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Lommatzsch M, Criée CP, de Jong CCM, Gappa M, Geßner C, Gerstlauer M, Hämäläinen N, Haidl P, Hamelmann E, Horak F, Idzko M, Ignatov A, Koczulla AR, Korn S, Köhler M, Lex C, Meister J, Milger-Kneidinger K, Nowak D, Pfaar O, Pohl W, Preisser AM, Rabe KF, Riedler J, Schmidt O, Schreiber J, Schuster A, Schuhmann M, Spindler T, Taube C, Christian Virchow J, Vogelberg C, Vogelmeier CF, Wantke F, Windisch W, Worth H, Zacharasiewicz A, Buhl R. [Diagnosis and treatment of asthma: a guideline for respiratory specialists 2023 - published by the German Respiratory Society (DGP) e. V.]. Pneumologie 2023; 77:461-543. [PMID: 37406667 DOI: 10.1055/a-2070-2135] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/07/2023]
Abstract
The management of asthma has fundamentally changed during the past decades. The present guideline for the diagnosis and treatment of asthma was developed for respiratory specialists who need detailed and evidence-based information on the new diagnostic and therapeutic options in asthma. The guideline shows the new role of biomarkers, especially blood eosinophils and fractional exhaled NO (FeNO), in diagnostic algorithms of asthma. Of note, this guideline is the first worldwide to announce symptom prevention and asthma remission as the ultimate goals of asthma treatment, which can be achieved by using individually tailored, disease-modifying anti-asthmatic drugs such as inhaled steroids, allergen immunotherapy or biologics. In addition, the central role of the treatment of comorbidities is emphasized. Finally, the document addresses several challenges in asthma management, including asthma treatment during pregnancy, treatment of severe asthma or the diagnosis and treatment of work-related asthma.
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Affiliation(s)
- Marek Lommatzsch
- Zentrum für Innere Medizin, Abt. für Pneumologie, Universitätsmedizin Rostock
| | | | - Carmen C M de Jong
- Abteilung für pädiatrische Pneumologie, Abteilung für Pädiatrie, Inselspital, Universitätsspital Bern
| | - Monika Gappa
- Klinik für Kinder und Jugendliche, Evangelisches Krankenhaus Düsseldorf
| | | | | | | | - Peter Haidl
- Abteilung für Pneumologie II, Fachkrankenhaus Kloster Grafschaft GmbH, Schmallenberg
| | - Eckard Hamelmann
- Kinder- und Jugendmedizin, Evangelisches Klinikum Bethel, Bielefeld
| | | | - Marco Idzko
- Abteilung für Pulmologie, Universitätsklinik für Innere Medizin II, Medizinische Universität Wien
| | - Atanas Ignatov
- Universitätsklinik für Frauenheilkunde, Geburtshilfe und Reproduktionsmedizin, Universitätsklinikum Magdeburg
| | - Andreas Rembert Koczulla
- Schön-Klinik Berchtesgadener Land, Berchtesgaden
- Klinik für Innere Medizin Schwerpunkt Pneumologie, Universitätsklinikum Marburg
| | - Stephanie Korn
- Pneumologie und Beatmungsmedizin, Thoraxklinik, Universitätsklinikum Heidelberg
| | - Michael Köhler
- Deutsche Patientenliga Atemwegserkrankungen, Gau-Bickelheim
| | - Christiane Lex
- Klinik für Kinder- und Jugendmedizin, Universitätsmedizin Göttingen
| | - Jochen Meister
- Klinik für Kinder- und Jugendmedizin, Helios Klinikum Aue
| | | | - Dennis Nowak
- Institut und Poliklinik für Arbeits-, Sozial- und Umweltmedizin, LMU München
| | - Oliver Pfaar
- Klinik für Hals-Nasen-Ohrenheilkunde, Kopf- und Hals-Chirurgie, Sektion für Rhinologie und Allergie, Universitätsklinikum Marburg, Philipps-Universität Marburg, Marburg
| | - Wolfgang Pohl
- Gesundheitszentrum Althietzing, Karl Landsteiner Institut für klinische und experimentelle Pneumologie, Wien
| | - Alexandra M Preisser
- Zentralinstitut für Arbeitsmedizin und Maritime Medizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Klaus F Rabe
- Pneumologie, LungenClinic Großhansdorf, UKSH Kiel
| | - Josef Riedler
- Abteilung für Kinder- und Jugendmedizin, Kardinal Schwarzenberg Klinikum Schwarzach
| | | | - Jens Schreiber
- Universitätsklinik für Pneumologie, Universitätsklinikum Magdeburg
| | - Antje Schuster
- Klinik für Allgemeine Pädiatrie, Neonatologie und Kinderkardiologie, Universitätsklinikum Düsseldorf
| | | | | | - Christian Taube
- Klinik für Pneumologie, Universitätsmedizin Essen-Ruhrlandklinik
| | | | - Christian Vogelberg
- Klinik und Poliklinik für Kinder- und Jugendmedizin, Universitätsklinikum Carl Gustav Carus, Dresden
| | | | | | - Wolfram Windisch
- Lungenklinik Köln-Merheim, Lehrstuhl für Pneumologie, Universität Witten/Herdecke
| | - Heinrich Worth
- Pneumologische & Kardiologische Gemeinschaftspraxis, Fürth
| | | | - Roland Buhl
- Klinik für Pneumologie, Zentrum für Thoraxerkrankungen, Universitätsmedizin Mainz
