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Abstract: More than 22 million Americans have asthma. It is one of the most common chronic diseases of childhood, affecting about 6 million children. With these statistics in mind, The National Heart, Lung, and Blood Institute of the National Institutes of Health recently released the 2007 asthma guidelines, “Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma.” Because of the continued burden and impact asthma has on our patients, a broad and marked change is needed in our treatment approach. Nurse practitioners can lead that change with the implementation of the new asthma guidelines. [Copyright &y& Elsevier]

Emergency hospital utilization rates for asthma remain high despite advances in asthma controller medications and the presence of widely accepted asthma treatment guidelines. To explore this phenomenon, we analyzed administrative data to determine characteristics of patients seen in the emergency department (ED) for asthma. Complete pharmacy and diagnostic coding records were obtained from consecutive adults (aged 19–56 years) treated for asthma in the ED of a closed-network health maintenance organization between April and July of 2002. Subjects were stratified into asthma severity categories (persistent or non-persistent) based on the National Committee for Quality Assurance 2006 Health Plan and Employer Data and Information Set (HEDIS) criteria for persistent asthma. Eighty-one unique patients made a total of 89 ED visits for asthma during the study period. Of the 89 total ED visits for asthma, 44 (49%) occurred in patients that did not meet HEDIS criteria for persistent asthma. Of the 81 unique patients making asthma-related ED visits, 41 (51%) did not meet HEDIS criteria for persistent asthma. Over one-half (51%) of this nonpersistent population were not given either asthma reliever or asthma controller medications during the 12-month period before their index ED visit. Over the 24-month period before their index ED visit, 37% of nonpersistent patients were dispensed neither asthma reliever nor controller medications. Patients that do not meet HEDIS criteria for persistent asthma account for a substantial percentage of asthma-related ED visits. These patients have a history of low use of asthma medications before their ED visit. [ABSTRACT FROM AUTHOR]

The evolution of our understanding of treatment of asthma begins with assessment of severity which is primarily related to the natural history of the disease. Control is defined as normalizing of the physiologic abnormalities and lessening economic and social burden of the disease. This paper reviews the factors that influence the variability and determinants of asthma control. The tools to validate and access asthma control should be employed in daily clinical practice.Therefore, it is important to determine asthma control based on a multidimensional approach including physiologic assessment, global assessment of functionality, daytime symptoms, nighttime symptoms, healthcare utilization, and adherence to therapy. [ABSTRACT FROM AUTHOR]

The article features asthma classification. The most widely known method of asthma classification is the severity classification recommended in the National Asthma Education and Prevention Program 1997 guidelines. This method was developed to direct a hierarchy of asthma therapy based on the patient's severity of disease. In the clinical setting, tools are used to enable longitudinal assessments of symptom control and disease progression.

Background. The National Heart, Lung, and Blood Institute (NHLBI) guidelines recommend that patients receive a follow-up outpatient asthma visit after being discharged from an emergency department (ED) for asthma. OBJECTIVE: To measure the frequency of follow-up outpatient asthma visits and its association with repeat ED asthma visit. DESIGN: We conducted a retrospective cohort study of children with asthma using claims data from a university-based managed care organization from 01 1998 to 10 2000. We performed a multivariate survival analysis using Cox proportional hazards model to determine the effect of follow-up outpatient asthma visits on the likelihood of a repeat ED asthma visit, after controlling for severity of illness, patient age, gender, insurance, and the specialty of the primary care provider. RESULTS: A total of 561 children had 780 ED asthma visits. Of these, 103 (17%) had a repeat ED asthma visit within 1 year. Almost two-thirds of children (66%) did not receive outpatient follow-up for asthma within 30 days of an ED asthma visit. Outpatient asthma visits within 30 days of an ED asthma visit are associated with an increased likelihood (relative risk = 1.80; 95% confidence interval 1.19, 2.72) for repeat ED asthma visits within 1 year. CONCLUSIONS: Most patients do not have outpatient follow-up after an ED asthma visit. However, those patients that present for outpatient follow-up have an increased likelihood for repeat ED asthma visits. For the primary care provider, these outpatient follow-up visits signal an increased risk that a patient will return to the ED for asthma and are a key opportunity to prevent future ED asthma visits. [ABSTRACT FROM AUTHOR]

