM area within and between bronchial pathways were calculated. Asthma cases with 12 large and 12 small airways available (n = 42) were classified on the basis of the presence or absence of ASM remodeling (more than two SD of mean ASM area of control cases, n = 86) in the large or small airway or both. Measurements and Main Results: ASM remodeling varied widely within and between cases of nonfatal asthma and was more widespread and confluent and more marked in fatal cases. There were weak correlations of ASM between levels within the same or separate bronchial pathways; however, predictable patterns of remodeling were not observed. Using mean data, 44% of all asthma cases were classified as having no ASM remodeling in either the large or small airway despite a three- to 10-fold increase in the number of airways with ASM remodeling and 81% of asthma cases having ASM remodeling in at least one large and small airway. Conclusions: ASM remodeling is related to asthma severity but is heterogeneous within and between individuals and may contribute to the heterogeneous functional defects observed in asthma. These findings support the need for patient-specific targeting of ASM remodeling.
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Affiliation(s)
- Alan L James
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Medicine and Pharmacology and
| | - Graham M Donovan
- Department of Mathematics, University of Auckland, Auckland, New Zealand
| | - Francis H Y Green
- Department of Pathology and Laboratory Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Thais Mauad
- Department of Pathology, Sao Paulo University Medical School, Sao Paulo, Brazil; and
| | - Michael J Abramson
- School of Public Health & Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alvenia Cairncross
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - Peter B Noble
- School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
| | - John G Elliot
- West Australian Sleep Disorders Research Institute, Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,School of Human Sciences, The University of Western Australia, Crawley, Western Australia, Australia
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3
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Shimizu K, Kimura H, Tanabe N, Chubachi S, Sato S, Suzuki M, Tanimura K, Iijima H, Oguma A, Ito YM, Wakazono N, Takimoto-Sato M, Matsumoto-Sasaki M, Abe Y, Takei N, Makita H, Nishimura M, Konno S. Relationships of computed tomography-based small vessel indices of the lungs with ventilation heterogeneity and high transfer coefficients in non-smokers with asthma. Front Physiol 2023; 14:1137603. [PMID: 36935740 PMCID: PMC10014854 DOI: 10.3389/fphys.2023.1137603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 02/17/2023] [Indexed: 03/05/2023] Open
Abstract
Background: The mechanism of high transfer coefficients of the lungs for carbon monoxide (Kco) in non-smokers with asthma is explained by the redistribution of blood flow to the area with preserved ventilation, to match the ventilation perfusion. Objectives: To examine whether ventilation heterogeneity, assessed by pulmonary function tests, is associated with computed tomography (CT)-based vascular indices and Kco in patients with asthma. Methods: Participants were enrolled from the Hokkaido-based Investigative Cohort Analysis for Refractory Asthma (Hi-CARAT) study that included a prospective asthmatic cohort. Pulmonary function tests including Kco, using single breath methods; total lung capacity (TLC), using multiple breath methods; and CT, were performed on the same day. The ratio of the lung volume assessed using single breath methods (alveolar volume; VA) to that using multiple breath methods (TLC) was calculated as an index of ventilation heterogeneity. The volume of the pulmonary small vessels <5 mm2 in the whole lung (BV5 volume), and number of BV5 at a theoretical surface area of the lungs from the plural surface (BV5 number) were evaluated using chest CT images. Results: The low VA/TLC group (the lowest quartile) had significantly lower BV5 number, BV5 volume, higher BV5 volume/BV5 number, and higher Kco compared to the high VA/TLC group (the highest quartile) in 117 non-smokers, but not in 67 smokers. Multivariable analysis showed that low VA/TLC was associated with low BV5 number, after adjusting for age, sex, weight, lung volume on CT, and CT emphysema index in non-smokers (not in smokers). Conclusion: Ventilation heterogeneity may be associated with low BV5 number and high Kco in non-smokers (not in smokers). Future studies need to determine the dynamic regional system in ventilation, perfusion, and diffusion in asthma.
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Affiliation(s)
- Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- *Correspondence: Kaoruko Shimizu,
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Naoya Tanabe
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Shotaro Chubachi
- Department of Medicine, Division of Pulmonary Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazuya Tanimura
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Hiroaki Iijima
- Department of Respiratory Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Akira Oguma
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yoichi M. Ito
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Nobuyasu Wakazono
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Michiko Takimoto-Sato
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Yuki Abe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Nozomu Takei
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Hironi Makita
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
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Robinson PD, Salimi F, Cowie CT, Clifford S, King GG, Thamrin C, Hardaker K, Mazaheri M, Morawska L, Toelle BG, Marks GB. Ultrafine particle exposure and biomarkers of effect on small airways in children. ENVIRONMENTAL RESEARCH 2022; 214:113860. [PMID: 35820650 DOI: 10.1016/j.envres.2022.113860] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/03/2022] [Accepted: 07/06/2022] [Indexed: 06/15/2023]
Abstract
The small size and large surface area of ultrafine particles (UFP) enhance their ability to deposit in the lung periphery and their reactivity. The Ultrafine Particles from Traffic Emissions and Children's Health (UPTECH) cross-sectional study was conducted in 8-11-year-old schoolchildren attending 25 primary (elementary) schools, randomly selected from the Brisbane Metropolitan Area, Queensland, Australia. Main study findings outlined indirect evidence of distal airway deposition (raised C reactive protein) but as yet, there is no direct evidence in the literature of effects of UFP exposure on peripheral airway function. We present further UPTECH study data from two sensitive peripheral airway function tests, Oscillometry and Multiple Breath Nitrogen Washout (MBNW), performed in 577 and 627 children (88% and 96% of UPTECH study cohort) respectively: mean(SD) age 10.1(0.9) years, 46% male, with 50% atopy and 14% current asthma. Bayesian generalised linear mixed effects regression models were used to estimate the effect of UFP particle number count (PNC) exposure on key oscillometry (airway resistance, (Rrs), and reactance, (Xrs)) and MBNW (lung clearance index, (LCI) and functional residual capacity, (FRC)) indices. We adjusted for age, sex, and height, and potential confounders including socio-economic disadvantage, PM2.5 and NO2 exposure. All models contained an interaction term between UFP PNC exposure and atopy, allowing estimation of the effect of exposure on non-atopic and atopic students. Increasing UFP PNC was associated with greater lung stiffness as evidenced by a decrease in Xrs [mean (95% credible interval) -1.63 (-3.36 to -0.05)%] per 1000#.cm-3]. It was also associated with greater lung stiffness (decrease in Xrs) in atopic subjects across all models [mean change ranging from -2.06 to -2.40% per 1000#.cm-3]. A paradoxical positive effect was observed for Rrs across all models [mean change ranging from -1.55 to -1.70% per 1000#.cm-3] (decreases in Rrs indicating an increase in airway calibre), which was present for both atopic and non-atopic subjects. No effects on MBNW indices were observed. In conclusion, a modest detrimental effect of UFP on peripheral airway function among atopic subjects, as assessed by respiratory system reactance, was observed extending the main UPTECH study findings which reported a positive association with a biomarker for systemic inflammation, C-reactive protein (CRP). Further studies are warranted to explore the pathophysiological mechanisms underlying increased respiratory stiffness, and whether it persists through to adolescence and adulthood.
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Affiliation(s)
- Paul D Robinson
- The Children's Hospital at Westmead, Sydney, Australia; Airway Physiology and Imaging, Woolcock Institute of Medical Research, University of Sydney, Australia; University of Sydney, Sydney, Australia
| | - Farhad Salimi
- University of Sydney, Sydney, Australia; Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Centre for Air Pollution, Energy and Health Research (CAR), Australia
| | - Christine T Cowie
- Centre for Air Pollution, Energy and Health Research (CAR), Australia; Respiratory and Environmental Epidemiology, Woolcock Institute of Medical Research, University of Sydney, Australia; South Western Sydney Clinical Campus, University of New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, Australia
| | - Samuel Clifford
- Centre for Air Pollution, Energy and Health Research (CAR), Australia; London School of Hygiene and Tropical Medicine, London, UK; International Laboratory for Air Quality and Health, Queensland University of Technology, Brisbane, Australia
| | - Gregory G King
- Airway Physiology and Imaging, Woolcock Institute of Medical Research, University of Sydney, Australia; University of Sydney, Sydney, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging, Woolcock Institute of Medical Research, University of Sydney, Australia; University of Sydney, Sydney, Australia
| | - Kate Hardaker
- Airway Physiology and Imaging, Woolcock Institute of Medical Research, University of Sydney, Australia; University of Sydney, Sydney, Australia
| | - Mandana Mazaheri
- Centre for Air Pollution, Energy and Health Research (CAR), Australia; Department of Planning, Industry and the Environment, Sydney, Australia
| | - Lidia Morawska
- Centre for Air Pollution, Energy and Health Research (CAR), Australia; International Laboratory for Air Quality and Health, Queensland University of Technology, Brisbane, Australia
| | - Brett G Toelle
- University of Sydney, Sydney, Australia; Respiratory and Environmental Epidemiology, Woolcock Institute of Medical Research, University of Sydney, Australia; Sydney Local Health District, Sydney, Australia.
| | - Guy B Marks
- Centre for Air Pollution, Energy and Health Research (CAR), Australia; Respiratory and Environmental Epidemiology, Woolcock Institute of Medical Research, University of Sydney, Australia; South Western Sydney Clinical Campus, University of New South Wales, Australia; Ingham Institute of Applied Medical Research, Sydney, Australia
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5
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Involvement of Cu-containing amine oxidases in the development of lung pathology in ovalbumin-induced bronchial asthma in guinea pigs. UKRAINIAN BIOCHEMICAL JOURNAL 2022. [DOI: 10.15407/ubj94.03.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
Bronchial asthma is developed as an immune response to allergen challenges accompanied by inflammation and fibrosis implicated in airway remodeling. To reveal the causative implication of Cu-containing amino oxidases semicarbazide-sensitive amine oxidase (SSAO), DAO and lysyl oxidase (LOX) in BA development we used their irreversible inhibitor semicarbazide and guinea pig model of BA induced by ovalbumin. Semicarbazide was introduced to asthmatic animals via drink or inhalation. At the 16th week after disease induction, the increase in the activity of pro-inflammatory SSAO and DAO in plasma (1.6 and 2 times, respectively) was observed. The introduction of semicarbazide to asthmatic animals via drink or inhalation significantly decreased activities of these enzymes compared to the untreated asthmatic animals. A considerable increase in IL-13 content and LOX activity in the lung tissue of asthmatic animals were observed that evidenced airway inflammation and pulmonary fibrosis development. The uptake of semicarbazide by guinea pigs with bronchial asthma led to normalization of LOX activity. Histological studies confirmed that semicarbazide attenuated morphopathological changes in the lungs of asthmatic animals. Thus, the data obtained indicate the direct participation of the studied enzymes in the progression of pathological processes in atopic bronchial asthma as well as the potential use of semicarbazide as a drug in complex anti-asthmatic therapy. Keywords: atopic bronchial asthma, histaminase/diamine oxidase, IL-13, lysyl oxidase, nitric oxide, semicarbazide, semicarbazide sensitive amine oxidase
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6
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Hassoun D, Rose L, Blanc FX, Magnan A, Loirand G, Sauzeau V. Bronchial smooth muscle cell in asthma: where does it fit? BMJ Open Respir Res 2022; 9:9/1/e001351. [PMID: 36109087 PMCID: PMC9478857 DOI: 10.1136/bmjresp-2022-001351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 09/04/2022] [Indexed: 11/04/2022] Open
Abstract
Asthma is a frequent respiratory condition whose pathophysiology relies on altered interactions between bronchial epithelium, smooth muscle cells (SMC) and immune responses. Those leads to classical hallmarks of asthma: airway hyper-responsiveness, bronchial remodelling and chronic inflammation. Airway smooth muscle biology and pathophysiological implication in asthma are now better understood. Precise deciphering of intracellular signalling pathways regulating smooth muscle contraction highlighted the critical roles played by small GTPases of Rho superfamily. Beyond contractile considerations, active involvement of airway smooth muscle in bronchial remodelling mechanisms is now established. Not only cytokines and growth factors, such as fibroblats growth factor or transforming growth factor-β, but also extracellular matrix composition have been demonstrated as potent phenotype modifiers for airway SMC. Although basic science knowledge has grown significantly, little of it has translated into improvement in asthma clinical practice. Evaluation of airway smooth muscle function is still limited to its contractile activity. Moreover, it relies on tools, such as spirometry, that give only an overall assessment and not a specific one. Interesting technics such as forced oscillometry or specific imagery (CT and MRI) give new perspectives to evaluate other aspects of airway muscle such as bronchial remodelling. Finally, except for the refinement of conventional bronchodilators, no new drug therapy directly targeting airway smooth muscle proved its efficacy. Bronchial thermoplasty is an innovative and efficient therapeutic strategy but is only restricted to a small proportion of severe asthmatic patients. New diagnostic and therapeutic strategies specifically oriented toward airway smooth muscle are needed to improve global asthma care.
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Affiliation(s)
- Dorian Hassoun
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Lindsay Rose
- Nantes Université, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, Pays de la Loire, France
| | - François-Xavier Blanc
- Nantes Université, CHU Nantes, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, France
| | - Antoine Magnan
- INRAe, UMR 0892, Hôpital Foch, Suresnes, France.,Université Versailles-Saint-Quentin-en-Yvelines Paris-Saclay, Versailles, France
| | - Gervaise Loirand
- Nantes Université, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, Pays de la Loire, France
| | - Vincent Sauzeau
- Nantes Université, CNRS, INSERM, l'institut du thorax, F-44000 Nantes, Pays de la Loire, France
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7
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O'Sullivan CF, Nilsen K, Borg BM, Ellis MJ, Matsas P, Thien F, Douglass JA, Stuart-Andrews C, King GG, Prisk GK, Thompson BR. Small Airways Dysfunction is Associated with Increased Exacerbations in Patients with Asthma. J Appl Physiol (1985) 2022; 133:629-636. [PMID: 35861519 DOI: 10.1152/japplphysiol.00103.2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
There is poor understanding of why some patients with asthma experience recurrent exacerbations despite high levels of treatment. We compared measurements of peripheral ventilation heterogeneity and respiratory system mechanics in participants with asthma who were differentiated according to exacerbation history, to ascertain whether peripheral airway dysfunction was related to exacerbations. Three asthmatic groups: "Stable" (no exacerbations for >12 months, n=18), "Exacerbation-prone" (≥1 exacerbation requiring systemic corticosteroids within the last 12 months, but stable for ≥1-month, n=9) and "Treated-exacerbation" (exacerbation requiring systemic corticosteroids within the last 1 month, n=12) were studied. All participants were current non-smokers with <10pack/years smoking history. Spirometry, static lung volumes, ventilation heterogeneity from multi-breath nitrogen washout (MBW) and respiratory system mechanics from oscillometry were measured. The Exacerbation-prone group compared to the Stable group had slightly worse spirometry (FEV1 Z-score -3.58(1.13) vs -2.32(1.06), p=0.03), however acinar ventilation heterogeneity (Sacin Z-score 7.43(8.59) vs 3.63(3.88), p=0.006) and respiratory system reactance (Xrs cmH2O.s.L-1 -2.74(3.82) vs -1.32(1.94), p=0.01) were much worse in this group. The Treated-exacerbation group had worse spirometry but similar small airway function, compared with the Stable group. Patients with asthma who exacerbate have worse small airway function as evidenced by increases in Sacin measured by MBW and delta Xrs from oscillometry, both markers of small airway dysfunction, compared with those that do not.
