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Shimizu K, Kimura H, Tanabe N, Tanimura K, Chubachi S, Iijima H, Sato S, Wakazono N, Nakamaru Y, Okada K, Makita H, Goudarzi H, Suzuki M, Nishimura M, Konno S. Increased adiposity-to-muscle ratio and severity of sinusitis affect quality of life in asthma: Computed tomographic analysis. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY. GLOBAL 2024; 3:100277. [PMID: 38983113 PMCID: PMC11231708 DOI: 10.1016/j.jacig.2024.100277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 03/03/2024] [Accepted: 04/05/2024] [Indexed: 07/11/2024]
Abstract
Background Deteriorated sinusitis and increased adiposity relative to muscle mass may affect quality of life in patients with asthma. However, whether these effects are observed regardless of intrapulmonary pathology is unknown. Objectives We evaluated the correlation of the cross-sectional ratio of abdominal visceral fat (VF) to erector spinae muscle (ESM) and sinus findings based on Lund-Mackey scoring system (LMS) on computed tomography (CT) with the impaired score of the Asthma Quality of Life Questionnaire (AQLQ), regardless of airway and parenchymal disease, in patients with asthma. Methods We recruited participants from the Hokkaido-based severe asthma cohort who had completed AQLQ and CT examination at the entry. The participants were divided into high (highest) and low (other quartiles) groups on the bases of the extrapulmonary indices. Multivariate analysis examined the association of VF/ESM for the adiposity-to-muscle ratio and LMS with AQLQ after adjusting for the airway fractal dimension for airway index and percentage of low attenuation volume to lung volume for parenchymal index. Results No significant differences were observed in VF/ESM and LMS in terms of sex. The AQLQ score in the high VF/ESM group and high LMS group was lower than those in low VF/ESM group and low LMS group (63 male and 100 female subjects). High VF/ESM (estimate [95% confidence interval] (-0.43 [-0.61, -0.25]) and high LMS scores (-0.22 [-0.41, -0.03]) were associated with low AQLQ scores when adjusted for age, body mass index, smoking status, blood eosinophil count, and intrapulmonary CT indices. Conclusions Increased VF relative to ESM mass and high LMS may deteriorate asthma-related quality of life, regardless of presence of intrapulmonary disease.
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Affiliation(s)
- Kaoruko Shimizu
- Division of Emergent Respiratory and Cardiovascular Medicine, Hokkaido University Hospital, Sapporo, Japan
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - 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
| | - Kazuya Tanimura
- Department of Respiratory Medicine, Nara Medical University, Kashihara, Japan
| | - Shotaro Chubachi
- Department of Medicine, Division of Pulmonary Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hiroaki Iijima
- Department of Respiratory Medicine, Tsukuba Medical Center Hospital, Tsukuba, Japan
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Nobuyasu Wakazono
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Yuji Nakamaru
- Department of Otolaryngology-Head and Neck Surgery, School of Medicine, Hokkaido University, Sapporo, Japan
| | - Kazufumi Okada
- Data Science Center, Promotion Unit, Institute of Health Science Innovation for Medical Care, Hokkaido University Hospital, Sapporo, Japan
| | - Hironi Makita
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
- Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Houman Goudarzi
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, 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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Baglivo I, Quaranta VN, Dragonieri S, Colantuono S, Menzella F, Selvaggio D, Carpagnano GE, Caruso C. The New Paradigm: The Role of Proteins and Triggers in the Evolution of Allergic Asthma. Int J Mol Sci 2024; 25:5747. [PMID: 38891935 PMCID: PMC11171572 DOI: 10.3390/ijms25115747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2024] [Revised: 05/18/2024] [Accepted: 05/23/2024] [Indexed: 06/21/2024] Open
Abstract
Epithelial barrier damage plays a central role in the development and maintenance of allergic inflammation. Rises in the epithelial barrier permeability of airways alter tissue homeostasis and allow the penetration of allergens and other external agents. Different factors contribute to barrier impairment, such as eosinophilic infiltration and allergen protease action-eosinophilic cationic proteins' effects and allergens' proteolytic activity both contribute significantly to epithelial damage. In the airways, allergen proteases degrade the epithelial junctional proteins, allowing allergen penetration and its uptake by dendritic cells. This increase in allergen-immune system interaction induces the release of alarmins and the activation of type 2 inflammatory pathways, causing or worsening the main symptoms at the skin, bowel, and respiratory levels. We aim to highlight the molecular mechanisms underlying allergenic protease-induced epithelial barrier damage and the role of immune response in allergic asthma onset, maintenance, and progression. Moreover, we will explore potential clinical and radiological biomarkers of airway remodeling in allergic asthma patients.
