Type-2 Inflammation in Asthma
Prof. Karl-Christian Bergmann is Chair of Centre for Severe Asthma at the Charité, Berlin, Germany. Prof. Bergmann is a pulmonologist and allergist. In 2006, he opened the first Center for Second Opinion on the use of biologics. The system is being used successfully throughout Germany today.
What are the unmet needs in Type-2 inflammation in clinical practice?
Type-2 asthma is characterised by Type-2 inflammation and typically includes different forms of asthma, e.g. allergic asthma, exercise-induced asthma, late-onset asthma, and moderate-to-severe eosinophilic asthma. In Type-2 inflammation in asthma, the inflammatory response is amplified by recruited eosinophils via a positive feedback loop. The inflammatory mediators secreted by eosinophils and other inflammatory cells lead to tissue damage, creating a cycle of chronic inflammation. Understanding the allergic, eosinophilic, and mixed allergic/eosinophilic phenotypes has been greatly advanced in recent years and has underpinned new approaches to improve asthma control, such as biologics aimed at inhibiting interleukin signalling.
However, despite the fact that these recent advances in understanding the pathophysiology driving Type-2 inflammation has led to clinical trials applying this knowledge to return aberrant signals to physiological levels, the primary unmet need remains the timely and accurate identification of the individual disease status in a given patient. Each patient requires a thorough assessment, more extensive than is currently the norm. The disease can be complex, but important clues can be found in accurate phenotyping in order to adequately manage Type-2 asthma.
What would you like to see change in routine management of Type-2 asthma?
There are two things I would really like to see change. Firstly, I would like to stress the value of routine analysis of fractional exhaled nitric oxide (FeNO). FeNO is a marker for airway inflammation and is a non-invasive, safe, and simple method of quantifying the degree of asthma inflammation. It can be used to assess whether airway inflammation is contributing to poor asthma control, particularly in the presence of other contributors such as rhinosinusitis, anxiety, gastroesophageal reflux, obesity, or continued allergen exposure. Beyond aiding the identification of an eosinophilic asthma phenotype in a patient, FeNO can also help establish a baseline reading during a period of clinical stability for subsequent monitoring of chronic persistent Type-2 asthma. Rechecking the nitric oxide levels can also be a tool to verify that the steroid inhalers are adequately suppressing the nitric oxide level.
Secondly, the initial evaluation and assessment of a new patient with suspected Type-2 asthma is an essential element in achieving an optimal and individualised care plan. The physician needs to expect to spend at least 25-30 minutes with a new patient to properly understand the extent and nature of their specific disease with the aim to decrease acute exacerbations and reduce the frequency of corticosteroid treatments. A skilled multidisciplinary team may be required to get the full picture. Combined FeNO and spirometry are recommended in addition to a thorough physical examination, in addition to supplemental laboratory tests.
"Every ambulance should be equipped with a portable device to measure FeNO; although this is rarely the case, at least in Germany.
The added value of careful and thorough patient evaluation is that one can use the collective phenotypes to assign asthma endotypes, wherein a specific biological pathway is identified that explains the observable properties of a phenotype, with the goal to improve therapy."
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Table of Contents: ATS 2019
Featured articles
Letter from the Editor
Interview with Prof. Christian Bergmann
Treatable Traits in Chronic Inflammatory Airway Disease: Back to Basics
Treatable traits in chronic inflammatory airway disease: back to basics
Critical Care Medicine
Distinguishing between 4 different subtypes of sepsis sets the stage for individualised treatment
Stem cell therapy in acute respiratory distress syndrome improves 28-day mortality
SPICE III trial: Early sedation with dexmedetomidine in critically ill patients
SAATELLITE trial: Suvratoxumab prevents ventilator-associated Staphylococcus Aureus pneumonia in intensive care unit patients
Sleep Medicine
Million-patient study reveals gaps in long-term adherence among various sub-populations
Sleep apnoea severity has a non-linear relationship with acute myocardial infarction risk
Obstructive sleep apnoea affects morning spatial navigational memory processing in asymptomatic older individuals
Pulmonary Vascular Disease and Interstitial Lung Disease
Nintedanib reduces lung function decline in systemic sclerosis-associated ILD
Pulmonary arterial hypertension: early treatment with selexipag most effective
Long-term safety and efficacy of recombinant human pentraxin-2 in patients with idiopathic pulmonary fibrosis
Infection
Dupilumab improves outcomes in patients with severe chronic rhinosinusitis with nasal polyps and comorbid asthma
Durability of culture conversion in patients receiving ALIS for treatment-refractory MAC lung disease
E-cigarette use disrupts normal immune response to viral infections, particularly in women
Paediatric Pulmonary Medicine
Bacterial pneumonia predicts ongoing lung problems in infants hospitalised for acute respiratory failure
Aspergillus and early cystic fibrosis lung disease: does it need to be treated?
COPD
CORTICO-COP trial: eosinophil-guided therapy reduces systemic corticosteroid exposure
A randomised controlled trial of a smoking cessation smartphone application
Benralizumab does not ameliorate COPD exacerbations (GALATHEA/TERRANOVA trials)
Aclidinium bromide delays COPD exacerbation without increased MACE risk
Bench-to-Bedside (Pre-Clinical)
Human lung organoids to study foetal RSV infection
CRISPR/Cas9 genome editing therapy of hereditary pulmonary alveolar proteinosis
Cilia diagnostics in primary ciliary dyskinesia
Tuberous sclerosis complex 2 may be a novel target in pulmonary arterial hypertension therapy
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