Asthma morbidity and mortality have increased at alarming rates. Morbidity is significantly higher among minorities and low-income populations. The purpose of this study was to survey pharmacies licensed to provide both asthma medications and durable medical equipment (DME) to evaluate their acceptance of Medicaid as payment for spacers and peak flow meters in patients with Medicaid. Twenty-four pharmacies were identified and completed a telephone survey. Only 64% of the pharmacies licensed to accept Medicaid for DME provide this service. We postulate that improving DME licensing and claims reimbursement will impact medication compliance, as well as asthma morbidity and mortality. [ABSTRACT FROM AUTHOR]

This retrospective study was conducted to assess Taiwanese emergency physicians fobr their preference in management and adherence to guidelines in treating patients with acute exacerbation of asthma. One hundred twenty patients from hospitals of three different levels were evaluated by reviewing their medical records. Our study revealed that physicians from medical centers and regional hospitals assessed patients more often with arterial blood gas or pulse oxymetry; prescribed more doses of β[sub 2]-agonist nebulizers; administered more doses of β[sub 2]-agonist nebulizers before administering parenteral aminophylline; and prescribed ipratropium nebulizers more often as adjunctive therapy. On the other hand, physicians from district hospitals more frequently prescribed parenteral aminophylline as the first-line medication and more often prescribed only a single dose of β[sub 2]-agonist nebulizer. Most emergency physicians in Taiwan did not adhere to guidelines. Specifically, these included omission of peak expiratory flow as the means to assess the severity of asthma exacerbation and response to treatment; suboptimal use of inhaled bronchodilators, such as β[sub 2]-agonists and ipratropium; and inappropriate use of parenteral aminophylline as the first-line medication. [ABSTRACT FROM AUTHOR]

Background Asthma education is a necessary and critical component of asthma management. Methods A review of the most-to-date global and national (US) guidelines and standards provides the basis for this concise asthma education primer. Results Effective asthma education that yields enhanced long-term health outcomes is accomplished by the proper patient-specific knowledge and behavior change tools. Communication technique (quality) as well as asthma education content (quantity) should receive recurrent assessment by all healthcare team members. Conclusion Asthma education delivery can be easily planned for and routinely delivered, keeping the shared goals of patient and healthcare team in mind. [ABSTRACT FROM AUTHOR]

Background: Inhaled therapies are key components of asthma and chronic obstructive pulmonary disease (COPD) treatments. Although the use of pressurised metered-dose inhalers (pMDIs) accounts for <0.1% of global greenhouse gas emissions, their contribution to global warming has been debated and efforts are underway to reduce the carbon footprint of pMDIs. Our aim was to establish the extent to which different scenarios led to reductions in greenhouse gas emissions associated with inhaler use, and their clinical implications., Methods: We conducted a series of scenario analyses using asthma and COPD inhaler usage data from 2019 to model carbon dioxide equivalent (CO 2 e) emissions reductions over a 10-year period (2020-2030) in the UK, Italy, France, Germany and Spain: switching propellant-driven pMDIs for propellant-free dry-powder inhalers (DPIs)/soft mist inhalers (SMIs); transitioning to low global warming potential (GWP) propellant (hydrofluoroalkane (HFA)-152a) pMDIs; reducing short-acting β 2 -agonist (SABA) use; and inhaler recycling., Results: Transition to low-GWP pMDIs and forced switching to DPI/SMIs (excluding SABA inhalers) would reduce annual CO 2 e emissions by 68%-84% and 64%-71%, respectively, but with different clinical implications. Emission reductions would be greatest (82%-89%) with transition of both maintenance and SABA inhalers to low-GWP propellant. Only minimising SABA inhaler use would reduce CO 2 e emissions by 17%-48%. Although significant greenhouse gas emission reductions would be achieved with high rates of end-of-life recycling (81%-87% of the inhalers), transition to a low-GWP propellant would still result in greater reductions., Conclusions: While the absolute contribution of pMDIs to global warming is very small, substantial reductions in the carbon footprint of pMDIs can be achieved with transition to low-GWP propellant (HFA-152a) inhalers. This approach outperforms the substitution of pMDIs with DPI/SMIs while preserving patient access and choice, which are essential for optimising treatment and outcomes. These findings require confirmation in independent studies., Competing Interests: Competing interests: DP was contracted by Chiesi Farmaceutici for the analysis. SP, FS, RF and YU are employees of Chiesi Farmaceutici., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Asthma is a major cause of chronic morbidity and mortality throughout the world, affecting people of all ages. There is evidence that its prevalence is increasing, especially among children. When uncontrolled, asthma can place severe limits on daily life. By diagnosing asthma early and implementing appropriate therapy, the condition can be treated effectively, and most patients will be able to achieve good control of the disease. Inhaled corticosteroids help to reduce airway inflammation and are effective in the prophylactic management of chronic persistent asthma. The role of ciclesonide, an inhaled corticosteroid for the management of asthma, will be discussed in this short review article. [ABSTRACT FROM AUTHOR]