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Affiliation(s)
- Ilaria Baglivo
- Centro Malattie Apparato Digerente (CEMAD) Digestive Disease Center, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Vitaliano Nicola Quaranta
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, 70121 Bari, Italy (S.D.)
| | - Silvano Dragonieri
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, 70121 Bari, Italy (S.D.)
| | - Stefania Colantuono
- Unità Operativa Semplice Dipartimentale Day Hospital (UOSD DH) Medicina Interna e Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
| | - Francesco Menzella
- Pulmonology Unit, S. Valentino Hospital-AULSS2 Marca Trevigiana, 31100 Treviso, Italy
| | - David Selvaggio
- UOS di Malattie dell’Apparato Respiratorio Ospedale Cristo Re, 00167 Roma, Italy
| | - Giovanna Elisiana Carpagnano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University “Aldo Moro” of Bari, 70121 Bari, Italy (S.D.)
| | - Cristiano Caruso
- Unità Operativa Semplice Dipartimentale Day Hospital (UOSD DH) Medicina Interna e Malattie dell’Apparato Digerente, Fondazione Policlinico Universitario “A. Gemelli” IRCCS, Università Cattolica del Sacro Cuore, 00168 Roma, Italy
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Georas SN, Khurana S. Update on asthma biology. J Allergy Clin Immunol 2024; 153:1215-1228. [PMID: 38341182 DOI: 10.1016/j.jaci.2024.01.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/17/2024] [Accepted: 01/24/2024] [Indexed: 02/12/2024]
Abstract
This is an exciting time to be conducting asthma research. The recent development of targeted asthma biologics has validated the power of basic research to discover new molecules amenable to therapeutic intervention. Advances in high-throughput sequencing are providing a wealth of "omics" data about genetic and epigenetic underpinnings of asthma, as well as about new cellular interacting networks and potential endotypes in asthma. Airway epithelial cells have emerged not only as key sensors of the outside environment but also as central drivers of dysregulated mucosal immune responses in asthma. Emerging data suggest that the airway epithelium in asthma remembers prior encounters with environmental exposures, resulting in potentially long-lasting changes in structure and metabolism that render asthmatic individuals susceptible to subsequent exposures. Here we summarize recent insights into asthma biology, focusing on studies using human cells or tissue that were published in the past 2 years. The studies are organized thematically into 6 content areas to draw connections and spur future research (on genetics and epigenetics, prenatal and early-life origins, microbiome, immune and inflammatory pathways, asthma endotypes and biomarkers, and lung structural alterations). We highlight recent studies of airway epithelial dysfunction and response to viral infections and conclude with a framework for considering how bidirectional interactions between alterations in airway structure and mucosal immunity can lead to sustained lung dysfunction in asthma.
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Affiliation(s)
- Steve N Georas
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY.
