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Purpose of Review: Gastro-esophageal reflux is a possible cause of uncontrolled symptoms of asthma and should be actively investigated and treated before severe asthma is diagnosed and biological therapy started., Recent Findings: Recent investigations on esophageal function and tissue biomarkers in patients with asthma and associated GERD have established a relevant role for esophageal motility and neuronal sensory abnormalities in linking the two diseases. Characterization of the underpinning inflammatory substrate has showed mixed results as both neutrophilic and eosinophilic type 2 inflammatory changes have been described., Summary: New findings regarding inflammatory mechanisms in GERD-associated asthma as well as new diagnostic tools to investigate functional esophageal abnormalities and characterize asthma endotype have identified potential treatable traits that may improve the clinical management and outcome of asthmatic patients with GERD., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Purpose of Review: Allergen-specific immunotherapy has established as an indispensable disease-modifying treatment in allergy practice but its safety and efficacy might be furtherly improved by combining it with other drugs or therapeutic intervention that co-modulate immune type 2 immune networks., Recent Findings: In the past two decades, clinical research focused on AIT and omalizumab co-treatment to improve both safety and long-term efficacy of allergic disease treatment. Recently, combination of AIT with other biologicals targeting different mediators of type 2 inflammation has been set up with interesting preliminary results. Moreover, AIT current contraindication might be overcome by contemporarily controlling underlying type 2 inflammation in severe atopic patients., Summary: AIT--biological combination treatment can realize a complex multitargeted treatment strategy allowing for consistently improving disease control and sparing steroid administration., (Copyright © 2020 Wolters Kluwer Health, Inc. All rights reserved.)

Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory disease highly impacting patient's quality of life, and associated with lower airway inflammation often evolving into asthma. Exhaled nitric oxide (FE NO ) is a non-invasive tool to assess Type 2 airway inflammation and its extended analysis allows to differentiate between alveolar concentration (CalvNO) and bronchial output (JawNO). It is also possible to assess the sino-nasal production of nitric oxide (nNO). We studied extended nitric oxide production in patients with CRSwNP with or without associated asthma. Consecutive adult patients with CRSwNP, with or without asthma, and 15 healthy controls were enrolled. Exclusion criteria were: smoking, uncontrolled asthma, recent upper or lower airway infections and oral corticosteroid therapy in the 4 weeks preceding clinical evaluation. Patients' demographic and clinical data were collected; patients underwent pulmonary function tests and extended nitric oxide analysis including nasal nNO assessment. A total of 125 subjects were enrolled (15 healthy controls; 69 with CRSwNP and asthma, and 41 with CRSwNP only). FE NO , JawNO and CalvNO values were higher, while nNO was lower, in all patients with CRSwNP compared to healthy controls; no difference was found in CalvNO between patients with concomitant asthma and non-asthmatic subjects; in asthmatic patients, FE NO and JawNO were significantly higher, while nNO values was lower, compared to patients with CRSwNP only. These results suggest that CRSwNP could be the first manifestation of a more complex systemic inflammatory pathology driven by Type 2 inflammation. An 'inflammatory gradient' hypothesis could describe a pattern of inflammation in CRSwNP patients that starts distally in the alveoli. Finally, our study indirectly reinforces the concept that novel biological drugs could become valid therapeutic options for nasal polyposis.

Background: Lack of therapeutic adherence is a relevant problem in clinical practice and it can be assessed via validated tools such as the Test of Adherence to Inhalers (TAI). Education on the correct use of inhaler devices has been associated with improvement in adherence. Many studies highlighted the pivotal role of pharmacists in promoting therapeutic adherence in the management of respiratory diseases., Objective: To evaluate the effectiveness on adherence and clinical parameters of an educational intervention administered by clinical pharmacists (CPs) to patients with asthma on long-term inhalation therapy., Methods: A prospective comparative study involving 34 community pharmacies in Italy (23 intervention, 11 control). Enrolled subjects were evaluated for adherence to inhalation therapy by TAI, asthma control by "Asthma Control Test" (ACT), and lung function at baseline and after 2 months. The educational intervention at baseline was based on TAI results and administered by specifically trained pharmacists., Results: A total of 242 consecutive subjects (167 intervention, 75 control) were enrolled. There was a significant improvement in TAI score, ACT and lung function parameters (p-value<0.001) in the intervention group between baseline and the follow-up visit. Patients with baseline ACT≥20 maintained disease control more frequently in the intervention group compared to the control arm (95% vs 79.5%, p = 0.004). Conclusions through administration of TAI-driven educational interventions addressing both technical and psychological issues, trained CPs can help improve adherence to treatment and asthma control., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

It is well known that tobacco smoking worsens asthma. Conversely, few data are currently available in the literature on the effects of vaping in asthmatic patients. This work aims to investigate the effects of vaping on asthmatic patients and in asthmatic patients that switched from tobacco smoking to electronic cigarette (e-cig), in particular focusing on quality of life, asthma control, and pulmonary function. We designed a two-group study. One group encompassed vapers with asthma selected through a web survey with questions on quality of life and symptoms worsening; the other group encompassed vapers that switched from tobacco smoking to e-cig, and that volunteered to undergo clinical visits at our outpatient clinic. 2787 people responded to the web survey, including 631 asthmatics. In the second group, 55 volunteers, including 15 asthmatics, were enrolled after a visit. The visit included physical examination and pulmonary function tests (PFT). Internationally validated questionnaires were administered to all subjects: Asthma Control Test (ACT), Asthma Control Questionnaire (ACQ), 36-Item Short Form Survey (SF-36) and Asthma Quality of Life Questionnaire (AQLQ). The 382 asthmatic vapers-only in the web survey were mainly males (86.9%), 31-65 years old. 90% of them declared that vaping did not worsen asthma symptoms and would recommend asthmatic smokers to switch to vaping (98.4%). There was worsening of asthma symptoms due to the actual asthma therapy used by the participants, while no relationship was found with other aspects analysed. In the second group, the analysis of variance in the questionnaires administered to the 10 asthmatics showed a significant improvement in ACQ, ACT and SF-36 for asthmatics that switched from tobacco to vaping, while PFT remained stable throughout the three visits. Almost all of the asthmatics who previously smoked would recommend switching to e-cig, and vaping did not worsen their asthma symptoms. Furthermore, switching from tobacco smoking to e-cigs showed a significant improvement in asthma control and quality of life, not showing, in the period studied, to affect pulmonary function tests.

Purpose of Review: Chronic rhinosinusitis with nasal polyps (CRSwNP) is a complex inflammatory sinonasal disease that deserves a multidisciplinary precision medicine approach. In a precision medicine model, a more pragmatic approach taking in consideration disease features that are potentially treatable should be considered., Recent Findings: Several treatable traits in CRSwNP can be identified: from disease-related ones, to extra-ENT features, to behavioral and environmental factors. This review article summarizes primarily the recent findings of CRSwNP-related treatable traits and how they can be modified by given treatments., Summary: The advent of biological agents acting directly to the endotype underlying CRSwNP pushes the scientific community to integrate clinical, surgical and immunological evaluations for each single patient; this naturally leads to the identification of specific treatable traits that can serve as possible outcomes for any single biological.