Decreasing exposure to indoor allergens has been studied extensively and is a well accepted part of the treatment for allergic disease. The 2007 revision of the evidence-based guidelines recommends allergen avoidance as part of the management of asthma. In contrast, a recent meta-analysis concluded that dust mite avoidance is “of no use” in the treatment of asthma. There are obvious sources of bias that could have influenced the evaluation of published trials either by the guideline panel or by the group conducting the meta-analysis. An important issue is whether meta-analysis is a valid method of evaluating studies such as those on dust mite avoidance that are highly variable. Reading the published series of 4 meta-analyses on this subject from the Cochrane Library suggests that decisions about which trials to include can have a major effect on the outcome. The process of meta-analysis may also have other potential conflicts. The recent meta-analysis on dust mite avoidance appears to be seriously flawed because of the decisions about inclusion and exclusion as well as the way in which studies were evaluated. The conclusion is that the criticisms of the recommendations in the 2007 guidelines were not well founded. [Copyright &y& Elsevier]

Introduction: Occupational asthma (OA) accounts for one in six cases of adult-onset asthma and is associated with a large societal cost. Many cases of OA are missed or delayed, leading to ongoing exposure to the causative agent and avoidable lung function loss and poor employment-related outcomes. Enquiry about work-related symptoms and the nature of work by healthcare professionals (HCPs) is limited, evident in primary and secondary care. Potential reasons cited for this are time pressure, lack of expertise and poor access to specialists., Aim: To understand organisational factors and beliefs and behaviours among primary HCPs that may present barriers to identifying OA., Methods: We employed a qualitative phenomenological methodology and undertook 20-45 min interviews with primary HCPs in West Midlands, UK. We used purposive and snowball sampling to include general practitioners (GPs) and practice nurses with a range of experience, from urban and rural settings. Interviews were recorded digitally and transcribed professionally for analysis. Data were coded by hand, and thematic analysis was undertaken and determined theoretically until themes were saturated., Results: Eleven HCPs participated (eight GPs, three nurses). Four themes were identified that were considered to impact on identification of OA: (1) training and experience, (2) perceptions and beliefs, (3) systems constraints, and (4) variation in individual practice. OA-specific education had been inadequate at every stage of training and practice, and clinical exposure to OA had been generally limited. OA-specific beliefs varied, as did clinical behaviour with working-age individuals with asthma. There was a focus on diagnosis and treatment rather than attributing causation. Identified issues regarding organisation of asthma care were time constraints, lack of continuity, referral pressure, use of guidelines and templates, and external targets., Conclusion: Organisation and delivery of primary asthma care, negative OA-related beliefs, lack of formal education, and exposure to OA may all currently inhibit its identification., Competing Interests: Competing interests: Participant 1 was the wife of the primary author and a GP in a city centre practice., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

With the help of a routine clinical case, we highlighted the difference between two of the best asthma guidelines available at the time regarding therapeutic suggestions for the so-called "third step" for school-age asthmatic children. We have analyzed the scientific evidence that each of the two guidelines brings to support their position. Finally, we have motivatedly solved the clinical scenario. However, the question of disagreement between two guidelines remains unresolved. This can lead to unjustified differences in the management of schoolchildren with persistent asthma., (Copyright © 2020 SEICAP. Published by Elsevier España, S.L.U. All rights reserved.)

