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Lin T, Pham J, Denton E, Lee J, Hore-Lacy F, Sverrild A, Stojanovic S, Tay TR, Murthee KG, Radhakrishna N, Dols M, Bondarenko J, Mahoney J, O'Hehir RE, Dabscheck E, Hew M. Trait profiles in difficult-to-treat asthma: Clinical impact and response to systematic assessment. Allergy 2023; 78:2418-2427. [PMID: 36940306 DOI: 10.1111/all.15719] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 01/12/2023] [Accepted: 01/31/2023] [Indexed: 03/22/2023]
Abstract
BACKGROUND Multidisciplinary systematic assessment improves outcomes in difficult-to-treat asthma, but without clear response predictors. Using a treatable-traits framework, we stratified patients by trait profile, examining clinical impact and treatment responsiveness to systematic assessment. METHODS We performed latent class analysis using 12 traits on difficult-to-treat asthma patients undergoing systematic assessment at our institution. We examined Asthma Control Questionnaire (ACQ-6) and Asthma Quality of Life Questionnaire (AQLQ) scores, FEV1 , exacerbation frequency, and maintenance oral corticosteroid (mOCS) dose, at baseline and following systematic assessment. RESULTS Among 241 patients, two airway-centric profiles were characterized by early-onset with allergic rhinitis (n = 46) and adult onset with eosinophilia/chronic rhinosinusitis (n = 60), respectively, with minimal comorbid or psychosocial traits; three non-airway-centric profiles exhibited either comorbid (obesity, vocal cord dysfunction, dysfunctional breathing) dominance (n = 51), psychosocial (anxiety, depression, smoking, unemployment) dominance (n = 72), or multi-domain impairment (n = 12). Compared to airway-centric profiles, non-airway-centric profiles had worse baseline ACQ-6 (2.7 vs. 2.2, p < .001) and AQLQ (3.8 vs. 4.5, p < .001) scores. Following systematic assessment, the cohort showed overall improvements across all outcomes. However, airway-centric profiles had more FEV1 improvement (5.6% vs. 2.2% predicted, p < .05) while non-airway-centric profiles trended to greater exacerbation reduction (1.7 vs. 1.0, p = .07); mOCS dose reduction was similar (3.1 mg vs. 3.5 mg, p = .782). CONCLUSION Distinct trait profiles in difficult-to-treat asthma are associated with different clinical outcomes and treatment responsiveness to systematic assessment. These findings yield clinical and mechanistic insights into difficult-to-treat asthma, offer a conceptual framework to address disease heterogeneity, and highlight areas responsive to targeted intervention.
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Affiliation(s)
- Tiffany Lin
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Jonathan Pham
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Joy Lee
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Asger Sverrild
- Department of Respiratory Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Stephanie Stojanovic
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore City, Singapore
| | | | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Monique Dols
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Janine Mahoney
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology Service, Alfred Health, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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2
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Benfante A, Sousa-Pinto B, Pillitteri G, Battaglia S, Fonseca J, Bousquet J, Scichilone N. Applicability of the MASK-Air® App to Severe Asthma Treated with Biologic Molecules: A Pilot Study. Int J Mol Sci 2022; 23:ijms231911470. [PMID: 36232771 PMCID: PMC9569460 DOI: 10.3390/ijms231911470] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 09/16/2022] [Accepted: 09/21/2022] [Indexed: 11/16/2022] Open
Abstract
MASK-air®, a good practice of the DG Santé, has been fully validated in allergic rhinitis, but little is known about its applicability to asthmatics. We explored whether the MASK-air® application is applicable to patients with severe asthma. Severe asthmatics were proposed to use the MASK-air® application for 6 months, along with best practice treatment. Treatment of the patients was not changed based on the application results. The evolution of the visual analogue scales (VAS) for asthma, shortness of breath, rhinitis, conjunctivitis, work, and sleep was monitored using MASK-air®. Adherence to MASK-air® and to the asthma treatment was also checked. Thirteen patients reported on 1229 days of MASK-air® use. The average application adherence was 51.8% (range: 19.7–98.9%). There was no correlation between application and medication adherence. Highly variably trends were found for the VAS for asthma. Five patients had over 90% well-controlled days, four had well- or moderately controlled asthma (with up to 20% uncontrolled days), one patient had moderately controlled asthma with approximately 20% uncontrolled days, and one patient had 80% uncontrolled days. Highly significant correlations were found for the VAS for asthma, and other patients reported VASs for work, dyspnea, sleep, and rhinitis. MASK-air® can be used in patients with severe asthma. VAS asthma appears to be an interesting patient-reported outcome highly correlated with dyspnea and impacts on work. Adherence to the application was better than that for rhinitis, but it needs to be improved.
