The Asthmas: A Precision Medicine Approach to Treatable Traits, Diagnosis and Management

142 Pages·2022·17.937 MB·English

by  Vibeke Backer, Peter G. Gibson, Ian D. Pavord

The Asthmas
The field of asthma has expanded in the last decade with specific drugs targeting the disease mechanisms.
This book is an updated treatise covering diagnoses, phenotypes and endotypes of asthma along with
its management. It includes diagnostic work-up which is required prior to medical assistance and basic
immunology assessment, illustrating the types, severity, number of exacerbations due to disease activity,
allergy or infections. As the treatment selection has changed from one size fits all to precision-based medi-
cine, it aims to refine asthma management with right medication usage, neither overuse nor underuse and
initiation of the new hospital administered biologic drugs.
Key Features
● Covers both respiratory physiology and airway inflammation
● Highlights the use of biologic drugs
● Discusses precision-based medicine
● Explores the comorbidities through clinical cases

The Asthmas
A Precision Medicine Approach to Treatable Traits,
Diagnosis and Management
Vibeke Backer
Peter G. Gibson
Ian D. Pavord
First edition published 2023
by CRC Press
6000 Broken Sound Parkway NW, Suite 300, Boca Raton, FL 33487-2742
and by CRC Press
4 Park Square, Milton Park, Abingdon, Oxon, OX14 4RN
CRC Press is an imprint of Taylor & Francis Group, LLC
© 2023 Taylor & Francis Group, LLC
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Library of Congress Cataloging-in-Publication Data
Names: Backer, Vibeke, author. | Gibson, Peter G., author. | Pavord, Ian D., author.
Title: The asthmas : a precision medicine approach to treatable traits, diagnosis and management /
by Vibeke Backer, Peter G. Gibson, Ian D. Pavord.
Description: First edition. | Boca Raton, FL : Taylor & Francis, 2023. | Includes bibliographical references
and index. | Summary: “The field of asthma has expanded in the last decade with specific drugs targeting
the disease mechanisms. This book is an updated treatise covering diagnoses, phenotypes and endotypes
of asthma along with its management. Including diagnostic work-up which is required prior to medical
assistance, as well as basic immunology assessment”-- Provided by publisher.
Identifiers: LCCN 2022017955 | ISBN 9780367352738 (hardback) | ISBN 9781032323237 (paperback) |
ISBN 9780429330292 (ebook)
Subjects: MESH: Asthma | Precision Medicine
Classification: LCC RC591 | NLM WF 553 | DDC 616.2/38--dc23/eng/20220708
LC record available at https://lccn.loc.gov/2022017955
ISBN: 9780367352738 (hbk)
ISBN: 9781032323237 (pbk)
ISB N: 9780429330292 (ebk)
DOI: 10.1201/9780429330292
Typeset in Minion
by KnowledgeWorks Global Ltd.
Contents
Preface vii
Acknowledgements ix
Authors xi
Abbreviations xiii
1 Introduction 1
1.1 Asthma: A historical perspective 1
1.2 A new era: Asthma phenotypes, endotypes, treatable traits and
personalised management 2
2 Pulmonary – Treatable traits 5
2.1 Airflow limitation 5
2.2 What clinical problems does it cause? 9
2.3 How can it be detected? 10
2.4 How is it treated? 11
2.5 What is the result of treatment? 14
2.6 Type-2 airway inflammation 14
2.7 How is it treated? 19
2.8 What is the result of treatment? 23
2.9 Disordered airway mucosal immunity 23
2.10 Altered cough reflex sensitivity 24
2.11 Structural changes to the airway 25
2.12 Common patterns of asthma 25
3 Extrapulmonary – Treatable traits 29
3.1 Upper airway (UA) 29
3.2 UA – Vocal cord dysfunction (VCD) and exercise-induced laryngeal
obstruction mechanism 35
3.3 Upper airway mechanisms in obstructive sleep apnoea 37
3.4 Exercise and asthma 40
3.5 Overlap between COPD and asthma 43
3.6 Gastro-oesophageal reflux disease 44
3.7 Depression and anxiety with asthma 45
4 Risk factors – Treatable traits 47
4.1 Tobacco exposure and the asthmas 47
4.2 The allergic history – And allergic asthma 53
4.3 Air pollution and the asthmas 57
4.4 Infection 60
4.5 Obesity 63
4.6 Adherence 64
v
vi Contents
5 Diagnostic tests in respiratory medicine 69
5.1 Diagnoses of respiratory allergies 69
5.2 Fraction of exhaled nitric oxide 70
5.3 Inflammatory cell counts: Eosinophilic and neutrophilic cells 73
5.4 Blood, sputum or bronchial alveolar lavage fluid cytokines 75
5.5 Lung function 76
5.6 Airway hyperresponsiveness 77
5.7 Fitness in asthma 82
5.8 Cough reflex sensitivity 83
6 Key cases – Treatable traits 87
6.1 Pulmonary cases 87
6.2 Extrapulmonary cases 89
6.3 Risk factors 91
7 Evaluation of the asthmas 95
7.1 A pragmatic, assumption-free approach to asthma diagnosis and management 95
7.2 Severity of respiratory symptoms 98
8 Organising an asthma clinic 109
8.1 Introduction 109
8.2 Principles of treatable traits in organisation of care 109
8.3 Severe asthma clinic 109
8.4 Other factors in organisation of care 112
9 The future of the asthmas 113
9.1 Introduction 113
9.2 Future research needs 113
9.3 Excellent asthma papers supporting treatable traits 114
10 Conclusion 117
Index 119
Preface
This book was created in response to the rapid and research within the areas of inflammation,
development within the asthma field over the last hyperresponsiveness, disease management, data
decade. After years of standard care and one size capture and pharmaceuticals, with an increas-
