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Zhang L, Fu Z, Deng H, Xie Q, Wu W. Identification and treatment of persistent small airway dysfunction in paediatric patients with asthma: a retrospective cohort study. BMC Pulm Med 2024; 24:94. [PMID: 38395894 PMCID: PMC10893734 DOI: 10.1186/s12890-024-02907-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: 06/24/2023] [Accepted: 02/13/2024] [Indexed: 02/25/2024] Open
Abstract
BACKGROUND Asthma is a common respiratory disease. In asthma, the small airways have more intensive inflammation and prominent airway remodelling, compared to the central airways. We aimed to investigate the predictive value of risk factors and the fractional concentration of exhaled nitric oxide (FeNO) for persistent small airway dysfunction (p-SAD), and compare the effects of different treatment modalities. METHODS This retrospective cohort study included 248 children with asthma (aged 4-11 years). Binary logistic regression was used to analyse the risk factors for p-SAD. Correlations among FEV1/FVC, small airway function parameters, and FeNO levels in patients with asthma were analysed using Spearman's rank correlation. The receiver operating characteristic curve and the Delong test were used to analyse the predictive value of FeNO for p-SAD. Differences in the treatment effects of inhaled corticosteroids (ICS) and ICS with a long-acting beta-agonist (ICS/LABA) on p-SAD were analysed using Fisher's exact test. RESULTS Asthmatic children with older age of receiving the regular treatment (OR 1.782, 95% CI 1.082-2.935), with younger age at the time of onset of suspected asthma symptoms (OR 0.602, 95% CI 0.365-0.993), with longer duration of using ICS or ICS/LABA (OR 1.642, 95% CI 1.170-2.305) and with worse asthma control (OR 3.893, 95% CI 1.699-8.922) had increased risk for p-SAD. Significant negative correlations of small airway function parameters with FeNO at a 200 mL/s flow rate (FeNO200), and the concentration of nitric oxide in the alveolar or acinar region (CaNO) were observed. The areas under the curve of FeNO200 (cut-off:10.5ppb), CaNO (cut-off:5.1ppb), and FeNO200 combined with CaNO were 0.743, 0.697, and 0.750, respectively, for asthma with p-SAD. After using ICS or ICS/LABA, switching to ICS/LABA was easier than continuing with ICS to improve small airway dysfunction (SAD) in the 8th month. CONCLUSIONS Paediatric asthma with p-SAD is associated with older age at receiving regular treatment, younger age at the time of onset of suspected asthma symptoms, longer duration of using ICS or ICS/LABA, worse asthma control, and higher FeNO200 and CaNO levels, all of which can be combined with small airway function indicators to distinguish p-SAD from asthma. ICS/LABA improves SAD better than ICS alone.
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Affiliation(s)
- Lulu Zhang
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, NO.136, Zhongshan Second Road, 400014, Chongqing, China
| | - Zhou Fu
- Department of Respiratory Medicine, Children's Hospital of Chongqing Medical University, National Clinical Research Center for Child Health and Disorders, Ministry of Education Key Laboratory of Child Development and Disorders, Chongqing Key Laboratory of Pediatrics, NO.136, Zhongshan Second Road, 400014, Chongqing, China
| | - Hua Deng
- Department of Pediatric Internal Medicine, Chongqing Youyoubaobei Women and Children's Hospital, NO.999, Jiarong Road, 401122, Chongqing, China
| | - Qin Xie
- Department of Pediatric Internal Medicine, Chongqing Youyoubaobei Women and Children's Hospital, NO.999, Jiarong Road, 401122, Chongqing, China
| | - Wenjie Wu
- Department of Pediatric Internal Medicine, Chongqing Youyoubaobei Women and Children's Hospital, NO.999, Jiarong Road, 401122, Chongqing, China.
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Sesé L, Mahay G, Barnig C, Guibert N, Leroy S, Guilleminault L. [Markers of severity and predictors of response to treatment in severe asthma]. Rev Mal Respir 2022; 39:740-757. [PMID: 36115752 DOI: 10.1016/j.rmr.2022.08.009] [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: 03/28/2022] [Accepted: 08/19/2022] [Indexed: 10/14/2022]
Abstract
Asthma is a multifactorial disease with complex pathophysiology. Knowledge of its immunopathology and inflammatory mechanisms is progressing and has led to the development over recent years of increasingly targeted therapeutic strategies. The objective of this review is to pinpoint the different predictive markers of asthma severity and therapeutic response. Obesity, nasal polyposis, gastroesophageal reflux disease and intolerance to aspirin have all been considered as clinical markers associated with asthma severity, as have functional markers such as bronchial obstruction, low FEV1, small daily variations in FEV1, and high FeNO. While sinonasal polyposis and allergic comorbidities are associated with better response to omalizumab, nasal polyposis or long-term systemic steroid use are associated with better response to antibodies targeting the IL5 pathway. Elevated total IgE concentrations and eosinophil counts are classic biological markers regularly found in severe asthma. Blood eosinophils are predictive biomarkers of response to anti-IgE, anti-IL5, anti-IL5R and anti-IL4R biotherapies. Dupilumab is particularly effective in a subgroup of patients with marked type 2 inflammation (long-term systemic corticosteroid therapy, eosinophilia≥150/μl or FENO>20 ppb). Chest imaging may help to identify severe patients by seeking out bronchial wall thickening and bronchial dilation. Study of the patient's environment is crucial insofar as exposure to tobacco, dust mites and molds, as well as outdoor and indoor air pollutants (cleaning products), can trigger asthma exacerbation. Wider and more systematic use of markers of severity or response to treatment could foster increasingly targeted and tailored approaches to severe asthma.
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Affiliation(s)
- L Sesé
- AP-HP, service de physiologie, hôpital Avicenne, Bobigny, France
| | - G Mahay
- Service de pneumologie, oncologie thoracique et soins intensifs respiratoires, CHU Rouen, Rouen, France
| | - C Barnig
- INSERM, EFS BFC, LabEx LipSTIC, UMR1098, Interactions Hôte-Greffon-Tumeur/Ingénierie Cellulaire et Génique, University Bourgogne Franche-Comté, Besançon, France; Service de pneumologie, oncologie thoracique et allergologie respiratoire, CHRU Besançon, Besançon, France
| | - N Guibert
- AP-HP, service de physiologie, hôpital Avicenne, Bobigny, France
| | - S Leroy
- Université Côte d'Azur, Centre Hospitalier Universitaire de Nice, CNRS UMR 7275-FHU OncoAge, service de pneumologie oncologie thoracique et soins intensifs respiratoires, CHU de Nice, hôpital Pasteur, Nice, France
| | - L Guilleminault
- AP-HP, service de physiologie, hôpital Avicenne, Bobigny, France; Institut Toulousain des maladies infectieuses et inflammatoires (Infinity) inserm UMR1291-CNRS UMR5051-université Toulouse III, CRISALIS F-CRIN, Toulouse, France.
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Scioscia G, Lacedonia D, Quarato CMI, Tondo P, Del Colle A, Sperandeo M, Carpagnano GE, Foschino Barbaro MP. Could transthoracic ultrasound be useful to suggest a small airways disease in severe uncontrolled asthma? Ann Allergy Asthma Immunol 2022; 129:461-466. [PMID: 35643297 DOI: 10.1016/j.anai.2022.05.024] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/17/2022] [Accepted: 05/20/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Transthoracic ultrasound (TUS) is an accepted complementary tool in the diagnostic process of several pleuro-pulmonary diseases. However, to the best of our knowledge, TUS findings in patients with severe asthma have never been systematically described. OBJECTIVE To explore if TUS examination is a useful imaging method in suggesting the presence of a "small airways disease" in patients with severe uncontrolled asthma. METHODS Seventy-two consecutive subjects with a diagnosis of severe uncontrolled asthma were enrolled. The presence of a "small airways disease" was assessed through the execution of pulmonary function tests. All the patients underwent a complete TUS examination and a chest high resolution computed tomography (HRCT), which was regarded as the reference standard for comparison with TUS findings. RESULTS Pulmonary function tests results have confirmed a reduction in expiratory flows relative to the small airways and a condition of hyperinflation in 78% and 82% of our patients, respectively. The main signs observed in the TUS examination were a thickened and/or irregular pleural line and the lack or reduction of the "gliding sign." TUS showed high sensitivity and specificity in suggesting the presence of hyperinflation and distal airways inflammation according to the HRCT scan. K Cohen's coefficients showed substantial agreement between the 2 diagnostic tests. CONCLUSION TUS in patients with severe uncontrolled asthma can provide useful information on the state of the peripheral lung, suggesting the execution of a second-line HRCT scan for better assessment of eventual alterations that may represent the underlying causes of nonresponse to treatment.
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Affiliation(s)
- Giulia Scioscia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Institute of Respiratory Diseases, Policlinico universitario "Riuniti" di Foggia, Foggia, Italy
| | - Donato Lacedonia
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Institute of Respiratory Diseases, Policlinico universitario "Riuniti" di Foggia, Foggia, Italy
| | - Carla Maria Irene Quarato
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Institute of Respiratory Diseases, Policlinico universitario "Riuniti" di Foggia, Foggia, Italy.
| | - Pasquale Tondo
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Institute of Respiratory Diseases, Policlinico universitario "Riuniti" di Foggia, Foggia, Italy
| | - Anna Del Colle
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Institute of Respiratory Diseases, Policlinico universitario "Riuniti" di Foggia, Foggia, Italy
| | - Marco Sperandeo
- Department of Internal Medicine, Unit of Interventional and Diagnostic Ultrasound, IRCCS, Fondazione "Casa Sollievo della Sofferenza", San Giovanni Rotondo, Foggia, Italy
| | - Giovanna Elisiana Carpagnano
- Department of Basic Medical Sciences, Neuroscience and Sense Organs, Section of Respiratory Disease, University "Aldo Moro" of Bari, Bari, Italy
| | - Maria Pia Foschino Barbaro
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy; Institute of Respiratory Diseases, Policlinico universitario "Riuniti" di Foggia, Foggia, Italy
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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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Liu T, Yang D, Liu C. Extrafine HFA-beclomethasone-formoterol vs. nonextrafine combination of an inhaled corticosteroid and a long acting β2-agonist in patients with persistent asthma: A systematic review and meta-analysis. PLoS One 2021; 16:e0257075. [PMID: 34478483 PMCID: PMC8415610 DOI: 10.1371/journal.pone.0257075] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Accepted: 08/23/2021] [Indexed: 02/05/2023] Open
Abstract
Objective Airway inflammation in asthma involves not only the central airways but extends to peripheral airways. Lung deposition may be key for an appropriate treatment of asthma. We compared the clinical effects of extrafine hydrofluoroalkane (HFA)-beclomethasone-formoterol (BDP-F) versus equipotent doses of nonextrafine combination of an inhaled corticosteroid and a long acting β2-agonist (ICS-LABA) in asthma. Methods We identified eligible studies by a comprehensive literature search of PubMed, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL). Data analysis was performed with the Review Manager 5.3.5 software (Cochrane IMS, 2014). Results A total of 2326 patients with asthma from ten published randomized controlled trials (RCTs) were enrolled for analysis. Change from baseline in morning pre-dose peak expiratory flow (PEF), evening pre-dose PEF and forced expiratory volume in one second (FEV1) were detected no significant differences between extrafine HFA-BDP-F and nonextrafine ICS-LABAs (p = 0.23, p = 0.99 and p = 0.23, respectively). Extrafine HFA-BDP-F did not show any greater benefit in forced expiratory flow between 25% and 75% of forced vital capacity (FEF25-75%), the parameter concerning peripheral airways (MD 0.03L/s, p = 0.65; n = 877). There were no substantial differences between interventions in fractional exhaled nitric oxide (FeNO) levels or in its alveolar fraction. The overall analysis showed no significant benefit of extrafine HFA-BDP-F over nonextrafine ICS-LABA in improving Asthma Control Test (ACT) score (p = 0.30) or decreasing the number of puffs of rescue medication use (p = 0.16). Extrafine HFA-BDP-F did not lead to less exacerbations than nonextrafine ICS-LABA (RR 0.61, 95% CI: 0.31 to 1.20; I2 = 0; p = 0.15). Conclusion Enrolled RCTs of extrafine HFA-BDP-F have demonstrated no significant advantages over the equivalent combination of nonextrafine ICS-LABA in improving pulmonary function concerning central airways or peripheral airways, improving asthma symptom control or reducing exacerbation rate.