Background: Aerobic training and breathing exercises are interventions that improve asthma control. However, the outcomes of these 2 interventions have not been compared., Objective: To compare the effects of aerobic training versus breathing exercises on clinical control (primary outcome), quality of life, exercise capacity, and airway inflammation in outpatients with moderate-to-severe asthma., Methods: Fifty-four asthmatics were randomized into either the aerobic training group (AG, n = 29) or the breathing exercise group (BG, n = 25). Both interventions lasted for 24 sessions (2/week, 40 minutes/session). Asthma clinical control (Asthma Control Questionnaire [ACQ]), quality of life (Asthma Quality of Life Questionnaire), asthma symptom-free days (ASFD), airway inflammation, exercise capacity, psychological distress (Hospital Anxiety and Depression Scale), daily-life physical activity (DLPA), and pulmonary function were evaluated before, immediately after, and 3 months after the intervention., Results: Both interventions presented similar results regarding the ACQ score, psychological distress, ASFD, DLPA, and airway inflammation (P > .05). However, participants in the AG were 2.6 times more likely to experience clinical improvement at the 3-month follow-up than participants in the BG (P = .02). A greater proportion of participants in the AG also presented a reduction in the number of days without rescue medication use compared with BG (34% vs 8%; P = .04)., Conclusions: Outpatients with moderate-to-severe asthma who participated in aerobic training or breathing exercise programs presented similar results in asthma control, quality of life, asthma symptoms, psychological distress, physical activity, and airway inflammation. However, a greater proportion of participants in the AG presented improvement in asthma control and reduced use of rescue medication., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Guidelines endorse systematic assessment for severe asthma, with data indicating benefit across multiple outcome domains., Objective: We examined which patients respond to systematic assessment and whether oral corticosteroid burden can be decreased independent of monoclonal biologic use., Methods: Specialist-referred patients are assessed systematically for difficult asthma at our center. We undertook a responder analysis for improvements in the domains of symptom control, quality of life, exacerbations, and airflow obstruction, assessed 6 months after initial assessment. Multivariate analyses were performed for each domain to identify predictors of response. Changes in oral corticosteroid burden were also measured, stratified by monoclonal biologics commenced during assessment., Results: Among 161 patients assessed systematically, 64% had a reduction in exacerbations, 54% achieved minimum clinically important differences for both symptom control and quality of life, and 40% increased their forced expiratory volume in 1 second by ≥100 mL. Altogether, 87% of patients with asthma improved in at least 1 domain. The most consistent predictor of response across domains was poorer baseline asthma status. There was a substantial reduction in mean chronic oral corticosteroid dose (11-5 mg, n = 46, P < .001), even after excluding 7 patients commenced on monoclonal biologics (11-5.6 mg, n = 39, P < .001)., Conclusions: Almost 90% of patients undergoing systematic assessment for difficult asthma improve significantly in at least 1 key asthma outcome, with few reliable predictors of response. The halving of oral corticosteroid burden during systematic assessment is independent of, and comparable in magnitude with, that achieved by monoclonal biologics., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: The minimum controlling dose of treatment must be established in patients with asthma, but the outcome of step-down is unpredictable., Objective: To identify factors associated with risk of control loss when stepping down asthma treatment and to develop a score to predict this risk., Methods: A prospective, multicenter study including adults with well-controlled asthma was performed. Treatment was stepped up or stepped down over a 12-month period to maintain asthma control. We determined associations between clinical and functional variables and step-down failure. Finally, we derived a score to predict loss of control in 1 cohort and validated it in an independent cohort., Results: The derivation cohort consisted of 228 patients; 218 completed at least 1 step-down episode and a total of 495 step-down episodes were evaluated. A medical-record documented postbronchodilator spirometry result of <70% forced expiratory volume in 1 second (FEV 1 )/forced vital capacity (odds ratio [OR] = 2.08; 95% confidence interval [CI]: 1.26-3.43), current FEV 1 < 80% (OR = 1.80; 95% CI: 1.03-3.14), ≥1 severe exacerbation in the previous 12 months (OR = 2.43; 95% CI: 1.48-4.01), and Asthma Control Test score < 25 (OR = 2.30; 95% CI: 1.35-3.92) were independently associated with failure. The score showed an area under the curve of 0.690 (95% CI: 0.633-0.747; P < .05) in the derivation cohort and 0.76 (95% CI: 0.643-0.882; P < .001) in a validation cohort of 114 patients. A score <4.5 implies a low risk of failure (<20%), whereas a score >8 implies a high risk (>40%)., Conclusion: This score can facilitate the prediction of step-down failure before medication taper in patients with well-controlled asthma., (Copyright © 2018 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Introduction: The eucapnic voluntary hyperpnoea (EVH) challenge is used to screen for exercise-induced bronchoconstriction. Several criteria have been proposed to determine the decrease in lung function (fall index, FI) following EVH. We compared three published FI calculation methods to determine if they affect the diagnostic classification., Methods: The three FIs were calculated for 126 EVH tests. Spirometry was performed in duplicate at baseline and repeated 3, 5, 10, 15 and 20 min following 6 min of EVH. The higher of the two forced expiratory volume in 1 s (FEV 1 ) measures at all time-points post-hyperpnoea was selected for the calculation of the FIs. The FI A was determined as the single lowest of the five postchallenge values, and a test was considered positive if FEV 1 decreased ≥10 %. In FI B , a test was considered positive if FEV 1 decreased ≥10% at two consecutive post-challenge time-points. The FI C was calculated identically to FI A , but was normalised to the achieved minute ventilation during the EVH challenge., Results: Calculation method affected the raw FIs with FI B generating the smallest and FI C generating the highest values (p<0.001) and a within-subject range of 7%±10%. The number of positive tests differed between the calculation criteria: FI A : 62, FI B : 48 and FI C : 70, p<0.001. Nineteen participants (15%) tested positive in one or two FI methods only, indicating that the FI method used determined whether the test was positive or negative., Discussion: Inconsistency in methodology of calculating the FI leads to differences in the diagnostic rate of the EVH test, with potential implications in both treatment and research outcomes., Competing Interests: Competing interests: None declared.