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Affiliation(s)
- Claire F O'Sullivan
- Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Kris Nilsen
- Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia.,School of Health Science, Swinburne University of Technology, Melbourne, VIC, Australia
| | - Brigitte M Borg
- Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia.,Monash University, Melbourne, VIC, Australia
| | - Matthew J Ellis
- Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Pam Matsas
- Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Frank Thien
- Monash University, Melbourne, VIC, Australia.,Respiratory Medicine, Eastern Health, Melbourne, VIC, Australia
| | - Jo A Douglass
- The Department of Medicine, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | | | - Gregory G King
- Airway Physiology and Imaging Group, The Woolcock Institute, Sydney, NSW, Australia
| | - Gordon Kim Prisk
- Department of Medicine, University of California, San Diego, La Jolla, CA, United States
| | - Bruce R Thompson
- Respiratory Medicine, The Alfred Hospital, Melbourne, VIC, Australia.,School of Health Science, University of Melbourne, Melbourne, VIC, Australia
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8
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Östling J, Van Geest M, Olsson HK, Dahlen SE, Viklund E, Gustafsson PM, Mirgorodskaya E, Olin AC. A novel non-invasive method allowing for discovery of pathologically relevant proteins from small airways. Clin Proteomics 2022; 19:20. [PMID: 35668386 PMCID: PMC9167914 DOI: 10.1186/s12014-022-09348-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 04/04/2022] [Indexed: 01/01/2023] Open
Abstract
Background There is a lack of early and precise biomarkers for personalized respiratory medicine. Breath contains an aerosol of droplet particles, which are formed from the epithelial lining fluid when the small airways close and re-open during inhalation succeeding a full expiration. These particles can be collected by impaction using the PExA method (Particles in Exhaled Air), and are derived from an area of high clinical interest previously difficult to access, making them a potential source of biomarkers reflecting pathological processes in the small airways. Research question Our aim was to investigate if PExA method is useful for discovery of biomarkers that reflect pathology of small airways. Methods and analysis Ten healthy controls and 20 subjects with asthma, of whom 10 with small airway involvement as indicated by a high lung clearance index (LCI ≥ 2.9 z-score), were examined in a cross-sectional design, using the PExA instrument. The samples were analysed with the SOMAscan proteomics platform (SomaLogic Inc.). Results Two hundred-seven proteins were detected in up to 80% of the samples. Nine proteins showed differential abundance in subjects with asthma and high LCI as compared to healthy controls. Two of these were less abundant (ALDOA4, C4), and seven more abundant (FIGF, SERPINA1, CD93, CCL18, F10, IgM, IL1RAP). sRAGE levels were lower in ex-smokers (n = 14) than in never smokers (n = 16). Gene Ontology (GO) annotation database analyses revealed that the PEx proteome is enriched in extracellular proteins associated with extracellular exosome-vesicles and innate immunity. Conclusion The applied analytical method was reproducible and allowed identification of pathologically interesting proteins in PEx samples from asthmatic subjects with high LCI. The results suggest that PEx based proteomics is a novel and promising approach to study respiratory diseases with small airway involvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12014-022-09348-y. Key question Can the PExA method identify individual protein profiles that reflect pathology of small airways, using the SOMAscan platform? What is the bottom line? Two hundred-seven proteins were detected in up to 80% of the PEx samples, with a strong overrepresentation of proteins related to innate immune responses, including nine proteins that that discriminated subjects with asthma and high LCI as compared to healthy controls. Why read on The results support that PEx based proteomics is a novel and promising approach to study respiratory diseases with small airway involvement. Supplementary Information The online version contains supplementary material available at 10.1186/s12014-022-09348-y.
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Affiliation(s)
- Jörgen Östling
- Department of Bioscience, Respiratory, Inflammation and Autoimmunity, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden.,PExA AB, Gothenburg, Sweden
| | - Marleen Van Geest
- Department of Bioscience, Respiratory, Inflammation and Autoimmunity, IMED Biotech Unit, AstraZeneca, Gothenburg, Sweden.,Hansa Biopharma AB, Lund, Sweden
| | - Henric K Olsson
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Sven-Erik Dahlen
- Institute of Environmental Medicine, Karolinska Institute, Stockholm, Sweden
| | - Emilia Viklund
- Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | | | - Anna-Carin Olin
- Occupational and Environmental Medicine, Department of Public Health and Community Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.
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9
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Cottini M, Lombardi C, Passalacqua G, Bagnasco D, Berti A, Comberiati P, Imeri G, Landi M, Heffler E. Small Airways: The “Silent Zone” of 2021 GINA Report? Front Med (Lausanne) 2022; 9:884679. [PMID: 35677830 PMCID: PMC9168121 DOI: 10.3389/fmed.2022.884679] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2022] [Accepted: 04/20/2022] [Indexed: 01/08/2023] Open
Abstract
Asthma is a chronic disease, affecting approximately 350 million people worldwide. Inflammation and remodeling in asthma involve the large airways, and it is now widely accepted that the small airways (those with an internal diameter <2 mm) are involved in the pathogenesis of asthma and are the major determinant of airflow obstruction in this disease. From a clinical perspective, small airways dysfunction (SAD) is associated with more severe bronchial hyperresponsiveness, worse asthma control and more exacerbations. Unlike the GOLD guidelines which, in their definition, identify COPD as a disease of the small airways, the Global Initiative for Asthma (GINA) guidelines do not refer to the prevalence and role of SAD in asthmatic patients. This decision seems surprising, given the growing body of compelling evidence accumulating pointing out the high prevalence of SAD in asthmatic patients and the importance of SAD in poor asthma control. Furthermore, and remarkably, SAD appears to possess the characteristics of a treatable pulmonary trait, making it certainly appealing for asthma control optimization and exacerbation rate reduction. In this mini-review article, we address the most recent evidence on the role of SAD on asthma control and critically review the possible inclusion of SAD among treatable pulmonary traits in international guidelines on asthma.
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Affiliation(s)
- Marcello Cottini
- Allergy and Pneumology Outpatient Clinic, Bergamo, Italy
- Marcello Cottini
| | - Carlo Lombardi
- Departmental Unit of Allergology, Immunology & Pulmonary Diseases, Fondazione Poliambulanza, Brescia, Italy
- *Correspondence: Carlo Lombardi
| | - Giovanni Passalacqua
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Genova, Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Genova, Italy
| | - Alvise Berti
- Ospedale Santa Chiara and Department of Cellular, Computational and Integrative Biology (CIBIO), Thoracic Disease Research, University of Trento, Trento, Italy
| | - Pasquale Comberiati
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Gianluca Imeri
- Respiratory Unit, Department of Medical Sciences, Papa Giovanni XXIII Hospital, University of Milan-Bergamo, Bergamo, Italy
| | - Massimo Landi
- Institute for Biomedical Research and Innovation, National Research Council, Palermo, Italy
- Pediatric National Healthcare System, Turin, Italy
| | - Enrico Heffler
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Personalized Medicine, Asthma and Allergy - IRCCS Humanitas Research Hospital - Rozzano, Milan, Italy
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10
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Oscillometry and Asthma Control in Patients With and Without Fixed Airflow Obstruction. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. IN PRACTICE 2022; 10:1260-1267.e1. [PMID: 34979333 DOI: 10.1016/j.jaip.2021.12.026] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 12/16/2021] [Accepted: 12/17/2021] [Indexed: 02/06/2023]
Abstract
BACKGROUND Asthma is defined by the presence of reversible airflow limitation, yet persistently abnormal spirometry may develop despite appropriate asthma treatment. Fixed airflow obstruction (FAO) describes abnormal postbronchodilator spirometry that is associated with greater symptom burden and disease severity. Respiratory oscillometry measures the mechanics of the entire airway tree, including peripheral airway changes that have been shown to influence asthma symptoms. OBJECTIVE To evaluate the relationship between abnormal oscillometry following bronchodilator and symptom control in adults with asthma. METHODS A prospective cohort of patients with asthma attending an airways clinic completed oscillometry (resistance and reactance), spirometry, and the Asthma Control Test. Postbronchodilator lung function below the lower limit of normal was considered abnormal. Spirometric FAO was defined as FEV1/forced vital capacity below the lower limit of normal. Spearman's rank coefficient and multiple linear regression were performed to assess associations of lung function parameters with Asthma Control Test. The discriminative ability of abnormal lung function to identify poor asthma control was determined using Cohen's kappa. RESULTS Ninety patients with asthma were included; 48% had spirometric FAO. Only reactance parameters, not spirometry, significantly related to (rs ≥ 0.315; P < .05) and identified asthma control (r2 = 0.236; P < .001). Lung function was more strongly associated with asthma control in patients with FAO compared with those without. Abnormal oscillometry identified an additional 24% of patients with poor asthma control as compared with spirometric FAO. CONCLUSIONS Reactance related to asthma control, independently of spirometric FAO. Abnormal postbronchodilator reactance identified more patients with poor asthma control compared with spirometry. These findings confirm that oscillometry is a relevant lung function test in the clinical assessment of asthma.
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11
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Bozier J, Jeagal E, Robinson PD, Prisk GK, Chapman DG, King GG, Thamrin C, Rutting S. The effect of O 2 and CO 2 cross-sensitivity sensor error in the Eco Medics Exhalyzer D device on measures of conductive and acinar airway function. ERJ Open Res 2022; 8:00614-2021. [PMID: 35854872 PMCID: PMC9289373 DOI: 10.1183/23120541.00614-2021] [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: 10/31/2021] [Accepted: 02/17/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction The multiple breath nitrogen washout (MBNW) test provides important clinical information in obstructive airways diseases. Recently, a significant cross-sensitivity error in the O2 and CO2 sensors of a widely used commercial MBNW device (Exhalyzer D, Eco Medics AG, Duernten, Switzerland) was detected, which leads to overestimation of N2 concentrations. Significant errors in functional residual capacity (FRC) and lung clearance index (LCI) have been reported in infants and children. This study investigated the impact in adults, and on additional important indices reflecting conductive (Scond) and acinar (Sacin) ventilation heterogeneity, in health and disease. Methods Existing MBNW measurements of 27 healthy volunteers, 20 participants with asthma and 16 smokers were reanalysed using SPIROWARE V 3.3.1, which incorporates an error correction algorithm. Uncorrected and corrected indices were compared using paired t-tests and Bland–Altman plots. Results Correction of the sensor error significantly lowered FRC (mean difference 9%) and LCI (8–10%) across all three groups. Scond was higher following correction (11%, 14% and 36% in health, asthma and smokers, respectively) with significant proportional bias. Sacin was significantly lower following correction in the asthma and smoker groups, but the effect was small (2–5%) and with no proportional bias. Discussion The O2 and CO2 cross-sensitivity sensor error significantly overestimated FRC and LCI in adults, consistent with data in infants and children. There was a high degree of underestimation of Scond but minimal impact on Sacin. The presence of significant proportional bias indicates that previous studies will require reanalysis to confirm previous findings and to allow comparability with future studies. O2 and CO2 cross-sensitivity sensor error in the Exhalyzer D device significantly overestimates FRC and LCI in adults, consistent with infants and children. Importantly, there was a high degree of underestimation of Scond, but minimal impact on Sacin.https://bit.ly/3HcH3Tp
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12
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Yi F, Jiang Z, Li H, Guo C, Lu H, Luo W, Chen Q, Lai K. Small Airway Dysfunction in Cough Variant Asthma: Prevalence, Clinical, and Pathophysiological Features. Front Physiol 2022; 12:761622. [PMID: 35095550 PMCID: PMC8793490 DOI: 10.3389/fphys.2021.761622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2021] [Accepted: 12/09/2021] [Indexed: 11/27/2022] Open
Abstract
Introduction: Small airway dysfunction (SAD) commonly presents in patients with classic asthma, which is associated with airway inflammation, disease severity, and asthma control. However, the prevalence of SAD, its relationship with cough severity and airway inflammation, and its development after antiasthmatic treatment in patients with cough variant asthma (CVA) need to be clarified. This study aimed to investigate the prevalence of SAD and its relationship with clinical and pathophysiological characteristics in patients with CVA and the change in small airway function after antiasthmatic treatment. Methods: We retrospectively analyzed 120 corticosteroid-naïve patients with CVA who had finished a standard questionnaire and relevant tests in a specialist cough clinic, such as cough visual analog scale (VAS), differential cells in induced sputum, fractional exhaled nitric oxide (FeNO) measurement, spirometry, and airway hyper-responsiveness. Information of 1-year follow-up was recorded in a part of patients who received complete cough relief after 2 months of treatment. SAD was defined as any two parameters of maximal mid-expiratory flow (MMEF)% pred, forced expiratory flow at 50% of forced vital capacity (FEF50%) pred, and forced expiratory flow at 75% of forced vital capacity (FEF75%) pred measuring <65%. Results: SAD occurred in 73 (60.8%) patients with CVA before treatment. The patients with SAD showed a significantly longer cough duration (24.0 vs. 6.0, p = 0.031), a higher proportion of women (78.1 vs. 59.6%, p = 0.029), older mean age (41.9 vs. 35.4, p = 0.005), and significantly lower forced expiratory volume in 1 s (FEV1%) pred, FEV1/FVC, MMEF% pred, FEF50% pred, FEF75% pred, PEF% pred, and PD20 (all p < 0.01) as compared with patients without SAD. There were no significant differences in cough VAS, sputum eosinophils count, FeNO, and TIgE level between patients with SAD and those without SAD. Among 105 patients who completed 2 months of antiasthmatic treatment and repeatedly experienced spirometry measurement, 57 (54.3%) patients still had SAD, despite a significant improvement in cough VAS, sputum eosinophils, FeNO, FEF50% pred, and PEF% pred (all p < 0.01). As compared with patients without SAD, patients with SAD showed no significant differences in the relapse rate (50.0 vs. 41.9%, p = 0.483) and wheeze development rate (10.4 vs. 0%, p = 0.063) during the follow-up. Conclusions: Small airway dysfunction occurred in over half of patients with CVA and persisted after short-term antiasthmatic treatment, which showed distinctive clinical and pathophysiological features.
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13
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Commentaries on Viewpoint: Small airways vs. large airways in asthma: time for a new perspective. J Appl Physiol (1985) 2021; 131:1842-1848. [PMID: 34898290 DOI: 10.1152/japplphysiol.00762.2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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14
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Maglio A, Vitale C, Pellegrino S, Calabrese C, D’Amato M, Molino A, Pelaia C, Triggiani M, Pelaia G, Stellato C, Vatrella A. Real-Life Effectiveness of Mepolizumab on Forced Expiratory Flow between 25% and 75% of Forced Vital Capacity in Patients with Severe Eosinophilic Asthma. Biomedicines 2021; 9:1550. [PMID: 34829778 PMCID: PMC8615088 DOI: 10.3390/biomedicines9111550] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 10/22/2021] [Accepted: 10/24/2021] [Indexed: 01/20/2023] Open
Abstract
Severe eosinophilic asthma (SEA) is associated with high peripheral blood and airway eosinophilia, recurrent disease exacerbations and severe airflow limitation. Eosinophilic inflammation is also responsible for small airway disease (SAD) development. SEA patients experience poor disease control and response to standard therapy and are prime candidates for anti-IL5 biologicals, such as mepolizumab, but the effect of treatment on SAD is unclear. We investigated the effect of mepolizumab on lung function in SEA patients, focusing on SAD parameters, and searched for an association between patients' phenotypic characteristics and changes in small airways function. In this real-life study, data from 105 patients with SEA were collected at baseline and after 6, 12 and 18 months of mepolizumab treatment. Along with expected improvements in clinical and lung function parameters brought by Mepolizumab treatment, FEF2525-75% values showed a highly significant, gradual and persistent increase (from 32.7 ± 18.2% at baseline to 48.6 ± 18.4% after 18 months) and correlated with ACT scores at 18 months (r = 0.566; p ≤ 0.0001). A patient subgroup analysis showed that changes in FEF25-75% values were higher in patients with a baseline peripheral blood eosinophil count ≥400 cells/μL and oral corticosteroid use. Mepolizumab significantly improves small airway function. This effect correlates with clinical benefits and may represent an accessible parameter through which to evaluate therapeutic response. This study provides novel insights into the phenotypic characteristics associated with the improved functional outcome provided by mepolizumab treatment.