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Affiliation(s)
- Alida Benfante
- PROMISE—Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n. 2, 90127 Palermo, Italy
- Correspondence: ; Tel.: +39-0916552681
| | - Bernardo Sousa-Pinto
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- CINTESIS—Center for Health Technology and Services Research, University of Porto, 4200-450 Porto, Portugal
- RISE—Health Research Network, University of Porto, 4200-450 Porto, Portugal
| | - Gianluca Pillitteri
- PROMISE—Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n. 2, 90127 Palermo, Italy
| | - Salvatore Battaglia
- PROMISE—Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n. 2, 90127 Palermo, Italy
| | - Joao Fonseca
- MEDCIDS—Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, 4200-450 Porto, Portugal
- CINTESIS—Center for Health Technology and Services Research, University of Porto, 4200-450 Porto, Portugal
- RISE—Health Research Network, University of Porto, 4200-450 Porto, Portugal
| | - Jean Bousquet
- MACVIA-France, 34000 Montpellier, France
- Department of Dermatology and Allergy, Comprehensive Allergy Center, Charité, Universitätsmedizin Berlin, Humboldt-Universität zu Berlin, 10099 Berlin, Germany
- Centre Hospitalier Universitaire, 34295 Montpellier, France
| | - Nicola Scichilone
- PROMISE—Dipartimento di Promozione della Salute, Materno-Infantile, di Medicina Interna e Specialistica di Eccellenza “G. D’Alessandro”, University of Palermo, Piazza delle Cliniche n. 2, 90127 Palermo, Italy
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3
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Gao E, Radparvar I, Dieu H, Ross MK. User Experience Design for Adoption of Asthma Clinical Decision Support Tools. Appl Clin Inform 2022; 13:971-982. [PMID: 36223869 PMCID: PMC9556170 DOI: 10.1055/s-0042-1757292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Emily Gao
- University of California Los Angeles, Los Angeles, California, United States
| | - Ilana Radparvar
- University of California Los Angeles, Los Angeles, California, United States
| | - Holly Dieu
- Department of Pediatrics, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
| | - Mindy K Ross
- Department of Pediatrics, University of California Los Angeles, David Geffen School of Medicine, Los Angeles, California, United States
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4
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Dynamics of inhaled corticosteroid use are associated with asthma attacks. Sci Rep 2021; 11:14715. [PMID: 34282212 PMCID: PMC8289909 DOI: 10.1038/s41598-021-94219-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 06/30/2021] [Indexed: 12/15/2022] Open
Abstract
Inhaled corticosteroids (ICS) suppress eosinophilic airway inflammation in asthma, but patients may not adhere to prescribed use. Mean adherence-averaging total doses taken over prescribed-fails to capture many aspects of adherence. Patients with difficult-to-treat asthma underwent electronic monitoring of ICS, with data collected over 50 days. These were used to calculate entropy (H) a measure of irregular inhaler use over this period, defined in terms of transitional probabilities between different levels of adherence, further partitioned into increasing (Hinc) or decreasing (Hdec) adherence. Mean adherence, time between actuations (Gapmax), and cumulative time- and dose-based variability (area-under-the-curve) were measured. Associations between adherence metrics and 6-month asthma status and attacks were assessed. Only H and Hdec were associated with poor baseline status and 6-month outcomes: H and Hdec correlated negatively with baseline quality of life (H:Spearman rS = - 0·330, p = 0·019, Hdec:rS = - 0·385, p = 0·006) and symptom control (H:rS = - 0·288, p = 0·041, Hdec: rS = - 0·351, p = 0·012). H was associated with subsequent asthma attacks requiring hospitalisation (Wilcoxon Z-statistic = - 2.34, p = 0·019), and Hdec with subsequent asthma attacks of other severities. Significant associations were maintained in multivariable analyses, except when adjusted for blood eosinophils. Entropy analysis may provide insight into adherence behavior, and guide assessment and improvement of adherence in uncontrolled asthma.