Background: The 2007 Guidelines for the Diagnosis and Management of Asthma provide evidence-based recommendations to improve asthma care. Limited national-level data are available about clinician agreement and adherence to these guidelines., Objective: To assess clinician-reported adherence with specific guideline recommendations, as well as agreement with and self-efficacy to implement guidelines., Methods: We analyzed 2012 National Asthma Survey of Physicians data for 1412 primary care clinicians and 233 asthma specialists about 4 cornerstone guideline domains: asthma control, patient education, environmental control, and pharmacologic treatment. Agreement and self-efficacy were measured using Likert scales; 2 overall indices of agreement and self-efficacy were compiled. Adherence was compared between primary care clinicians and asthma specialists. Logistic regression models assessed the association of agreement and self-efficacy indices with adherence., Results: Asthma specialists expressed stronger agreement, higher self-efficacy, and greater adherence with guideline recommendations than did primary care clinicians. Adherence was low among both groups for specific core recommendations, including written asthma action plan (30.6% and 16.4%, respectively; P < .001); home peak flow monitoring, (12.8% and 11.2%; P = .34); spirometry testing (44.7% and 10.8%; P < .001); and repeated assessment of inhaler technique (39.7% and 16.8%; P < .001). Among primary care clinicians, greater self-efficacy was associated with greater adherence. For specialists, self-efficacy was associated only with increased odds of spirometry testing. Guideline agreement was generally not associated with adherence., Conclusions: Agreement with and adherence to asthma guidelines was higher for specialists than for primary care clinicians, but was low in both groups for several key recommendations. Self-efficacy was a good predictor of guideline adherence among primary care clinicians but not among specialists., (Published by Elsevier Inc.)

