Figures
- 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
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
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
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.
- 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
- TABLE 1
Focused history and examination of a young person with difficult asthma
History or examination domain Questions to elucidate asthma severity, phenotype and comorbidities Age and mode of onset Age of symptoms and asthma onset, any relation to puberty Symptoms pattern Dyspnoea pattern (episodic versus constant), presence and phase of wheeze (inspiratory/expiratory), cough, sputum production and colour, propensity for LRTI Allergies and triggers Rhinitis, hay fever, atopic dermatitis, food and aeroallergies, nonspecific triggers (e.g. strong smells, changing temperature), aspirin intolerance, perimenstrual exacerbation Asthma control and severity measures Frequency 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 symptoms History 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 disorder Features of hyperventilation syndrome such as air hunger, perioral and extremities paraesthesia during attacks, constant dyspnoea, disproportionate level of exercise limitation Past medical history Obesity, sleep apnoea, metabolic syndrome, cardiac disease, congenital anomalies, etc. Psychological factors Childhood traumatic experience, schooling difficulties, panic, anxiety, depression, personality traits, home and family factors Personal and social history Home, number of people at home, indoor pollution (pets, moulds, dust), outdoor pollution, smoking (passive/active), alcohol and illicit drug use School and occupational history Schooling and sport performance and attendance, triggers at school or work Physical examination Height, 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
Investigation Specification and description Asthma control and quality of life quantification ACQ, AQLQ, HADS Allergy tests Specific IgE, total IgE, aeroallergen- and food-specific IgE, skin prick testing (guided by history) Type 2 asthma biomarkers FENO, blood eosinophils, sputum eosinophils Screening for other diseases including metabolic screen Connective disease screen, vasculitis, immunoglobulins, functional antibodies#, vitamin D, cortisol assay, HbA1c, lipid profile Lung function Full set, loops, gas transfer, reversibility, peak flow records, bronchial provocation testing Radiology Chest 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 TBMCPET and nasendoscopy CPET for unexplained breathlessness and BPD
Nasendoscopy for suspected ILOBronchoscopy Upper 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 barriers Adherence facilitators Complex treatment regimen Simplified treatment regimen: combination inhalers, once daily options Fear of side-effects, bad taste of ICS Asthma medicine education, inhaler technique optimisation, oral hygiene, alternative ICS options Non-intentional, forgetfulness, busy schedule Developing routines, smart inhalers, audio-visual reminders, mobile/web alerts, electronic monitors and feedback Embarrassment, denial Supporting relationships, family or peer-led interventions, CBT# Low self-efficacy Motivational interviewing Cognitive difficulty Literacy assessment¶, simplified treatment regimen Negative perception of HCPs HCP team communication skills and motivational interviewing skills, non-judgemental with the aim to gain patient trust Financial and social barriers, costs and affordability of treatment Consideration of domestic and financial factors, treatment supply options, social services input Maintaining adherence Short- 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.