| | - Sandhya Khurana
- Division of Pulmonary and Critical Care Medicine, University of Rochester Medical Center, Rochester, NY
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Vianello A, Guarnieri G, Achille A, Lionello F, Lococo S, Zaninotto M, Caminati M, Senna G. Serum biomarkers of remodeling in severe asthma with fixed airway obstruction and the potential role of KL-6. Clin Chem Lab Med 2023; 61:1679-1687. [PMID: 36989607 DOI: 10.1515/cclm-2022-1323] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 03/10/2023] [Indexed: 03/31/2023]
Abstract
Over 3% of asthmatic patients are affected by a particularly severe form of the disease ("severe asthma", SA) which is often refractory to standard treatment. Airway remodeling (AR), which can be considered a critical characteristic of approximately half of all patients with SA and currently thought to be the main mechanism triggering fixed airway obstruction (FAO), seems to be a key factor affecting a patient's outcome. Despite the collective efforts of internationally renowned experts, to date only a few biomarkers indicative of AR and no recognizable biomarkers of lung parenchymal remodeling have been identified. This work examines the pathogenesis of airway and lung parenchymal remodeling and the serum biomarkers that may be able to identify the severe asthmatic patients who may develop FAO. The study also aims to examine if Krebs von den Lungen-6 (KL-6) could be considered a diagnostic biomarker of lung structural damage in SA.
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Affiliation(s)
- Andrea Vianello
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Gabriella Guarnieri
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Alessia Achille
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Federico Lionello
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Sara Lococo
- Department of Cardiac Thoracic Vascular Sciences and Public Health, University of Padova, Padova, Italy
| | - Martina Zaninotto
- Department of Laboratory Medicine, University-Hospital of Padova, Padova, Italy
| | - Marco Caminati
- Asthma Center and Allergy Unit, University of Verona, Verona, Italy
| | - Gianenrico Senna
- Asthma Center and Allergy Unit, University of Verona, Verona, Italy
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Yao X, Chen Q, Wang X, Liu X, Zhang L. IL-25 induces airway remodeling in asthma by orchestrating the phenotypic changes of epithelial cell and fibrocyte. Respir Res 2023; 24:212. [PMID: 37635231 PMCID: PMC10463650 DOI: 10.1186/s12931-023-02509-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 08/11/2023] [Indexed: 08/29/2023] Open
Abstract
BACKGROUND Previous studies have shown that IL-25 levels are increased in patients with asthma with fixed airflow limitation (FAL). However, the mechanism by which IL-25 contributes to airway remodeling and FAL remains unclear. Here, we hypothesized that IL-25 facilitates pro-fibrotic phenotypic changes in bronchial epithelial cells (BECs) and circulating fibrocytes (CFs), orchestrates pathological crosstalk from BECs to CFs, and thereby contributes to airway remodeling and FAL. METHODS Fibrocytes from asthmatic patients with FAL and chronic asthma murine models were detected using flow cytometry, multiplex staining and multispectral imaging analysis. The effect of IL-25 on BECs and CFs and on the crosstalk between BECs and CFs was determined using cell culture and co-culture systems. RESULTS We found that asthmatic patients with FAL had higher numbers of IL-25 receptor (i.e., IL-17RB)+-CFs, which were negatively correlated with forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC). The number of airway IL-17RB+-fibrocytes was significantly increased in ovalbumin (OVA)- and IL-25-induced asthmatic mice versus the control subjects. BECs stimulated with IL-25 exhibited an epithelial-mesenchymal transition (EMT)-like phenotypic changes. CFs stimulated with IL-25 produced high levels of extracellular matrix (ECM) proteins and connective tissue growth factors (CTGF). These profibrotic effects of IL-25 were partially blocked by the PI3K-AKT inhibitor LY294002. In the cell co-culture system, OVA-challenged BECs facilitated the migration and expression of ECM proteins and CTGF in CFs, which were markedly blocked using an anti-IL-17RB antibody. CONCLUSION These results suggest that IL-25 may serve as a potential therapeutic target for asthmatic patients with FAL.
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Affiliation(s)
- Xiujuan Yao
- Department of Respiratory and Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No.2, Xinanhuan Road, Yizhuang District, Beijing, 100176, China
| | - Qinglin Chen
- Department of Respiratory and Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No.2, Xinanhuan Road, Yizhuang District, Beijing, 100176, China
| | - Xiangdong Wang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China
- Key Laboratory of Otolaryngology Head and Neck Surgery of Ministry of Education of China, Beijing Institute of Otolaryngology, No. 17, Hougou Hutong, Dongcheng District, Beijing, 100005, China
| | - Xiaofang Liu
- Department of Respiratory and Critical Care Medicine, Beijing Tongren Hospital, Capital Medical University, No.2, Xinanhuan Road, Yizhuang District, Beijing, 100176, China.
| | - Luo Zhang
- Department of Otolaryngology Head and Neck Surgery, Beijing Tongren Hospital, Capital Medical University, Beijing, China.