Background: With the availability of high-quality asthma guidelines worldwide, one possible approach of developing a valid guideline, without re-working the evidence, already analysed by major guidelines, is the ADAPTE approach, as was used for the development of National Guidelines on asthma., Methods: The guidelines development group (GDG) covered a broad range of experts from medical specialities, primary care physicians and methodologists. The core group of the GDG searched the literature for asthma guidelines 2005 onward, and analysed the 11 best guidelines with AGREE-II to select three mother guidelines. Key clinical questions were formulated covering each step of the asthma management., Results: The selected mother guidelines are British Thoracic Society (BTS), GINA and GEMA 2015. Responses to the questions were formulated according to the evidence in the mother guidelines. Recommendations or suggestions were made for asthma treatment in Mexico by the core group, and adjusted during several rounds of a Delphi process, taking into account: 1. Evidence; 2. Safety; 3. Cost; 4. Patient preference - all these set against the background of the local reality. Here the detailed analysis of the evidence present in BTS/GINA/GEMA sections on prevention and diagnosis in paediatric asthma are presented for three age-groups: children with asthma ≤5 years, 6-11 years and ≥12 years., Conclusions: For the prevention and diagnosis sections, applying the AGREE-II method is useful to develop a scientifically-sustained document, adjusted to the local reality per country, as is the Mexican Guideline on Asthma., (Copyright © 2017. Published by Elsevier España, S.L.U.)

Introduction: Asthma is nowadays regarded as a syndrome of various overlapping phenotypes with defined clinical characteristics, different underlying inflammatory mechanisms, identifiable genetic background, environmental risk factors and possible biomarkers. There are no doubts that due to the diversity of asthma, a 'one size fits all' management of the disease is no longer valid. Areas covered: Nowadays asthma management is based on the control of the disease, and the goals of asthma treatment are defined as good symptom control, decreased future risk of exacerbations, fixed airflow limitation, and side-effects of treatment. Alternative strategies for adjusting asthma treatment such as sputum or exhaled nitric oxide guided protocols have been evaluated and despite some effectiveness, are regarded as impractical in every-day clinical conditions. Further studies in the field of asthma phenotypes/endotypes and biomarkers are warranted with the main goal to define which of those possible subgroups will be useful in clinical practice in regards to the potential allocation of successful treatment. Expert commentary: Despite the availability of guidelines on the diagnosis and management of asthma, it seems that the disease is still not optimally controlled. Addressing unmet needs in every day care, improving education, adherence/compliance and inhalation technique may significantly improve asthma control across all severities of the disease.

Background: Chronic oral corticosteroid (C-OCS) use in asthma is an indicator of disease severity, but its risk factors are largely unknown., Objective: To describe patient characteristics and disease burden associated with C-OCS use by adults with persistent asthma., Methods: We identified 9546 patients aged 18 to 64 years in a large managed care organization who met the Healthcare Effectiveness Data and Information Set 2-year criteria (2009-2010) for persistent asthma. A subgroup had blood eosinophil counts. We calculated cumulative OCS dispensed per patient in 2010 and examined the distribution of disease characteristics by average daily amounts of OCS dispensed. C-OCS use was defined as 2.5 mg/d or more. Baseline factors (2010) associated with C-OCS use during follow-up (2011) were investigated by multivariable Poisson regression., Results: At baseline, 782 (8.2%) patients were C-OCS users. Compared with patients who received no or less than 2.5 mg/d OCS, C-OCS users were older and more often female and ethnic minorities; and had more comorbidities, asthma specialist care, greater step-care level, controllers, asthma exacerbations, and greater blood eosinophil counts (all P < .01). Baseline factors significantly associated with C-OCS use in the follow-up year included (1) demographic characteristics: older age, females, blacks versus whites, and whites versus others/unknown ethnicities; (2) disease burden: more asthma emergency department or hospitalization visits, greater step-care level, excessive short-acting β 2 -agonist dispensed, theophylline use, asthma specialist care, and nasal polyposis; (3) greater blood eosinophil counts; and (4) most strongly, C-OCS use., Conclusions: C-OCS use was associated with more asthma burden, comorbidities, and greater blood eosinophil counts. Prior C-OCS use was the strongest predictor of future C-OCS use., (Copyright © 2017 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Introduction: Severe therapy-resistant asthma is an area where there has been recent advances in understanding that is percolating into improvements in management. Areas covered: This review covers the recent definition and approach to the diagnosis of severe asthma and its differentiation from difficult-to-treat asthma. The recent advances in phenotyping severe asthma and in ensuing changes in management approaches together with the introduction of new therapies are covered from a review of the recent literature. Expert commentary: After ascertaining the diagnosis of severe asthma, patients need to be treated adequately with existing therapies. The management approach to severe asthma now comprises of a phenotyping step for the definition of either an allergic or eosinophilic severe asthma for which targeted therapies are currently available. This will lead to a precision medicine approach to the management of severe asthma.