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Affiliation(s)
- Ting Liu
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu Province, China
| | - Dan Yang
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu Province, China
| | - Chuntao Liu
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu Province, China
- * E-mail:
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Calzetta L, Aiello M, Frizzelli A, Bertorelli G, Chetta A. Small airways in asthma: from bench-to-bedside. Minerva Med 2021; 113:79-93. [PMID: 33496163 DOI: 10.23736/s0026-4806.21.07268-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
INTRODUCTION Historically, asthma was considered a disease predominantly of the large airways, but gradually small airways have been recognized as the major site of airflow obstruction. Small airway dysfunction (SAD) significantly contributes to the pathophysiology of asthma and it is present across all asthma severities. Promising pre-clinical findings documented enhanced beneficial effects of combination therapies on small airways compared to monocomponents, thus it was questioned whether this could translate into further clinical implications from bench-to-bedside. The aim of this review was to systematically assess the state of the art of small airway involvement in asthma, especially in response to different pharmacological treatments acting on the respiratory system. EVIDENCE ACQUISITION A comprehensive literature search was performed in MEDLINE for randomized controlled trials (RCTs) characterizing the impact on small airways of different pharmacological treatments acting on the respiratory system. The results were extracted and reported via qualitative synthesis. EVIDENCE SYNTHESIS Overall, 63 studies were identified from the literature search, whereas 23 RCTs met the inclusion criteria. Evidence confirms that both drug particle size and the type of inhalation devices represent two of the most important variables for an effective peripheral lung distribution. CONCLUSIONS Despite the numerous methodological tools to detect SAD, there is still no gold standard diagnostic method to assess small airways, especially in severe asthma. Further research should be directed to improve primary and secondary prevention strategies by supporting the combined approach of different non-invasive techniques for an early detection of peripheral abnormalities and optimization of asthma therapy.
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Affiliation(s)
- Luigino Calzetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy -
| | - Marina Aiello
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Annalisa Frizzelli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Giuseppina Bertorelli
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
| | - Alfredo Chetta
- Department of Medicine and Surgery, Respiratory Disease and Lung Function Unit, University of Parma, Parma, Italy
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Underner M, Peiffer G, Perriot J, Jaafari N. [Smoking cessation in asthmatic patients and its impact]. Rev Mal Respir 2021; 38:87-107. [PMID: 33414027 DOI: 10.1016/j.rmr.2020.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2020] [Accepted: 06/18/2020] [Indexed: 02/08/2023]
Abstract
INTRODUCTION The prevalence of smoking in asthmatic patients is similar to, or even higher than in the general population. OBJECTIVES This systematic review addresses (1) the effects of smoking on asthma, (2) smoking cessation strategies in asthmatic patients, and (3) the consequences of smoking cessation for people with asthma. RESULTS Active or passive smoking can promote the development of asthma. The few studies on smoking cessation in asthma confirm the efficacy of validated smoking cessation strategies in these patients (nicotine replacement therapy, varenicline, bupropion, cognitive and behavioural therapies). Smoking cessation in parents with asthmatic children is essential and is based on the same strategies. Electronic cigarettes may be a useful help to quit smoking in some patients. Smoking cessation is beneficial in asthmatic smokers and associated with (1) a reduction of asthma symptoms, acute exacerbations, bronchial hyperresponsiveness, and bronchial inflammation, (2) decreased use of rescue medications and in doses of inhaled corticosteroids, (3) improved asthma control, quality of life, and lung function. CONCLUSION In asthmatic patients, it is essential to assess smoking status and health professionals must assist them to quit smoking.
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Affiliation(s)
- M Underner
- Unité de recherche clinique, centre hospitalier Henri-Laborit, université de Poitiers, 86021 Poitiers, France.
| | - G Peiffer
- Service de pneumologie, hôpital de Mercy, CHR Metz-Thionville, 57085 Metz cedex 3, France
| | - J Perriot
- Dispensaire Émile-Roux, CLAT 63, centre de tabacologie, 63100 Clermont-Ferrand, France
| | - N Jaafari
- Unité de recherche clinique, centre hospitalier Henri-Laborit, université de Poitiers, 86021 Poitiers, France
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Almeshari MA, Stockley J, Sapey E. The diagnosis of asthma. Can physiological tests of small airways function help? Chron Respir Dis 2021; 18:14799731211053332. [PMID: 34693751 PMCID: PMC8543738 DOI: 10.1177/14799731211053332] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Asthma is a common, chronic, and heterogeneous disease with a global impact and substantial economic costs. It is also associated with significant mortality and morbidity and the burden of undiagnosed asthma is significant. Asthma can be difficult to diagnose as there is no gold standard test and, while spirometry is central in diagnosing asthma, it may not be sufficient to confirm or exclude the diagnosis. The most commonly reported spirometric measures (forced expiratory volume in one second (FEV1) and forced vital capacity assess function in the larger airways. However, small airway dysfunction is highly prevalent in asthma and some studies suggest small airway involvement is one of the earliest disease manifestations. Moreover, there are new inhaled therapies with ultrafine particles that are specifically designed to target the small airways. Potentially, tests of small airways may more accurately diagnose early or mild asthma and assess the response to treatment than spirometry. Furthermore, some assessment techniques do not rely on forced ventilatory manoeuvres and may, therefore, be easier for certain groups to perform. This review discusses the current evidence of small airways tests in asthma and future research that may be needed to further assess their utility.
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Affiliation(s)
- Mohammed A Almeshari
- Rehabilitation Health Sciences
Department, College of Applied Medical Sciences, King Saud University, Riyadh, Saudi Arabia
- Institute of Inflammation and
Ageing, University of
Birmingham, Birmingham, UK
- Mohammed A. Almeshari, Institute of
Inflammation and Ageing, University of Birmingham, Edgbaston, Birmingham B152TT,
UK.
| | - James Stockley
- Department of Lung Function and
Sleep, University Hospitals Birmingham NHS
Foundation Trust, Birmingham, UK
| | - Elizabeth Sapey
- Institute of Inflammation and
Ageing, University of
Birmingham, Birmingham, UK
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Foy BH, Soares M, Bordas R, Richardson M, Bell A, Singapuri A, Hargadon B, Brightling C, Burrowes K, Kay D, Owers-Bradley J, Siddiqui S. Lung Computational Models and the Role of the Small Airways in Asthma. Am J Respir Crit Care Med 2020; 200:982-991. [PMID: 31106566 DOI: 10.1164/rccm.201812-2322oc] [Citation(s) in RCA: 73] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Rationale: Asthma is characterized by disease within the small airways. Several studies have suggested that forced oscillation technique-derived resistance at 5 Hz (R5) - resistance at 20 Hz (R20) is a measure of small airway disease; however, there has been limited validation of this measurement to date.Objectives: To validate the use of forced oscillation R5 - R20 as a measure of small airway narrowing in asthma, and to investigate the role that small airway narrowing plays in asthma.Methods: Patient-based complete conducting airway models were generated from computed tomography scans to simulate the impact of different degrees of airway narrowing at different levels of the airway tree on forced oscillation R5 - R20 (n = 31). The computational models were coupled with regression models in an asthmatic cohort (n = 177) to simulate the impact of small airway narrowing on asthma control and quality of life. The computational models were used to predict the impact on small airway narrowing of type-2 targeting biologics using pooled data from two similarly design randomized, placebo-controlled biologic trials (n = 137).Measurements and Main Results: Simulations demonstrated that narrowing of the small airways had a greater impact on R5 - R20 than narrowing of the larger airways and was associated (above a threshold of approximately 40% narrowing) with marked deterioration in both asthma control and asthma quality of life, above the minimal clinical important difference. The observed treatment effect on R5 - R20 in the pooled trials equated to a predicted small airway narrowing reversal of approximately 40%.Conclusions: We have demonstrated, using computational modeling, that forced oscillation R5 - R20 is a direct measure of anatomical narrowing in the small airways and that small airway narrowing has a marked impact on both asthma control and quality of life and may be modified by biologics.
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Affiliation(s)
- Brody H Foy
- Department of Computer Science, University of Oxford, Oxfordshire, United Kingdom
| | - Marcia Soares
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Rafel Bordas
- Department of Computer Science, University of Oxford, Oxfordshire, United Kingdom.,Roxar Software Solutions, Oxford, United Kingdom
| | - Matthew Richardson
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Alex Bell
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Amisha Singapuri
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Beverley Hargadon
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Christopher Brightling
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Kelly Burrowes
- Department of Chemical and Materials Engineering, University of Auckland, Auckland, New Zealand; and
| | - David Kay
- Department of Computer Science, University of Oxford, Oxfordshire, United Kingdom
| | - John Owers-Bradley
- School of Physics and Astronomy, University of Nottingham, Nottingham, United Kingdom
| | - Salman Siddiqui
- College of Life Sciences and Respiratory Research Theme, National Institute for Health Research Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
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Woo SD, Ye YM, Lee Y, Lee SH, Shin YS, Park JH, Choi H, Lee HY, Shin HJ, Park HS. Efficacy and Safety of a Pressurized Metered-Dose Inhaler in Older Asthmatics: Comparison to a Dry Powder Inhaler in a 12-Week Randomized Trial. ALLERGY, ASTHMA & IMMUNOLOGY RESEARCH 2020; 12:454-466. [PMID: 32141259 PMCID: PMC7061154 DOI: 10.4168/aair.2020.12.3.454] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 12/19/2019] [Accepted: 12/19/2019] [Indexed: 12/16/2022]
Abstract
Purpose Asthma control in older asthmatics is often less effective, which may be attributed to small airway dysfunction and poor inhalation technique. We compared the efficacy of 2 inhalers (fluticasone propionate/formoterol treatment using a pressurized metered-dose inhaler [p-MDI group] vs. fluticasone propionate/salmeterol treatment using a dry powder inhaler [DPI group]) in older asthmatics. Methods We conducted a 12-week, randomized, open-label, parallel-designed trial in older patients (over 55 years old) with moderate-to-severe asthma, and compared the efficacy and safety for asthma control between the 2 groups. Subgroup analyses on disease duration and air trapping were performed. Clinical parameters, including changes in lung function parameters, inhaler technique and adherence, were compared with monitoring adverse reactions between the 2 groups. Results A total of 68 patients underwent randomization, and 63 (30 in the p-MDI group and 33 in the DPI group) completed this study. The p-MDI group was non-inferior to the DPI group with regard to the rate of well-controlled asthma (53.3% vs. 45.5%, P < 0.001; a predefined non-inferiority limit of 17%). In subgroup analyses, the proportion of patients who did not reach well-controlled asthma in the p-MDI group was non-inferior to that in the DPI group; the difference was 12.7% among those with a longer disease duration (≥ 15 years) and 17.5% among those with higher air-trapping (RV/TLC ≥ 45%), respectively (a predefined non-inferiority limit of 17%, P < 0.001). No significant differences were observed in lung function parameters, inhalation techniques, adherence and adverse reactions between the 2 groups. Conclusion These results suggest that the p-MDI group may be comparable to the DPI group in the management of older asthmatics in aspects of efficacy and safety.