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Affiliation(s)
- Angelantonio Maglio
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84100 Salerno, Italy; (A.M.); (C.V.); (S.P.); (M.T.); (C.S.)
| | - Carolina Vitale
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84100 Salerno, Italy; (A.M.); (C.V.); (S.P.); (M.T.); (C.S.)
| | - Simona Pellegrino
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84100 Salerno, Italy; (A.M.); (C.V.); (S.P.); (M.T.); (C.S.)
| | - Cecilia Calabrese
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80100 Naples, Italy;
| | - Maria D’Amato
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80100 Naples, Italy; (M.D.); (A.M.)
| | - Antonio Molino
- Department of Clinical Medicine and Surgery, University of Naples “Federico II”, 80100 Naples, Italy; (M.D.); (A.M.)
| | - Corrado Pelaia
- Department of Experimental and Clinical Medicine, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (C.P.); (G.P.)
| | - Massimo Triggiani
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84100 Salerno, Italy; (A.M.); (C.V.); (S.P.); (M.T.); (C.S.)
| | - Girolamo Pelaia
- Department of Experimental and Clinical Medicine, University of Catanzaro “Magna Graecia”, 88100 Catanzaro, Italy; (C.P.); (G.P.)
| | - Cristiana Stellato
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84100 Salerno, Italy; (A.M.); (C.V.); (S.P.); (M.T.); (C.S.)
| | - Alessandro Vatrella
- Department of Medicine, Surgery and Dentistry “Scuola Medica Salernitana”, University of Salerno, 84100 Salerno, Italy; (A.M.); (C.V.); (S.P.); (M.T.); (C.S.)
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15
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Lung heterogeneity as a predictor for disease severity and response to therapy. CURRENT OPINION IN PHYSIOLOGY 2021. [DOI: 10.1016/j.cophys.2021.05.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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16
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Rutting S, Chapman DG, Thamrin C, Tang FSM, Dame Carroll JR, Bailey DL, Trifunovic M, Magnussen JS, King GG, Farrow CE. Effect of combination inhaled therapy on ventilation distribution measured by SPECT/CT imaging in uncontrolled asthma. J Appl Physiol (1985) 2021; 131:621-629. [PMID: 34166109 DOI: 10.1152/japplphysiol.01068.2020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Asthma is characterized by heterogeneous ventilation as measured by three-dimensional ventilation imaging. Combination inhaled corticosteroid/long-acting β2-agonist (ICS/LABA) treatment response is variable in asthma, and effects on regional ventilation are unknown. Our aims were to determine whether regional ventilation defects decrease after ICS/LABA treatment and whether small airways dysfunction predicts response in uncontrolled asthma. Twenty-two symptomatic participants with asthma underwent single-photon emission computed tomography (SPECT)/CT imaging with Technegas, before and after 8-wk fluticasone/formoterol (1,000/40 µg/day) treatment. Lung regions that were nonventilated, low ventilated, or well ventilated were calculated using an adaptive threshold method and were expressed as a percentage of total lung volume. Multiple-breath nitrogen washout (MBNW) was used to measure diffusion-dependent and convection-dependent small airways function (Sacin and Scond, respectively). Forced oscillation technique (FOT) was used to measure respiratory system resistance and reactance. At baseline and posttreatment, Scond z-score was related to percentage of nonventilated lung, whereas Sacin z-score was related to percentage of low-ventilated lung. Although symptoms, spirometry, FOT, and MBNW improved following treatment, there was no mean change in ventilation measured by SPECT. There was, however, a wide range of changes in SPECT ventilation such that greater percentage of nonventilated lung, older age, and higher Scond predicted a reduction in nonventilated lung after treatment. SPECT ventilation defects are overall unresponsive to ICS/LABA, but the response is variable, with improvement occurring when small airways dysfunction and ventilation defects are more severe. Persistent ventilation defects that correlate with Scond suggest that mechanisms such as non-ICS responsive inflammation or remodeling underlie these defects.NEW & NOTEWORTHY This study provides insights into the mechanisms of high-dose ICS treatment in uncontrolled asthma. Ventilation defects as measured by SPECT/CT imaging respond heterogeneously to increased ICS/LABA treatment, with improvement occurring when ventilation defects and impairment of convection-dependent small airways function are more severe. Persistent correlations between ventilation defects and measures of small airways function suggest the potential presence of ICS nonresponsive inflammation and/or remodeling.
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Affiliation(s)
- Sandra Rutting
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, New South Wales, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,National Health and Medical Research Council Centre of Excellence in Severe Asthma, New Lambton Heights, New South Wales, Australia
| | - David G Chapman
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,Faculty of Science, School of Life Sciences, University of Technology Sydney, Ultimo, New South Wales, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Francesca S M Tang
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, New South Wales, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Jessica R Dame Carroll
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
| | - Dale L Bailey
- Department of Nuclear Medicine, Royal North Shore Hospital, St. Leonards, New South Wales, Australia.,Faculty of Health and Medicine, Northern Clinical School, University of Sydney, New South Wales, Australia
| | - Marko Trifunovic
- Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University, New South Wales, Australia
| | - John S Magnussen
- Macquarie Medical Imaging, Macquarie University Hospital, Macquarie University, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, New South Wales, Australia
| | - Gregory G King
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, New South Wales, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,National Health and Medical Research Council Centre of Excellence in Severe Asthma, New Lambton Heights, New South Wales, Australia.,Faculty of Health and Medicine, Northern Clinical School, University of Sydney, New South Wales, Australia
| | - Catherine E Farrow
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia.,Department of Respiratory Medicine, Westmead Hospital, Westmead, New South Wales, Australia
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17
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Cottini M, Licini A, Lombardi C, Bagnasco D, Comberiati P, Berti A. Small airway dysfunction and poor asthma control: a dangerous liaison. Clin Mol Allergy 2021; 19:7. [PMID: 34051816 PMCID: PMC8164746 DOI: 10.1186/s12948-021-00147-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/22/2021] [Indexed: 01/05/2023] Open
Abstract
Asthma is a common chronic condition, affecting approximately 339 million people worldwide. The main goal of the current asthma treatment guidelines is to achieve clinical control, encompassing both the patient symptoms and limitations and the future risk of adverse asthma outcomes. Despite randomized controlled trials showing that asthma control is an achievable target, a substantial proportion of asthmatics remain poorly controlled in real life. The involvement of peripheral small airways has recently gained greater recognition in asthma, and many studies suggest that the persistent inflammation at these sites leads to small airway dysfunction (SAD), strongly contributing to a worse asthma control. Overall, the impulse oscillometry (IOS), introduced in the recent years, seems to be able to sensitively assess small airways, while conventional spirometry does not. Therefore, IOS may be of great help in characterizing SAD and guiding therapy choice. The aim of this article is to review the literature on SAD and its influence on asthma control, emphasizing the most recent evidence.
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Affiliation(s)
| | - Anita Licini
- Allergy and Pneumology Outpatient Clinic, Bergamo, Italy
| | - Carlo Lombardi
- Departmental Unit of Allergology, Immunology and Pulmonary Diseases, Fondazione Poliambulanza, Brescia, Italy
| | - Diego Bagnasco
- Allergy and Respiratory Diseases, IRCCS Policlinico San Martino, University of Genoa, Genova, Italy.
| | - Pasquale Comberiati
- Section of Pediatrics, Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Alvise Berti
- Ospedale Santa Chiara and Department of Cellular, Computational and Integrative Biology (CIBIO), University of Trento, Trento, Italy.,Thoracic Disease Research Unit, Mayo Clinic, Rochester, MN, USA
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18
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Liu Y, Zhang L, Li HL, Liang BM, Wang J, Zhang X, Chen ZH, Zhang HP, Xie M, Wang L, Wang G, Oliver BG. Small Airway Dysfunction in Asthma Is Associated with Perceived Respiratory Symptoms, Non-Type 2 Airway Inflammation, and Poor Responses to Therapy. Respiration 2021; 100:767-779. [PMID: 33895739 DOI: 10.1159/000515328] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 02/15/2021] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Emerging evidence has indicated that small airway dysfunction (SAD) contributes to the clinical expression of asthma. OBJECTIVES The aim of the study was to explore the relationships of SAD assessed by forced expiratory flow between 25 and 75% (FEF25-75%), with clinical and inflammatory profile and treatment responsiveness in asthma. METHOD In study I, dyspnea intensity (Borg scale), chest tightness, wheezing and cough (visual analog scales, VASs), and pre- and post-methacholine challenge testing (MCT) were analyzed in asthma patients with SAD and non-SAD. In study II, asthma subjects with SAD and non-SAD underwent sputum induction, and inflammatory mediators in sputum were detected. Asthma patients with SAD and non-SAD receiving fixed treatments were prospectively followed up for 4 weeks in study III. Spirometry, Asthma Control Questionnaire (ACQ), and Asthma Control Test (ACT) were carried out to define treatment responsiveness. RESULTS SAD subjects had more elevated ΔVAS for dyspnea (p = 0.027) and chest tightness (p = 0.032) after MCT. Asthma patients with SAD had significantly elevated interferon (IFN)-γ in sputum (p < 0.05), and Spearman partial correlation found FEF25-75% significantly related to IFN-γ and interleukin-8 (both having p < 0.05). Furthermore, multivariable regression analysis indicated SAD was significantly associated with worse treatment responses (decrease in ACQ ≥0.5 and increase in ACT ≥3) (p = 0.022 and p = 0.032). CONCLUSIONS This study indicates that SAD in asthma predisposes patients to greater dyspnea intensity and chest tightness during bronchoconstriction. SAD patients with asthma are characterized by non-type 2 inflammation that may account for poor responsiveness to therapy.
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Affiliation(s)
- Ying Liu
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Li Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Hong Lin Li
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Bin Miao Liang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Ji Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China.,Division of Allergy and Clinical Immunology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Xin Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China.,Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Zhi Hong Chen
- Shanghai Institute of Respiratory Disease, Respiratory Division of Zhongshan Hospital, Fudan University, Shanghai, China
| | - Hong Ping Zhang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Min Xie
- Department of Respiratory and Critical Care Medicine, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China
| | - Lei Wang
- Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, State Key Laboratory of Biotherapy, West China Hospital, Sichuan University, and Collaborative Innovation Center for Biotherapy, Chengdu, China.,Pneumology Group, Department of Integrated Traditional Chinese and Western Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Gang Wang
- Department of Respiratory and Critical Care Medicine, Clinical Research Center for Respiratory Disease, West China Hospital, Sichuan University, Chengdu, China
| | - Brian G Oliver
- School of Life Sciences, University of Technology Sydney, Sydney, New South Wales, Australia.,Respiratory Cellular and Molecular Biology, Woolcock Institute of Medical Research, The University of Sydney, Sydney, New South Wales, Australia
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19
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Cottee AM, Seccombe LM, Thamrin C, Badal T, King GG, Peters MJ, Farah CS. Longitudinal monitoring of asthma in the clinic using respiratory oscillometry. Respirology 2021; 26:566-573. [PMID: 33797141 DOI: 10.1111/resp.14053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2020] [Accepted: 02/23/2021] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND OBJECTIVE Asthma guidelines emphasize the importance of assessing lung function and symptoms. The forced oscillation technique (FOT) and its longitudinal relationship with spirometry and symptoms are unresolved. We examined concordance between longitudinal spirometry, FOT and symptom control, and determined FOT limits of agreement in stable asthma. METHODS Over a 3-year period, adults with asthma attending a tertiary clinic completed the asthma control test (ACT), fraction of exhaled nitric oxide (FeNO), FOT and spirometry. Analysis included between-visit concordance for significant change using Cohen's kappa (κ) and stable asthma FOT limits of agreement. RESULTS Data (n = 186) from 855 visits (mean ± SD 4.6 ± 3.0 visits), 114 ± 95 days apart, were analysed. Between-visit concordance was moderate between reactance at 5 Hz (X5) and forced expiratory volume in 1 s (FEV1 ) (κ = 0.34, p = 0.001), and weak between ACT and FEV1 (κ = 0.18, p = 0.001). Change in FeNO did not correlate with lung function or ACT (κ < 0.05, p > 0.1). Stable asthma between visits (n = 75; 132 visits) had reduced lung function variability, but comparable concordance to the entire cohort. Limits of agreement for FEV1 (0.42 L), resistance at 5 Hz (2.06 cm H2 O s L-1 ) and X5 (2.75 cm H2 O s L-1 ) in stable asthma were at least twofold greater than published values in health. CONCLUSION In adults with asthma, there is moderate concordance between longitudinal change in FOT and spirometry. Both tests relate poorly to changes in asthma control, highlighting the need for multi-modal assessment in asthma rather than symptoms alone. The derivation of longitudinal FOT limits of agreement will assist in its clinical interpretation.
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Affiliation(s)
- Alice M Cottee
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Leigh M Seccombe
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia
| | - Tanya Badal
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Gregory G King
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Department of Respiratory Medicine, Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Matthew J Peters
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, North Ryde, New South Wales, Australia
| | - Claude S Farah
- Department of Respiratory Medicine, Concord Repatriation General Hospital, Concord, New South Wales, Australia.,Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, Glebe, New South Wales, Australia.,Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, North Ryde, New South Wales, Australia
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20
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Chaiwong W, Namwongprom S, Liwsrisakun C, Pothirat C. The roles of impulse oscillometry in detection of poorly controlled asthma in adults with normal spirometry. J Asthma 2021; 59:561-571. [PMID: 33356696 DOI: 10.1080/02770903.2020.1868499] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
BACKGROUND Impulse oscillometry (IOS) has been introduced as a method of assessing asthma control. However, the cutoff IOS values for the detection of asthma control in adults are still unclear. OBJECTIVE To assess the diagnostic ability of IOS for distinguishing between poorly controlled and well controlled adult asthmatic subjects with normal spirometry. METHODS This cross-sectional study was conducted at the Lung Health Center, Chiang Mai, Thailand, between July 2019 and June 2020. IOS and spirometry were performed in all adult asthmatic subjects but only subjects with normal spirometry were enrolled. Poorly controlled asthma was defined in accordance with the Global Initiative for Asthma (GINA) plus an asthma control test (ACT) score ≤19. A Receiver Operating Characteristic (ROC) curve was plotted to detect poorly controlled asthma using the area under the ROC (AuROC) and 95%CI. RESULTS One hundred and forty-two adult asthmatic subjects registering normal spirometry with a mean age of 53.4 ± 15.8 years were enrolled. Eighty-nine (62.7%) subjects were female. IOS parameters including heterogeneity of resistance at 5 Hz and resistance at 20 Hz (R5-R20) and area under reactance (AX) demonstrated excellent detection of poorly controlled asthma with an AuROC of 0.911 and 0.904, respectively. The z-score or absolute value of R5-R20 ≥ 0 and 1 cmH2O/L/s, respectively, represented the highest AuROC of 0.86, with a sensitivity and a specificity of ≥80.0% for the detection of poorly controlled asthma. CONCLUSION IOS is a valuable tool for the detection of poorly controlled asthma in adults with normal spirometry.
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Affiliation(s)
- Warawut Chaiwong
- Division of Pulmonary, Critical Care, and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Sirianong Namwongprom
- Clinical Epidemiology and Clinical Statistics Center, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand.,Department of Radiology, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chalerm Liwsrisakun
- Division of Pulmonary, Critical Care, and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
| | - Chaicharn Pothirat
- Division of Pulmonary, Critical Care, and Allergy, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, Thailand
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21
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Hwang HJ, Lee SM, Seo JB, Lee JS, Kim N, Lee SW, Oh YM. Visual and Quantitative Assessments of Regional Xenon-Ventilation Using Dual-Energy CT in Asthma-Chronic Obstructive Pulmonary Disease Overlap Syndrome: A Comparison with Chronic Obstructive Pulmonary Disease. Korean J Radiol 2020; 21:1104-1113. [PMID: 32691546 PMCID: PMC7371623 DOI: 10.3348/kjr.2019.0936] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Revised: 03/11/2020] [Accepted: 03/22/2020] [Indexed: 01/08/2023] Open
Abstract
Objective To assess the regional ventilation in patients with asthma-chronic obstructive pulmonary disease (COPD) overlap syndrome (ACOS) using xenon-ventilation dual-energy CT (DECT), and to compare it to that in patients with COPD. Materials and Methods Twenty-one patients with ACOS and 46 patients with COPD underwent xenon-ventilation DECT. The ventilation abnormalities were visually determined to be 1) peripheral wedge/diffuse defect, 2) diffuse heterogeneous defect, 3) lobar/segmental/subsegmental defect, and 4) no defect on xenon-ventilation maps. Emphysema index (EI), airway wall thickness (Pi10), and mean ventilation values in the whole lung, peripheral lung, and central lung areas were quantified and compared between the two groups using the Student's t test. Results Most patients with ACOS showed the peripheral wedge/diffuse defect (n = 14, 66.7%), whereas patients with COPD commonly showed the diffuse heterogeneous defect and lobar/segmental/subsegmental defect (n = 21, 45.7% and n = 20, 43.5%, respectively). The prevalence of ventilation defect patterns showed significant intergroup differences (p < 0.001). The quantified ventilation values in the peripheral lung areas were significantly lower in patients with ACOS than in patients with COPD (p = 0.045). The quantified Pi10 was significantly higher in patients with ACOS than in patients with COPD (p = 0.041); however, EI was not significantly different between the two groups. Conclusion The ventilation abnormalities on the visual and quantitative assessments of xenon-ventilation DECT differed between patients with ACOS and patients with COPD. Xenon-ventilation DECT may demonstrate the different physiologic changes of pulmonary ventilation in patients with ACOS and COPD.