- Key Laboratory of Otolaryngology Head and Neck Surgery of Ministry of Education of China, Beijing Institute of Otolaryngology, No. 17, Hougou Hutong, Dongcheng District, Beijing, 100005, China.
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Suzuki M, Makita H, Konno S, Nishimura M. Clinical characteristics and natural course of chronic obstructive pulmonary disease and/or asthma in Japanese patients: a summary report of two Hokkaido-based cohort studies. Respir Investig 2023; 61:527-539. [PMID: 37300900 DOI: 10.1016/j.resinv.2023.05.002] [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: 12/17/2022] [Revised: 04/16/2023] [Accepted: 05/01/2023] [Indexed: 06/12/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) and asthma are the most common chronic airway diseases and are characterized by chronic airway inflammation and airflow limitation. Japanese patients with COPD or asthma have characteristics different from those of Westerners. Therefore, understanding the characteristics and clinical course of Japanese patients with COPD and those with asthma, particularly severe asthma, is critical for their management and appropriate treatment. The Hokkaido COPD cohort and Hokkaido-based Investigative Cohort Analysis for Refractory Asthma (Hi-CARAT) are high-quality cohort studies of COPD and asthma in the Japanese population and provide valuable data. This report summarizes the clinical findings from the two cohort studies and provides data for more appropriate management of Japanese patients with COPD and/or asthma. Overall, 279 patients with COPD were followed up for up to 10 years in the Hokkaido COPD cohort study, and 127 with severe asthma were followed up for up to 6 years in the Hi-CARAT study. Seventy-nine patients with mild-to-moderate asthma provided baseline data for the Hi-CARAT study. In each disease, several distinct factors, including systemic status and non-pulmonary factors, were associated with important clinical outcomes, such as lung function decline, exacerbations, impaired quality of life, and mortality. Therefore, multifaceted evaluation based on the characteristics of the Japanese population is necessary for the management of COPD and asthma.
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Affiliation(s)
- Masaru Suzuki
- 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
| | - Satoshi Konno
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaharu Nishimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan; Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan.
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Kim JH, Shin KE, Chang HS, Lee JU, Park SL, Park JS, Park JS, Park CS. Relationships Between High-Resolution Computed Tomographic Features and Lung Function Trajectory in Patients With Asthma. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2023; 15:174-185. [PMID: 37021504 PMCID: PMC10079522 DOI: 10.4168/aair.2023.15.2.174] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 10/01/2022] [Accepted: 10/17/2022] [Indexed: 04/07/2023]
Abstract
PURPOSE A subset of asthmatics suffers from persistent airflow limitation, known as remodeled asthma, despite optimal treatment. Typical quantitative scoring methods to evaluate structural changes of airway remodeling on high-resolution computed tomography (HRCT) are time-consuming and laborious. Thus, easier and simpler methods are required in clinical practice. We evaluated the clinical usefulness of a simple, semi-quantitative method based on 8 HRCT parameters by comparing asthmatics with a persistent decline of post-bronchodilator (BD)-FEV1 to those with a BD-FEV1 that normalized over time and evaluated the relationships of the parameters with BD-FEV1. METHODS Asthmatics (n = 59) were grouped into 5 trajectories (Trs) according to the changes of BD-FEV1 over 1 year. After 9-12 months of guideline-based treatment, HRCT parameters including emphysema, bronchiectasis, anthracofibrosis, bronchial wall thickening (BWT), fibrotic bands, mosaic attenuation on inspiration, air-trapping on expiration, and centrilobular nodules were classified as present (1) or absent (0) in 6 zones. RESULTS The Tr5 group (n = 11) was older and exhibited a persistent decline in BD-FEV1. The Tr5 and Tr4 groups (n = 12), who had a lower baseline BD-FEV1 that normalized over time, had longer durations of asthma, frequent exacerbations, and higher doses of steroid use compared to the Tr1-3 groups (n = 36), who had a normal baseline BD-FEV1. The Tr5 group had higher emphysema and BWT scores than the Tr4 (P = 8.25E-04 and P = 0.044, respectively). Scores for the other 6 parameters were not significantly different among the Tr groups. BD-FEV1 was inversely correlated with the emphysema and BWT scores in multivariate analysis (P = 1.70E-04, P = 0.006, respectively). CONCLUSIONS Emphysema and BWT are associated with airway remodeling in asthmatics. Our simple, semi-quantitative scoring system based on HRCT may be an easy-to-use method for estimating airflow limitation.