fits all treatment, things have improved substan- ing number of studies following RCT principles.
tially, and little in the medical field has changed so Although there are different traditions in different
much and so fast since the appearance of inhaled places in terms of asthma management, hospital
corticosteroids than asthma care, involving asthma systems and peripheral versus centralised care, we
assessment, differentiated testing, multimodal have found that the basic science has led to funda-
treatment options and follow-up schedules. The mentally similar approaches to asthma manage-
latter has, during the COVID pandemic, switched ment and monitoring of patients with asthma. All
from clinic visits to web-based follow-up, requir- patients should be managed individually in order
ing even more differentiated care, as objective to be managed equally, and we have discovered
measurements must be taken in patients’ homes. through discussions that our fundamental views
Although many asthma patients are easy to on the science have produced similar reflections
manage, there is a substantial group with moder- on Type-2 and non-Type-2 inflammation, how to
ate to severe asthma who are more complicated evaluate them and the choices of treatment. This
and need the evaluation of endotypes, phenotypes principle of focusing on treatable traits can also
and comorbidities. Thus, since the discovery of be used in the management of less severe patients,
targeted biologic drugs (i.e., monoclonal anti- although not all management tools are needed
bodies), everything concerning the assessment of for all severities of asthma, and decisions will be
patients with moderate to severe asthma, the man- influenced by the setting in which the patients
agement of their disease and the follow-up sched- are treated and sometimes the interests of the
ules has changed substantially. Furthermore, the hospital.
comorbidities in asthma, which as part of treat- Many patients are easy to manage in primary
able traits, that is pulmonary, extrapulmonary care, while the more severe segment of patients
and other risk factors, have also changed from will have many different treatable traits, which
being simplistically assessed and managed to a need orderly assessment, and this differentiated
more multidisciplinary approach. Importantly, approach will be shown in the various chapters
asthma treatment has changed from a one size fits in this book, which will address the needs of the
all approach to personalised medicine and care, student in an internship at a specialised asthma
which has required a change from simple assess- clinic, the young doctor working in an outpatient
ment to a systemic assessment in which the exact service and both new and experienced researchers
endotype and phenotype must be clarified. stepping into the area of asthma assessment for
The three authors are very similar in age but the first time. These chapters seek to describe what
were educated and lived in different parts of the symptoms to enquire about, which questionnaires
world. They all trained as MDs during the one to use and which tests to conduct in the diagnosis
size fits all era but have grown and developed of asthma. We have used the concept of treatable
clinically and scientifically based on experience traits, split into pulmonary and extrapulmonary
vii
viii Preface
issues, and of selected but important risk factors the Nordic area, we have found out that our basic
that you, as a clinician and researcher, will meet knowledge and the basic tools used in both clinical
in practice. When evaluating patients, we suggest and research settings point in the same direction.
that you consider the same three issues mentioned Nevertheless, we have not always agreed, but when
above, and this approach will ensure not only that we have not, we have included the different views
everything is covered, but also that you do not for the reader to consider.
focus too much on one issue. When the patient’s We hope that this book will be useful at univer-
history is complete and a conclusion is reached, you sity, when setting up an asthma service and before
can then ensure that the treatment, which could be conducting a research study, and we have, there-
pharmacological or non-pharmacological, covers fore, included minimal important clinical differ-
all three issues. ences (MICD), when available, for the reader to use
We hope that this book will lead clinicians to in clinical decisions, projects and evaluations of
use the right tools, make the right decisions and everyday patients.
develop their management skills to the benefit of
their patients – using the right treatment based Professor Vibeke Backer
on the right inflammatory endotype and in the Copenhagen, Denmark
right doses and administrative forms. We have Professor Peter G. Gibson
enjoyed the development of this book, and the pro- Newcastle, Australia
cess of writing it has also made the topics clearer Professor Ian D. Pavord
for us as well. Whether in the UK, Australia or Oxford, UK
Acknowledgements
We owe an enormous debt to so many powerful you to our patients who have shown immense
educators who introduced us to the field of asthma patience and have been deeply involved in the
and encouraged us to explore various opportuni- research and development of this condition.
ties to improve asthma management. A big thank
ix