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Affiliation(s)
- Hye Jeon Hwang
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang Min Lee
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
| | - Joon Beom Seo
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae Seung Lee
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Namkug Kim
- Department of Radiology and Research Institute of Radiology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sei Won Lee
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yeon Mok Oh
- Department of Pulmonary and Critical Care Medicine, and Clinical Research Center for Chronic Obstructive Airway Diseases, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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22
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Abdo M, Watz H, Veith V, Kirsten AM, Biller H, Pedersen F, von Mutius E, Kopp MV, Hansen G, Waschki B, Rabe KF, Trinkmann F, Bahmer T. Small airway dysfunction as predictor and marker for clinical response to biological therapy in severe eosinophilic asthma: a longitudinal observational study. Respir Res 2020; 21:278. [PMID: 33087134 PMCID: PMC7579879 DOI: 10.1186/s12931-020-01543-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2020] [Accepted: 10/11/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Anti-T2 biological therapies have proven to effectively reduce acute exacerbations and daily doses of oral steroids in severe eosinophilic asthma. Despite the remarkable clinical efficacy, there are usually only moderate improvements in airflow limitation, suggesting that other measures of lung function like small airway dysfunction (SAD) might better reflect the clinical response. We aimed to investigate if measures of small airway function would predict and correlate with the clinical response to anti-T2 therapy. METHODS We studied data of patients who were previously included in the German prospective longitudinal All Age Asthma Cohort (ALLIANCE) that recruits asthma patients of all severity grades and inflammatory phenotypes. The selection criteria for this analysis were adult patients with severe eosinophilic asthma under treatment with anti-T2 biological agents. Asthma control was assessed by asthma control test (ACT) and number of severe exacerbations. Small airway function was assessed by the frequency dependence of resistance (FDR, R5-20)) derived from impulse oscillometry (IOS) and the mean forced expiratory flow between 25 and 75% of the forced vital capacity (FEF25-75). We also studied air trapping (RV and RV/TLC), blood eosinophils and FeNO. Patients were classified into responders and partial or non-responders. Clinical response was defined as at least 50% reduction in annualized severe exacerbations and daily oral steroid doses accompanied with a minimum increase of 3 points in the ACT score. We used a Receiver Operator Characteristic (ROC) to study the capacity of FDR in predicting clinical response compared to other clinical variable like blood eosinophils. We studied the correlation between FDR measures and clinical response, represented by the ACT score and number of exacerbations, using linear regressions. RESULTS 20 patients were included (mean age, 59 ± 9 years; 60% female; mean body mass index (BMI), 27.6 ± 5.4 kg/m2; mean absolute blood eosinophils, 570 ± 389/µl; mean number of severe exacerbations 12 months prior to initiating the biological therapy, 5.0 ± 3; mean predicted FEV1, 76 ± 21%; mean predicted FDR, 224 ± 140%; mean daily prednisolone dose, 6.4 ± 4.9 mg; mean ACT score, 15 ± 5). Responders had significantly higher baseline FDR compared to partial or non-responders but similar FEV1, FEF25-75, RV and RV/TLC. ROC analysis showed that the combination of FDR and blood eosinophils had the best predictive capacity of the clinical response among all tested clinical markers (FeNO, FEV1, FDR, blood eosinophils) with an AUC of 85% [67-100%], (CI = 0.95, p = 0.01). Linear regressions indicated better associations between improvements in FDR and ACT score (R2 = 0.42, p = 0.001) than with FEV1 and ACT score (R2 = 0.25, p = 0.013). Likewise, we observed better associations between improvements in FDR and reduction of exacerbations (R2 = 0.41, p = 0.001) than with FEV1 (R2 = 0.20, p = 0.025). CONCLUSION Our data suggest that severe SAD may represent a distinct phenotype of eosinophilic asthma that substantially improves under anti-T2 biological therapy. Measures of small airway function might be useful in selecting appropriate patients qualifying for anti-T2 biological therapy in addition to blood eosinophil count.
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Affiliation(s)
- Mustafa Abdo
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany.
| | - Henrik Watz
- Pulmonary Research Institute At the LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Vera Veith
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany
| | - Anne-Marie Kirsten
- Pulmonary Research Institute At the LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Heike Biller
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany
| | - Frauke Pedersen
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany.,Pulmonary Research Institute At the LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Grosshansdorf, Germany
| | - Erika von Mutius
- Dr. Von Hauner Children's Hospital, Ludwig Maximilians University of Munich, Comprehensive Pneumology Center Munich (CPC-M), German Center for Lung Research (DZL), Munich, Germany
| | - Matthias V Kopp
- Division of Pediatric Pulmonology and Allergology, University Children's Hospital Luebeck, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Luebeck, Germany
| | - Gesine Hansen
- Department of Paediatric Pneumology, Allergology and Neonatology, Hannover Medical School, Biomedical Research in Endstage and Obstructive Lung Disease (BREATH), German Center for Lung Research (DZL), Hannover, Germany
| | - Benjamin Waschki
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany.,Department of General and Interventional Cardiology, University Heart Center Hamburg, Hamburg, Germany
| | - Klaus F Rabe
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany
| | - Frederik Trinkmann
- Department of Respiratory and Critical Care Medicine, Thoraxklinik, University of Heidelberg, Translational Lung Research Center Heidelberg (TLRC), German Center for Lung Research (DZL), Heidelberg, Germany
| | - Thomas Bahmer
- LungenClinic Grosshansdorf, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Wöhrendamm 80, 22927, Grosshansdorf, Germany.,Dept for Internal Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Airway Research Center North (ARCN), German Center for Lung Research (DZL), Kiel, Germany
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23
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Ramos-Ramírez P, Noreby M, Liu J, Ji J, Abdillahi SM, Olsson H, Dahlén SE, Nilsson G, Adner M. A new house dust mite-driven and mast cell-activated model of asthma in the guinea pig. Clin Exp Allergy 2020; 50:1184-1195. [PMID: 32691918 DOI: 10.1111/cea.13713] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 06/23/2020] [Accepted: 07/14/2020] [Indexed: 01/24/2023]
Abstract
BACKGROUND Animal models are extensively used to study underlying mechanisms in asthma. Guinea pigs share anatomical, pharmacological and physiological features with human airways and may enable the development of a pre-clinical in vivo model that closely resembles asthma. OBJECTIVES To develop an asthma model in guinea pigs using the allergen house dust mite (HDM). METHODS Guinea pigs were intranasally sensitized to HDM which was followed by HDM challenges once weekly for five weeks. Antigen-induced bronchoconstriction (AIB) was evaluated as alterations in Rn (Newtonian resistance), G (tissue damping) and H (tissue elastance) at the first challenge with forced oscillation technique (FOT), and changes in respiratory pattern upon each HDM challenge were assessed as enhanced pause (Penh) using whole-body plethysmography. Airway responsiveness to methacholine was measured one day after the last challenge by FOT. Inflammatory cells and cytokines were quantified in bronchoalveolar lavage fluid, and HDM-specific immunoglobulins were measured in serum by ELISA. Airway pathology was evaluated by conventional histology. RESULTS The first HDM challenge after the sensitization generated a marked increase in Rn and G, which was abolished by pharmacological inhibition of histamine, leukotrienes and prostanoids. Repeated weekly challenges of HDM caused increase of Penh and a marked increase in airway hyperresponsiveness for all three lung parameters (Rn , G and H) and eosinophilia. Levels of IgE, IgG1 , IgG2 and IL-13 were elevated in HDM-treated guinea pigs. HDM exposure induced infiltration of inflammatory cells into the airways with a pronounced increase of mast cells. Subepithelial collagen deposition, airway wall thickness and goblet cell hyperplasia were induced by repeated HDM challenge. CONCLUSION AND CLINICAL RELEVANCE Repeated intranasal HDM administration induces mast cell activation and hyperplasia together with an asthma-like pathophysiology in guinea pigs. This model may be suitable for mechanistic investigations of asthma, including evaluation of the role of mast cells.
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Affiliation(s)
- Patricia Ramos-Ramírez
- Experimental Asthma and Allergy Research Unit, Institute of Environmental Medicine (IMM), Stockholm, Sweden
| | - Malin Noreby
- Experimental Asthma and Allergy Research Unit, Institute of Environmental Medicine (IMM), Stockholm, Sweden
| | - Jielu Liu
- Experimental Asthma and Allergy Research Unit, Institute of Environmental Medicine (IMM), Stockholm, Sweden
| | - Jie Ji
- Bioscience COPD/IPF, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Suado M Abdillahi
- Bioscience COPD/IPF, Research and Early Development, Respiratory & Immunology, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Henric Olsson
- Translational Science and Experimental Medicine, Research and Early Development, Respiratory, Inflammation and Autoimmune (RIA), AstraZeneca, Gothenburg, Sweden
| | - Sven-Erik Dahlén
- Experimental Asthma and Allergy Research Unit, Institute of Environmental Medicine (IMM), Stockholm, Sweden
| | - Gunnar Nilsson
- Division of Immunology and Allergy, Department of Medicine, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Mikael Adner
- Experimental Asthma and Allergy Research Unit, Institute of Environmental Medicine (IMM), Stockholm, Sweden
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24
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Abstract
This article will discuss in detail the pathophysiology of asthma from the point of view of lung mechanics. In particular, we will explain how asthma is more than just airflow limitation resulting from airway narrowing but in fact involves multiple consequences of airway narrowing, including ventilation heterogeneity, airway closure, and airway hyperresponsiveness. In addition, the relationship between the airway and surrounding lung parenchyma is thought to be critically important in asthma, especially as related to the response to deep inspiration. Furthermore, dynamic changes in lung mechanics over time may yield important information about asthma stability, as well as potentially provide a window into future disease control. All of these features of mechanical properties of the lung in asthma will be explained by providing evidence from multiple investigative methods, including not only traditional pulmonary function testing but also more sophisticated techniques such as forced oscillation, multiple breath nitrogen washout, and different imaging modalities. Throughout the article, we will link the lung mechanical features of asthma to clinical manifestations of asthma symptoms, severity, and control. © 2020 American Physiological Society. Compr Physiol 10:975-1007, 2020.
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Affiliation(s)
- David A Kaminsky
- University of Vermont Larner College of Medicine, Burlington, Vermont, USA
| | - David G Chapman
- University of Technology Sydney, Sydney, New South Wales, Australia
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25
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Zheng S, Hu Y, Chen Z, Wang M, Liao W. Predicting asthma exacerbation by impulse oscillometry evaluation of small airway function and fractional exhaled nitric oxide in preschool children. Pediatr Pulmonol 2020; 55:1601-1607. [PMID: 32353216 DOI: 10.1002/ppul.24790] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Revised: 04/13/2020] [Accepted: 04/15/2020] [Indexed: 01/05/2023]
Abstract
OBJECTIVE To study impulse oscillometry (IOS) indices of peripheral airway function and FeNO as predictors of future loss of asthma control in preschool children. METHODS Patients aged 3 to 6 years who were actively being treated for asthma and children without asthma were enrolled in the study. Participants had no change in medication on visit 1 and returned for a follow-up visit within 8 to 12 weeks. At the first visit, nursing assessment, symptom history, IOS analysis, FeNO, and physician evaluation were repeated. RESULTS Fifty-one (64.6%) subjects had lost asthma control (UC-Group) and 28 (35.4%) subjects had maintained asthma control (C-Group) at their follow-up visit. Thirty-two children without asthma were enrolled in the study as a normal control group (N-Group). R5, R5-20, AX, and Z5 values were all significantly higher in subjects whose symptoms remained uncontrolled compared with those in the controlled asthma group (P < .01) and also significantly higher than those in the normal control group (P < .01). FeNO showed no significant difference between the UC-Group and C-Group (P = .399). Four indices-R5, R5-20, AX, and Z5-had an estimated area under the curve (AUC) of greater than 0.8 and were thus easily able to distinguish the UC-Group from the C-Group. CONCLUSIONS AX had the highest overall AUC (0.884) of the investigated parameters, and the optimal cut-off point of 37.435 cm H2 O/L was able to predict future loss of asthma control in preschool children.
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Affiliation(s)
- Shouyan Zheng
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing, China
| | - Ying Hu
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing, China
| | - Zhiqiang Chen
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing, China
| | - Mei Wang
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing, China
| | - Wei Liao
- Department of Pediatrics, The First Hospital Affiliated to Army Medical University, Chongqing, China
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26
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Chapman DG, King GG, Robinson PD, Farah CS, Thamrin C. The need for physiological phenotyping to develop new drugs for airways disease. Pharmacol Res 2020; 159:105029. [PMID: 32565310 DOI: 10.1016/j.phrs.2020.105029] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Revised: 06/01/2020] [Accepted: 06/12/2020] [Indexed: 11/25/2022]
Abstract
Asthma and COPD make up the majority of obstructive airways diseases (OADs), which affects ∼11 % of the population. The main drugs used to treat OADs have not changed in the past five decades, with advancements mainly comprising variations on existing treatments. The recent biologics are beneficial to only specific subsets of patients. Part of this may lie in our inability to adequately characterise the tremendous heterogeneity in every aspect of OAD. The field is currently moving towards the concept of personalised medicine, based on a focus on treatable traits that are objective, measurable and modifiable. We propose extending this concept via the use of emerging clinical tools for comprehensive physiological phenotyping. We describe, based on published data, the evidence for the use of functional imaging, gas washout techniques and oscillometry, as well as potential future applications, to more comprehensively assess and predict treatment response in OADs. In this way, we hope to demonstrate how physiological phenotyping tools will improve the way in which drugs are prescribed, but most importantly, will facilitate development of new drugs for OADs.