Many people with asthma do not achieve disease control, despite bronchodilators and inhaled corticosteroid therapy. People with uncontrolled asthma are at higher risk of an asthma attack and death, with mortality rates estimated at 1000 deaths/year in England and Wales. The recent National Review of Asthma Deaths (NRAD) report, 'Why asthma still kills', recommended that patients at step 4 or 5 of the British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) guidance must be referred to a specialist asthma service. This article reviews the 2014 evidence base for therapy of asthma patients at BTS/SIGN step 4 of the treatment cascade, in response to key findings of the NRAD report and lack of preferred treatment option at this step.

Background: Severe asthma is associated with disproportionately high morbidity, but little is known about its natural history and how risk factors at first year of diagnosis modify its subsequent development., Methods: Using administrative health data, we retrospectively followed patients 14-55 years of age with newly diagnosed severe asthma in British Columbia, Canada. Based on intensity of resource use (drug therapy) and occurrence of exacerbations, each patient-year was classified into mild, moderate, or severe asthma. We estimated the probability of transition between severity levels or to death over the study period using a four-state Markov model, and used this to assess the 10-year trajectory of severe asthma and the influence of baseline risk factors., Results: We followed 13,467 patients. Ten years after incident severe asthma, 83% had transitioned to a less severe level (mild: 43%, moderate: 40%). Low socioeconomic status, high comorbidity burden, and high adherence (proportion of days covered (PDC) by asthma controller therapy) in the first year were independently associated with, respectively, 10%, 24% and 35% more time in severe asthma over the next 10 years. Sex was not associated with the clinical course., Conclusions: Most patients with incident severe asthma used fewer resources over time, indicating a long-term transition to milder asthma. Potentially modifiable risk factors for poor prognosis of severe asthma include low socioeconomic status and high comorbidity burden. The association between PDC and future asthma severity is likely due to residual confounding by disease severity., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/)