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Affiliation(s)
- Joo-Hee Kim
- Division of Pulmonary, Allergy, and Critical Care Medicine, Department of Medicine, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Kyung Eun Shin
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hun Soo Chang
- Department of Anatomy and BK21 FOUR Project, Soonchunhyang University College of Medicine, Cheonan, Korea
| | - Jong-Uk Lee
- Department of Interdisciplinary Program in Biomedical Science Major, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Seung-Lee Park
- Department of Interdisciplinary Program in Biomedical Science Major, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jai Soung Park
- Department of Radiology, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jong Sook Park
- Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
| | - Choon-Sik Park
- Division of Allergy and Respiratory Medicine, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea.
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8
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Khan DA. The best of 2022 American College of Allergy, Asthma, and Immunology Literature Review. Ann Allergy Asthma Immunol 2023; 130:123-124. [PMID: 36463071 DOI: 10.1016/j.anai.2022.10.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 10/26/2022] [Indexed: 12/05/2022]
Affiliation(s)
- David A Khan
- Division of Allergy and Immunology, Department of Internal Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas.
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9
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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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10
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Abe Y, Suzuki M, Kimura H, Shimizu K, Takei N, Oguma A, Matsumoto-Sasaki M, Goudarzi H, Makita H, Nishimura M, Konno S. Blood eosinophil count variability in chronic obstructive pulmonary disease and severe asthma. Allergol Int 2022:S1323-8930(22)00139-3. [PMID: 36586746 DOI: 10.1016/j.alit.2022.11.012] [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: 09/08/2022] [Revised: 11/10/2022] [Accepted: 11/30/2022] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Blood eosinophils are essential biomarkers that vary substantially over time in patients with COPD and asthma. However, no study has identified the changes and effects in the changes of the blood eosinophil counts over time in both diseases. This study aimed to demonstrate blood eosinophil variability in patients with COPD and severe asthma based on these backgrounds. METHODS A total of 172 patients with COPD from the Hokkaido COPD cohort study and 96 patients with severe asthma from the Hokkaido Severe Asthma Cohort Study, whose blood eosinophil counts were measured annually over a 3-year period, were analyzed. The factors contributing to consistently high or low blood eosinophil counts were examined in each cohort. The stability of the eosinophil classification (<150, 150-299, ≥300 cells/μL) was compared based on the number of asthma-like features in patients with COPD and the smoking status in patients with severe asthma. RESULTS Among all the patients, the most stable range of baseline blood eosinophil counts differed between the two diseases, with <150 cells/μL in COPD and ≥300 cells/μL in severe asthma. In COPD, the number of asthma-like features (bronchodilator reversibility, blood eosinophilia, and atopy) affects the blood eosinophil count variation patterns. In severe asthma, smoking status did not affect the blood eosinophil count variation patterns. CONCLUSIONS We identified variations in the blood eosinophil counts and their contributing factors in patients with COPD and severe asthma.