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Kellerer C, Hapfelmeier A, Jörres RA, Schultz K, Brunn B, Schneider A. Evaluation of the diagnostic accuracy of fractional exhaled nitric oxide (FeNO) in patients with suspected asthma: study protocol for a prospective diagnostic study. BMJ Open 2021; 11:e045420. [PMID: 33579773 PMCID: PMC7883850 DOI: 10.1136/bmjopen-2020-045420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION The measurement of fractional exhaled nitric oxide (FeNO) is promising for diagnosing asthma and might substitute for bronchial provocation (BP) tests. To evaluate the diagnostic accuracy of FeNO within a confirmatory study, the following hypotheses will be tested: (1) A FeNO cut-off >50 ppb (parts per billion) is suitable for diagnosing asthma (sensitivity 35%, specificity 95%); (2) If the clinical symptoms 'allergic rhinitis' and 'wheezing' are present, asthma can be diagnosed at FeNO >33 ppb with a positive predictive value (PPV) >70% and (3) A FeNO >33 ppb can predict responsiveness to inhaled corticosteroid (ICS) with a PPV >70%. METHODS AND ANALYSIS A prospective diagnostic study will be conducted in three practices of pneumologists in Germany. 300 patients suspected of suffering from asthma will be included. As an index test, patients perform FeNO measurement with the device NIOX VERO. As reference a test, patients are examined with whole bodyplethysmography and BP, if necessary. After 3 months, patients with an asthma diagnosis will be examined again to verify the diagnosis and evaluate ICS responsiveness. Patients who did not receive an asthma diagnosis at the initial examination will be phoned after 3 months and asked about persistent respiratory symptoms to exclude false negative findings. As a primary target, sensitivity and specificity of FeNO >50 ppb will be determined. As a secondary target the PPV for asthma at FeNO >33 ppb, when the symptoms 'allergic rhinitis' and 'wheezing' are present, will be calculated. Regarding ICS responsiveness, the PPV of FeNO >33 ppb will be determined. ETHICS AND DISSEMINATION The study was approved by the Ethical Committee of the Technical University of Munich (Reference number 122/20 S). The major results will be published in peer-reviewed academic journals and disseminated through conferences. TRIAL REGISTRATION NUMBER DRKS00021125.
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Affiliation(s)
- Christina Kellerer
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
| | - Alexander Hapfelmeier
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
- Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational, Social and Environmental Medicine, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Konrad Schultz
- Clinic Bad Reichenhall, Center for Rehabilitation, Pneumology and Orthopedics, Bad Reichenhall, Germany
| | - Benjamin Brunn
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
| | - Antonius Schneider
- Technical University of Munich, School of Medicine, Institute of General Practice and Health Services Research, Munich, Germany
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Capnovolumetry in combination with clinical history for the diagnosis of asthma and COPD. NPJ Prim Care Respir Med 2020; 30:32. [PMID: 32732930 PMCID: PMC7393160 DOI: 10.1038/s41533-020-00190-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2019] [Accepted: 06/19/2020] [Indexed: 11/09/2022] Open
Abstract
Capnovolumetry performed during resting ventilation is an easily applicable diagnostic tool sensitive to airway obstruction. In the present analysis, we investigated in which way capnovolumetric parameters can be combined with basic anamnestic information to support the diagnosis of asthma and COPD. Among 1400 patients of a previous diagnostic study, we selected 1057 patients with a diagnosis of asthma (n = 433), COPD (n = 260), or without respiratory disease (n = 364). Besides performing capnovolumetry, patients answered questions on symptoms and smoking status. Logistic regression analysis, single decision trees (CHAID), and ensembles of trees (random forest) were used to identify diagnostic patterns of asthma and COPD. In the random forest approach, area/volume of phase 3, dyspnea upon strong exertion, s3/s2, and current smoking were identified as relevant parameters for COPD vs control. For asthma vs control, they were wheezing, volume of phase 2, current smoking, and dyspnea at strong exertion. For COPD vs asthma, s3/s2 was the primary criterion, followed by current smoking and smoking history. These parameters were also identified as relevant in single decision trees. Regarding the diagnosis of asthma vs control, COPD vs control, and COPD vs asthma, the area under the curve was 0.623, 0.875, and 0.880, respectively, in the random forest approach. Our results indicate that for the diagnosis of asthma and COPD capnovolumetry can be combined with basic anamnestic information in a simple, intuitive, and efficient manner. As capnovolumetry requires less cooperation from the patient than spirometry, this approach might be helpful for clinical practice.
