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Management of difficult-to-treat asthma in adolescence and young adults

Adel H. Mansur, Nagakumar Prasad
Breathe 2023 19: 220025; DOI: 10.1183/20734735.0025-2022
Adel H. Mansur
1Department of Respiratory Medicine, Heartlands Hospital, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
3Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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  • For correspondence: Adel.Mansur@uhb.nhs.uk
Nagakumar Prasad
2Department of Respiratory medicine, Birmingham Women and Children's Hospital NHS Trust, , Birmingham, UK
3Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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  • FIGURE 1
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    FIGURE 1

    Asthma severity model. Uncontrolled asthma is often due to a lack of baseline treatment, but a minority will continue to have poor control despite treatment at steps 4–5 of the GINA guidelines and are labelled as difficult-to-treat asthma (DTA). A subset of DTA have severe asthma.

  • FIGURE 2
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    FIGURE 2

    Methods of assessing adherence to asthma therapies in routine clinical practice. ICS: inhaled corticosteroids; MPR: medication possession ratio; FENO: fraction exhaled nitric oxide; ACQ: asthma control questionnaire.

  • FIGURE 3
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    FIGURE 3

    Treatable traits of severe asthma. Treatable traits relate to all asthma and are not necessarily specific to the AYA group of asthma patients. #: one or more phenotypes can exist in the same individual, concept of “the dominant phenotype”. T2: type 2; IL-5: interleukin 5; anti-IL-5R: anti-interleukin 5 receptor; anti-IL-4R: anti-interleukin 4 receptor; anti-TSLP: anti-thymic stromal lymphopoietin; SAFS: severe asthma with fungal sensitisation; ABPA: allergic bronchopulmonary aspergillosis.

  • FIGURE 4
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    FIGURE 4

    Example of a model of transition for adolescents and young adults with asthma from paediatric to adult services that specifies the key measures to activate transition, the overlap period and the ultimate transition goals to be achieved during adulthood. AYA: adolescent and young adult; MDT: multidisciplinary team.

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    FIGURE 5

    Severe asthma transition from paediatric to adult services pathway followed in Birmingham, UK. Using key transition triggers, patients are identified and assessed by the paediatric difficult asthma MDT and discussed at the adult MDT of the Birmingham Regional Severe Asthma Service (BRSAS). Patients with specific needs, such as biologic treatment, and those requiring specialised MDT input transition to the hub site in BRSAS, while others with no specific concerns transition to local spokes within the network. BCH: Birmingham Children's Hospital; MDT: multidisciplinary team; BHH: Birmingham Heartlands Hospital “hub”; DGH: district general hospital.

Tables

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  • TABLE 1

    Focused history and examination of a young person with difficult asthma

    History or examination domainQuestions to elucidate asthma severity, phenotype and comorbidities
    Age and mode of onsetAge of symptoms and asthma onset, any relation to puberty
    Symptoms patternDyspnoea pattern (episodic versus constant), presence and phase of wheeze (inspiratory/expiratory), cough, sputum production and colour, propensity for LRTI
    Allergies and triggersRhinitis, hay fever, atopic dermatitis, food and aeroallergies, nonspecific triggers (e.g. strong smells, changing temperature), aspirin intolerance, perimenstrual exacerbation
    Asthma control and severity measuresFrequency of OCS and antibiotic use, SABA use (inhaled or nebulised), emergency room visits, hospitalisation, high dependency and intensive care unit admission, and intubation history
    Upper airways symptomsHistory of rhinitis, polyps, blocked nose, post-nasal drip, and any features of ILO (e.g. throat level symptoms, sensation of strangulation, breathing through a straw, or difficulty to breathe in)
    Breathing pattern disorderFeatures of hyperventilation syndrome such as air hunger, perioral and extremities paraesthesia during attacks, constant dyspnoea, disproportionate level of exercise limitation
    Past medical historyObesity, sleep apnoea, metabolic syndrome, cardiac disease, congenital anomalies, etc.
    Psychological factorsChildhood traumatic experience, schooling difficulties, panic, anxiety, depression, personality traits, home and family factors
    Personal and social historyHome, number of people at home, indoor pollution (pets, moulds, dust), outdoor pollution, smoking (passive/active), alcohol and illicit drug use
    School and occupational historySchooling and sport performance and attendance, triggers at school or work
    Physical examinationHeight, weight, BMI, nose and throat assessment, breath sounds, presence of wheeze (polyphonic and variable versus monophonic and fixed), breathing pattern such as apical breathing, stigmata of other diseases including skin and any OCS-related side-effects

    LRTI: lower respiratory tract infection; SABA: short acting β2-agonist; OCS: oral corticosteroids; BMI: body mass index; ILO: inducible laryngeal obstruction.