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Affiliation(s)
- Yuki Abe
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan.
| | - Hirokazu Kimura
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Nozomu Takei
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Akira Oguma
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | | | - Houman Goudarzi
- 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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11
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Oguma A, Shimizu K, Kimura H, Tanabe N, Sato S, Yokota I, Takimoto-Sato M, Matsumoto-Sasaki M, Abe Y, Takei N, Goudarzi H, Suzuki M, Makita H, Hirai T, Nishimura M, Konno S. Differential role of mucus plugs in asthma: Effects of smoking and association with airway inflammation. Allergol Int 2022; 72:262-270. [PMID: 36402674 DOI: 10.1016/j.alit.2022.10.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 09/26/2022] [Accepted: 10/03/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND The physiological importance of mucus plugs in computed tomography (CT) imaging is being increasingly recognized. However, whether airway inflammation and smoking affect the association between mucus plugs and clinical-physiological outcomes in asthma remains to be elucidated. The objective of this study is to examine how airway inflammation and/or smoking affect the correlation of CT-based mucus plug scores with exacerbation frequency and airflow limitation indices in asthma. METHODS A total of 168 patients with asthma who underwent chest CT and sputum evaluation were enrolled and classified in eosinophilic asthma (EA; n = 103) and non-eosinophilic asthma (NEA; n = 65) groups based on sputum eosinophil percentage (cut-off: 3%). The mucus plug score was defined as the number of lung segments with mucus plugs seen on CT. RESULTS More mucus plugs were detected on CT scans in the EA group than in the NEA group, regardless of smoking status. Mucus plug score and exacerbation frequency during one year after enrollment were significantly associated in the EA group but not in the NEA group after adjusting for demographics, blood eosinophil count, and fractional exhaled nitric oxide. Mucus plug score was associated with percentage of predicted forced expiratory volume in 1 s in non-smoking individuals in the EA and NEA group and in smoking individuals in the EA group but not in the NEA group after adjusting for demographics. CONCLUSIONS The association of mucus plug score with exacerbation frequency and reduced lung function may vary due to airway inflammatory profile and smoking status in asthma.
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Affiliation(s)
- Akira Oguma
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Kaoruko Shimizu
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan.
| | - 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
| | - Susumu Sato
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Isao Yokota
- Department of Biostatistics, Graduate School 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
| | - Houman Goudarzi
- Department of Respiratory Medicine, Faculty of Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- 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
| | - Toyohiro Hirai
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, 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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12
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Kimura H, Shimizu K, Tanabe N, Makita H, Taniguchi N, Kimura H, Suzuki M, Abe Y, Matsumoto-Sasaki M, Oguma A, Takimoto-Sato M, Takei N, Matsumoto M, Goudarzi H, Sato S, Ono J, Izuhara K, Hirai T, Nishimura M, Konno S. Further evidence for association of YKL-40 with severe asthma airway remodeling. Ann Allergy Asthma Immunol 2022; 128:682-688.e5. [PMID: 35342020 DOI: 10.1016/j.anai.2022.03.016] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Revised: 02/25/2022] [Accepted: 03/16/2022] [Indexed: 11/25/2022]
Abstract
BACKGROUND The chitinase-like protein YKL-40 is associated with airflow limitation on spirometry and airway remodeling in patients with asthma. It remains unclear whether YKL-40 is associated with morphologic changes in the airways and parenchyma or with future progression of airflow limitation in severe asthma. OBJECTIVE To evaluate the association of circulating YKL-40 levels with morphologic changes in the airways and parenchyma and with longitudinal progression of airflow limitation. METHODS The patients were participants in the Hokkaido Severe Asthma Cohort Study (n = 127), including smokers. This study consisted of 2 parts. In analysis 1, we analyzed associations between circulating YKL-40 levels and several asthma-related indices, including computed tomography-derived indices of proximal wall area percentage, the complexity of the airways (airway fractal dimension), and the parenchyma (exponent D) cross-sectionally (n = 97). In analysis 2, we evaluated the impact of circulating YKL-40 levels on forced expiratory volume in 1 second (FEV1) decline longitudinally for a 5-year follow-up (n = 103). RESULTS Circulating YKL-40 levels were significantly associated with proximal wall area percentage and airway fractal dimension (r = 0.25, P = .01; r = -0.22, P = .04, respectively), but not with exponent D. The mean annual change in FEV1 was -33.7 (± 23.3) mL/y, and the circulating YKL-40 level was a significant independent factor associated with annual FEV1 decline (β = -0.24, P = .02), even after controlling for exponent D (β = -0.26, P = .01). CONCLUSION These results provide further evidence for the association of YKL-40 with the pathogenesis of airway remodeling in severe asthma.