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5
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Maltby S, McDonald VM, Upham JW, Bowler SD, Chung LP, Denton EJ, Fingleton J, Garrett J, Grainge CL, Hew M, James AL, Jenkins C, Katsoulotos G, King GG, Langton D, Marks GB, Menzies-Gow A, Niven RM, Peters M, Reddel HK, Thien F, Thomas PS, Wark PAB, Yap E, Gibson PG. Severe asthma assessment, management and the organisation of care in Australia and New Zealand: expert forum roundtable meetings. Intern Med J 2021; 51:169-180. [PMID: 32104958 DOI: 10.1111/imj.14806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2019] [Revised: 02/06/2020] [Accepted: 02/20/2020] [Indexed: 12/11/2022]
Abstract
Severe asthma imposes a significant burden on individuals, families and the healthcare system. Treatment is complex, due to disease heterogeneity, comorbidities and complexity in care pathways. New approaches and treatments improve health outcomes for people with severe asthma. However, emerging multidimensional and targeted treatment strategies require a reorganisation of asthma care. Consensus is required on how reorganisation should occur and what areas require further research. The Centre of Excellence in Severe Asthma convened three forums between 2015 and 2018, hosting experts from Australia, New Zealand and the UK. The forums were complemented by a survey of clinicians involved in the management of people with severe asthma. We sought to: (i) identify areas of consensus among experts; (ii) define activities and resources required for the implementation of findings into practice; and (iii) identify specific priority areas for future research. Discussions identified areas of unmet need including assessment and diagnosis of severe asthma, models of care and treatment pathways, add-on treatment approaches and patient perspectives. We recommend development of education and training activities, clinical resources and standards of care documents, increased stakeholder engagement and public awareness campaigns and improved access to infrastructure and funding. Further, we propose specific future research to inform clinical decision-making and develop novel therapies. A concerted effort is required from all stakeholders (including patients, healthcare professionals and organisations and government) to integrate new evidence-based practices into clinical care and to advance research to resolve questions relevant to improving outcomes for people with severe asthma.
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Affiliation(s)
- Steven Maltby
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia
| | - Vanessa M McDonald
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - John W Upham
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Respiratory Medicine, Princess Alexandra Hospital, Woolloongabba, Queensland, Australia
| | - Simon D Bowler
- Immunity, Infection, and Inflammation Program, Mater Medical Research Institute, South Brisbane, Queensland, Australia
| | - Li P Chung
- Department of Respiratory Medicine, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Eve J Denton
- Department of Respiratory Medicine, The Alfred Hospital and Austin Health, Melbourne, Victoria, Australia
| | - James Fingleton
- Capital and Coast District Health Board and Medical Research Institute of New Zealand, Wellington, New Zealand
| | | | - Christopher L Grainge
- Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Mark Hew
- Department of Respiratory Medicine, The Alfred Hospital and Austin Health, Melbourne, Victoria, Australia
| | - Alan L James
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Pulmonary Physiology and Sleep Medicine, Sir Charles Gairdner Hospital, Nedlands, Western Australia, Australia.,Australia and School of Medicine and Pharmacology, University of Western Australia, Western Australia, Australia
| | - Christine Jenkins
- Department of Thoracic Medicine, Concord Hospital, Concord Clinical School and Respiratory Discipline, University of Sydney, Concord, New South Wales, Australia.,The George Institute for Global Health, Newtown, New South Wales, Australia.,UNSW, Sydney, Liverpool, New South Wales, Australia
| | | | - Gregory G King
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - David Langton
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Thoracic Medicine, Frankston Hospital, Frankston, Victoria, Australia
| | - Guy B Marks
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, UNSW, Australia
| | | | - Robert M Niven
- Division of Infection, Immunity & Respiratory Medicine, Manchester Academic Health Science Centre and North West Lung Centre, Wythenshawe Hospital, Manchester University NHS Foundation Trust, Manchester, UK
| | - Matthew Peters
- Department of Thoracic Medicine, Concord Hospital, Concord, New South Wales, Australia
| | - Helen K Reddel
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Woolcock Institute of Medical Research, University of Sydney, Sydney, New South Wales, Australia
| | - Francis Thien