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Affiliation(s)
- Seong Dae Woo
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Young Min Ye
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Youngsoo Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - So Hee Lee
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Yoo Seob Shin
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea
| | - Joo Hun Park
- Department of Pulmonary and Critical Care Medicine, Ajou University School of Medicine, Suwon, Korea
| | - Hyunna Choi
- Clinical Trial Center, Ajou University Medical Center, Suwon, Korea
| | - Hyun Young Lee
- Clinical Trial Center, Ajou University Medical Center, Suwon, Korea
| | - Hyun Jung Shin
- Clinical Trial Center, Ajou University Medical Center, Suwon, Korea
| | - Hae Sim Park
- Department of Allergy and Clinical Immunology, Ajou University School of Medicine, Suwon, Korea.
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11
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Carpagnano GE, Scioscia G, Lacedonia D, Stornelli SR, Irene Quarato CM, Soccio P, Resta O, Foschino Barbaro MP. Treatment response according to small airways disease status: The effects of high-strength extrafine pMDI beclomethasone dipropionate/formoterol fumarate in fixed dose combination in moderate uncontrolled asthmatic patients. Pulm Pharmacol Ther 2019; 60:101879. [PMID: 31866498 DOI: 10.1016/j.pupt.2019.101879] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2019] [Revised: 12/17/2019] [Accepted: 12/17/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND Inflammation in small airways is particularly clinically active in severe asthma but they still continue to be ignored as considered silent. Recently, the Atlantis study reports small airways involvement in 91% of the asthma population. Therefore in the era of phenotype driven therapy, the aim of this study was to verify if high-strength extrafine ICS/LABA in fixed dose increases clinical efficacy in moderate asthmatic patients with small airways dysfunction and it could be proposed as phenotype driven therapy. METHODS In this prospective, non-interventional, real-life pilot study we enrolled 37 consecutive patients with moderate asthma who were uncontrolled despite GINA step 3 treatment. All subjects at enrollment were divided in two groups according to the presence of small airways dysfunction:1) small airways phenotype (SAP) group: smokers (≥10 packs/die), ex-smokers (>20 packs/year) with air trapping (FVC <80% - VR >100% - FEF 25-75%<60%); 2) non-small airways phenotype (NSAP) group: non-smokers, without air trapping (FVC ≥80% - VR ≤ 100% - FEF 25-75%≥60%). We later proceeded in both groups with a step up in therapy with high-strength extrafine pMDI beclomethasone dipropionate/formoterol fumarate (BDP/FF) (200/6 μg) in fixed dose to achieve a better control and followed patients for 6 months. RESULTS Treatment with extrafine BDP/FF(200/6 μg) in SAP group showed a more significant improvement of FEF25-75%, FVC, RV, and a reduction of alveolar inflammatory markers such as FENO350 and alveolar exhaled pH compared with NSAP patients. CONCLUSIONS Our preliminary results support the use of high-strength extrafine pMDI BDP/FF (200/6 μg) as phenotype driven treatment directed to small airways dysfunction demonstrating an increase of clinical efficacy in moderate asthmatics with SAP.
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Affiliation(s)
- Giovanna E Carpagnano
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy.
| | - Giulia Scioscia
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Donato Lacedonia
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Silvia Romana Stornelli
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Carla Maria Irene Quarato
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Piera Soccio
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
| | - Onofrio Resta
- Institute of Respiratory Diseases, University of Bari, Italy
| | - Maria Pia Foschino Barbaro
- Institute of Respiratory Diseases, Department of Medical and Surgical Sciences, University of Foggia, Italy
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12
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Hallberg J, Ballardini N, Almqvist C, Westman M, van Hage M, Lilja G, Bergström A, Kull I, Melén E. Impact of IgE sensitization and rhinitis on inflammatory biomarkers and lung function in adolescents with and without asthma. Pediatr Allergy Immunol 2019; 30:74-80. [PMID: 30341960 DOI: 10.1111/pai.12994] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/10/2018] [Accepted: 10/02/2018] [Indexed: 12/21/2022]
Abstract
BACKGROUND Both allergic and non-allergic rhinitis are associated with worse asthma control. However, it is unclear how IgE sensitization and/or rhinitis are associated with lung function. We therefore evaluated the effect of rhinitis and sensitization on lung function, including the periphery of the airway system, and inflammatory biomarkers in individuals with and without asthma. METHODS Participants in the BAMSE longitudinal birth cohort study underwent measures of spirometry, impulse oscillometry, and FeNO at age 16 years. Questionnaires were used to obtain data on asthma and rhinitis. Blood samples were analyzed for eosinophils and allergen-specific IgE. RESULTS Groups based on the combination of asthma, rhinitis, and sensitization were compared to a healthy reference group. Lower FEV1 /FVC levels were seen for groups with asthma only (adjusted mean difference -2.8% units (95% CI -4.7; -1.0), P < 0.01), asthma with sensitization (-2.0 (-3.9; -0.2), P < 0.05), and asthma with sensitization and rhinitis (-2.5 (-3.6; -1.4), P < 0.001). The index of peripheral airway resistance R5-20 was higher in groups with asthma and sensitization (adjusted median difference 94.9 Pa L-1 s-1 (95% CI 60.4; 129.3), P < 0.001), as well as asthma with sensitization and rhinitis (36.9(15.0; 58.8), P < 0.01). These groups also had increased FeNO and blood eosinophil levels. CONCLUSIONS We found signs of peripheral airway obstruction and increased levels of inflammatory biomarkers in the presence of allergic asthma, irrespective of rhinitis status. Despite having a reduced FEV1 /FVC, peripheral airway engagement was not seen in non-sensitized adolescents with asthma. We suggest that small airway disease is a feature related to the eosinophilic inflammation in allergic asthma in adolescence.
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Affiliation(s)
- Jenny Hallberg
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Natalia Ballardini
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,St John's Institute of Dermatology, King's College London, London, UK
| | - Catarina Almqvist
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Pediatric Allergy and Pulmonology Unit, Astrid Lindgren Children's Hospital, Karolinska University Hospital, Stockholm, Sweden
| | - Marit Westman
- Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden.,Department of Ear- Nose and Throat Diseases, Karolinska University Hospital, Stockholm, Sweden
| | - Marianne van Hage
- Immunology and Allergy Unit, Department of Medicine Solna, Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Gunnar Lilja
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Anna Bergström
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Center of Occupational and Environmental Medicine, Stockholm County Council, Stockholm, Sweden
| | - Inger Kull
- Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden.,Department of Clinical Science and Education, Södersjukhuset, Karolinska Institutet, Stockholm, Sweden
| | - Erik Melén
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden.,Sachs' Children and Youth Hospital, Södersjukhuset, Stockholm, Sweden
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13
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Doras C, Petak F, Bayat S, Baudat A, Von Garnier C, Eigenmann P, Habre W. Lung responses in murine models of experimental asthma: Value of house dust mite over ovalbumin sensitization. Respir Physiol Neurobiol 2017; 247:43-51. [PMID: 28890402 DOI: 10.1016/j.resp.2017.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Revised: 08/08/2017] [Accepted: 09/02/2017] [Indexed: 11/25/2022]
Abstract
Ovalbumin (OVA) sensitization has limitations in modelling asthma. Thus, we examined the value of allergic sensitization using a purified natural allergen, house dust mite (HDM), over the sensitization performed with OVA. Mice were sham-treated, or sensitized with OVA- or HDM with identical chronology. Airway resistance, tissue damping and elastance were assessed under control conditions and after challenging the animals with methacholine (MCh) and the specific allergen. Inflammatory profile of the bronchoalveolar lavage fluid was characterized and lung histology was performed. While no difference in the lung responsiveness to the specific allergen was noted, hyperresponsiveness to MCh was observed only in the HDM-sensitized animals in the lung peripheral parameters. Lung inflammation differed between the models, but excessive bronchial smooth muscle remodelling occurred only with OVA. In conclusion, we demonstrate that a purified natural allergen offers a more relevant murine model of human allergic asthma by expressing the key features of this chronic inflammatory disease both in the lung function and structure.
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Affiliation(s)
- Camille Doras
- Anaesthesiological Investigations Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Ferenc Petak
- Department of Medical Physics and Informatics, University of Szeged, Szeged, Hungary
| | - Sam Bayat
- Anaesthesiological Investigations Unit, University Hospitals of Geneva, Geneva, Switzerland
| | - Aurélie Baudat
- Anaesthesiological Investigations Unit, University Hospitals of Geneva, Geneva, Switzerland
| | | | - Philippe Eigenmann
- Department of Paediatrics, University Hospitals of Geneva, Geneva, Switzerland
| | - Walid Habre
- Anaesthesiological Investigations Unit, University Hospitals of Geneva, Geneva, Switzerland.
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14
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Port J, Tao Z, Junger A, Joppek C, Tempel P, Husemann K, Singer F, Latzin P, Yammine S, Nagel JH, Kohlhäufl M. A simple method to reconstruct the molar mass signal of respiratory gas to assess small airways with a double-tracer gas single-breath washout. Med Biol Eng Comput 2017; 55:1975-1987. [PMID: 28357624 DOI: 10.1007/s11517-017-1633-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2014] [Accepted: 03/13/2017] [Indexed: 01/13/2023]
Abstract
For the assessment of small airway diseases, a noninvasive double-tracer gas single-breath washout (DTG-SBW) with sulfur hexafluoride (SF6) and helium (He) as tracer components has been proposed. It is assumed that small airway diseases may produce typical ventilation inhomogeneities which can be detected within one single tidal breath, when using two tracer components. Characteristic parameters calculated from a relative molar mass (MM) signal of the airflow during the washout expiration phase are analyzed. The DTG-SBW signal is acquired by subtracting a reconstructed MM signal without tracer gas from the signal measured with an ultrasonic sensor during in- and exhalation of the double-tracer gas for one tidal breath. In this paper, a simple method to determine the reconstructed MM signal is presented. Measurements on subjects with and without obstructive lung diseases including the small airways have shown high reliability and reproducibility of this method.