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Affiliation(s)
- Hirokazu Kimura
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan.
| | - Kaoruko Shimizu
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Naoya Tanabe
- Graduate School of Medicine, Department of Respiratory Medicine, Kyoto University, Kyoto, Japan
| | - Hironi Makita
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Natsuko Taniguchi
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Hiroki Kimura
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Masaru Suzuki
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Yuki Abe
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | | | - Akira Oguma
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Michiko Takimoto-Sato
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Nozomu Takei
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Munehiro Matsumoto
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Houman Goudarzi
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
| | - Susumu Sato
- Graduate School of Medicine, Department of Respiratory Medicine, Kyoto University, Kyoto, Japan
| | - Junya Ono
- R&D Center, Shino-Test Corporation, Kanagawa, Japan
| | - Kenji Izuhara
- Division of Medical Biochemistry, Department of Biomolecular Sciences, Saga Medical School, Saga, Japan
| | - Toyohiro Hirai
- Graduate School of Medicine, Department of Respiratory Medicine, Kyoto University, Kyoto, Japan
| | - Masaharu Nishimura
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan; Hokkaido Medical Research Institute for Respiratory Diseases, Sapporo, Japan
| | - Satoshi Konno
- Faculty of Medicine, Department of Respiratory Medicine, Hokkaido University, Sapporo, Japan
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13
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Moslemi A, Kontogianni K, Brock J, Wood S, Herth F, Kirby M. Differentiating COPD and Asthma using Quantitative CT Imaging and Machine Learning. Eur Respir J 2022; 60:13993003.03078-2021. [PMID: 35210316 DOI: 10.1183/13993003.03078-2021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2021] [Accepted: 02/04/2022] [Indexed: 11/05/2022]
Abstract
There are similarities and differences between chronic obstructive pulmonary disease (COPD) and asthma patients in terms of computed tomography (CT) disease-related features. Our objective was to determine the optimal subset of CT imaging features for differentiating COPD and asthma using machine learning.COPD and asthma patients were recruited from Heidelberg University Hospital. CT was acquired and 93 features were extracted (VIDA Diagnostics): percentage of low-attenuating-areas below -950HU (LAA950), LAA950 hole count, estimated airway-wall-thickness for a 10 mm internal perimeter airway (Pi10), total-airway-count (TAC), as well as inner/outer perimeter/areas and wall thickness for each of five segmental airways, and the average of those five airways. Hybrid feature selection was used to select the optimum number of features, and support vector machine was used to classify COPD and asthma.Ninety-five participants were included (n=48 COPD; n=47 asthma); there were no differences between COPD and asthma for age (p=0.25) or FEV1 (p=0.31). In a model including all CT features, the accuracy and F1-score was 80% and 81%, respectively. The top features were: LAA950, LAA950 hole count, average outer and inner airway perimeter, outer and inner airway area RB1, and TAC. In the model with only airway features, the accuracy and F1-score were 66% and 68%, respectively. The top features were: inner area RB1, wall thickness RB1, outer area LB1, TAC LB10, average outer/inner perimeter, Pi10, and TAC.In conclusions, COPD and asthma can be differentiated using machine learning with moderate-high accuracy by a subset of only 7 CT features.