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Affiliation(s)
- David G Chapman
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, The Woolcock Institute of Medical Research, The University of Sydney, Glebe NSW 2037, Australia; School of Life Sciences, Faculty of Science, University of Technology Sydney, Ultimo NSW 2007, Australia.
| | - G G King
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, The Woolcock Institute of Medical Research, The University of Sydney, Glebe NSW 2037, Australia; Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, NSW 2065, Australia; NHMRC Centre of Excellence in Severe Asthma, New Lambton Heights NSW 2305, Australia; Faculty of Medicine and Health Sciences, The University of Sydney, NSW 2006, Australia
| | - Paul D Robinson
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, The Woolcock Institute of Medical Research, The University of Sydney, Glebe NSW 2037, Australia; Department of Respiratory Medicine, The Children's Hospital at Westmead, Westmead, NSW 2145, Australia; Faculty of Medicine and Health Sciences, The University of Sydney, NSW 2006, Australia
| | - Claude S Farah
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, The Woolcock Institute of Medical Research, The University of Sydney, Glebe NSW 2037, Australia; Faculty of Medicine and Health Sciences, The University of Sydney, NSW 2006, Australia; Department of Thoracic Medicine, Concord Repatriation General Hospital, Concord, NSW 2137, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging Group and Woolcock Emphysema Centre, The Woolcock Institute of Medical Research, The University of Sydney, Glebe NSW 2037, Australia; Faculty of Medicine and Health Sciences, The University of Sydney, NSW 2006, Australia
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27
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Irving S, Fleming L, Ahmad F, Biggart E, Bingham Y, Cook J, Hall P, Jamalzadeh A, Nagakumar P, Bossley C, Gupta A, Macleod K, Saglani S, Bush A. Lung clearance index and steroid response in pediatric severe asthma. Pediatr Pulmonol 2020; 55:890-898. [PMID: 32027471 DOI: 10.1002/ppul.24675] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 01/19/2020] [Indexed: 11/06/2022]
Abstract
INTRODUCTION Lung clearance index (LCI) is a measure of airway disease that has been shown to be abnormal in asthma. We hypothesized that LCI would be higher (worse) in children with severe therapy-resistant asthma (STRA) compared with difficult asthma (DA) and healthy controls and that LCI would fall in response to parenteral steroids in STRA. METHODS Sixty-four children with asthma who were prescribed high-dose asthma therapy (GINA steps 4 or 5) performed LCI and spirometry. Forty-three had STRA and 21 DA. Thirty-nine of forty-three STRA patients attended for a clinically indicated bronchoscopy during which an intramuscular injection of triamcinolone was given. LCI, spirometry, and fractional exhaled nitric oxide (FeNO) were performed on the day of the bronchoscopy and repeated 4 weeks later. RESULTS LCI was more abnormal in STRA (median: 7.40, range: 5.58-12.34) than in DA (6.55, 5.77-7.75), P = .0006, and healthy controls (6.53, 5.57-7.35), P = .005. In contrast to the first second forced expired volume (FEV1 ), LCI improved following systemic steroids; of 20 STRA patients with an abnormal LCI at baseline, 13 improved following triamcinolone. LCI and FeNO responses were concordant. CONCLUSIONS There is a subgroup of children with STRA in whom LCI is elevated who improve following parenteral steroids. LCI may be a valuable additional domain in assessing steroid response in pediatric asthma.
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Affiliation(s)
- Samantha Irving
- Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Louise Fleming
- Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Fatima Ahmad
- National Heart and Lung Institute, Imperial College London, London, UK
| | | | - Yvvone Bingham
- National Heart and Lung Institute, Imperial College London, London, UK
| | - James Cook
- Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Pippa Hall
- Royal Brompton and Harefield NHS Foundation Trust, London, UK
| | | | - Prasad Nagakumar
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Cara Bossley
- King's College Hospital NHS Trust, London, UK.,Child Health Clinical Academic Group, King's College, London, UK
| | - Atul Gupta
- King's College Hospital NHS Trust, London, UK.,Child Health Clinical Academic Group, King's College, London, UK
| | | | - Sejal Saglani
- Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
| | - Andrew Bush
- Royal Brompton and Harefield NHS Foundation Trust, London, UK.,National Heart and Lung Institute, Imperial College London, London, UK
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28
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Foy B, Kay D, Siddiqui S, Brightling C, Paiva M, Verbanck S. Increased ventilation heterogeneity in asthma can be attributed to proximal bronchioles. Eur Respir J 2020; 55:13993003.01345-2019. [PMID: 31806713 DOI: 10.1183/13993003.01345-2019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 11/12/2019] [Indexed: 11/05/2022]
Affiliation(s)
- Brody Foy
- Center for Systems Biology and Dept of Pathology, Massachusetts General Hospital, Boston, MA, USA.,Dept of Systems Biology, Harvard Medical School, Boston, MA, USA
| | - David Kay
- Dept of Computer Science, University of Oxford, Oxford, UK
| | - Salman Siddiqui
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Chris Brightling
- Dept of Respiratory Sciences, University of Leicester, Leicester, UK
| | - Manuel Paiva
- Respiratory Division, University Hospital Erasme, Brussels, Belgium
| | - Sylvia Verbanck
- Respiratory Division, University Hospital UZBrussel, Brussels, Belgium
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29
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Bateman ME, Oakland H, Oral E, Nuss H, Fisher P, Udemgba C, Walker C, Daigrepont N, Parada NA. Evaluation of a Multidisciplinary Disease Management Program to Achieve Asthma Control in Seven Safety Net Hospitals in Louisiana. Popul Health Manag 2020; 24:133-140. [PMID: 32096685 DOI: 10.1089/pop.2019.0209] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
The objective was to evaluate a multidisciplinary guideline-driven disease management program focused on achievement of asthma control among sustained patients with confirmed asthma in Louisiana and to assess factors affecting achievement of asthma control. Data were extracted from the electronic health records of 1596 adults with confirmed asthma, sustained care for >1 year in the outpatient setting, and ≥2 recorded Asthma Control Test (ACT) scores. Multivariable logistic regression modeling was used to assess the association of demographic variables, comorbidities, and process measures with the best achieved asthma control as represented by the highest ACT score. Most subjects were female (81.1%) and African American (63.9%). Approximately half of them (48.9%) were able to achieve asthma control (ACT ≥20). The most prevalent comorbidities were hypertension (79.8%), rhinitis (55.3%), and obesity (50.5%). Most patients received pulmonary function testing (PFT) (88.6%), controller medication therapy (85.5%), or written asthma action plans (92.7%). Asthma control was positively associated with presence of PFT (OR = 1.63, 95% CI: 1.13, 2.37) and being a "never" smoker (OR = 1.49, 95% CI: 1.08, 2.04). Asthma control was less likely to be achieved by patients who were African American (OR = 0.68, 95% CI: 0.52, 0.87), had more comorbidities (OR = 0.89, 95% CI: 0.83, 0.96), or were on more medications (OR = 0.79, 95% CI: 0.72, 0.88). Asthma control was achieved in 48.9% of an adult, primarily African American population with the implementation of comprehensive guideline-driven care. Furthermore, this is the first study to observe that the presence of PFT may be associated with asthma control.
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Affiliation(s)
- Marjorie E Bateman
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Hannah Oakland
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Evrim Oral
- School of Public Health, Biostatistics Program, LSUHSC, New Orleans, Louisiana, USA
| | - Henry Nuss
- School of Public Health, Behavioral and Community Health Sciences Program, LSUHSC, New Orleans, Louisiana, USA
| | - Paige Fisher
- School of Public Health, Biostatistics Program, LSUHSC, New Orleans, Louisiana, USA
| | - Chioma Udemgba
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
| | - Carl Walker
- Lousisana State University Health Care Services Division, New Orleans, Louisiana, USA
| | - Nathan Daigrepont
- Lousisana State University Health Care Services Division, New Orleans, Louisiana, USA
| | - Nereida A Parada
- John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA.,Section of Pulmonary Diseases, Critical Care, and Environmental Medicine, Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana, USA
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Tang FSM, Rutting S, Farrow CE, Tonga KO, Watts J, Dame-Carrol JR, Bertolin A, King GG, Thamrin C, Chapman DG. Ventilation heterogeneity and oscillometry predict asthma control improvement following step-up inhaled therapy in uncontrolled asthma. Respirology 2020; 25:827-835. [PMID: 32026586 DOI: 10.1111/resp.13772] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 12/17/2019] [Accepted: 01/14/2020] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND OBJECTIVE Abnormal peripheral airway function is an important feature of asthma and relates to asthma symptoms and poor asthma control. We aimed to determine whether peripheral airway function, as measured by forced oscillatory impedance and multiple-breath nitrogen washout (MBNW), relates to symptom improvement in asthmatic participants with uncontrolled asthma, after stepping up to high-dose ICS/LABA treatment. METHODS A total of 19 subjects (14 females, mean age: 29.9 ± 13.6 years) with uncontrolled asthma, as defined by an ACQ5 > 1.5, taking 500 μg/day fluticasone equivalent or less, underwent spirometry, plethysmography, fractional exhaled FeNO, forced oscillatory resistance (Rrs5Hz ) and reactance (Xrs5Hz ), and indices of MBNW ventilation heterogeneity (lung clearance index (LCI), diffusion-convection-dependent (Sacin) and convection-dependent (Scond)). Measurements were made before and after 8 weeks of treatment with fluticasone/formoterol combination inhaler 250/10 μg, 2 puffs twice daily. RESULTS Treatment improved ACQ5 (P = 0.0002), FEV1 (P = 0.02), FVC (P = 0.04), FeNO (P = 0.0008), Xrs5Hz (P = 0.01), LCI (P = 0.0002), Sacin (P = 0.006) and Scond (P = 0.01). At baseline, ACQ5 correlated with Xrs5Hz (rs = 0.52, P = 0.03) and Rrs5Hz (rs = 0.55, P = 0.02). The improvement in ACQ5 was predicted by more abnormal baseline LCI (P = 0.03), Scond (P = 0.02) and Rrs5Hz (P = 0.006). Baseline Scond was the best predictor of a clinically meaningful improvement in asthma control (ΔACQ > 0.5, ROC-AUC = 0.91, P = 0.007). CONCLUSION Step-up to high-dose combination treatment in uncontrolled asthma is associated with improved peripheral airway function as measured by Xrs5Hz and MBNW. Baseline MBNW and FOT parameters correlated with the improvement in symptoms and may predict a positive response to up-titration in uncontrolled asthmatic patients.
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Affiliation(s)
- Francesca S M Tang
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Sandra Rutting
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Excellence in Severe Asthma, Newcastle, NSW, Australia
| | - Catherine E Farrow
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,Department of Respiratory and Sleep Medicine, Westmead Hospital, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia
| | - Katrina O Tonga
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,Faculty of Medicine and Health Sciences, The University of Sydney, Sydney, NSW, Australia.,Department of Thoracic and Transplant Medicine, St Vincent's Hospital, Sydney, NSW, Australia.,St Vincent's Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Joanna Watts
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Jessica R Dame-Carrol
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Amy Bertolin
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - Gregory G King
- Department of Respiratory Medicine, Royal North Shore Hospital, Sydney, NSW, Australia.,Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,NHMRC Centre of Excellence in Severe Asthma, Newcastle, NSW, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia
| | - David G Chapman
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, The University of Sydney, Sydney, NSW, Australia.,School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, NSW, Australia
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Trinkmann F, Lenz SA, Schäfer J, Gawlitza J, Schroeter M, Gradinger T, Akin I, Borggrefe M, Ganslandt T, Saur J. Feasibility and clinical applications of multiple breath wash-out (MBW) testing using sulphur hexafluoride in adults with bronchial asthma. Sci Rep 2020; 10:1527. [PMID: 32001782 PMCID: PMC6992773 DOI: 10.1038/s41598-020-58538-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 01/15/2020] [Indexed: 11/17/2022] Open
Abstract
Ventilation heterogeneity is frequent in bronchial asthma and can be assessed using multiple breath wash-out testing (MBW). Most data is available in paediatric patients and using nitrogen as a tracer gas. We aimed to evaluate sulphur hexafluoride (SF6) MBW in adult asthmatics. Spirometry, whole-body plethysmography, impulse oscillometry and SF6-MBW were prospectively performed. MBW parameters reflecting global (lung clearance index, LCI), acinar (Sacin) and conductive (Scond) ventilation heterogeneity were derived from three consecutive wash-outs. LCI was calculated for the traditional 2.5% and an earlier 5% stopping point that has the potential to reduce wash-out times. 91 asthmatics (66%) and 47 non-asthmatic controls (34%) were included in final analysis. LCI2.5 and LCI5 were higher in asthmatics (p < 0.001). Likewise, Sacin and Scond were elevated (p < 0.001 and p < 0.01). Coefficient of variation was 3.4% for LCI2.5 and 3.5% for LCI5 in asthmatics. Forty-one asthmatic patients had normal spirometry. ROC analysis revealed an AUC of 0.906 for the differentiation from non-asthmatic controls exceeding diagnostic performance of individual and conventional parameters (AUC = 0.819, p < 0.05). SF6-MBW is feasible and reproducible in adult asthmatics. Ventilation heterogeneity is increased as compared to non-asthmatic controls persisting in asthmatic patients with normal spirometry. Diagnostic performance is not affected using an earlier LCI stopping point while reducing wash-out duration considerably.
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Affiliation(s)
- Frederik Trinkmann
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany. .,Department of Biomedical Informatics of the Heinrich-Lanz-Centre, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.
| | - Steffi A Lenz
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Julia Schäfer
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Joshua Gawlitza
- Institute of Clinical Radiology and Nuclear Medicine, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Michele Schroeter
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Tobias Gradinger
- Department of Biomedical Informatics of the Heinrich-Lanz-Centre, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Ibrahim Akin
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Mannheim, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Martin Borggrefe
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Mannheim, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Thomas Ganslandt
- Department of Biomedical Informatics of the Heinrich-Lanz-Centre, University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
| | - Joachim Saur
- 1st Department of Medicine (Cardiology, Angiology, Pulmonary and Intensive Care), University Medical Centre Mannheim, Medical Faculty Mannheim, Heidelberg University, Heidelberg, Germany
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To M, Tsuzuki R, Katsube O, Yamawaki S, Soeda S, Kono Y, Honda N, Kano I, Haruki K, To Y. Persistent Asthma from Childhood to Adulthood Presents a Distinct Phenotype of Adult Asthma. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1921-1927.e2. [PMID: 31981729 DOI: 10.1016/j.jaip.2020.01.011] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/26/2018] [Revised: 12/21/2019] [Accepted: 01/07/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND In approximately 30% of children with asthma, the condition persists into adulthood. The longer duration of asthma in these patients is a risk factor for poor asthma control. However, the characteristics of adult patients with asthma that has persisted since childhood are not well documented. OBJECTIVE We sought to compare the clinical characteristics among patients with adult-onset asthma, patients who outgrew childhood asthma but relapsed, and patients with persistent asthma since childhood. METHODS We conducted a cross-sectional study of adult patients with asthma who visited our hospital. We classified them into 3 groups: those with adult-onset asthma (adult-onset), those who had remitted childhood asthma that relapsed (relapsed), and those who had asthma that had persisted since childhood (persistent). The clinical characteristics of these groups were compared. RESULTS A total of 1443 patients were enrolled. The persistent group was younger and included fewer patients with a smoking history. There were statistically significant differences among the 3 groups in the percentages of patients with a family history of asthma and comorbidities of allergic rhinitis and atopic dermatitis. The proportion of patients with severe asthma differed among the 3 groups (31% in the adult-onset group, 34% in the relapsed group, and 40% in the persistent group; P = .015). The values of forced expiratory flow at 75% of vital capacity were lower in the persistent group than the relapsed or adult-onset group. A multivariable logistic regression analysis (dependent variable: severe asthma) in each group revealed that the factors associated with severe asthma differed among the adult-onset, relapsed, and persistent groups. When we established an overall model that included interaction terms of cohort-by-other factors, there was a trend that comorbidity of allergic rhinitis affected the severity of asthma differently in the relapsed group compared with the other groups. CONCLUSION The clinical phenotype of asthma that persists from childhood to adulthood seems to be a distinct phenotype of adult asthma.
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Affiliation(s)
- Masako To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan; Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Ryuta Tsuzuki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Otohiro Katsube
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Satoshi Yamawaki
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Seiko Soeda
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Yuta Kono
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan
| | - Natsue Honda
- Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Ichino Kano
- Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Kosuke Haruki
- Department of Laboratory Medicine, Dokkyo Medical University, Saitama Medical Center, Koshigaya City, Saitama, Japan
| | - Yasuo To
- Department of Allergy and Respiratory Medicine, The Fraternity Memorial Hospital, Sumida, Tokyo, Japan.
