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Astrid Crespo-Lessmann,1– 3,* Elena Curto,1– 3,* Eder Freddy Mateus Medina,1– 3 Esther Palones,1– 3 Alicia Belda Soler,1– 3 Soraya Sánchez Maza,1– 3 Lorena Soto-Retes,1– 3 Vicente Plaza1– 3 1Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain; 2Institut d’Investigació Biomédica Sant Pau, Barcelona, Spain; 3Departament de Medicina, Universitat Autònoma de Barcelona, Barcelona, Spain*These authors contributed equally to this workCorrespondence: Astrid Crespo-Lessmann, Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Pau, Carrer Mas Casanovas 90, Barcelona, 08041, Spain, Tel +34-935565972, Fax +34 935565601, Email acrespo@santpau.catPurpose: The objectives of this study were, for patients attending a specialist asthma clinic at a tertiary care hospital, to determine, from sputum induction (SI), proportions of bronchial inflammatory phenotypes, demographic, clinical and functional characteristics of each phenotype, and the most accessible non-invasive inflammatory marker that best discriminates between phenotypes.Patients and Methods: Included were 96 patients with asthma, attending a specialist asthma clinic at a tertiary care hospital, who underwent testing as follows: SI, spirometry, fractional exhaled nitric oxide (FeNO), blood eosinophilia, total immunoglobulin E (IgE), and a skin prick test.Results: SI phenotypes were 46.9% eosinophilic, 33.3% paucigranulocytic, 15.6% neutrophilic, and 4.2% mixed. No significantly different clinical or functional characteristics were observed between the phenotypes. A positive correlation was observed between SI eosinophilia and both emergency visits in the last 12 months (p = 0.041; r = 0.214) and FeNO values (p = 0.000; r = 0.368). Blood eosinophilia correlated with SI eosinophilia (p = 0.001; r = 0.362) and was the best predictor of bronchial eosinophilia, followed by FeNO, and total blood IgE (area under the receiver operating characteristic curve (AUC-ROC) 72%, 65%, and 53%, respectively), although precision was only fair.Conclusion: In consultations for severe asthma, the most frequent phenotype was eosinophilic. Peripheral blood eosinophilia is a reliable marker for discriminating between different bronchial inflammatory phenotypes, is useful in enabling doctors to select a suitable biologic treatment and so prevent asthma exacerbation, and is a better predictor of bronchial eosinophilia than FeNO and IgE values.Keywords: asthma, sputum induction, phenotype, eosinophilia

OBJECTIVE: To develop a set of recommendations for the management of severe asthma during COVID-19 pandemic. METHODS: Eleven pneumologists and allergologists who were staff members of officially accredited asthma units in Catalonia (Spain) participated in a cross-section study based on three 2-hour virtual workshops (first: brainstorming, second: identification of impacts and challenges summarized in 10 topics, third: establishment of final recommendations by consensus). RESULTS: Impacts and challenges identified were improvement of referral protocols between different levels of care; assessment of the minimum number of function tests to be performed and promote the performance of spirometry in primary care; implementation of videoconferencing, mobile apps, telephone calls, or integral virtual platforms for the follow-up of patients, and definition of the model of care (face-to-face, telematics, mixed) according to the patient's individual needs; self-administration of biologics for domiciliary treatment; and empowerment of the role of nursing and hospital pharmacy in particular for follow-up and self-administration of biologics. The main recommendations included coordination between primary care and specialized care consultation, optimization of lung function testing, implementation of telemedicine, and the role of nursing and hospital pharmacy. CONCLUSION: The specific proposals in response to the effect of COVID-19 pandemic focused on four areas of interest (coordination between primary care and specialized care, optimization of lung function testing, implementation of telemedicine, and empowerment of the role of nursing and hospital pharmacy) may be generalized to other health care settings, and help to introduce new ways of caring asthma patients in the COVID-19 context.