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Affiliation(s)
- Johannes Port
- Institut für Biomedizinische Technik, Universität Stuttgart, Stuttgart, Germany.
| | - Ziran Tao
- Institut für Biomedizinische Technik, Universität Stuttgart, Stuttgart, Germany
| | - Annika Junger
- Institut für Biomedizinische Technik, Universität Stuttgart, Stuttgart, Germany
| | - Christoph Joppek
- Institut für Biomedizinische Technik, Universität Stuttgart, Stuttgart, Germany
| | - Philipp Tempel
- Institut für Biomedizinische Technik, Universität Stuttgart, Stuttgart, Germany
| | - Kim Husemann
- Klinik Schillerhöhe, Zentrum für Pneumologie und Thoraxchirurgie, Robert-Bosch-Hospital, Gerlingen, Germany.,Internistische Facharztpraxis für Pneumologie, Allergologie, Thoraxonkologie, Bronchoskopie und Schlafmedizin, MVZ Klinikum Kempten GmbH, Kempten, Germany
| | - Florian Singer
- University Children's Hospital Zurich, Zurich, Switzerland
| | - Philipp Latzin
- University Children's Hospital Basel, Basel, Switzerland
| | - Sophie Yammine
- University Children's Hospital Basel, Basel, Switzerland
| | - Joachim H Nagel
- Institut für Biomedizinische Technik, Universität Stuttgart, Stuttgart, Germany
| | - Martin Kohlhäufl
- Klinik Schillerhöhe, Zentrum für Pneumologie und Thoraxchirurgie, Robert-Bosch-Hospital, Gerlingen, Germany
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15
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Boulet LP, Laviolette M. Acute effects of bronchial thermoplasty: a matter of concern or an indicator of possible benefit to small airways? Eur Respir J 2017; 49:49/3/1700029. [PMID: 28298407 DOI: 10.1183/13993003.00029-2017] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 01/09/2017] [Indexed: 01/08/2023]
Affiliation(s)
- Louis-Philippe Boulet
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), Québec, QC, Canada
| | - Michel Laviolette
- Institut universitaire de cardiologie et de pneumologie de Québec - Université Laval (IUCPQ-UL), Québec, QC, Canada
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16
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Sekioka T, Kadode M, Yonetomi Y, Kamiya A, Fujita M, Nabe T, Kawabata K. CysLT 2 receptor activation is involved in LTC 4-induced lung air-trapping in guinea pigs. Eur J Pharmacol 2016; 794:147-153. [PMID: 27887950 DOI: 10.1016/j.ejphar.2016.11.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2016] [Revised: 11/21/2016] [Accepted: 11/21/2016] [Indexed: 12/15/2022]
Abstract
CysLT1 receptors are known to be involved in the pathogenesis of asthma. However, the functional roles of CysLT2 receptors in this condition have not been determined. The purpose of this study is to develop an experimental model of CysLT2 receptor-mediated LTC4-induced lung air-trapping in guinea pigs and use this model to clarify the mechanism underlying response to such trapping. Because LTC4 is rapidly converted to LTD4 by γ-glutamyltranspeptidase (γ-GTP) under physiological conditions, S-hexyl GSH was used as a γ-GTP inhibitor. In anesthetized artificially ventilated guinea pigs with no S-hexyl GSH treatment, i.v. LTC4-induced bronchoconstriction was almost completely inhibited by montelukast, a CysLT1 receptor antagonist, but not by BayCysLT2RA, a CysLT2 receptor antagonist. The inhibitory effect of montelukast was diminished by treatment with S-hexyl GSH, whereas the effect of BayCysLT2RA was enhanced with increasing dose of S-hexyl GSH. Macroscopic and histological examination of lung tissue isolated from LTC4-/S-hexyl-GSH-treated guinea pigs revealed air-trapping expansion, particularly at the alveolar site. Inhaled LTC4 in conscious guinea pigs treated with S-hexyl GSH increased both airway resistance and airway hyperinflation. On the other hand, LTC4-induced air-trapping was only partially suppressed by treatment with the bronchodilator salmeterol. Although montelukast inhibition of LTC4-induced air-trapping was weak, treatment with BayCysLT2RA resulted in complete suppression of this air-trapping. Furthermore, BayCysLT2RA completely suppressed LTC4-induced airway vascular hyperpermeability. In conclusion, we found in this study that CysLT2 receptors mediate LTC4-induced bronchoconstriction and air-trapping in S-hexyl GSH-treated guinea pigs. It is therefore believed that CysLT2 receptors contribute to asthmatic response involving air-trapping.
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Affiliation(s)
- Tomohiko Sekioka
- Minase Research Institute, Ono Pharmaceutical Co., Ltd, Osaka, Japan.
| | - Michiaki Kadode
- Minase Research Institute, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Yasuo Yonetomi
- Minase Research Institute, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Akihiro Kamiya
- Minase Research Institute, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Manabu Fujita
- Minase Research Institute, Ono Pharmaceutical Co., Ltd, Osaka, Japan
| | - Takeshi Nabe
- Department of Immunopharmacology, Faculty of Pharmaceutical Sciences, Setsunan University, Osaka, Japan
| | - Kazuhito Kawabata
- Minase Research Institute, Ono Pharmaceutical Co., Ltd, Osaka, Japan
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17
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The prevalence of small airways disease in adult asthma: A systematic literature review. Respir Med 2016; 116:19-27. [PMID: 27296816 DOI: 10.1016/j.rmed.2016.05.006] [Citation(s) in RCA: 82] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Small airways dysfunction and inflammation contribute significantly to the clinical impact of asthma, yet conventional methods of assessing airways function in the clinic cannot reliably evaluate its presence. However, most recently, promising methods of assessment are being utilised. METHODS We conducted a systematic literature review, using PubMed, with the aim of determining the prevalence of small airways disease in adult patients with asthma. We ascertained how small airways disease prevalence compared between different studies when measured using distinct techniques of small airways assessment. RESULTS Fifteen publications were identified determining the prevalence of small airways disease in asthma. Methods of assessments included impulse oscillometry, spirometry, body plethysmography, multiple-breath nitrogen washout, and high-resolution computed tomography. These studies used differing inclusion characteristics and recruited patients with a broad range of asthma severity, yet collectively they reported an overall prevalence of small airways disease of 50-60%. Small airways disease was present across all asthma severities, with evidence of distal airway disease even in the absence of proximal airway obstruction. CONCLUSIONS Small airways disease is highly prevalent in asthma, even in patients with milder disease. Given the clinical impact of small airways disease, its presence should not be underestimated or overlooked as part of the daily management of patients with asthma.
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18
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Marth K, Spinola M, Kisiel J, Woergetter C, Petrovic M, Pohl W. Treatment response according to small airway phenotypes: a real-life observational study. Ther Adv Respir Dis 2016; 10:200-10. [PMID: 27060186 DOI: 10.1177/1753465816642635] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVE Scant clinical data are available on the effects of current treatments for asthma on different subgroups of patients with this disease. We conducted a prospective, noninterventional, multicenter real-life study in adult patients with persistent asthma, and we specifically analyzed the effects of treatment with extrafine beclometasone dipropionate/formoterol (BDP/F) in asthma patients categorized by phenotypes related to small airways (i.e. smoking habits, disease duration, and air trapping). METHODS Patients received BDP/F as a fixed combination (100/6 μg), administered in 1-2 inhalations twice daily over a period of 12 weeks. Peak expiratory flow (PEF), forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), number of asthma attacks, asthma control, and severity of asthma symptoms were evaluated in the overall population and in different subgroups at three different time points. RESULTS Overall, 213 patients were enrolled. In the overall population the treatment resulted in a significant increase in the proportion of well controlled patients (from 6.1% to 66.3%; p<0.001), and a reduction of uncontrolled subjects (70.3% versus 10.0%; p<0.001). BDP/F was also associated with a reduction in asthma attacks and an improvement of symptoms. These results were confirmed in specific subgroups of patients identified as small airway phenotypes: smokers, elderly patients, those with long duration of disease and air trapping. CONCLUSIONS This real-life observational study indicates that extrafine BDP/F in a fixed combination improves asthma control and symptoms in the overall population as well as specific subgroups of patients.
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Affiliation(s)
| | | | | | | | | | - Wolfgang Pohl
- 1130 Wien, KH Hietzing, Abt. f. Atmungs- u. Lungenkrankheiten, Austria
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19
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Abstract
PURPOSE OF REVIEW The prevalence of active smoking in adults with asthma is similar to the general population. Smoking asthma is associated with poorer disease control, impaired response to corticosteroid therapy, accelerated decline in lung function, and increased rate of healthcare utilization. Current asthma guidelines do not provide specific treatment advice for smoking asthmatic patients. There is an urgent need for better understanding of the underlying mechanisms and effective treatment for smoking asthmatic patients. RECENT FINDINGS An association between both active and passive smoking and adult-onset asthma is supported by many studies.The asthma-COPD overlap syndrome (ACOS) has recently gained particular interest and smoking asthmatic patients should be evaluated for ACOS.Treatment regimens for smoking asthma include higher doses of inhaled corticosteroids (ICS), extrafine particle ICS formulations, antileukotrienes, and combinations of these options.Asthma is associated with increased risk of cardiovascular comorbidities whereas smoking is an additional strong independent risk factor for pulmonary and cardiovascular diseases. Tobacco smoking and not asthma per se seems to be the reason of poor prognosis, especially with regard to lung cancer, cardiovascular diseases, and mortality in asthmatic patients. SUMMARY Smoking asthma represents a common challenge to the clinician both in terms of diagnosis and management. These aspects have not been thoroughly evaluated and deserve further investigation.
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20
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Contoli M, Bellini F, Morandi L, Forini G, Bianchi S, Gnesini G, Marku B, Rabe KF, Papi A. Assessing small airway impairment in mild-to-moderate smoking asthmatic patients. Eur Respir J 2016; 47:1264-7. [PMID: 26869674 DOI: 10.1183/13993003.01708-2015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2015] [Accepted: 12/06/2015] [Indexed: 11/05/2022]
Affiliation(s)
- Marco Contoli
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Federico Bellini
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Luca Morandi
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Giacomo Forini
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Stefano Bianchi
- Dept of Pharmacy, University Hospital of Ferrara, Ferrara, Italy
| | - Giulia Gnesini
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Brunilda Marku
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Klaus F Rabe
- LungClinic Grosshansdorf, Member of the German Center for Lung Research, Grosshansdorf, Germany Dept of Medicine, Christian Albrechts University Kiel, Member of the German Center for Lung Research, Kiel, Germany
| | - Alberto Papi
- Research Centre on Asthma and COPD, Dept of Medical Sciences, University of Ferrara, Ferrara, Italy
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21
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Malerba M, Radaeli A, Olivini A, Damiani G, Ragnoli B, Sorbello V, Ricciardolo FLM. Association of FEF25-75% Impairment with Bronchial Hyperresponsiveness and Airway Inflammation in Subjects with Asthma-Like Symptoms. Respiration 2016; 91:206-14. [PMID: 26855322 DOI: 10.1159/000443797] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2015] [Accepted: 12/30/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Forced expiratory flow at 25 and 75% of the pulmonary volume (FEF25-75%) might be considered as a marker of early airway obstruction. FEF25-75% impairment might suggest earlier asthma recognition in symptomatic subjects even in the absence of other abnormal spirometry values. OBJECTIVES The study was designed in order to verify whether FEF25-75% impairment in a cohort of subjects with asthma-like symptoms could be associated with the risk of bronchial hyperresponsiveness (BHR) and with airway inflammation expressed as fractional exhaled nitric oxide (FeNO) and eosinophil counts in induced sputum. METHODS Four hundred adults with a history of asthma-like symptoms (10.5% allergic) underwent spirometry, determination of BHR to methacholine (PD20FEV1), FeNO analysis and sputum induction. FEF25-75% <65% of predicted or <-1.64 z-score was considered abnormal. RESULTS All subjects had normal FVC, FEV1 and FEV1/FVC, while FEF25-75% was abnormal in 27.5% of them. FEF25-75% (z-score) was associated with PD20FEV1 (p < 0.001), FeNO (p < 0.001) and sputum eosinophils (p < 0.001). Patients with abnormal FEF25-75% showed higher levels of FeNO and eosinophils in induced sputum than did patients with normal FEF25-75% (p < 0.01 and p < 0.01, respectively). Subjects with abnormal FEF25-75% had an increased probability of being BHR positive (OR = 13.38; 95% CI: 6.7-26.7; p < 0.001). CONCLUSIONS Our data show that abnormal FEF25-75% might be considered an early marker of airflow limitation associated with eosinophilic inflammation and BHR in subjects with asthma-like symptoms, indicating a role for FEF25-75% as a predictive marker of newly diagnosed asthma.