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Department of Respiratory Medicine, Eastern Health and Monash University, Box Hill, Victoria, Australia
| | - Paul S Thomas
- Faculty of Medicine, University of New South Wales, Sydney, New South Wales, Australia
| | - Peter A B Wark
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
| | - Elaine Yap
- Middlemore Hospital, Auckland, New Zealand
| | - Peter G Gibson
- National Health and Medical Research Council Centre of Excellence in Severe Asthma, Newcastle, Australia.,Priority Research Centre for Healthy Lungs, The University of Newcastle, Newcastle, Australia.,Hunter Medical Research Institute, Newcastle, Australia.,Department of Respiratory and Sleep Medicine, John Hunter Hospital, Newcastle, Australia
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6
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Hew M, Denton E. Prioritizing Treatable Traits in Airways Disease. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2021; 9:1265-1266. [PMID: 33685609 DOI: 10.1016/j.jaip.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Accepted: 11/10/2020] [Indexed: 12/27/2022]
Affiliation(s)
- Mark Hew
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Clayton, VIC, Australia
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7
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Hew M, Menzies-Gow A, Hull JH, Fleming L, Porsbjerg C, Brinke AT, Allen D, Gore R, Tay TR. Systematic Assessment of Difficult-to-Treat Asthma: Principles and Perspectives. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2222-2233. [PMID: 32173508 DOI: 10.1016/j.jaip.2020.02.036] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 01/13/2020] [Revised: 02/20/2020] [Accepted: 02/26/2020] [Indexed: 12/14/2022]
Abstract
Difficult-to-treat asthma affects a minority of adults and children with asthma but represents a challenging mix of misdiagnosis, multimorbidity, inadequate self-management, severe airway pathobiology, and treatment complications. Management of these patients extends beyond asthma pharmacotherapy, because multiple other patient-related domains need to be addressed as well. Such complexity can hinder adequate clinical assessment even when performed in specialist practice. Systematic assessment undertaken by specialized multidisciplinary teams brings a broad range of resources to bear on patients with difficult-to-treat asthma. Although the concept of systematic assessment is not new, practices vary considerably and implementation is not universal. Nevertheless, assessment protocols are already in place in several institutions worldwide, and outcomes after such assessments have been highly encouraging. This review discusses the rationale, components, and benefits of systematic assessment, outlining its clinical utility and the available evidence for improved outcomes. It describes a range of service configurations and assessment approaches, drawing examples from severe asthma centers around the world to highlight common essential elements. It also provides a framework for establishing such services and discusses practical considerations for implementation.
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Affiliation(s)
- Mark Hew
- Allergy, Asthma and Clinical Immunology, Alfred Health, Melbourne, VIC, Australia; Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Andrew Menzies-Gow
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - James H Hull
- Asthma and Allergy, Royal Brompton Hospital, London, United Kingdom; National Heart and Lung Institute, Imperial College London, London, United Kingdom
| | - Louise Fleming
- National Heart and Lung Institute, Imperial College London, London, United Kingdom; Paediatric Difficult Asthma Service, Royal Brompton Hospital, London, United Kingdom
| | - Celeste Porsbjerg
- Respiratory Research Unit, Bispebjerg University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Anneke Ten Brinke
- Department of Respiratory Medicine, Medical Centre Leeuwarden, Leeuwarden, the Netherlands
| | - David Allen
- North West Lung Centre, Wythenshawe Hospital, Manchester, United Kingdom
| | - Robin Gore
- Department of Respiratory Medicine, Cambridge University Hospitals, Cambridge, United Kingdom
| | - Tunn Ren Tay
- Department of Respiratory and Critical Care Medicine, Changi General Hospital, Singapore
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8