    • TABLE 2

      Investigations to be considered in a young person with difficult-to-treat asthma

      InvestigationSpecification and description
      Asthma control and quality of life quantificationACQ, AQLQ, HADS
      Allergy testsSpecific IgE, total IgE, aeroallergen- and food-specific IgE, skin prick testing (guided by history)
      Type 2 asthma biomarkersFENO, blood eosinophils, sputum eosinophils
      Screening for other diseases including metabolic screenConnective disease screen, vasculitis, immunoglobulins, functional antibodies#, vitamin D, cortisol assay, HbA1c, lipid profile
      Lung functionFull set, loops, gas transfer, reversibility, peak flow records, bronchial provocation testing
      RadiologyChest radiography, bone density scan
      CT-scan of thorax (dynamic inspiratory and expiratory and lung parenchyma high-resolution scan) in cases of diagnostic uncertainty and suspicion of EDAC or TBM
      CPET and nasendoscopyCPET for unexplained breathlessness and BPD
      Nasendoscopy for suspected ILO
      BronchoscopyUpper airway, TBM and EDAC, airway disease, BAL, biopsies

      ACQ: Asthma Control Questionnaire; AQLQ: Asthma Quality Of Life Questionnaire; HADS: Hospital Anxiety and Depression Score; FENO: fraction exhaled nitric oxide; HbA1c: haemoglobin A1C; CT: computed tomography; EDAC: excessive dynamic airway collapse; TBM: tracheobronchomalacia; CPET: cardiopulmonary exercise test; BAL: bronchoalveolar lavage; BPD: breathing pattern disorder; ILO: inducible laryngeal obstruction. #: Functional antibodies refer to serum IgG antibodies to Streptococcus pneumoniae (pneumococcus) and Haemophilus influenzae.

      • TABLE 3

        Potential barriers to and proposed facilitators of adherence in adolescence and young adulthood

        Adherence barriersAdherence facilitators
        Complex treatment regimenSimplified treatment regimen: combination inhalers, once daily options
        Fear of side-effects, bad taste of ICSAsthma medicine education, inhaler technique optimisation, oral hygiene, alternative ICS options
        Non-intentional, forgetfulness, busy scheduleDeveloping routines, smart inhalers, audio-visual reminders, mobile/web alerts, electronic monitors and feedback
        Embarrassment, denialSupporting relationships, family or peer-led interventions, CBT#
        Low self-efficacyMotivational interviewing
        Cognitive difficultyLiteracy assessment¶, simplified treatment regimen
        Negative perception of HCPsHCP team communication skills and motivational interviewing skills, non-judgemental with the aim to gain patient trust
        Financial and social barriers, costs and affordability of treatmentConsideration of domestic and financial factors, treatment supply options, social services input
        Maintaining adherenceShort- versus long-term adherence strategies, regular review by HCP

        ICS: inhaled corticosteroids; HCP: healthcare professional; CBT: cognitive behaviour therapy. #: CBT is a psychological approach to change people's beliefs and behaviour; ¶: health literacy represents the ability of an individual to obtain, read, understand and use healthcare information to make appropriate decisions and treatment plans.

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        Management of difficult-to-treat asthma in adolescence and young adults
        Adel H. Mansur, Nagakumar Prasad
        Breathe Mar 2023, 19 (1) 220025; DOI: 10.1183/20734735.0025-2022

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        Management of difficult-to-treat asthma in adolescence and young adults
        Adel H. Mansur, Nagakumar Prasad
        Breathe Mar 2023, 19 (1) 220025; DOI: 10.1183/20734735.0025-2022
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        • Article
          • Abstract
          • Abstract
          • Definitions
          • Natural history of asthma in adolescence and young adulthood
          • Diagnostic algorithm for DTA in AYA
          • Systematic assessment of DTA in AYA
          • Conclusions
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          • References
        • Figures & Data
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