Airway examination techniques are procedures that can potentially transmit infectious diseases to both patients and healthcare professionals who perform them, by various mechanisms. The pandemic situation due to the COVID-19 disease has practically halted most of the activity of the clinics and laboratories of pulmonary and nasal function, with clear recommendations in this regard. Being already in the early stages after the peak of the pandemic, we still do not know for sure what its consequences will be in the short or long term, since there are important gaps in the knowledge of aspects as fundamental as the transmission mechanisms of the virus, its pathophysiology and immune response or its diagnosis. In this review we will examine the different examination techniques available on the assessment of patients suffering from respiratory allergy, asthma and associated diseases, int the postpandemic momentum, highlighting their possible advantages and disadvantages. For this reason, we wanted to focus on exploring the entire upper and lower airways, from the perspective of the safety of both the healthcare professionals and patients and their specific characteristics. And at the same time we will approach the analysis of the intrinsic value that these interventions provide from the point of view of both diagnosis and management of these patients. The changing situation of this disease may cause some modifications of the assertions presented in this review in the future.While this guidance seeks to ensure a consistent wide approach, some differences in operational details may be applied due to local regulations.

Non Eosinophilic Asthma; Survey Asma no eosinofílica; Encuesta Asma no eosinofílica; Enquesta

Background The prevalence of chronic diseases in the elderly (> 65 years), including asthma, is growing, yet information available on asthma in this population is scarce. Our objective is to determine the differential clinical and functional characteristics of the population > 65 years old with asthma included in the Integrated Research Programs of Asthma Databank of the Spanish Society of Pneumology and Thoracic Surgery (www.bancodatosasma.com). Methods Retrospective comparative descriptive study of demographic, clinical and functional variables for 1713 patients with asthma categorized into 3 age groups as follows: adults aged 65 is more severe and associated with greater comorbidity, which would indicate the need for a more integrated and multidimensional approach to asthma treatment for these patients.

There has been growing interest in the last 10 years in the study of innate immunity, in particular because of the possible role that toll-like receptors (TLR) may play in the pathogenesis of some respiratory diseases including, asthma, chronic obstructive pulmonary disease, and infections. TLR are a family of type 1 transmembrane proteins, responsible for recognising molecular patterns associated with pathogens (PAMP, pathogen-associated molecular patterns), and expressed by a broad spectrum of infectious agents. This recognition leads to a quick production of cytokines and chemokines which provides a long-lasting adaptive response to the pathogen. At present, it is considered //It is currently considered that the administration of drugs which modulate the activity of these receptors upwards or downwards may represent major therapeutic progress for handling these diseases. The aim of this review is to describe the different TLS, define their possible role in the pathogenesis of the main respiratory diseases and finally, speculate over the therapeutic possibilities which their modulation, agonist or antagonist, offers as possible therapeutic targets.

Resumen En los ultimos 10 anos se ha constatado un creciente interes por el estudio de la inmunidad innata, particularmente por el posible papel que los denominados “receptores toll-like” (TLR) pueden desempenar en la patogenia de algunas enfermedades respiratorias, como, por ejemplo, el asma, la enfermedad pulmonar obstructiva cronica y las infecciones. Los TLR son una familia de proteinas transmembranarias de tipo I, responsables del reconocimiento de patrones moleculares asociados a patogenos (PAMP, de pathogen-associated molecular patterns), y expresados por un amplio espectro de agentes infecciosos. Este reconocimiento lleva a una rapida produccion de citocinas y quimiocinas, lo que proporciona una respuesta adaptativa duradera contra el patogeno. En la actualidad se considera que la administracion de farmacos que modulen, al alza o a la baja, la actividad de estos receptores puede suponer un gran avance terapeutico en el manejo de dichas enfermedades. El proposito de la presente revision es describir los diferentes TLR, definir su posible papel en la patogenia de las principales enfermedades respiratorias y, finalmente, conjeturar las posibilidades terapeuticas que su modulacion, agonista o antagonista, ofrece como posibles dianas terapeuticas.