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Affiliation(s)
- Mario Malerba
- Department of Internal Medicine, University of Brescia, Spedali Civili di Brescia, Brescia, Italy
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Aberrant small airways function relates to asthma severity in young children. Respir Med 2015; 111:16-20. [PMID: 26733229 DOI: 10.1016/j.rmed.2015.12.006] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2015] [Revised: 12/11/2015] [Accepted: 12/17/2015] [Indexed: 11/20/2022]
Abstract
BACKGROUND Frequency dependence of resistance (R5-20) assessed by impulse oscillometry (IOS) is suggested to be a measure of small airways. Small airways involvement during induced bronchoconstriction has been shown to reflect severity of asthma in adults. OBJECTIVE Our aim was to evaluate if methacholine (Mch) induced changes in R5-20 are associated with the severity of exercise induced bronchoconstriction (EIB) in young children. METHODS A total of 109 children aged 3-8 years were studied, 95 with obstructive symptoms and 14 in good health, to assess small airways function during a Mch challenge. R5-20 and other IOS resistance and reactance parameters were measured at baseline and after the Mch challenge. In a standardized exercise test, the children were grouped according to the severity of EIB expressed as the percentage increase in resistance at 5 Hz (ΔR5) after exercise, indicating either no EIB (ΔR5 < 40%, n = 84), moderate EIB (ΔR5 40-80%, n = 13) and severe EIB (ΔR5 > 80%, n = 12). RESULTS The baseline R5-20 was not associated with the severity of EIB, but during Mch induced bronchoconstriction the change in R5-20 was significantly higher in children with severe EIB (2.61 fold increase) than in children with moderate EIB (1.48) or no EIB (1.74, p = 0.036). No significant associations were found in changes of other IOS parameters. The children with severe EIB also used more short-acting beta-agonists during the past two months than the other two groups (p < 0.001). CONCLUSION Frequency dependence of resistance (R5-20) measured by IOS during the Mch induced bronchoconstriction and more frequent use of beta-agonists are associated with severe EIB in young children.
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Cottini M, Lombardi C, Micheletto C. Small airway dysfunction and bronchial asthma control : the state of the art. Asthma Res Pract 2015; 1:13. [PMID: 27965766 PMCID: PMC5142439 DOI: 10.1186/s40733-015-0013-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 11/17/2015] [Indexed: 11/10/2022] Open
Abstract
According to national and international guidelines, achieving and maintaining asthma control is a major goal of disease management. In closely controlled clinical trials, good asthma control can be achieved , with the medical treatments currently available, in the majority of patients , but large population-based studies suggest that a significant proportion of patients in real-life setting experience suboptimal levels of asthma control and report lifestyle limitations with a considerable burden on quality of life. Poor treatment adherence and persistence, failure to use inhalers correctly, heterogeneity of asthma phenotypes and associated co-morbidities are the main contributing factors to poor disease control. Now, it is widely accepted that peripheral airway dysfunction , already present in patients with mild asthma, is a key contributor of worse control. The aim of this paper is to investigate the association between small-airways dysfunction and asthma symptoms/control. We therefore performed a PubMed search using keywords : small airways; asthma (limits applied: Humans, English language) and selected papers with a study population of asthmatic patients, reporting measurement of small-airways parameters and clinical symptoms/control.
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Affiliation(s)
| | - Carlo Lombardi
- Departmental Unit of Allergology, Immunology & Pulmonary Diseases, Fondazione Poliambulanza, Via Bissolati, 57, Brescia, 25124 Italy
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24
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Small airway disease in asthma: pathophysiological and diagnostic considerations. Curr Opin Pulm Med 2015; 21:68-73. [PMID: 25415403 DOI: 10.1097/mcp.0000000000000122] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The aim of the current review is to summarize the evidence of small airway abnormalities in asthma, the proposed diagnostic tools for small airway abnormalities and the clinical implications of small airway abnormalities in asthma. RECENT FINDINGS Pathological abnormalities in the peripheral membranous bronchioles less than 2 mm in diameter (i.e. small airways) can be very frequently detected in asthma patients across severity: from mild to the more severe clinical manifestations of the disease. Interestingly, not only are small airway abnormalities present in asthma, but there is evidence that the magnitude of small airway abnormalities correlates with the severity of the disease. So far no unanimously accepted method and/or algorithm is available for small airway abnormality detection; however, some functional techniques and inflammatory markers have been used as surrogates of small airway dysfunction. SUMMARY Clinicians, and not only researchers, must consider small airways when approaching asthma patients, particularly when dealing with patients with a 'difficult-to-treat phenotype'. The identification of subgroups of asthma patients with prominent small airway disease is not merely speculative, and carries pathophysiological and therapeutic implications.
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25
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Ledford DK. Optimal asthma diagnosis: A destination or a process? J Allergy Clin Immunol 2015; 136:654-5. [PMID: 26100083 DOI: 10.1016/j.jaci.2015.05.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2015] [Accepted: 05/04/2015] [Indexed: 11/20/2022]
Affiliation(s)
- Dennis K Ledford
- Morsani College of Medicine, University of South Florida, Tampa, Fla.
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26
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Roche N, Postma DS, Colice G, Burden A, Guilbert TW, Israel E, Martin RJ, van Aalderen WMC, Grigg J, Hillyer EV, von Ziegenweidt J, Price DB. Differential effects of inhaled corticosteroids in smokers/ex-smokers and nonsmokers with asthma. Am J Respir Crit Care Med 2015; 191:960-4. [PMID: 25876207 DOI: 10.1164/rccm.201411-2116le] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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27
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Ciet P, Serra G, Bertolo S, Spronk S, Ros M, Fraioli F, Quattrucci S, Assael MB, Catalano C, Pomerri F, Tiddens HAWM, Morana G. Assessment of CF lung disease using motion corrected PROPELLER MRI: a comparison with CT. Eur Radiol 2015; 26:780-7. [PMID: 26024847 DOI: 10.1007/s00330-015-3850-9] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 05/05/2015] [Accepted: 05/13/2015] [Indexed: 01/01/2023]
Abstract
OBJECTIVES To date, PROPELLER MRI, a breathing-motion-insensitive technique, has not been assessed for cystic fibrosis (CF) lung disease. We compared this technique to CT for assessing CF lung disease in children and adults. METHODS Thirty-eight stable CF patients (median 21 years, range 6-51 years, 22 female) underwent MRI and CT on the same day. Study protocol included respiratory-triggered PROPELLER MRI and volumetric CT end-inspiratory and -expiratory acquisitions. Two observers scored the images using the CF-MRI and CF-CT systems. Scores were compared with intra-class correlation coefficient (ICC) and Bland-Altman plots. The sensitivity and specificity of MRI versus CT were calculated. RESULTS MRI sensitivity for detecting severe CF bronchiectasis was 0.33 (CI 0.09-0.57), while specificity was 100% (CI 0.88-1). ICCs for bronchiectasis and trapped air were as follows: MRI-bronchiectasis (0.79); CT-bronchiectasis (0.85); MRI-trapped air (0.51); CT-trapped air (0.87). Bland-Altman plots showed an MRI tendency to overestimate the severity of bronchiectasis in mild CF disease and underestimate bronchiectasis in severe disease. CONCLUSIONS Motion correction in PROPELLER MRI does not improve assessment of CF lung disease compared to CT. However, the good inter- and intra-observer agreement and the high specificity suggest that MRI might play a role in the short-term follow-up of CF lung disease (i.e. pulmonary exacerbations). KEY POINTS PROPELLER MRI does not match CT sensitivity to assess CF lung disease. PROPELLER MRI has lower sensitivity than CT to detect severe bronchiectasis. PROPELLER MRI has good to very good intra- and inter-observer variability. PROPELLER MRI can be used for short-term follow-up studies in CF.
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Affiliation(s)
- Pierluigi Ciet
- Radiology Department, General Hospital Ca' Foncello, Treviso, Italy.,Pediatric Pulmonology Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands.,Radiology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Silvia Bertolo
- Radiology Department, General Hospital Ca' Foncello, Treviso, Italy
| | - Sandra Spronk
- Radiology, Erasmus MC, Rotterdam, The Netherlands.,Epidemiology, Erasmus MC, Rotterdam, The Netherlands
| | - Mirco Ros
- Pediatrics, Ca' Foncello Hospital, Treviso, Italy
| | - Francesco Fraioli
- Institute of Nuclear Medicine, University College London (UCL), London, UK
| | | | | | | | - Fabio Pomerri
- Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Harm A W M Tiddens
- Pediatric Pulmonology Erasmus MC, Sophia Children's Hospital, Rotterdam, The Netherlands.,Radiology, Erasmus MC, Rotterdam, The Netherlands
| | - Giovanni Morana
- Radiology Department, General Hospital Ca' Foncello, Treviso, Italy.
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Thomson NC, Chaudhuri R, Spears M, Messow CM, MacNee W, Connell M, Murchison JT, Sproule M, McSharry C. Poor symptom control is associated with reduced CT scan segmental airway lumen area in smokers with asthma. Chest 2015; 147:735-744. [PMID: 25356950 DOI: 10.1378/chest.14-1119] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND Cigarette smoking is associated with worse symptoms in asthma and abnormal segmental airways in healthy subjects. We tested the hypothesis that current symptom control in smokers with asthma is associated with altered segmental airway dimensions measured by CT scan. METHODS In 93 subjects with mild, moderate, and severe asthma (smokers and never smokers), we recorded Asthma Control Questionnaire-6 (ACQ-6) score, spirometry (FEV1; forced expiratory flow rate, midexpiratory phase [FEF(25%-75%)]), residual volume (RV), total lung capacity (TLC), and CT scan measures of the right bronchial (RB) and left bronchial (LB) segmental airway dimensions (wall thickness, mm; lumen area, mm²) in the RB3/LB3, RB6/LB6, and RB10/LB10 (smaller) airways. RESULTS The CT scan segmental airway (RB10 and LB10) lumen area was reduced in smokers with asthma compared with never smokers with asthma; RB10, 16.6 mm² (interquartile range, 12.4-19.2 mm²) vs 19.6 mm² (14.7-24.2 mm²) (P = .01); LB10, 14.8 mm² (12.1-19.0 mm²) vs 19.9 mm² (14.5-25.0 mm²) (P = .003), particularly in severe disease, with no differences in wall thickness or in larger airway (RB3 and LB3) dimensions. In smokers with asthma, a reduced lumen area in fifth-generation airways (RB10 or LB10) was associated with poor symptom control (higher ACQ-6 score) (-0.463 [-0.666 to -0.196], P = .001, and -0.401 [-0.619 to -0.126], P = .007, respectively) and reduced postbronchodilator FEF(25%-75%) (0.521 [0.292-0.694], P < .001, and [0.471 [0.236-0.654], P = .001, respectively) and higher RV/TLC %. CONCLUSIONS The CT scan segmental airway lumen area is reduced in smokers with asthma compared with never smokers with asthma, particularly in severe disease, and is associated with worse current symptom control and small airway dysfunction.