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Kohler B, Kellerer C, Schultz K, Wittmann M, Atmann O, Linde K, Hapfelmeier A, Schneider A. An Internet-Based Asthma Self-Management Program Increases Knowledge About Asthma. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 117:64-71. [PMID: 32070472 DOI: 10.3238/arztebl.2020.0064] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 08/15/2019] [Accepted: 11/14/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Asthma education (AE) is associated with reduced hospitalization and disability. We compared the effectiveness of an electronic AE program (eAEP) with a conventional face-to-face AE program (presence-based AEP; pAEP) for asthma knowledge (AK) with regard to self-management. METHODS A randomized controlled pilot study was conducted in a pulmonary reha- bilitation clinic. AK was determined by means of the Asthma Knowledge Test (AKT). The change in AKT score within each group was calculated with a paired t-test. Group differences were estimated with adjusted linear regression models. RESULTS In the intervention group (n = 41), the AKT score increased from 41.57 (standard deviation 5.63) at baseline to 45.82 (3.84) after completion of the eAEP (p < 0.001), and again to 47.20 (3.78) after completion of the pAEP (p = 0.046). In the control group (n = 41), the score increased from 41.73 (4.74) at baseline to 45.72 (3.65) after completion of the pAEP (p < 0.001). There was no relevant differ- ence in knowledge gain between the eAEP and the pAEP group after completion of the corresponding educational sessions (p = 0.881). The AKT score was higher in the eAEP group after obligatory participation in pAEP than in the group that only completed the pAEP (p = 0.020). CONCLUSION An internet-based AEP could help to reduce the knowledge deficits of a large proportion of patients with asthma.
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Affiliation(s)
- Benedikt Kohler
- Institute of General Practice and Health Services Research, TUM School of Medicine, Technical University Munich; Clinic Bad Reichenhall, Center for Rehabilitation, Pneumology and Orthopedics, Bad Reichenhall; Institute of Medical Informatics, Statistics and Epidemiology, School of Medicine, Technical University Munich
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Schneider A, Wagenpfeil G, Jörres RA, Wagenpfeil S. Influence of the practice setting on diagnostic prediction rules using FENO measurement in combination with clinical signs and symptoms of asthma. BMJ Open 2015; 5:e009676. [PMID: 26603255 PMCID: PMC4663408 DOI: 10.1136/bmjopen-2015-009676] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVES To evaluate the influence of the practice setting on diagnostic accuracy of fractional exhaled nitric oxide (FENO) for diagnosing asthma; and to develop prediction rules for diagnostic decision-making including clinical signs and symptoms (CSS). SETTING Patients from 10 general practices and 1 private practice of 5 pneumologists in ambulatory care. PARTICIPANTS 553 patients, 57.9% female. Consecutive inclusion of diagnostic-naive patients suspected of suffering from obstructive airway disease. Exclusion criteria were respiratory tract infections within the last 6 weeks. INTERVENTIONS The index test was FENO measurement. Reference standard was the Tiffeneau ratio (forced expiratory volume in 1 s/vital capacity) or airway resistance as assessed by whole body plethysmography, with additional bronchoprovocation or bronchodilator testing. PRIMARY AND SECONDARY OUTCOME MEASURES Asthma as determined by pneumologists, who were blind to FENO measurement results. Prediction rules were derived from multiple logistic regression analysis. A freely available calculator that allows computing all combinations was developed. RESULTS The practice setting only had minor influence on sensitivities of FENO cut-off points. In the final model (n=472), allergic rhinitis, wheezing and previous medication were positively associated with asthma. Increasing age and recurrent respiratory tract infections were negatively associated. The area under the curve (AUC) of FENO (AUC=0.650; 95% CI 0.599 to 0.701) increased significantly (p<0.0001) when combined with CSS (AUC=0.753; 95% CI 0.707 to 0.798). Presence of wheezing and allergic rhinitis allowed ruling in asthma with FENO >30 ppb. Ruling out with FENO <16 ppb in patients <43 years was only possible without allergic symptoms when recurrent respiratory tract infections were present. CONCLUSIONS FENO results should be interpreted in the context of CSS to enhance their diagnostic value in primary care. The final diagnostic model appears as a sound algorithm fitting well to the established diagnostic rules related to CSS of asthma. FENO appears more effective for ruling in asthma than for ruling it out.
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Affiliation(s)
- Antonius Schneider
- Institute of General Practice, University Hospital Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Gudrun Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Rudolf A Jörres
- Institute and Outpatient Clinic for Occupational and Environmental Medicine, Ludwig-Maximilians-University,Munich, Germany
| | - Stefan Wagenpfeil
- Institute of Medical Biometry, Epidemiology and Medical Informatics, Universitätsklinikum des Saarlandes, Homburg, Germany
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