Resumen Dentro de las patologias adquiridas tras la instauracion de una via aerea artificial figuran las estenosis, los granulomas, la presencia de pseudomembranas y la formacion de tabiques traqueales, entre otros. La forma mas habitual de presentacion en el adulto es la estenosis circunferencial, y para su resolucion muchas veces requiere medidas endoscopicas terapeuticas. En esta Nota clinica se describe el caso de una pseudomembrana traqueal inflamatoria obstructiva (en forma de tabique traqueal) secundaria a intubaciones repetidas y que se resolvio con tratamiento conservador. La presentacion clinica de esta entidad generalmente incluye la aparicion de infeccion respiratoria y/o atelectasia tras la retirada del tubo orotraqueal, como consecuencia de la acumulacion de secreciones entre la pared traqueal y el tabique formado. Los tabiques traqueales inflamatorios se pueden resolver espontaneamente con ayuda de glucocorticoides, y otras veces requieren de un procedimiento endotraqueal invasivo en funcion de la evolucion.

Introduction Differences between the opinions of patients and physicians on the impact of asthma are common. We hypothesised that patient–physician discordance may negatively affect asthma outcome. Methods A total of 2902 patients (61% women, mean age 47 years) with moderate–severe asthma and 231 physicians participated in a prospective study. At the baseline visit, data on demographics, clinical variables, degree of asthma control according to the Asthma Control Test (ACT), basic spirometry and the Hospital Anxiety and Depression Scale (HADS) were collected and an ad hoc questionnaire was completed that allowed the degree of concordance between doctors and patients to be assessed. A scheduled telephone call after 3 months was used to elicit the ACT score and the future risk of asthma. At the final visit at 6 months, the following data were recorded: ACT score, spirometry, HADS score and an ad hoc questionnaire to assess the agreement between the doctor and the patient. Changes in study variables according to patient–physician concordance or discordance were analysed. Results The rate of patient–physician discordance was 27.2%, with overestimation of disease impact by the physician in 12.3% and underestimation in 14.9%. Patient–physician opinion discordance, particularly in the case of physicians underestimating the impact of asthma, showed worse results with statistically significant differences in ACT score, a higher percentage of patients with poor asthma control and lower HADS scores. The need for hospital and emergency department admissions was also higher. Conclusion Patient–physician opinion discordance may be contributing to lower symptomatic control and increased future risk, with a higher impact when physicians underestimate the impact of asthma on their patients.

Background: Exhaled breath temperature (EBT) has recently been proposed as a noninvasive marker of bronchial inflammation in patients with asthma. However, the usefulness of EBT in everyday clinical practice is not well established. Results to date are contradictory and are mainly derived from small, pediatric populations. A comparison of results is further complicated by the use of different equipment and measurements. Objective: We performed a comprehensive study to determine whether EBT is related to asthma control, disease severity, bronchial obstruction, or bronchial inflammation. Methods: Sixty-nine patients on maintenance treatment for asthma were included in a cross-sectional study. At the same visit, we measured the EBT plateau (EBTp) using an X-halo Breath Thermometer (Delmedica, Singapore), the fraction of exhaled nitric oxide (FeNO), spirometry, and inflammatory cell count in induced sputum, and we administered the Asthma Control Test questionnaire. Results: No significant differences were found between EBTp measurements and the level of asthma control, disease severity, bronchial obstruction, FeNO levels, or inflammatory asthma phenotypes. We found a significant difference between EBTp and gender. The EBTp was 34.07°C (SD 0.74) in women and 34.38°C (0.46) in men (p = 0.038). We also found a significant correlation between EBTp measurements and the induced sputum eosinophil count (R = -0.348, p = 0.003). Conclusions: The results of this study do not support the usefulness of the EBTp in asthma management in routine clinical practice. Further research using standardized methods is needed to determine the potential use of the EBTp measurement in asthma management.

Pathologies acquired after the establishment of an artificial airway include stenosis, granulomas and the formation of pseudomembranes, to name a few. The most common form of presentation in adults is circumferential stenosis, which often requires therapeutic endoscopic measures to achieve resolution. This Case Report describes the case of an obstructive inflammatory tracheal pseudomembrane in the shape of a tracheal septum secondary to repeated intubations that was resolved with conservative treatment. The clinical presentation of this entity generally includes the appearance of respiratory infection and/or atelectasis after the withdrawal of the orotracheal tube as a consequence of the accumulation of secretions between the tracheal wall and the pseudomembrane. Inflammatory pseudomembranes can resolve spontaneously with the help of glucocorticoids, although on occasion they require an invasive endotracheal procedure depending on the evolution.