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Lee J, Denton E, Hoy R, Tay TR, Bondarenko J, Hore-Lacy F, Radhakrishna N, O'Hehir RE, Dabscheck E, Abramson MJ, Hew M. Paradoxical Vocal Fold Motion in Difficult Asthma Is Associated with Dysfunctional Breathing and Preserved Lung Function. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:2256-2262. [PMID: 32173506 DOI: 10.1016/j.jaip.2020.02.037] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Revised: 01/13/2020] [Accepted: 02/23/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Many patients with difficult asthma also have coexisting vocal cord dysfunction (VCD), evident by paradoxical vocal fold motion (PVFM) on laryngoscopy. OBJECTIVE Among patients with difficult asthma, we sought to identify clinical features associated with laryngoscopy-diagnosed PVFM. METHODS Consecutive patients with "difficult asthma" referred by respiratory specialists underwent systematic assessment in this observational study. Those with a high clinical suspicion for VCD were referred for laryngoscopy, either at rest or after mannitol provocation. Statistical analyses were performed to identify clinical factors associated with PVFM, and a multivariate logistic regression model was fitted to control for confounders. RESULTS Of 169 patients with difficult asthma, 63 (37.3%) had a high clinical probability of VCD. Of 42 who underwent laryngoscopy, 32 had PVFM confirmed. Patients with PVFM more likely had preserved lung function (prebronchodilator forced expiratory ratio 74% ± 11 vs 62% ± 16, P < .001); physiotherapist-confirmed dysfunctional breathing (odds ratio [OR] = 5.52, 95% confidence interval [CI]: 2.4-12.7, P < .001), gastro-oesophageal reflux (OR = 2.6, 95% CI: 1.16-5.8, P = .02), and a lower peripheral eosinophil count (0.09 vs 0.23, P = .004). On multivariate logistic regression, independent predictors for PVFM were dysfunctional breathing (OR = 4.93, 95% CI: 2-12, P < .001) and preserved lung function (OR = 1.07, 95% CI: 1.028-1.106, P < .001). CONCLUSION Among specialist-referred patients with difficult asthma, VCD pathogenesis may overlap with dysfunctional breathing but is not associated with severe airflow obstruction. Dysfunctional breathing and preserved lung function may serve as clinical clues for the presence of VCD.
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Affiliation(s)
- Joy Lee
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia.
| | - Eve Denton
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Ryan Hoy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Tunn Ren Tay
- Department of Respiratory & Critical Care Medicine, Changi General Hospital, Singapore
| | - Janet Bondarenko
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Fiona Hore-Lacy
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Naghmeh Radhakrishna
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Robyn E O'Hehir
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; Department of Respiratory Medicine, Allergy and Clinical Immunology, Central Clinical School, Monash University, Melbourne, VIC, Australia
| | - Eli Dabscheck
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia
| | - Michael J Abramson
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Mark Hew
- Allergy, Asthma & Clinical Immunology, The Alfred Hospital, Melbourne, VIC, Australia; School of Public Health & Preventive Medicine, Monash University, Melbourne, VIC, Australia
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9
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Systematic Assessment for Difficult and Severe Asthma Improves Outcomes and Halves Oral Corticosteroid Burden Independent of Monoclonal Biologic Use. THE JOURNAL OF ALLERGY AND CLINICAL IMMUNOLOGY-IN PRACTICE 2020; 8:1616-1624. [PMID: 31954193 DOI: 10.1016/j.jaip.2019.12.037] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/22/2019] [Accepted: 12/28/2019] [Indexed: 01/05/2023]
Abstract
BACKGROUND Guidelines endorse systematic assessment for severe asthma, with data indicating benefit across multiple outcome domains. OBJECTIVE We examined which patients respond to systematic assessment and whether oral corticosteroid burden can be decreased independent of monoclonal biologic use. METHODS Specialist-referred patients are assessed systematically for difficult asthma at our center. We undertook a responder analysis for improvements in the domains of symptom control, quality of life, exacerbations, and airflow obstruction, assessed 6 months after initial assessment. Multivariate analyses were performed for each domain to identify predictors of response. Changes in oral corticosteroid burden were also measured, stratified by monoclonal biologics commenced during assessment. RESULTS Among 161 patients assessed systematically, 64% had a reduction in exacerbations, 54% achieved minimum clinically important differences for both symptom control and quality of life, and 40% increased their forced expiratory volume in 1 second by ≥100 mL. Altogether, 87% of patients with asthma improved in at least 1 domain. The most consistent predictor of response across domains was poorer baseline asthma status. There was a substantial reduction in mean chronic oral corticosteroid dose (11-5 mg, n = 46, P < .001), even after excluding 7 patients commenced on monoclonal biologics (11-5.6 mg, n = 39, P < .001). CONCLUSIONS Almost 90% of patients undergoing systematic assessment for difficult asthma improve significantly in at least 1 key asthma outcome, with few reliable predictors of response. The halving of oral corticosteroid burden during systematic assessment is independent of, and comparable in magnitude with, that achieved by monoclonal biologics.
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