Background: Little is known of the disease burden of patients with persistent asthma (PA) who also have a chronic obstructive pulmonary disease (COPD) diagnosis code (AS-COPD)., Objective: The objective of this study was to characterize and compare patients with AS-COPD with those with PA without COPD diagnosis, and determine in AS-COPD the relationship between blood eosinophil count and future asthma exacerbations., Methods: This retrospective cohort study used administrative pharmacy and health care utilization data to identify, characterize, and compare the burden and asthma exacerbations in adults with AS-COPD (N = 901) with those with PA (N = 2392). Negative binomial regression and Poisson regression models were used to evaluate the relationships between baseline blood eosinophil counts (high vs low) based on various cutoff points and asthma exacerbations in the follow-up year, adjusting for demographics, comorbidities, and asthma burden., Results: Compared with patients with PA, those with AS-COPD were significantly (all P < .001) older, more frequently female, less well educated, more likely to be or have been a smoker, had more comorbidities, received more asthma controller medications, and had greater rates and frequencies of asthma exacerbations, but had similar blood eosinophil counts. The rate of asthma exacerbations/person-year in AS-COPD during follow-up was 1.61 (95% CI, 1.18-2.20). Patients with AS-COPD with a blood eosinophil count ≥400 cells/mm(3) had an increased rate of future asthma exacerbations compared with those whose blood eosinophil count was <400 cells/mm(3) (adjusted rate ratio, 1.44, 95% CI, 1.09-1.90)., Conclusions: Compared with patients with PA, those with AS-COPD had more disease burden, but a similar relationship of high blood eosinophil count to more future asthma exacerbations. These findings suggest a common inflammatory component between AS-COPD and PA., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: Clinical and economic burden of patients with severe uncontrolled asthma (SUA) in a real-world managed-care setting required further documentation., Objective: The objective of this study was to determine the characteristics, clinical, and economic burden of SUA in a managed-care setting., Methods: This observational study identified patients with persistent asthma aged 12 years or more (N = 25,935) using the International Classification of Diseases, 9th Revision asthma codes and Healthcare Effectiveness Data and Information Set administrative criteria. An SUA subgroup was identified when all of the following 3 criteria were met in 2012: (1) 2 or more asthma exacerbations; (2) 6 or more medium- or high-dose dispensed canisters of inhaled corticosteroid (ICS) as monotherapy or with long-acting β2-agonist; and (3) 3 or more dispensed non-ICS controllers. Health care utilization and direct costs (all-cause and asthma-related) in 2013 were compared between SUA and non-SUA subgroups using multivariable regression., Results: Compared with the non-SUA subgroup (N = 25,350, 97.7%), the SUA subgroup (N = 585, 2.3%) at baseline was significantly older and had more comorbidities, asthma specialist care, controller medication dispensed, and asthma exacerbations. During follow-up, patients with SUA exhibited significantly more asthma exacerbations and short-acting β2-agonist use, and higher all-cause and asthma-related costs than patients with non-SUA. The adjusted asthma-related average direct cost per patient at follow-up was significantly higher for SUA (mean ± SE) ($2325 ± $75) than non-SUA ($1261 ± $9) with an incremental cost of $1056 (95% CI, $907-$1205). Asthma drugs accounted for the major difference (incremental cost of $848/patient; 95% CI, $737-$959)., Conclusion: Increases and disparities in health care utilization and direct cost by SUA status suggest that patients with SUA require more intensive therapy, greater attention to adherence and comorbidities, more specialist care, and, possibly, personalized treatment approaches including novel biologic treatments., (Copyright © 2015 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Background: The overlap between asthma and COPD is increasingly recognised. This review examines the new insights, treatment and remaining knowledge gaps for asthma-COPD overlap., Method: A systematic literature review of cluster analyses of asthma and COPD was performed. Articles from 2009 to the present dealing with prevalence, morbidity and treatment of asthma-COPD overlap were identified and reviewed., Results: Asthma-COPD overlap was consistently recognised in studies using a variety of different study designs and sampling. The prevalence was approximately 20% in patients with obstructive airways diseases. Asthma-COPD overlap was associated with increased morbidity and possibly an increased mortality and comorbidity. There was evidence of a heterogeneous pattern of airway inflammation that included eosinophilic (in adult asthma), neutrophilic or mixed patterns (in severe asthma and COPD). Systemic inflammation was present in asthma-COPD overlap and resembled that of COPD. Within asthma-COPD overlap, there is evidence of different subgroups, and recognition using bronchodilator responsiveness has not been successful. Guidelines generally recommend a serial approach to assessment, with treatment recommendations dominated by an asthma paradigm. Research is needed into key clinical features that impact outcome, mechanisms and treatment approaches in asthma-COPD overlap. Identifying and treating disease components by multidimensional assessment shows promise., Conclusions: Asthma-COPD overlap has drawn attention to the significant heterogeneity that exists within obstructive airway diseases. It should be replaced by novel approaches that identify and manage the components of this heterogeneity, such as multidimensional assessment and treatment. Future research is needed to test these novel and personalised approaches., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)