Asthma‐chronic obstructive pulmonary disease overlap: A clinical entity?

Asthma and COPD are easily recognizable clinical entities in their characteristic presentations. Asthma is an early-onset disorder characterized by Type 2, eosinophil-predominant, inflammation of the airways and is associated with atopy. COPD presents in middle age and is characterized by neutrophilic inflammation of the airways and is associated with cigarette smoking or biomass fuel exposure. Between exacerbations, asthma typically has normal lung function whereas COPD has incompletely reversible lung function. Approximately one in five patients with either of these disorders will show some features of both COPD and Asthma. This overlap is far more common than can be accounted for by chance concurrence of two common diseases. There are likely genetic and environmental susceptibilities to both disorders, but there is no single pathobiological mechanism that identifies all such overlap patients. Most likely there are numerous predispositions that lead to Asthma-COPD overlap that may be grounded in early childhood or even pre-natal events. Thus, Asthma-COPD overlap is best considered a family of diseases with overlapping clinical manifestations. The future elucidation of these different pathways to Asthma-COPD overlap, in conjunction with highly targeted therapies will aid clinicians in treating these patients.

Phenotypic classification of asthma based on a new Type 2‐high and Type 2‐low endotypic classification: It all began with Rackemann

Background: Asthma is now recognized as a heterogeneous collection of disease entities associated with different clinical phenotypic presentations and diverse endotypic mechanisms. Recently, a new system of nomenclature of asthma has evolved by using a type 2 (T2) high and T2-low endotypic classification that has proven useful for diagnosis and for choosing the right biologic for patients with asthma. Aim: The purpose of this report was to provide an overview of molecular endotypes, asthma phenotypes, and existing biomarkers, with a focus on the new classification system of T2 and non-T2 pathways in the historical context of the contributions of Francis M. Rackemann, M.D., that set the stage both for our current understanding of the spectrum of disease entities of asthma and for the basis for the use of emerging biologics for the treatment of these disorders. Methods: This article was based on literature review of PubMed and the author’s own research and clinical experiences. Results: Currently, the therapy for asthma is being directed to a treatment strategy based on patient-specific phenotypic characteristics and underlying endotypic mechanisms of tissue injury that focus on a T2-high and T2-low airway inflammation classification. Based on this classification, the clinician is provided with a useful treatment stratagem for choosing the right biologic for personalized care of patients with asthma. Although not perfect in its total applicability, it affords a guide in helping to choose among the currently available biologics, the most appropriate one, as well as those that inevitably will become available. Conclusion: The phenotypic classification of asthma described in this report began with the clinical observations that were made by of an astute clinician long before the supernova emergence of information related to T2-high and T2-low immune function. Rackemann’s legacy to clinical allergy practice once again illustrates that science and technology can best progress through the energizing force of clinical observation.

Phenotypic classification of asthma based on a new Type 2–high and Type 2–low endotypic classification: It all began with Rackemann

Background: Asthma is now recognized as a heterogeneous collection of disease entities associated with different clinical phenotypic presentations and diverse endotypic mechanisms. Recently, a new system of nomenclature of asthma has evolved by using a type 2 (T2) high and T2-low endotypic classification that has proven useful for diagnosis and for choosing the right biologic for patients with asthma.Aim: The purpose of this report was to provide an overview of molecular endotypes, asthma phenotypes, and existing biomarkers,with a focus on the new classification system of T2 and non-T2 pathways in the historical context of the contributionsof Francis M. Rackemann, M.D., that set the stage both for our current understanding of the spectrum of disease entities of asthma and for the basis for the use of emerging biologics for the treatment of these disorders.Methods: This article was based on literature review of PubMed and the author’s own research and clinical experiences.Results: Currently, the therapy for asthma is being directed to a treatment strategy based on patient-specific phenotypic characteristics and underlying endotypic mechanisms of tissue injury that focus on a T2-high and T2-low airway inflammation classification. Based on this classification, the clinician is provided with a useful treatment stratagem for choosing the right biologic for personalized care of patients with asthma. Although not perfect in its total applicability, it affords a guide in helping to choose among the currently available biologics, the most appropriate one, as well as those that inevitably will become available.Conclusion: The phenotypic classification of asthma described in this report began with the clinical observations that weremade by of an astute clinician long before the supernova emergence of information related to T2-high and T2-low immunefunction. Rackemann’s legacy to clinical allergy practice once again illustrates that science and technology can best progressthrough the energizing force of clinical observation.