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Kreetapirom P, Kiewngam P, Jotikasthira W, Kamchaisatian W, Benjaponpitak S, Manuyakorn W. Forced oscillation technique as a predictor for loss of control in asthmatic children. Asia Pac Allergy 2020; 10:e3. [PMID: 32099825 PMCID: PMC7016320 DOI: 10.5415/apallergy.2020.10.e3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Accepted: 01/13/2020] [Indexed: 01/19/2023] Open
Abstract
Background A reliable objective tool using as a predictor of asthma control status could assist asthma management. Objective To find the parameters of forced oscillation technique (FOT) as predictors for the future loss of asthma symptom control. Methods Children with well-controlled asthma symptom, aged 6–12 years, were recruited for a 12-week prospective study. FOT and spirometer measures and their bronchodilator response were evaluated at baseline. The level of asthma symptom control was evaluated according to Global Initiative for Asthma. Results Among 68 recruited children, 41 children (60.3%) maintain their asthma control between 2 visits (group C-C), and 27 children (39.7%) lost their asthma control on the follow-up visit (group C-LC). Baseline FOT parameters, including the values of respiratory resistance at 5 Hz (R5), respiratory resistance at 20 Hz (R20), respiratory reactance at 5 Hz, area of reactance, %predicted of R5 and percentage of bronchodilator response (%∆) of R5 and R20 were significantly different between C-C and C-LC groups. In contrast, only %∆ of forced vital capacity, forced expiratory volume in 1 second (FEV1), and FEF25%–75% (forced expiratory flow 25%–75%) were significantly different between groups. Multiple logistic regression analysis revealed that %predicted of R5, %∆R5, %predicted of FEV1 and %∆FEV1 were the predictive factors for predicting the future loss of asthma control. The following cutoff values demonstrated the best sensitivity and specificity for predicting loss of asthma control: %predicted of R5=91.28, %∆R5=21.2, %predicted of FEV1=89.5, and %∆FEV1=7.8. The combination of these parameters predicted the risk of loss of asthma control with area under the curve of 0.924, accuracy of 83.8%. Conclusion Resistance FOT measures have an additive role to spirometric parameter in predicting future loss of asthma control.
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Affiliation(s)
- Piyawut Kreetapirom
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Potjanee Kiewngam
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wanlapa Jotikasthira
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wasu Kamchaisatian
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Suwat Benjaponpitak
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Wiparat Manuyakorn
- Division of Allergy and Immunology, Department of Pediatrics, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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Garcia-Marcos L, Edwards J, Kennington E, Aurora P, Baraldi E, Carraro S, Gappa M, Louis R, Moreno-Galdo A, Peroni DG, Pijnenburg M, Priftis KN, Sanchez-Solis M, Schuster A, Walker S. Priorities for future research into asthma diagnostic tools: A PAN-EU consensus exercise from the European asthma research innovation partnership (EARIP). Clin Exp Allergy 2019; 48:104-120. [PMID: 29290104 DOI: 10.1111/cea.13080] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
The diagnosis of asthma is currently based on clinical history, physical examination and lung function, and to date, there are no accurate objective tests either to confirm the diagnosis or to discriminate between different types of asthma. This consensus exercise reviews the state of the art in asthma diagnosis to identify opportunities for future investment based on the likelihood of their successful development, potential for widespread adoption and their perceived impact on asthma patients. Using a two-stage e-Delphi process and a summarizing workshop, a group of European asthma experts including health professionals, researchers, people with asthma and industry representatives ranked the potential impact of research investment in each technique or tool for asthma diagnosis and monitoring. After a systematic review of the literature, 21 statements were extracted and were subject of the two-stage Delphi process. Eleven statements were scored 3 or more and were further discussed and ranked in a face-to-face workshop. The three most important diagnostic/predictive tools ranked were as follows: "New biological markers of asthma (eg genomics, proteomics and metabolomics) as a tool for diagnosis and/or monitoring," "Prediction of future asthma in preschool children with reasonable accuracy" and "Tools to measure volatile organic compounds (VOCs) in exhaled breath."
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Affiliation(s)
- L Garcia-Marcos
- Respiratory and Allergy Units, Arrixaca University Children's Hospital, University of Murcia & IMIB Research Institute, Murcia, Spain
| | | | | | - P Aurora
- Department of Paediatric Respiratory Medicine, Great Ormond Street Hospital for Children, London, UK.,Department of Respiratory, Critical Care and Anaesthesia Unit, University College London (UCL) Great Ormond Street Institute of Child Health, London, UK
| | - E Baraldi
- Women's and Children's Health Department, University of Padua, Padova, Italy
| | - S Carraro
- Women's and Children's Health Department, University of Padua, Padova, Italy
| | - M Gappa
- Children's Hospital & Research Institute, Marienhospital Wesel, Wesel, Germany
| | - R Louis
- Department of Respiratory Medicine, University of Liege, Liege, Belgium
| | - A Moreno-Galdo
- Paediatric Pulmonology Unit, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - D G Peroni
- Department of Clinical and Experimental Medicine, Section of Paediatrics, University of Pisa, Pisa, Italy
| | - M Pijnenburg
- Paediatrics/Paediatric Respiratory Medicine, Erasmus MC - Sophia Children's Hospital, Rotterdam, The Netherlands
| | - K N Priftis
- Department of Paediatrics, Athens University Medical School, Attikon General Hospital, Athens, Greece
| | - M Sanchez-Solis
- Respiratory and Allergy Units, Arrixaca University Children's Hospital, University of Murcia & IMIB Research Institute, Murcia, Spain
| | - A Schuster
- Department of Paediatrics, University Hospital, Düsseldorf, Germany
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Korten I, Zacharasiewicz A, Bittkowski N, Hofmann A, Lex C. Asthma control in children: Body plethysmography in addition to spirometry. Pediatr Pulmonol 2019; 54:1141-1148. [PMID: 31172686 DOI: 10.1002/ppul.24320] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 02/28/2019] [Accepted: 03/07/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND There is a lack of agreement among measures of asthma control in children. In Central Europe, body plethysmography is additionally used for asthma monitoring. However, its value is still unclear. OBJECTIVES We investigated the possible additional value of body plethysmographic measures (specific resistance, residual volume-total lung capacity ratio [RV/TLC]) compared with spirometric measures forced expiratory volume in 1 second (FEV 1 ), forced vital capacity (FVC), FEV 1 /FVC, forced expiratory flow at 25% to 75% of forced vital capacity (FEF 25-75 ), and fraction of exhaled nitric oxide (FeNO) for assessment of asthma control. METHODS One hundred and forty-five asthmatic children aged 5 to 17 were included. All children performed measurements of FeNO, spirometry, and body plethymography. Asthma control was assessed by the asthma control test (c-ACT/ACT) and a doctor's assessment of asthma control. RESULTS Investigating single lung function parameters, FEV1 , FEV 1 /FVC, FEF 25-75 and RV/TLC differed between controlled and partly controlled asthma. However, we found no differences between controlled and uncontrolled asthma with regard to single lung function parameters or for any parameter if investigated in a multivariable approach. This was also true if we combined obtained parameters from spirometry (comparing pathologic vs normal spirometry). Investigating the combination of body plethysmography and doctor's assessment of asthma control a significant association was found ( P = 0.02). Furthermore, combined spirometry and body plethysmography showed a significant association with both doctor's assessed asthma control ( P = 0.009) and the c-ACT/ACT ( P = 0.04). The addition of FeNO did not improve the results. CONCLUSIONS The combination of body plethysmography and spirometry shows best agreement with asthma control in children compared with spirometry or body plethysmography alone. Further studies are needed to find out whether additional measurements of body plethysmography improve the outcome of children in asthma monitoring.
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Affiliation(s)
- Insa Korten
- Department of Pediatrics, Division of Pediatric Respiratory Medicine, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Angela Zacharasiewicz
- Department of Pediatrics and Adolescent Medicine, Teaching Hospital University of Vienna, Wilhelminenspital, Vienna, Austria
| | - Nina Bittkowski
- Department of Pediatric Cardiology and Intensive Care Medicine with Neonatology and Pediatric Pneumology, University Hospital Goettingen, Goettingen, Germany
| | - Alexander Hofmann
- Department of Pediatrics, University Hospital Halle (Saale), Halle, Germany
| | - Christiane Lex
- Department of Pediatric Cardiology and Intensive Care Medicine with Neonatology and Pediatric Pneumology, University Hospital Goettingen, Goettingen, Germany
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Díaz Palacios MÁ, Hervás Marín D, Giner Valero A, Colomer Hernández N, Torán Barona C, Hernández Fernández de Rojas D. Correlation between impulse oscillometry parameters and asthma control in an adult population. J Asthma Allergy 2019; 12:195-203. [PMID: 31410030 PMCID: PMC6643487 DOI: 10.2147/jaa.s193744] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2018] [Accepted: 03/01/2019] [Indexed: 01/27/2023] Open
Abstract
Purpose: Impulse oscillometry (IOS) has been proposed as an alternative test to evaluate the obstruction of small airways and to detect changes in airways earlier than spirometry. In this study, we sought to determine the utility and association of IOS parameters with spirometry and asthma control in an adult population. Patients and methods: Adults 14-82 years of age with asthma were classified into uncontrolled asthma (n=48), partially controlled asthma (n=45), and controlled asthma (n=49) groups, and characterized with fractional exhaled nitric oxide (FENO), IOS, and spirometry in a transversal analysis planned as a one-visit study. The basic parameters evaluated in IOS are resistance at 5 Hz (R5), an index affected by the large and small airway; resistance at 20 Hz (R20), an index of the resistance of large airways; difference between R5 and R20 (R5-R20), indicative of the function of the small peripheral airways; reactance at 5 Hz (X5), indicative of the capacitive reactance in the small peripheral airways; resonance frequency (Fres), the intermediate frequency at which the reactance is null, and reactance area (XA), which represents the total reactance (area under the curve) at all frequencies between 5 Hz to Fres. Results: There were statistical differences between groups in standard spirometry and IOS parameters reflecting small peripheral airways (R5, R10, R5-R20, Fres, XA and X5) (P<0.001). Accuracy of IOS and/or spirometry to discriminate between controlled asthma vs partially controlled asthma and uncontrolled asthma was low (AUC=0.61). Using linear regression models, we found a good association between spirometry and IOS. In order to evaluate IOS as an alternative or supplementary method for spirometry, we designed a predictive model for spirometry from IOS applying a penalized regression model (Lasso). Then, we compared the original spirometry values with the values obtained from the predictive model using Bland-Altman plots, and the models showed an acceptable bias in the case of FEV1/FVC, FEV1%, and FVC%. Conclusion: IOS did not show a discriminative capacity to correctly classify patients according to the degree of asthma control. However, values of IOS showed good association with values of spirometry. IOS could be considered as an alternative and accurate complement to spirometry in adults. In a predictive model, spirometry values estimated from IOS tended to overestimate in low values of "real" spirometry and underestimate in high values.
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Affiliation(s)
| | - David Hervás Marín
- Department of Biostatistics, Instituto de Investigación Sanitaria La Fe, Valencia, Spain
| | - Ana Giner Valero
- Department of Allergy, Hospital Universitari La Fe, Valencia, Spain
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Bell AJ, Foy BH, Richardson M, Singapuri A, Mirkes E, van den Berge M, Kay D, Brightling C, Gorban AN, Galbán CJ, Siddiqui S. Functional CT imaging for identification of the spatial determinants of small-airways disease in adults with asthma. J Allergy Clin Immunol 2019; 144:83-93. [PMID: 30682455 DOI: 10.1016/j.jaci.2019.01.014] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Revised: 01/09/2019] [Accepted: 01/14/2019] [Indexed: 02/05/2023]
Abstract
BACKGROUND Asthma is a disease characterized by ventilation heterogeneity (VH). A number of studies have demonstrated that VH markers derived by using impulse oscillometry (IOS) or multiple-breath washout (MBW) are associated with key asthmatic patient-related outcome measures and airways hyperresponsiveness. However, the topographical mechanisms of VH in the lung remain poorly understood. OBJECTIVES We hypothesized that specific regionalization of topographical small-airway disease would best account for IOS- and MBW-measured indices in patients. METHODS We evaluated the results of paired expiratory/inspiratory computed tomography in a cohort of asthmatic (n = 41) and healthy (n = 11) volunteers to understand the determinants of clinical VH indices commonly reported by using IOS and MBW. Parametric response mapping (PRM) was used to calculate the functional small-airways disease marker PRMfSAD and Hounsfield unit (HU)-based density changes from total lung capacity to functional residual capacity (ΔHU); gradients of ΔHU in gravitationally perpendicular (parallel) inferior-superior (anterior-posterior) axes were quantified. RESULTS The ΔHU gradient in the inferior-superior axis provided the highest level of discrimination of both acinar VH (measured by using phase 3 slope analysis of multiple-breath washout data) and resistance at 5 Hz minus resistance at 20 Hz measured by using impulse oscillometry (R5-R20) values. Patients with a high inferior-superior ΔHU gradient demonstrated evidence of reduced specific ventilation in the lower lobes of the lungs and high levels of PRMfSAD. A computational small-airway tree model confirmed that constriction of gravitationally dependent, lower-zone, small-airway branches would promote the largest increases in R5-R20 values. Ventilation gradients correlated with asthma control and quality of life but not with exacerbation frequency. CONCLUSIONS Lower lobe-predominant small-airways disease is a major driver of clinically measured VH in adults with asthma.
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Affiliation(s)
- Alex J Bell
- NIHR Respiratory Biomedical Research Centre (BRC), Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Brody H Foy
- Computational Biology, Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Matthew Richardson
- NIHR Respiratory Biomedical Research Centre (BRC), Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Amisha Singapuri
- NIHR Respiratory Biomedical Research Centre (BRC), Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Evgeny Mirkes
- Department of Mathematics, University of Leicester, Leicester, United Kingdom
| | - Maarten van den Berge
- Department of Pulmonology, University Medical Centre Groningen, Groningen, the Netherlands
| | - David Kay
- Computational Biology, Department of Computer Science, University of Oxford, Oxford, United Kingdom
| | - Chris Brightling
- NIHR Respiratory Biomedical Research Centre (BRC), Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom
| | - Alexander N Gorban
- Department of Mathematics, University of Leicester, Leicester, United Kingdom
| | - Craig J Galbán
- Department of Radiology, University of Michigan, Ann Arbor, Mich
| | - Salman Siddiqui
- NIHR Respiratory Biomedical Research Centre (BRC), Department of Respiratory Sciences, University of Leicester, Leicester, United Kingdom.
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King GG, Farrow CE, Chapman DG. Dismantling the pathophysiology of asthma using imaging. Eur Respir Rev 2019; 28:28/152/180111. [PMID: 30996039 DOI: 10.1183/16000617.0111-2018] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Accepted: 03/01/2019] [Indexed: 11/05/2022] Open
Abstract
Asthma remains an important disease worldwide, causing high burden to patients and healthcare systems and presenting a need for better management and ultimately prevention and cure. Asthma is a very heterogeneous condition, with many different pathophysiological processes. Better measurement of those pathophysiological processes are needed to better phenotype disease, and to go beyond the current, highly limited measurements that are currently used: spirometry and symptoms. Sophisticated three-dimensional lung imaging using computed tomography and ventilation imaging (single photon emission computed tomography and positron emission tomography) and magnetic resonance imaging and methods of lung imaging applicable to asthma research are now highly developed. The body of current evidence suggests that abnormalities in structure and ventilatory function measured by imaging are clinically relevant, given their associations with disease severity, exacerbation risk and airflow obstruction. Therefore, lung imaging is ready for more widespread use in clinical trials and to become part of routine clinical assessment of asthma.