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Affiliation(s)
- Neil C Thomson
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow.
| | - Rekha Chaudhuri
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow
| | - Mark Spears
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow
| | | | - William MacNee
- UoE/MRC Centre for Inflammation Research, Medical Physics and Clinical Radiology, University of Edinburgh, Edinburgh
| | - Martin Connell
- UoE/MRC Centre for Inflammation Research, Medical Physics and Clinical Radiology, University of Edinburgh, Edinburgh
| | - John T Murchison
- UoE/MRC Centre for Inflammation Research, Medical Physics and Clinical Radiology, University of Edinburgh, Edinburgh
| | - Michael Sproule
- Department of Radiology, Gartnavel General Hospital, Glasgow, Scotland
| | - Charles McSharry
- Institute of Infection, Immunity and Inflammation, University of Glasgow, Glasgow
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Gonem S, Natarajan S, Desai D, Corkill S, Singapuri A, Bradding P, Gustafsson P, Costanza R, Kajekar R, Parmar H, Brightling CE, Siddiqui S. Clinical significance of small airway obstruction markers in patients with asthma. Clin Exp Allergy 2014; 44:499-507. [PMID: 24341600 DOI: 10.1111/cea.12257] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Revised: 10/07/2013] [Accepted: 11/19/2013] [Indexed: 11/26/2022]
Abstract
BACKGROUND The role of small airway obstruction in the clinical expression of asthma is incompletely understood. OBJECTIVE We tested the hypotheses that markers of small airway obstruction are associated with (i) increased asthma severity, (ii) impaired asthma control and quality of life and (iii) frequent exacerbations. METHODS Seventy-four adults with asthma and 18 healthy control subjects underwent impulse oscillometry (IOS), multiple breath inert gas washout (MBW), body plethysmography, single-breath determination of carbon monoxide uptake and spirometry. Patients completed the six-point Asthma Control Questionnaire (ACQ-6) and standardized Asthma Quality of Life Questionnaire [AQLQ(S)]. Asthma severity was classified according to the Global Initiative for Asthma (GINA) treatment steps. RESULTS The putative small airway obstruction markers Sacin , resistance at 5 Hz minus resistance at 20 Hz (R5-R20) and reactance area (AX) were not independently associated with asthma severity, control, quality of life or exacerbations. In contrast, markers of total (R5) and mean airway resistance of large and small airways (R20) were significantly higher in the severe asthma group compared with the mild-moderate group (0.47 vs. 0.37, P < 0.05 for R5; 0.39 vs. 0.31, P < 0.01 for R20). The strongest independent contributors to ACQ-6 score were R20 and forced expiratory volume in one second (% pred.), and the strongest independent contributors to AQLQ(S) score were R20 and forced vital capacity (% pred.). A history of one or more exacerbations within the previous year was independently associated with R20. CONCLUSIONS AND CLINICAL RELEVANCE Previously reported markers of small airway obstruction do not appear to be independently associated with asthma disease expression. In contrast, the IOS parameter R20, a marker of mean airway resistance of both large and small airways, appears to have independent clinical significance. These observations require confirmation in prospective longitudinal studies.
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Affiliation(s)
- S Gonem
- Department of Infection, Immunity and Inflammation, Institute for Lung Health, University of Leicester, Leicester, UK
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30
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Scichilone N, Benfante A, Morandi L, Bellini F, Papi A. Impact of extrafine formulations of inhaled corticosteroids/long-acting beta-2 agonist combinations on patient-related outcomes in asthma and COPD. PATIENT-RELATED OUTCOME MEASURES 2014; 5:153-62. [PMID: 25473323 PMCID: PMC4251568 DOI: 10.2147/prom.s55276] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Asthma and chronic obstructive pulmonary disease (COPD) are among the most common chronic diseases worldwide, characterized by a condition of variable degree of airway obstruction and chronic airway inflammation. A large body of evidence has demonstrated the importance of small airways as a pharmacological target in these clinical conditions. Despite a deeper understanding of the pathophysiological mechanisms, the epidemiological observations show that a significant proportion of asthmatic and COPD patients have a suboptimal (or lack of) control of their diseases. Different factors could influence the effectiveness of inhaled treatment in chronic respiratory diseases: patient-related (eg, aging); disease-related (eg, comorbid conditions); and drug-related/formulation-related factors. The presence of multiple illnesses is common in the elderly patient as a result of two processes: the association between age and incidence of degenerative diseases; and the development over time of complications of the existing diseases. In addition, specific comorbidities may contribute to impair the ability to use inhalers, such as devices for efficient drug delivery in the respiratory system. The inability to reach and treat the peripheral airways may contribute to the lack of efficacy of inhaled treatments. The recent development of inhaled extrafine formulations allows a more uniform distribution of the inhaled treatment throughout the respiratory tree to include the peripheral airways. The beclomethasone/formoterol extrafine formulation is available for the treatment of asthma and COPD. Different biomarkers of peripheral airways are improved by beclomethasone/formoterol extrafine treatment in comparison with equivalent nonextrafine inhaled corticosteroids/long-acting beta-2 agonist (ICS/LABA) combinations. These improvements are associated with improved lung function and clinical outcomes, along with reduced systemic exposure to inhaled corticosteroids. The increased knowledge in the pathophysiology of the peripheral airways may lead to identify specific phenotypes of obstructive lung diseases that would mostly benefit from the treatments specifically targeting the peripheral airways.
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Affiliation(s)
- Nicola Scichilone
- Biomedical Department of Internal and Specialist Medicine, Section of Pulmonology, University of Palermo, Italy
| | - Alida Benfante
- Biomedical Department of Internal and Specialist Medicine, Section of Pulmonology, University of Palermo, Italy
| | - Luca Morandi
- Respiratory Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Federico Bellini
- Respiratory Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Alberto Papi
- Respiratory Medicine, Department of Medical Sciences, University of Ferrara, Ferrara, Italy
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31
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Schiphof-Godart L, van der Wiel E, Ten Hacken NHT, van den Berge M, Postma DS, van der Molen T. Development of a tool to recognize small airways dysfunction in asthma (SADT). Health Qual Life Outcomes 2014; 12:155. [PMID: 25416552 PMCID: PMC4253607 DOI: 10.1186/s12955-014-0155-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2013] [Accepted: 10/09/2014] [Indexed: 11/15/2022] Open
Abstract
Background Small airways dysfunction (SAD) contributes to the clinical expression of asthma. The identification of patients who suffer from SAD is important from a clinical perspective, as targeted therapy may improve patients’ well-being and treatment efficacy. Aims We aimed to realize the first step in the development of a simple small airways dysfunction tool (SADT) that may help to identify asthma patients having SAD. Methods Asthma patients with and without SAD were interviewed. Patients were selected to participate in this study based on FEF50% and R5-R20 values from spirometry and impulse oscillometry respectively. Results Ten in depth interviews and two focus groups revealed that patients with and without SAD perceived differences in symptoms and signs, habits and health related issues. For example, patients with SAD reported to wheeze easily, were unable to breathe in deeply, mentioned more symptoms related to bronchial hyperresponsiveness, experienced more pronounced exercise-induced symptoms and more frequently had allergic respiratory symptoms after exposure to cats and birds. Based on these differences, 63 items were retained to be further explored for the SADT. Conclusions The first step of the development of the SADT tool shows that there are relevant differences in signs and respiratory symptoms between asthma patients with and without SAD. The next step is to test and validate all items in order to retain the most relevant items to create a short and simple tool, which should be useful to identify asthma patients with SAD in clinical practice. Electronic supplementary material The online version of this article (doi:10.1186/s12955-014-0155-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Lieke Schiphof-Godart
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. .,University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), A. Deusinglaan 1, 9700 AV, PO Box 196, Groningen, HPC FA 21, The Netherlands.
| | - Erica van der Wiel
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), A. Deusinglaan 1, 9700 AV, PO Box 196, Groningen, HPC FA 21, The Netherlands. .,Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Nick H T Ten Hacken
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), A. Deusinglaan 1, 9700 AV, PO Box 196, Groningen, HPC FA 21, The Netherlands. .,Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Maarten van den Berge
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), A. Deusinglaan 1, 9700 AV, PO Box 196, Groningen, HPC FA 21, The Netherlands. .,Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Dirkje S Postma
- University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), A. Deusinglaan 1, 9700 AV, PO Box 196, Groningen, HPC FA 21, The Netherlands. .,Department of Pulmonary Medicine and Tuberculosis, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands.
| | - Thys van der Molen
- Department of General Practice, University of Groningen, University Medical Center Groningen, Groningen, the Netherlands. .,University of Groningen, University Medical Center Groningen, Groningen Research Institute for Asthma and COPD (GRIAC), A. Deusinglaan 1, 9700 AV, PO Box 196, Groningen, HPC FA 21, The Netherlands.
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Alveolar T-helper type-2 immunity in atopic asthma is associated with poor clinical control. Clin Sci (Lond) 2014; 128:47-56. [PMID: 25059741 DOI: 10.1042/cs20140309] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Real-world evaluation studies have shown that many patients with asthma remain symptomatic despite treatment with inhaled corticosteroids (ICSs). As conventional ICSs have poor access to the peripheral airways, the aim of the present paper was to study the relationship between peripheral airway inflammation and clinical control in allergic asthma. Consequently, bronchial and transbronchial biopsies were obtained from patients with poorly controlled asthma [n=12, asthma control test (ACT) score<20], patients with well-controlled asthma (n=12, ACT score≥20) and healthy controls (n=8). Tissue sections were immunostained to assess multiple leucocyte populations. To determine the degree of T-helper type-2 (Th2) immunity, the logarithmic value of the ratio between Th2 cells/mm2 and Th1 cells/mm2 was used as a surrogate score for Th2-skewed immunity. In the bronchi, the leucocyte infiltration pattern and the Th2-score were similar between patients with well-controlled asthma and those with poorly controlled asthma. In contrast, in the alveolar parenchyma, the expression of T-helper cells was significantly higher in patients with poorly controlled asthma than in patients with well-controlled asthma (P<0.01). Furthermore, the alveolar Th2-score was significantly higher in patients with poorly controlled asthma (median 0.4) than in the controlled patients (median -0.10, P<0.05). In addition, in contrast with bronchial Th2-score, the alveolar Th2-score correlated significantly with ACT score (rs=-0.62, P<0.01) in the pooled asthma group. Collectively, our data reveal an alveolar Th2-skewed inflammation, specifically in asthmatic patients who are poorly controlled with ICSs, and suggest that pharmacological targeting of the peripheral airways may be beneficial in this large patient category.