Families' perception, knowledge, and psychological stressors associated with transition of care from the intensive care unit

Background: During the process of transition of care from the intensive care setting, clarity, and understanding are vital to a patient's outcome. A successful transition of care requires collaboration between health-care providers and the patient's family. The objective of this project was to assess the quality of continuity of care with regard to family perceptions, education provided, and psychological stress during the process. Methods: A prospective study conducted in a long-term acute care (LTAC) facility. On admission, family members of individuals admitted to the LTAC were asked to fill out a 15-item questionnaire with regard to their experiences from preceding intensive care unit (ICU) hospitalization. The setting was an LTAC facility. Patients were admitted to an LTAC after ICU admission. Results: Seventy-six participants completed the questionnaire: 38% expected a complete recovery, 61% expected improvement with disabilities, and 1.3% expected no recovery. With regard to the length of stay in the LTAC, 11% expected < 1 week, 26% expected 1 to 2 weeks, 21% expected 3 to 4 weeks, and 42% were not sure. Before ICU discharge, 33% of the participants expected the transfer to the LTAC. Also, 72% did not report a satisfactory level of knowledge regarding their family's clinical condition or medical services required; 21% did not receive help from family members; and 50% reported anxiety, 20% reported depression, and 29% reported insomnia. Conclusion: Families' perception of patients' prognosis and disposition can be different from what was communicated by the physician. Families' anxiety and emotional stress may precipitate this discrepancy. The establishment of optimal projects to eliminate communication barriers and educate family members will undoubtedly improve the quality of transition of care from the ICU.

Biologic targeted therapy in allergic asthma

Background: Asthma is a heterogeneous inflammatory disease of the airway, characterized by airway hyperresponsiveness, airway obstruction, mucus hyperproduction, and airway-wall remodeling. Management of this disease involves the use of several types of therapeutic agents, each with unique indications based on the underlying cause of inflammation, clinical severity, and patient phenotype and/or endotype. Objective: A review of the function, clinical utility, and safety of biologic agents in the management of allergic asthma. This particular asthma phenotype involves multiple cytokines in its pathogenesis, specifically those secreted by T-helper type 2 cells. Methods: Medical literature was obtained from online biomedical archive searches from July 2018 to May 2019. An emphasis was placed on clinical trials that discussed biologic agents that target immunoglobulin E, interleukin (IL) 5, IL-4/IL-13, and chemoattractant receptor-homologous molecule expressed on Th2 cells (CRTh2) pathways involved in the expression of allergic asthma. Results: The treatment options reviewed in this article were shown to be effective in targeting these pathways associated with allergic asthma. However, because these biologic agents are commonly prescribed in the treatment of severe asthma, many patients continue to experience asthma signs and symptoms. Conclusion: Future clinical trials that study these agents should focus on ideal patient selection, dosing regimens, and cost-effectiveness in the management of asthma. Ideally, comparative trials should be undertaken to assist the clinician in choosing the optimal agent.

Comorbidities associated with severe asthma

Background: Severe asthma can be a challenging disease to manage by the provider and by the patient, supported by evidence of increased health-care utilization by this population. Patients with severe asthma should be screened for comorbidities because these often contribute to poorly controlled asthma. The impact of comorbidities, however, are not completely understood. Objective: To review common comorbidities and their impact on severe asthma. Methods: A review of relevant clinical research studies that examined comorbidities in severe or difficult-to-treat asthma. Results: A number of comorbid diseases, including rhinitis, rhinosinusitis, gastroesophageal reflux, and obstructive sleep apnea, are associated with severe or difficult-to-treat asthma. If present and untreated, these conditions may adversely affect asthma control, quality of life, and/or lung function, despite adequate treatment with step-up asthma controller therapy. Conclusion: Treatable comorbidities are associated with severe and difficult-to-control asthma. Failure to recognize these comorbidities may divert appropriate care and increase disease burden. Assessment and management of these risk factors may contribute to improved asthma outcome; however, more investigation is needed to understand the relationship of comorbidities and asthma due to inconsistency in the findings.