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Affiliation(s)
- Gregory G King
- Dept of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Australia .,Woolcock Institute of Medical Research and Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Centre of Excellence in Severe Asthma, Newcastle, Australia
| | - Catherine E Farrow
- Dept of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Australia.,Woolcock Institute of Medical Research and Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,Centre of Excellence in Severe Asthma, Newcastle, Australia
| | - David G Chapman
- Woolcock Institute of Medical Research and Northern Clinical School, Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.,School of Life Sciences, Faculty of Science, University of Technology Sydney, Sydney, Australia
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Tonga KO, Berend N, Thamrin C, Farah CS, Jetmalani K, Chapman DG, King GG. Lung elastic recoil and ventilation heterogeneity of diffusion-dependent airways in older people with asthma and fixed airflow obstruction. Eur Respir J 2019; 53:13993003.01028-2018. [PMID: 30578400 DOI: 10.1183/13993003.01028-2018] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2018] [Accepted: 12/13/2018] [Indexed: 11/05/2022]
Affiliation(s)
- Katrina O Tonga
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Dept of Respiratory Medicine, Royal North Shore Hospital, Sydney, Australia.,Dept of Respiratory Medicine, Concord Hospital, Sydney, Australia.,The University of Sydney, School of Medicine, Faculty of Medicine and Health, Sydney, Australia.,Dept of Thoracic and Transplant Medicine, St Vincent's Hospital, Sydney, Australia.,The University of New South Wales, Faculty of Medicine, Sydney, Australia
| | - Norbert Berend
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,The University of Sydney, School of Medicine, Faculty of Medicine and Health, Sydney, Australia.,The University of New South Wales, Faculty of Medicine, Sydney, Australia.,The George Institute for Global Health, Sydney, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,The University of Sydney, School of Medicine, Faculty of Medicine and Health, Sydney, Australia
| | - Claude S Farah
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Dept of Respiratory Medicine, Concord Hospital, Sydney, Australia.,The University of Sydney, School of Medicine, Faculty of Medicine and Health, Sydney, Australia.,Macquarie University, Faculty of Medicine and Health Sciences, Sydney, Australia
| | - Kanika Jetmalani
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia
| | - David G Chapman
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Translational Airways Group, School of Life Sciences, University of Technology Sydney, Sydney, Australia
| | - Gregory G King
- Airway Physiology and Imaging Group, The Woolcock Institute of Medical Research, University of Sydney, Sydney, Australia.,Dept of Respiratory Medicine, Royal North Shore Hospital, Sydney, Australia.,The University of Sydney, School of Medicine, Faculty of Medicine and Health, Sydney, Australia.,NHMRC Centre of Excellence in Severe Asthma, New Lambton Heights, Australia
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40
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Zimmermann SC, Tonga KO, Thamrin C. Dismantling airway disease with the use of new pulmonary function indices. Eur Respir Rev 2019; 28:28/151/180122. [PMID: 30918023 PMCID: PMC9488242 DOI: 10.1183/16000617.0122-2018] [Citation(s) in RCA: 30] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2018] [Accepted: 02/15/2019] [Indexed: 11/27/2022] Open
Abstract
We are currently limited in our abilities to diagnose, monitor disease status and manage chronic airway disease like asthma and chronic obstructive pulmonary disease (COPD). Conventional lung function measures often poorly reflect patient symptoms or are insensitive to changes, particularly in the small airways where disease may originate or manifest. Novel pulmonary function tests are becoming available which help us better characterise and understand chronic airway disease, and their translation and adoption from the research arena would potentially enable individualised patient care. In this article, we aim to describe two emerging lung function tests yielding novel pulmonary function indices, the forced oscillation technique (FOT) and multiple breath nitrogen washout (MBNW). With a particular focus on asthma and COPD, this article demonstrates how chronic airway disease mechanisms have been dismantled with the use of the FOT and MBNW. We describe their ability to assess detailed pulmonary mechanics for diagnostic and management purposes including response to bronchodilation and other treatments, relationship with symptoms, evaluation of acute exacerbations and recovery, and telemonitoring. The current limitations of both tests, as well as open questions/directions for further research, are also discussed. Spirometry is used to diagnose and manage airway disease such as asthma and COPD, but relates poorly to symptoms, lacks sensitivity and is effort dependent. FOT and MBNW are emerging clinical lung function tests that help us dismantle disease mechanisms.http://ow.ly/nM0G30nS6Ct
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Affiliation(s)
- Sabine C Zimmermann
- Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Dept of Respiratory Medicine, Royal North Shore Hospital, Sydney, Australia.,Sydney Medical School Northern, The University of Sydney, Sydney, Australia.,Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Katrina O Tonga
- Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Dept of Respiratory Medicine, Royal North Shore Hospital, Sydney, Australia.,Sydney Medical School Northern, The University of Sydney, Sydney, Australia.,Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia.,Dept of Thoracic and Transplant Medicine, St Vincent's Hospital, Sydney, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Cindy Thamrin
- Airway Physiology and Imaging Group, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia .,Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
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41
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Postma DS, Brightling C, Baldi S, Van den Berge M, Fabbri LM, Gagnatelli A, Papi A, Van der Molen T, Rabe KF, Siddiqui S, Singh D, Nicolini G, Kraft M. Exploring the relevance and extent of small airways dysfunction in asthma (ATLANTIS): baseline data from a prospective cohort study. THE LANCET RESPIRATORY MEDICINE 2019; 7:402-416. [PMID: 30876830 DOI: 10.1016/s2213-2600(19)30049-9] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 09/20/2018] [Revised: 11/26/2018] [Accepted: 12/18/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Small airways dysfunction (SAD) is well recognised in asthma, yet its role in the severity and control of asthma is unclear. This study aimed to assess which combination of biomarkers, physiological tests, and imaging markers best measure the presence and extent of SAD in patients with asthma. METHODS In this baseline assessment of a multinational prospective cohort study (the Assessment of Small Airways Involvement in Asthma [ATLANTIS] study), we recruited participants with and without asthma (defined as Global Initiative for Asthma severity stages 1-5) from general practices, the databases of chest physicians, and advertisements at 29 centres across nine countries (Brazil, China, Germany, Italy, Spain, the Netherlands, the UK, the USA, and Canada). All participants were aged 18-65 years, and participants with asthma had received a clinical diagnosis of asthma more than 6 months ago that had been confirmed by a chest physician. This diagnosis required support by objective evidence at baseline or during the past 5 years, which could be: positive airway hyperresponsiveness to methacholine, positive reversibility (a change in FEV1 ≥12% and ≥200 mL within 30 min) after treatment with 400 μg of salbutamol in a metered-dose inhaler with or without a spacer, variability in peak expiratory flow of more than 20% (measured over 7 days), or documented reversibility after a cycle (eg, 4 weeks) of maintenance anti-asthma treatment. The inclusion criteria also required that patients had stable asthma on any previous regular asthma treatment (including so-called rescue β2-agonists alone) at a stable dose for more than 8 weeks before baseline and had smoked for a maximum of 10 pack-years in their lifetime. Control group participants were recruited by advertisements; these participants were aged 18-65 years, had no respiratory symptoms compatible with asthma or chronic obstructive pulmonary disease, normal spirometry, and normal airways responsiveness, and had smoked for a maximum of 10 pack-years. We assessed all participants with spirometry, body plethysmography, impulse oscillometry, multiple breath nitrogen washout, CT (in selected participants), and questionnaires about asthma control, asthma-related quality of life (both in participants with asthma only), and health status. We applied structural equation modelling in participants with asthma to assess the contribution of all physiological and CT variables to SAD, from which we defined clinical SAD and CT SAD scores. We then classified patients with asthma into SAD groups with model-based clustering, and we compared asthma severity, control, and health-care use during the past year by SAD score and by SAD group. This trial is registered with ClinicalTrials.gov, number NCT02123667. FINDINGS Between June 30, 2014, and March 3, 2017, we recruited and evaluated 773 participants with asthma and 99 control participants. All physiological measures contributed to the clinical SAD model with the structural equation modelling analysis. The prevalence of SAD in asthma was dependent on the measure used; we found the lowest prevalence of SAD associated with acinar airway ventilation heterogeneity (Sacin), an outcome determined by multiple breath nitrogen washout that reflects ventilation heterogeneity in the most peripheral, pre-acinar or acinar airways. Impulse oscillometry and spirometry results, which were used to assess dysfunction of small-sized to mid-sized airways, contributed most to the clinical SAD score and differed between the two SAD groups. Participants in clinical SAD group 1 (n=452) had milder SAD than group 2 and comparable multiple breath nitrogen washout Sacin to control participants. Participants in clinical SAD group 2 (n=312) had abnormal physiological SAD results relative to group 1, particularly their impulse oscillometry and spirometry measurements, and group 2 participants also had more severe asthma (with regard to asthma control, treatments, exacerbations, and quality of life) than group 1. Clinical SAD scores were higher (indicating more severe SAD) in group 2 than group 1, and we found that these scores were related to asthma control, severity, and exacerbations. We found no correlation between clinical SAD and CT SAD scores. INTERPRETATION SAD is a complex and silent signature of asthma that is likely to be directly or indirectly captured by combinations of physiological tests, such as spirometry, body plethysmography, impulse oscillometry, and multiple breath nitrogen washout. SAD is present across patients with all severities of asthma, but it is particularly prevalent in severe disease. The clinical classification of SAD into two groups (a milder and a more severe group) by use of impulse oscillometry and spirometry, which are easy to use, is meaningful given its association with GINA severity stages, asthma control, quality of life, and exacerbations. FUNDING Chiesi Farmaceutici SpA.
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Affiliation(s)
- Dirkje S Postma
- Department of Pulmonology, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
| | - Chris Brightling
- Institute for Lung Health, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Simonetta Baldi
- Institute for Lung Health, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK; Department of Global Clinical Development, Chiesi SAS, Bois-Colombes, France
| | - Maarten Van den Berge
- Department of Pulmonology, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Leonardo M Fabbri
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy; COPD Centre, Sahlgrenska University Hospital, Gothenburg, Sweden
| | | | - Alberto Papi
- Research Centre on Asthma and COPD, University of Ferrara, Ferrara, Italy
| | - Thys Van der Molen
- Department of General Practice, Groningen Research Institute for Asthma and COPD, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Klaus F Rabe
- LungenClinic, Grosshansdorf, Germany; Department of Medicine, Christian Albrechts University, Kiel, Germany; Airway Research Center North, German Center for Lung Research (DZL), Hannover, Germany
| | - Salman Siddiqui
- Institute for Lung Health, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Dave Singh
- Centre for Respiratory Medicine and Allergy, University Hospital of South Manchester, University of Manchester, Manchester, UK
| | - Gabriele Nicolini
- Department of Global Clinical Development, Chiesi Farmaceutici SpA, Parma, Italy
| | - Monica Kraft
- University of Arizona College of Medicine, Department of Medicine, Tucson, AZ, USA
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Abstract
Uneven distribution of ventilation, or ventilation heterogeneity, has been observed in asthma for over 60 years using multiple breath nitrogen washout (MBNW) studies. Ventilation heterogeneity has been known to predict airway hyperresponsiveness (the ability of the airways to constrict too easily and by too much) in asthma, which is a core physiological characteristic of this disease. SPECT ventilation imaging allows topographical analysis of changes in ventilation distribution. Technegas as a SPECT ventilation agent has a key advantage as it remains fixed after inhalation, which allows imaging of upright ventilation distribution, analogous of pulmonary function tests. Recent studies using Technegas ventilation SPECT have shown spatial imaging markers also relate to airway hyperresponsiveness in asthma, and are predicted by a MBNW index of peripheral ventilation heterogeneity. It has also been shown that low-ventilation regions induced by bronchoconstriction were also related to peripheral ventilation heterogeneity. Furthermore, this suggests that the function of peripheral airways may determine the topographical pattern of airway narrowing with a more widespread distribution of narrowing. SPECT ventilation adds spatial characterisation information and it should be included in research protocols to enhance the understanding of complex physiological mechanisms in asthma.
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Affiliation(s)
- Catherine Farrow
- Airway Imaging and Physiology Group, The Woolcock Institute of Medical Research, Glebe NSW 2037; Northern Clinical School, Faculty of Medicine & Health, University of SydneyNSW 2006.
| | - Gregory King
- Airway Imaging and Physiology Group, The Woolcock Institute of Medical Research, Glebe NSW 2037; Department of Respiratory Medicine, Royal North Shore Hospital, Pacific Highway, St Leonards NSW 2065
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Langton D, Ing A, Sha J, Bennetts K, Hersch N, Kwok M, Plummer V, Thien F, Farah C. Measuring the effects of bronchial thermoplasty using oscillometry. Respirology 2018; 24:431-436. [PMID: 30419608 DOI: 10.1111/resp.13439] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2018] [Revised: 09/29/2018] [Accepted: 10/22/2018] [Indexed: 12/01/2022]
Abstract
BACKGROUND AND OBJECTIVE Bronchial thermoplasty (BT) has been consistently shown to reduce symptoms, exacerbations and the need for reliever medication in patients with severe asthma. Paradoxically, no consistent improvement in spirometry has been demonstrated. It has been suggested that this is due to a reduction in peripheral resistance in small airways, not captured by spirometry. Therefore, in this study, we evaluate the response to BT using oscillometry. METHODS A total of 43 patients with severe asthma from two centres were evaluated at baseline, 6 weeks and 6 months post BT, using spirometry, plethysmography and oscillometry, in addition to medication usage, exacerbation frequency and the Asthma Control Questionnaire (5-item version) (ACQ-5). RESULTS The mean age was 58.4 ± 11.2 years, forced expiratory volume in 1 s (FEV1 ) 55.5 ± 20.1% predicted, forced expiratory ratio 53.0 ± 14.5% and FEV1 response to salbutamol was 14.0 ± 14.5%. Following BT, the group responded to treatment with an improvement in ACQ-5 from 2.9 ± 0.9 at baseline to 1.7 ± 1.1 at 6 months (P < 0.005). There was an 81% reduction in exacerbation frequency (P < 0.001) and 50% of patients were weaned completely from maintenance oral corticosteroids. No changes after treatment were observed in spirometry but the residual volume reduced from 147 ± 38% to 139 ± 39% predicted (P < 0.01). Baseline oscillometry demonstrated high levels of resistance at 5 Hz with normal resistance at 20 Hz, indicating resistance in the small airways was elevated, but no changes were observed in any oscillometry parameter after BT treatment. CONCLUSION Lung impedance measured with oscillometry did not change following BT despite marked clinical improvements in patients with severe asthma.
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Affiliation(s)
- David Langton
- Department of Thoracic Medicine, Frankston Hospital, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Alvin Ing
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.,Sydney Adventist Hospital Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Joy Sha
- Department of Thoracic Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | - Kim Bennetts
- Department of Thoracic Medicine, Frankston Hospital, Melbourne, VIC, Australia
| | - Nicole Hersch
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia
| | - McKinny Kwok
- Sydney Adventist Hospital Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
| | - Virginia Plummer
- Department of Thoracic Medicine, Frankston Hospital, Melbourne, VIC, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia
| | - Francis Thien
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, VIC, Australia.,Department of Respiratory Medicine, Eastern Health, Melbourne, VIC, Australia
| | - Claude Farah
- Faculty of Medicine and Health Sciences, Macquarie University, Sydney, NSW, Australia.,Concord Clinical School, Faculty of Medicine and Health, University of Sydney, Sydney, NSW, Australia
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Small airway function in children with mild to moderate asthmatic symptoms. Ann Allergy Asthma Immunol 2018; 121:451-457. [PMID: 30059790 DOI: 10.1016/j.anai.2018.07.026] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 07/16/2018] [Accepted: 07/22/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND Clinical significance of small airway obstruction in mild pediatric asthma is unclear. OBJECTIVE To evaluate small airway properties in children with mild to moderate asthmatic symptoms and the association of small airway function with asthma control and exercise-induced bronchoconstriction (EIB). METHODS Children (5-10 years old) with recurrent wheezing (n = 42) or persistent troublesome cough (n = 16) and healthy controls (n = 19) performed impulse oscillometry (IOS), spirometry, and a multiple-breath nitrogen washout (MBNW) test. Exhaled nitric oxide (NO) was measured at multiple flow rates to determine alveolar NO concentration (Calv). Asthma control was evaluated with the Childhood Asthma Control Test (C-ACT), short-acting β2-agonist (SABA) use within the past month, and asthma exacerbations within the past year. RESULTS IOS, spirometry, and exhaled NO indexes that are related to small airway function differed between children with recurrent wheezing and healthy controls, whereas only forced expiratory flow at 25% to 75% of the forced vital capacity was associated with persistent cough. The MBNW indexes showed no difference between the groups. Among symptomatic children, conducting airway ventilation inhomogeneity and Calv were associated with asthma exacerbations (P = .03 and P = .002, respectively), and lung clearance index and Calv were associated with EIB (P = .04 and P = .004, respectively). None of the proposed small airway indexes was associated with the C-ACT score or SABA use. CONCLUSION Subtle changes were observed in the proposed small airway indexes of IOS, spirometry, and exhaled NO among children with mild to moderate recurrent wheezing. Small airway dysfunction, expressed as ventilation inhomogeneity indexes and Calv, was also associated with asthma exacerbations and EIB.