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Affiliation(s)
- Amir Moslemi
- Department of Physics, Ryerson University, Toronto, ON, Canada.,Co-first authors
| | - Konstantina Kontogianni
- Department of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center (TLRCH), University of Heidelberg, Germany.,Co-first authors
| | - Judith Brock
- Department of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center (TLRCH), University of Heidelberg, Germany
| | | | - Felix Herth
- Department of Pneumology and Critical Care Medicine, Thoraxklinik and Translational Lung Research Center (TLRCH), University of Heidelberg, Germany .,Co-senior authors
| | - Miranda Kirby
- Department of Physics, Ryerson University, Toronto, ON, Canada.,Co-senior authors
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14
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Asthma with Fixed Airflow Obstruction: From Fixed to Personalized Approach. J Pers Med 2022; 12:jpm12030333. [PMID: 35330333 PMCID: PMC8953236 DOI: 10.3390/jpm12030333] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/14/2022] [Accepted: 02/22/2022] [Indexed: 02/01/2023] Open
Abstract
Asthma is generally characterized by variable symptoms such as dyspnea and wheezing and variable airflow obstruction. This review focuses on a subset of patients suffering from asthma with persistent airflow limitation that is not fully reversible (asthma with fixed airflow obstruction, FAO). The pathophysiology, the risk factors and the clinical outcomes associated with FAO are presented, as well as the distinct clinical entity of severe asthma and its inflammatory subtypes (T2 and non-T2). The current strategies for the treatment of these endotypes and treatment of the distinct Asthma/COPD overlap (ACO) phenotype are described. Management and medical interventions in FAO and/or ACO patients demand a holistic approach, which is not yet clearly established in guidelines worldwide. Finally, a treatment algorithm that includes FAO/ACO management based on pharmacological and non-pharmacological treatment, guideline-based management for specific co-morbidities, and modification of the risk factors is proposed.
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15
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Park SY, Kang SY, Song WJ, Kim JH. Evolving Concept of Severe Asthma: Transition From Diagnosis to Treatable Traits. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2022; 14:447-464. [PMID: 36174989 PMCID: PMC9523415 DOI: 10.4168/aair.2022.14.5.447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/28/2022] [Accepted: 09/01/2022] [Indexed: 11/24/2022]
Abstract
In recent decades, the concept of severe asthma has evolved from an umbrella term encompassing patients with high-intensity treatment needs to a clinical syndrome with heterogeneous, albeit distinct, pathophysiological processes. Biased and unbiased cluster approaches have been used to identify several clinical phenotypes. In parallel, cellular and molecular approaches allow for the development of biological therapies, especially targeting type 2 (T2) cytokine pathways. Although T2-biologics have significantly improved clinical outcomes for patients with severe asthma in real-world practice, questions on the proper use of biologics remain open. Furthermore, a subset of severe asthma patients remains poorly controlled. The unmet needs require a new approach. The “treatable traits” concept has been suggested to address a diversity of pathophysiological factors in severe asthma and overcome the limitations of existing treatment strategies. With a tailored therapy that targets the treatable traits in individual patients, better personalized medical care and outcomes should be achieved.
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Affiliation(s)
- So-Young Park
- Department of Internal Medicine, Chung-Ang University College of Medicine, Seoul, Korea
- Division of Pulmonary, Allergy and Critical Care Medicine, Chung-Ang University Gwangmyeong Medical Center, Gwangmyeong, Korea
| | - Sung-Yoon Kang
- Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Woo-Jung Song
- Department of Allergy and Clinical Immunology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Joo-Hee Kim
- Department of Internal Medicine, Hallym University College of Medicine, Anyang, Korea
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16
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Rutting S, Tonga KO, King GG. Toward explaining fixed airflow obstruction in asthma. J Allergy Clin Immunol 2021; 149:890-892. [PMID: 34974066 DOI: 10.1016/j.jaci.2021.12.784] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 12/19/2021] [Accepted: 12/27/2021] [Indexed: 10/19/2022]
Affiliation(s)
- Sandra Rutting
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, Australia; Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia
| | - Katrina O Tonga
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, Australia; Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia; Department of Thoracic and Lung Transplant Medicine, St. Vincent's Hospital, Darlinghurst, Australia; St. Vincent's Clinical School, Faculty of Medicine, The University of New South Wales, Sydney, Australia
| | - Gregory G King
- Department of Respiratory Medicine, Royal North Shore Hospital, St. Leonards, Australia; Airway Physiology and Imaging Group and Woolcock Emphysema Centre, Woolcock Institute of Medical Research, The University of Sydney, Sydney, Australia; Faculty of Medicine and Health, The University of Sydney, Sydney, Australia.
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