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Elliot JG, Jones RL, Abramson MJ, Green FH, Mauad T, McKay KO, Bai TR, James AL. Distribution of airway smooth muscle remodelling in asthma: relation to airway inflammation. Respirology 2014; 20:66-72. [PMID: 25257809 DOI: 10.1111/resp.12384] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2014] [Revised: 06/20/2014] [Accepted: 07/16/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND OBJECTIVE Pathological phenotypes of asthma have been based predominantly on inflammation, rather than airway wall remodelling. Differences in the distribution of airway smooth muscle (ASM) remodelling between large and small airways may affect clinical outcomes in asthma. The aim of this study was to examine the distribution of ASM remodelling and its relation to airway inflammation. METHODS Post-mortem cases of asthma (n = 68) were categorized by the distribution of increased thickness of the ASM layer (relative to nonasthmatic controls, n = 37), into 'large only' (LO, n = 15), 'small only' (SO, n = 4) 'large/small' (LS, n = 24) or no increase (NI, n = 25). Subject characteristics, ASM and airway wall dimensions and inflammatory cell numbers were compared between groups. RESULTS Apart from reduced clinical severity of asthma in NI cases (P = 0.002), subject characteristics did not distinguish asthma groups. Compared with control subjects, ASM cell number, reticular basement membrane thickness, airway wall thickness, percent muscle shortening and eosinophil number were increased (P < 0.05) in both large and small airways in LS cases and only the large airways in LO cases. Increased numbers of neutrophils were observed only in the small airways of LO cases. CONCLUSIONS Distinct distributions of ASM remodelling are seen in asthma. Pathology limited to the small airways was uncommon. Increased thickness of the ASM layer was associated with airway remodelling and eosinophilia, but not neutrophilia. These data support the presence of distinct pathological phenotypes based on the site of increased ASM.
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Affiliation(s)
- John G Elliot
- Department of Pulmonary Physiology and Sleep Medicine, West Australian Sleep Disorders Research Institute, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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Mari A, Antonietta Ciardiello M, Passalacqua G, Vliagoftis H, Wardlaw AJ, Wickman M. Developments in the field of allergy in 2012 through the eyes of Clinical & Experimental Allergy. Clin Exp Allergy 2014; 43:1309-32. [PMID: 24118214 DOI: 10.1111/cea.12212] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
In 2012, we received 683 submissions and published 20 editorials, 38 reviews, 11 letters and 128 original articles. This represents an acceptance rate for original papers in the range of 20%. About 30% of original papers were triaged not to go out to review, either because the editors did not feel they had sufficient priority for publication or because the topic did not feel right for the readers of the journal. We place great emphasis on obtaining sufficient high-quality reviews to make our decisions on publication fair and consistent. Inevitably, however, there is a degree of luck about what gets published and which papers miss out, and we are always happy to receive an appeal on our decisions either at the triage stage or after review. This gives us the opportunity to revisit the decision and revise it or explain in more detail to the authors the basis for the decision. Once again in 2012, we were delighted by the quality of the papers submitted and the breadth and depth of research into allergic disease that it revealed. The pattern of papers submitted was similar in previous years with considerable emphasis on all aspects of asthma and rhinitis. We were particularly pleased with our special issue on severe asthma. Elucidating mechanisms using either animal models or patients has always been a major theme of the journal, and the excellent work in these areas has been summarized by Harissios Vliagoftis with a particularly interesting section on early-life events guiding the development of allergic disease, which understandably continue to be a major theme of research. Magnus Wickman summarized the papers looking at the epidemiology of allergic disease including work from birth cohorts, which are an increasingly rich source of data on risk factors for allergic disease, and two papers on the epidemiology of anaphylaxis. Giovanni Passalacqua discussed the papers in the clinical allergy section of the journal, and Adriano Mari who runs the excellent Allergome website discussed the papers looking at allergens including characterization and the relative usefulness of allergen arrays versus single extracts in diagnosis and management.
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Affiliation(s)
- A Mari
- Allergome, Allergy Data Laboratories s.c., Latina, Italy
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35
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Tajiri T, Niimi A, Matsumoto H, Ito I, Oguma T, Otsuka K, Takeda T, Nakaji H, Inoue H, Iwata T, Nagasaki T, Kanemitsu Y, Izuhara Y, Mishima M. Comprehensive efficacy of omalizumab for severe refractory asthma: a time-series observational study. Ann Allergy Asthma Immunol 2014; 113:470-5.e2. [PMID: 24994694 DOI: 10.1016/j.anai.2014.06.004] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2014] [Revised: 06/02/2014] [Accepted: 06/05/2014] [Indexed: 11/26/2022]
Abstract
BACKGROUND Omalizumab, a humanized anti-IgE monoclonal antibody, is reportedly an effective treatment for severe allergic asthma. However, there have been few comprehensive analyses of its efficacy, including assessments of small airways or airway remodeling. OBJECTIVE To comprehensively evaluate the efficacy of omalizumab, including its effects on small airways and airway remodeling, in adult patients with severe refractory asthma. METHODS In this prospective, time-series, single-arm observational study, 31 adult patients with severe refractory asthma despite the use of multiple controller medications, including high-dose inhaled corticosteroids (1,432 ± 581 μg/d of fluticasone propionate equivalent), were enrolled. Clinical variables, including Asthma Quality of Life Questionnaire, asthma exacerbations, exhaled nitric oxide, pulmonary function, methacholine airway responsiveness, induced sputum, and chest computed tomogram, were assessed at baseline and after 16 and 48 weeks of treatment with omalizumab. RESULTS Twenty-six of the 31 patients completed 48 weeks of treatment. For these patients, Asthma Quality of Life Questionnaire scores and peak expiratory flow values significantly and continuously improved throughout the 48 weeks (P < .001 for all comparisons). Unscheduled physician visits, asthma exacerbations requiring systemic corticosteroids, fractional exhaled nitric oxide at 50 mL/s and alveolar nitric oxide levels, sputum eosinophil proportions, and airway-wall thickness as assessed by computed tomography significantly decreased at 48 weeks (P < .05 for all comparisons). CONCLUSION Omalizumab was effective for adult patients with severe refractory asthma. Omalizumab may have anti-inflammatory effects on small airways and reverse airway remodeling. TRIAL REGISTRATION UMIN000002389.
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Affiliation(s)
- Tomoko Tajiri
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Akio Niimi
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan; Division of Respiratory Medicine, Department of Medical Oncology and Immunology, Nagoya City University School of Medical Sciences, Aichi, Japan.
| | - Hisako Matsumoto
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Isao Ito
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tsuyoshi Oguma
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Kojiro Otsuka
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tomoshi Takeda
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hitoshi Nakaji
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Hideki Inoue
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Toshiyuki Iwata
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Tadao Nagasaki
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yoshihiro Kanemitsu
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Yumi Izuhara
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
| | - Michiaki Mishima
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Matsuse H, Kohno S. Leukotriene receptor antagonists pranlukast and montelukast for treating asthma. Expert Opin Pharmacother 2013; 15:353-63. [PMID: 24350802 DOI: 10.1517/14656566.2014.872241] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION The prevalence of bronchial asthma, which is a chronic inflammatory disorder of the airway, is increasing worldwide. Although inhaled corticosteroids (ICS) play a central role in the treatment of asthma, they cannot achieve good control for all asthmatics, and medications such as leukotriene receptor antagonists (LTRAs) with bronchodilatory and anti-inflammatory effects often serve as alternatives or add-on drugs. AREAS COVERED Clinical trials as well as basic studies of montelukast and pranlukast in animal models are ongoing. This review report clarifies the current status of these two LTRAs in the treatment of asthma and their future direction. EXPERT OPINION LTRAs could replace ICS as first-line medications for asthmatics who are refractory to ICS or cannot use inhalant devices. Further, LTRAs are recommended for asthmatics under specific circumstances that are closely associated with cysteinyl leukotrienes (cysLTs). Considering the low incidence of both severe adverse effects and the induction of tachyphylaxis, oral LTRAs should be more carefully considered for treating asthma in the clinical environment. Several issues such as predicted responses, effects of peripheral airway and airway remodeling and alternative administration routes remain to be clarified before LTRAs could serve a more effective role in the treatment of asthma.
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Affiliation(s)
- Hiroto Matsuse
- Nagasaki University School of Medicine, Second Department of Internal Medicine , 1-7-1 Sakamoto, Nagasaki 852-8501 , Japan +81 95 819 7273 ; +81 95 849 7285 ;
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Chen X, Wang K, Jiang M, Nong GM. Leukotriene receptor antagonists for small-airway abnormalities in asthmatics: a systematic review and meta-analysis. J Asthma 2013; 50:695-704. [PMID: 23713591 DOI: 10.3109/02770903.2013.806543] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Airway inflammation that occurs in asthma is mainly distributed in the small airways. Leukotriene receptor antagonists (LTRAs) are systemically active drugs that may act on the small airways. OBJECTIVES The aim of our study was to assess the efficacy of LTRAs for small-airway abnormalities in asthmatics. METHODS We searched the databases of Cochrane Central, MEDLINE, and EMBASE from the time of the establishment of the databases to December 2012. The data were extracted using a pooled mean difference (MD) or standardized mean difference (SMD) with a 95% confidence interval (CI). RESULTS Eight studies were included. The outcomes were the conventional parameters for the detection of small-airway abnormalities. Eight studies were included. The outcomes were the conventional parameters for the detection of small-airway abnormalities. LTRAs compared to placebo improved small-airway abnormalities, as indicated by a number of radiological and physiological parameters, such as lung attenuation (MD, 61.00; 95% CI, 26.32 to 95.68) and residual volume (SMD, -0.85; 95% CI, -1.29 to -0.42). Conventional inhaled corticosteroids (ICSs) compared to LTRAs improved small-airway abnormalities, as indicated by the reactance area (p = 0.028). Compared with conventional treatment alone, a combination of LTRAs and conventional treatment improved small-airway abnormalities, as indicated by a number of radiological and physiological parameters, such as airway wall thickness (p < 0.05), alveolar nitric oxide concentration (p = 0.04), a decrease in resistance from 5 to 20 hertz (p = 0.032), reactance area (p = 0.014), eosinophil cationic protein levels (p = 0.045) and number of eosinophils (p = 0.035) in the late-phase induced sputum. However, there was no significant improvement in forced expiratory flow between 25% and 75% of forced vital capacity in any of the comparisons. CONCLUSIONS LTRAs may improve most of the conventional parameters for the detection of small-airway abnormalities in asthmatics. However, there is no evidence of the superiority of LTRAs over ICSs in improving functional parameters related to the small airways.