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King GG, Thamrin C. Complex lung function in severe asthma: seeing is believing. Eur Respir J 2018; 48:294-6. [PMID: 27478183 DOI: 10.1183/13993003.01120-2016] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 06/13/2016] [Indexed: 11/05/2022]
Affiliation(s)
- Gregory G King
- Woolcock Institute of Medical Research, The University of Sydney, Australia Dept of Respiratory Medicine, Royal North Shore Hospital, St Leonards, Australia NHMRC Centre of Excellence in Severe Asthma
| | - Cindy Thamrin
- Woolcock Institute of Medical Research, The University of Sydney, Australia
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46
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Vilmann L, Buchvald F, Green K, Nielsen KG. Fractional exhaled nitric oxide and multiple breath nitrogen washout in preschool healthy and asthmatic children. Respir Med 2017; 133:42-47. [PMID: 29173448 DOI: 10.1016/j.rmed.2017.10.027] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 10/05/2017] [Accepted: 10/31/2017] [Indexed: 01/01/2023]
Abstract
INTRODUCTION Objectively assessing pulmonary disease is challenging in preschool children with asthma. We evaluated the feasibility of measuring fractional exhaled nitrogen oxide (FeNO) and multiple breath nitrogen washout (N2MBW) in children. We compared their capacities for discriminating between children with asthma and healthy controls. METHODS We measured FeNO and N2MBW-derived indices of lung clearance (LCI2.5) and conductive and acinar ventilation heterogeneity (Scond and Sacin) in 65 preschool children; 35 with physician-diagnosed asthma and 30 healthy. FeNO was measured with a portable device (sampling time, 6 s). We employed data quality control guidelines on N2MBW. Feasibility was evaluated in a maximum of 8 attempts for both methods. Atopic co-morbidity and first-degree disposition were evaluated with the ISAAC-questionnaire. RESULTS FeNO and N2MBW testing were feasible in 45% and 91% of children, respectively. Feasibility was highly age-dependent. In children under 4 years old, FeNO was not feasible, but N2MBW was 85% feasible. Children with asthma had significantly elevated Scond values (median; 95% CI) (0.024; 0.020; 0.029) compared to healthy controls (0.019; 0.016; 0.023), but similar FeNO, LCI2.5 and Sacinvalues. CONCLUSION The feasibility of measuring FeNO was highly age-dependent and not applicable in children under age 4. N2MBW was feasible in the majority of preschool children. Scond, but not FeNO, could discriminate between children with asthma and healthy controls.
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Affiliation(s)
- Lea Vilmann
- Danish PCD & ChILD Centre, CF Centre Copenhagen, Pediatric Pulmonary Service, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Frederik Buchvald
- Danish PCD & ChILD Centre, CF Centre Copenhagen, Pediatric Pulmonary Service, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kent Green
- Danish PCD & ChILD Centre, CF Centre Copenhagen, Pediatric Pulmonary Service, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Kim Gjerum Nielsen
- Danish PCD & ChILD Centre, CF Centre Copenhagen, Pediatric Pulmonary Service, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
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Heijkenskjöld Rentzhog C, Janson C, Berglund L, Borres MP, Nordvall L, Alving K, Malinovschi A. Overall and peripheral lung function assessment by spirometry and forced oscillation technique in relation to asthma diagnosis and control. Clin Exp Allergy 2017; 47:1546-1554. [PMID: 28940832 DOI: 10.1111/cea.13035] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2016] [Revised: 06/21/2017] [Accepted: 08/19/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Classic spirometry is effort dependent and of limited value in assessing small airways. Peripheral airway involvement, and relation to poor control, in asthma, has been highlighted recently. Forced oscillation technique (FOT) offers an effort-independent assessment of overall and peripheral lung mechanics. We studied the association between lung function variables, obtained either by spirometry or multifrequency (5, 11 and 19 Hz) FOT, and asthma diagnosis and control. METHODS Spirometry measures, resistance at 5 (R5) and 19 Hz (R19), reactance at 5 Hz (X5), resonant frequency (fres ), resistance difference between 5-19 Hz (R5-R19) and Asthma Control Test scores were determined in 234 asthmatic and 60 healthy subjects (aged 13-39 years). We used standardized lung function variables in logistic regression analyses, unadjusted and adjusted for age, height, gender and weight. RESULTS Lower FEV1 /FVC (OR [95% CI] 0.47 [0.32, 0.69]) and FEF50 (0.62 [0.46, 0.85]) per standard deviation increase, and higher R5 (3.31 [1.95, 5.62]) and R19 (2.54 [1.65, 3.91]) were associated with asthma diagnosis. Independent predictive effects of FEV1 /FVC and R5 or R19, respectively, were found for asthma diagnosis. Lower FEV1 /FVC and altered peripheral FOT measures (X5, fres and R5-R19) were associated with uncontrolled asthma (P-values < .05). CONCLUSIONS Resistance FOT measures were equally informative as spirometry, related to asthma diagnosis, and, furthermore, offered additive information to FEV1 /FVC, supporting a complementary role for FOT. Asthma control was related to FOT measures of peripheral airways, suggesting a potential use in identifying such involvement. Further studies are needed to determine a clinical value and relevant reference values in children, for the multifrequency FOT measurements.
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Affiliation(s)
| | - C Janson
- Department of Medical Sciences: Respiratory, Allergy and Sleep Research, Uppsala University, Uppsala, Sweden
| | - L Berglund
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - M P Borres
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - L Nordvall
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - K Alving
- Department of Women's and Children's Health, Uppsala University, Uppsala, Sweden
| | - A Malinovschi
- Department of Medical Sciences: Clinical Physiology, Uppsala University, Uppsala, Sweden
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Knihtilä H, Kotaniemi-Syrjänen A, Pelkonen AS, Kalliola S, Mäkelä MJ, Malmberg LP. Small airway oscillometry indices: Repeatability and bronchodilator responsiveness in young children. Pediatr Pulmonol 2017; 52:1260-1267. [PMID: 28834381 DOI: 10.1002/ppul.23794] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 08/01/2017] [Indexed: 01/29/2023]
Abstract
INTRODUCTION The impulse oscillometry (IOS) indices absolute and relative difference between respiratory resistance at 5 and 20 Hz (R5-20 and R5-20%, respectively) and the area under the reactance curve (AX) are postulated to reflect small airway function. Data on their cutoff values to evaluate bronchodilator responsiveness (BDR) or between-visit changes after interventions are limited in young children. METHODS We evaluated the BDR of 103 healthy children aged 2-7 years, who received either salbutamol (n = 84) or placebo (n = 19) in order to determine cutoff values for BDR of R5-20, R5-20%, and AX. We then determined the repeatability within and between two IOS measurements 7-14 days apart in young children aged 4-8 years with asthmatic symptoms (n = 43), including cutoff values for significant between-visit changes. RESULTS The investigated IOS parameters showed marked BDR (fifth percentile cutoff of 75-110% of the baseline value) in healthy children, whereas no significant changes were seen after inhalation of placebo. The agreement within the triplicate IOS measurement was excellent (ICC > 0.80), and the agreement of results between visits was good (ICC > 0.60). A change in R5-20, R5-20%, and AX of 0.65, 1.08, and 0.84 z-scores, respectively, would exceed 95% confidence intervals for between-visit variability. CONCLUSION We introduce cutoff values for BDR of R5-20, R5-20%, and AX, and their repeatability indices and cutoff limits for significant between-visit changes. These IOS parameters may show greater variability than the conventional IOS indices during follow-up, but the between-visit agreement remains good, providing potentially useful endpoints for monitoring lung function in young children.
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Affiliation(s)
- Hanna Knihtilä
- Pediatric Unit of the Department of Allergy, Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anne Kotaniemi-Syrjänen
- Pediatric Unit of the Department of Allergy, Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Anna S Pelkonen
- Pediatric Unit of the Department of Allergy, Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Satu Kalliola
- Pediatric Unit of the Department of Allergy, Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Mika J Mäkelä
- Pediatric Unit of the Department of Allergy, Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Leo Pekka Malmberg
- Pediatric Unit of the Department of Allergy, Skin and Allergy Hospital, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
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49
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Sonnappa S, McQueen B, Postma DS, Martin RJ, Roche N, Grigg J, Guilbert T, Gouder C, Pizzichini E, Niimi A, Phipatanakul W, Chisholm A, Dandurand RJ, Kaplan A, Israel E, Papi A, van Aalderen WMC, Usmani OS, Price DB. Extrafine Versus Fine Inhaled Corticosteroids in Relation to Asthma Control: A Systematic Review and Meta-Analysis of Observational Real-Life Studies. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2017; 6:907-915.e7. [PMID: 28941668 DOI: 10.1016/j.jaip.2017.07.032] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/04/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND The particle size of inhaled corticosteroids (ICSs) may affect airway drug deposition and effectiveness. OBJECTIVE To compare the effectiveness of extrafine ICSs (mass median aerodynamic diameter, <2 μm) versus fine-particle ICSs administered as ICS monotherapy or ICS-long-acting β-agonist combination therapy by conducting a meta-analysis of observational real-life asthma studies to estimate the treatment effect of extrafine ICSs. METHODS MEDLINE and EMBASE databases were reviewed for asthma observational comparative effectiveness studies from January 2004 to June 2016. Studies were included if they reported odds and relative risk ratios and met all inclusion criteria (Respiratory Effectiveness Group/European Academy of Allergy and Clinical Immunology quality standards, comparison of extrafine ICSs with same or different ICS molecule, ≥12-month follow-up). End-point data (asthma control, exacerbations, prescribed ICS dose) were pooled. Random-effects meta-analysis modeling was used. The study protocol is published in the PROSPERO register CRD42016039137. RESULTS Seven studies with 33,453 subjects aged 5 to 80 years met eligibility criteria for inclusion. Six studies used extrafine beclometasone propionate and 1 study used both extrafine beclometasone propionate and extrafine ciclesonide as comparators with fine-particle ICSs. The overall odds of achieving asthma control were significantly higher for extrafine ICSs compared with fine-particle ICSs (odds ratio, 1.34; 95% CI, 1.22-1.46). Overall exacerbation rate ratios (0.84; 95% CI, 0.73-0.97) and ICS dose (weighted mean difference, -170 μg; 95% CI, -222 to -118 μg) were significantly lower for extrafine ICSs compared with fine-particle ICSs. CONCLUSIONS This meta-analysis demonstrates that extrafine ICSs have significantly higher odds of achieving asthma control with lower exacerbation rates at significantly lower prescribed doses than fine-particle ICSs.
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Affiliation(s)
- Samatha Sonnappa
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Department of Respiratory Paediatrics, Rainbow Children's Hospital, Bengaluru, India
| | - Brett McQueen
- University of Colorado Denver, Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Denver, Colo
| | - Dirkje S Postma
- Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands
| | - Richard J Martin
- National Jewish Health and the University of Colorado Denver, Denver, Colo
| | - Nicolas Roche
- Respiratory and Intensive Care Medicine, Cochin Hospital (APHP), University Paris Descartes (EA2511), Paris, France
| | - Jonathan Grigg
- Blizard Institute, Queen Mary University London, London, United Kingdom
| | - Theresa Guilbert
- Division of Pulmonology Medicine, Cincinnati Children's Hospital & Medical Center, Cincinnati, Ohio
| | - Caroline Gouder
- Department of Respiratory Medicine, Mater Dei Hospital, Msida, Malta
| | - Emilio Pizzichini
- Department of Medicine, Federal University of Santa Catarina, Santa Catarina, Brazil
| | - Akio Niimi
- Department of Respiratory Medicine, Allergy and Clinical Immunology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | | | - Alison Chisholm
- Respiratory Effectiveness Group, Oakington, Cambridge, United Kingdom
| | - Ronald J Dandurand
- Montreal Chest Institute, Meakins-Christie Laboratories and the McGill University Health Centre Research Institute, McGill University, Montreal, Canada
| | - Alan Kaplan
- Family Physician Airways Group of Canada, University of Toronto, Toronto, Ontario, Canada
| | - Elliot Israel
- Pulmonary and Critical Care Division, Brigham & Women's Hospital, Harvard Medical School, Boston, Mass
| | - Alberto Papi
- Department of Respiratory Medicine, University Hospital S. Anna, Ferrara, Italy
| | - Willem M C van Aalderen
- Department of Pediatric Respiratory Diseases, Emma Children's Hospital AMC, Amsterdam, The Netherlands
| | - Omar S Usmani
- National Heart and Lung Institute, Imperial College London & Royal Brompton Hospital, London, United Kingdom
| | - David B Price
- Observational and Pragmatic Research Institute Pte Ltd, Singapore; Academic Primary Care, Division of Applied Health Sciences, University of Aberdeen, Aberdeen, United Kingdom.
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50
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Farrow CE, Salome CM, Harris BE, Bailey DL, Berend N, King GG. Peripheral ventilation heterogeneity determines the extent of bronchoconstriction in asthma. J Appl Physiol (1985) 2017; 123:1188-1194. [PMID: 28798203 DOI: 10.1152/japplphysiol.00640.2016] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2016] [Revised: 08/08/2017] [Accepted: 08/08/2017] [Indexed: 11/22/2022] Open
Abstract
In asthma, bronchoconstriction causes topographically heterogeneous airway narrowing, as measured by three-dimensional ventilation imaging. Computation modeling suggests that peripheral airway dysfunction is a potential determinant of acute airway narrowing measured by imaging. We hypothesized that the development of low-ventilation regions measured topographically by three-dimensional imaging after bronchoconstriction is predicted by peripheral airway function. Fourteen asthmatic subjects underwent ventilation single-photon-emission computed tomography/computed tomography scan imaging before and after methacholine challenge. One-liter breaths of Technegas were inhaled from functional residual capacity in upright posture before supine scanning. The lung regions with the lowest ventilation (Ventlow) were calculated using a thresholding method and expressed as a percentage of total ventilation (Venttotal). Multiple-breath nitrogen washout was used to measure diffusion-dependent and convection-dependent ventilation heterogeneity (Sacin and Scond, respectively) and lung clearance index (LCI), before and after challenge. Forced expiratory volume in 1 s (FEV1) was 87.6 ± 15.8% predicted, and seven subjects had airway hyperresponsiveness. Ventlow at baseline was unrelated to spirometry or multiple-breath nitrogen washout indices. Methacholine challenge decreased FEV1 by 23 ± 5% of baseline while Ventlow increased from 21.5 ± 2.3%Venttotal to 26.3 ± 6.7%Venttotal (P = 0.03). The change in Ventlow was predicted by baseline Sacin (rs = 0.60, P = 0.03) and by LCI (rs = 0.70, P = 0.006) but not by Scond (rs = 0.30, P = 0.30). The development of low-ventilation lung units in three-dimensional ventilation imaging is predicted by ventilation heterogeneity in diffusion-dependent airways. This relationship suggests that acinar ventilation heterogeneity in asthma may be of mechanistic importance in terms of bronchoconstriction and airway narrowing.NEW & NOTEWORTHY Using ventilation SPECT/CT imaging in asthmatics, we show induced bronchoconstriction leads to the development of areas of low ventilation. Furthermore, the relative volume of the low-ventilation regions was predicted by ventilation heterogeneity in diffusion-dependent acinar airways. This suggests that the pattern of regional airway narrowing in asthma is determined by acinar airway function.
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Affiliation(s)
- Catherine E Farrow
- Woolcock Institute of Medical Research, The University of Sydney, Australia.,Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards Australia
| | - Cheryl M Salome
- Woolcock Institute of Medical Research, The University of Sydney, Australia
| | - Benjamin E Harris
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards Australia
| | - Dale L Bailey
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards Australia.,Department of Nuclear Medicine, Royal North Shore Hospital, St. Leonards Australia; and
| | - Norbert Berend
- Woolcock Institute of Medical Research, The University of Sydney, Australia.,Department of Respiratory Research, George Institute of Global Health, Australia
| | - Gregory G King
- Woolcock Institute of Medical Research, The University of Sydney, Australia; .,Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards Australia.,NHMRC Centre of Excellence in Severe Asthma, The University of Sydney, Australia
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