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Affiliation(s)
- Xun Chen
- Department of Paediatrics, First Affiliated Hospital of Guangxi Medical University, Nanning, PR China
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Popov TA, Petrova D, Kralimarkova TZ, Ivanov Y, Popova T, Peneva M, Odzhakova T, Ilieva Y, Yakovliev P, Lazarova T, Georgiev O, Hodzhev V, Hodzheva E, Staevska MT, Dimitrov VD. Real life clinical study design supporting the effectiveness of extra-fine inhaled beclomethasone/formoterol at the level of small airways of asthmatics. Pulm Pharmacol Ther 2013; 26:624-9. [PMID: 23769863 DOI: 10.1016/j.pupt.2013.06.002] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2013] [Revised: 05/19/2013] [Accepted: 06/04/2013] [Indexed: 11/27/2022]
Abstract
BACKGROUND In an attempt to establish how treatment with inhaled extra-fine beclomethasone/formoterol (I-EF-BDP/F) formulation differs from other combinations of inhaled corticosteroid (ICS) and long acting beta-agonist (LABA), we studied lung function and markers of airway inflammation upon switching to the extra-fine formulation and after 8 weeks of treatment with it. METHODS We carried out a real-life clinical observation of undercontrolled asthmatic patients switched over from dry powder inhalers of fluticasone/salmeterol and budesonide/formoterol to I-EF-BDP/F (Foster(®), Chiesi Farmaceutici S.p.A., Italy). The effects of 8-weeks of treatment were documented by means of visual analog scale (VAS), quality of life by Asthma Quality of Life Questionnaire (AQLQ), spirometry and markers of airway or systemic inflammation: exhaled breath temperature (EBT), blood eosinophils (Eos), and high sensitivity C-reactive protein (CRP). Before/after treatment differences between forced vital capacity percent of predicted (%FVC), a simple indicator of small airways involvement, were calculated and subjects were ranked accordingly to reflect the magnitude of the therapeutic response. Subjects above the 75th percentile (n = 15), "top responders", were then compared with those below the 25th percentile (n = 15) "poor responders". RESULTS On average, the 59 patients completing the study (mean age ± SD 51 ± 12 years, 38 women) had significant improvement in VAS and QLQ scores at the end of the treatment period (49.1 ± 2.4 vs. 73.1 ± 2.05 and 146.1 ± 2.7 vs. 176.7.1 ± 3.4 respectively, P < 0.001), but not in the inflammatory indicators (EBT, CRP and Eos). However, when comparing the "top responders" with the "poor responders", significant improvement in these inflammatory indicators was observed: EBT significantly decreased from 34.04/mean/± 0.30/s.e.m./[°C] to 33.57 ± 0.33, P = 0.003, Eos in blood fell from 381.7 ± 91.2 [cells/μL] to 244.2 ± 43.2, P = 0.02. Before/after treatment differences in hsCRP decreased significantly in the top responders compared with the poor responders (Mann-Whitney test, P = 0.04). CONCLUSION Asthmatic subjects who had the most improvement in FVC after transition to I-EF-BDP/F from other combined ICS/LABA preparations also demonstrated a significant decrease in some indicators of airway/systemic inflammation. These results support the notion that I-EF-BDP/F exerts an effect also at the level of the small airways through a reduction of the level of air trapping. Patients in whom inflammation of the small airways plays an important clinical role are the ones to derive most benefit from this small airways tailored treatment. However, improved compliance due to the "promise of a new drug" effect should also be considered as contributing to the treatment results.
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Ivancsó I, Böcskei R, Müller V, Tamási L. Extrafine inhaled corticosteroid therapy in the control of asthma. J Asthma Allergy 2013; 6:69-80. [PMID: 23776339 PMCID: PMC3681407 DOI: 10.2147/jaa.s25415] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Small airways disease plays an important role in the pathogenesis of asthma, but assessment of small airways impairment is not easy in everyday clinical practice. The small airways can be examined by several invasive and noninvasive methods, most of which can at present be used only in the experimental setting. Inhalers providing extrafine inhaled corticosteroid particle sizes may achieve sufficient deposition in the peripheral airways. Many studies have reported the beneficial effects of extrafine inhaled corticosteroids on inflammation, ie, on dysfunction in both the central and distal airways in asthmatics, and there are some data on asthma phenotypes in which the small airways seem to be affected more than in other phenotypes, including nocturnal asthma, severe steroid-dependent or difficult-to-treat asthma, asthma complicated by smoking, elderly asthmatic patients and/or patients with fixed airflow obstruction, and asthmatic children. The relevant randomized controlled clinical trials indicate that the efficacy of extrafine and nonextrafine inhaled corticosteroid formulations is similar in terms of primary endpoints, but there are certain clinically important endpoints for which the extrafine formulations show additional benefits.
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Affiliation(s)
- István Ivancsó
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Renáta Böcskei
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Veronika Müller
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
| | - Lilla Tamási
- Department of Pulmonology, Semmelweis University, Budapest, Hungary
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Barnes N, van Noord JA, Brindicci C, Lindemann L, Varoli G, Perpiña M, Guastalla D, Casula D, Patel S, Chanez P. Stepping-across controlled asthmatic patients to extrafine beclometasone/formoterol combination. Pulm Pharmacol Ther 2013; 26:555-61. [PMID: 23524015 DOI: 10.1016/j.pupt.2013.01.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2012] [Revised: 01/29/2013] [Accepted: 01/31/2013] [Indexed: 01/24/2023]
Abstract
BACKGROUND Asthma management focuses on achieving and maintaining asthma control. Few studies have assessed whether complete and sustained asthma control is maintained in clinical practice after stepping-across ICS/LABA fixed combinations. Aim of this double-blind, double-dummy, randomized, parallel group, controlled study was to demonstrate clinical equivalence between equipotent doses of extrafine beclometasone/formoterol (BDP/F) pMDI and fluticasone/salmeterol (FP/S) Diskus® in maintaining lung function and asthma control. METHODS A total of 416 asthmatic patients already controlled with FP/S 500/100 μg/day (Diskus®, pMDI or separate inhalers) were randomized to a 12-week treatment with extrafine BDP/F 400/24 μg/day pMDI or FP/S 500/100 μg/day Diskus®. Pre-dose 1-s forced expiratory volume (FEV(1)) was the primary efficacy variable; secondary variables included asthma control questionnaire (ACQ-7) and FEV(1)0-1 h area under the curve (FEV(1)AUC(0-1h)). Safety was assessed through adverse events monitoring and vital signs. RESULTS After 12 weeks of treatment, pre-dose FEV(1) did not differ between treatments (difference between means 0.01 L; 95% CI -0.03-0.06 L) with no significant changes from baseline in both groups (p = 0.726 and p = 0.783 in BDF/F arm and FP/S, respectively). ACQ-7 score showed that control was maintained after stepping-across to extrafine BDP/F. FEV(1)AUC(0-1h) was significantly higher in BDP/F arm at the beginning (p = 0.004) and at the end of the 12-week treatment period (p = 0.019). No safety issues were reported in both groups. CONCLUSIONS Patients previously controlled with FP/S in any device formulation can effectively step-across to extrafine BDP/F pMDI, maintaining lung function and asthma control with a 5-min onset of action.
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Affiliation(s)
- Neil Barnes
- Department of Respiratory Medicine, London Chest Hospital, Barts & The London NHS Trust, Bonner Road, E2 9JX London, UK.
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Efficacy of omalizumab in eosinophilic chronic rhinosinusitis patients with asthma. Ann Allergy Asthma Immunol 2013; 110:387-8. [PMID: 23622013 DOI: 10.1016/j.anai.2013.01.024] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2012] [Revised: 01/30/2013] [Accepted: 01/31/2013] [Indexed: 01/08/2023]
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Nakaji H, Petrova G, Matsumoto H, Iwata T, Ito I, Oguma T, Inoue H, Tajiri T, Nagasaki T, Kanemitsu Y, Niimi A, Mishima M. Effects of 24-week add-on treatment with ciclesonide and montelukast on small airways inflammation in asthma. Ann Allergy Asthma Immunol 2013; 110:198-203.e3. [PMID: 23548532 DOI: 10.1016/j.anai.2012.12.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2012] [Revised: 11/26/2012] [Accepted: 12/18/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Eosinophilic inflammation of the small airways is a key process in asthma that often smolders in treated patients. The long-term effects of add-on therapy on the persistent inflammation in the small airways remain unknown. OBJECTIVE To examine the effects of add-on therapy with either ciclesonide, an inhaled corticosteroid with extrafine particles, or montelukast on small airway inflammation. METHODS Sixty patients with stable asthma receiving inhaled corticosteroid treatment were enrolled in a randomized, open-label, parallel comparison study of 24-week add-on treatment with ciclesonide or montelukast. Patients were randomly assigned to 3 groups: ciclesonide (n = 19), montelukast (n = 22), or no add-on as controls (n = 19). At baseline and at weeks 4, 12, and 24, extended nitric oxide analysis; pulmonary function tests, including impulse oscillometry; blood eosinophil counts; and asthma control tests (ACTs) were performed. RESULTS A total of 18 patients in the ciclesonide group, 19 in the montelukast group, and 15 in the control group completed the study and were analyzed. With repeated-measures analysis of variance, ciclesonide produced a significant decrease in alveolar nitric oxide and a significant improvement in ACT scores over time. Montelukast produced significant decreases in alveolar nitric oxide concentrations and blood eosinophil counts over time and slightly improved ACT scores, whereas no such changes were observed in the control group. Alveolar nitric oxide concentrations with ciclesonide and reactance area at low frequencies with montelukast produced greater improvements over time compared with control. CONCLUSION Ciclesonide add-on therapy and montelukast add-on therapy may act differently, but both separately can improve small airway abnormalities and provide better asthma control. TRIAL REGISTRATION umin.ac.jp/ctr Identifier: UMIN000001083.
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Affiliation(s)
- Hitoshi Nakaji
- Department of Respiratory Medicine, Graduate School of Medicine, Kyoto University, Kyoto, Japan
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Concave pattern of a maximal expiratory flow-volume curve: a sign of airflow limitation in adult bronchial asthma. Pulm Med 2012; 2012:797495. [PMID: 23227333 PMCID: PMC3514841 DOI: 10.1155/2012/797495] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2012] [Revised: 10/12/2012] [Accepted: 10/29/2012] [Indexed: 11/25/2022] Open
Abstract
Background. In patients with bronchial asthma, spirometry could identify the airflow limitation of small airways by evaluating the concave shape of the maximal expiratory flow-volume (MEFV) curve. As the concave shape of the MEFV curve is not well documented, we reevaluated the importance of this curve in adult asthmatic patients. Methods. We evaluated spirometric parameters, the MEFV curve, and its concave shape (scoop between the peak and endpoint of expiration) in 27 nonsmoking asthmatic patients with physician-confirmed wheeze and positive bronchial reversibility after a short-acting β2-agonist inhalation. We also calculated angle β and shape factors (SF25% and SF50%) to quantitate the curvilinearity of the MEFV curve. Results. The MEFV curve was concave in all patients. Along with improvements in standard spirometric parameters, curvilinear parameters, angle β, SF25%, and SF50% were significantly improved after bronchodilator inhalation. There were significant correlations between improvements in angle β, and FEF50%, and FEF25-75%, and between improvements in SF25%, and SF50%, and FEF75%. Conclusions. The bronchodilator greatly affected the concave shape of the MEFV curve, correlating with spirometric parameters of small airway obstructions (FEF50%, FEF75%, and FEF25-75%). Thus, the concave shape of the MEFV curve is an important indicator of airflow limitation in adult asthmatic patients.
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Assessing and accessing the small airways; implications for asthma management. Pulm Pharmacol Ther 2012; 26:172-9. [PMID: 23073337 DOI: 10.1016/j.pupt.2012.10.001] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2012] [Revised: 10/01/2012] [Accepted: 10/06/2012] [Indexed: 11/21/2022]
Abstract
Despite the wealth of experience in the management of asthma, the disease remains inadequately controlled in some patients, who face long-term respiratory impairment and disability. The disease has been characterised as an inflammatory condition affecting first the larger airways and eventually the smaller airways, but there is evidence that peripheral airway involvement defines a particular and more severe phenotype of asthma. For this reason, assessing functional and biological parameters reflective of small airways involvement is important prognostically. No assessment method is universally and directly representative of peripheral airway function, but the traditional spirometric tests, including vital capacity, residual volume and forced vital capacity, are somewhat correlated with this function; useful methods for further assessment include the single-breath nitrogen wash-out test, impulse oscillometry, nitrous oxide and exhaled breath concentrate measurements, as well as computed tomography to reflect air trapping and response to treatment. Formulation advancements have made for easier treatment access to the smaller airways, with the new extrafine formulations resulting in better asthma control compared with non-extrafine formulations.
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