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The role of small airways in asthma control

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Kraft et al (2022) examined the role of small airway dysfunction in asthma control and exacerbations in a longitudinal, observational analysis using data from the ATLANTIS study.  

Although small airway disease is a feature of asthma, its association with relevant asthma outcomes remains unclear. ATLANTIS is the largest study of patients with asthma to date, involving 773 evaluable patients with asthma and 99 controls without airway obstruction, specifically designed to determine the prevalence and impact of small airway disease in asthma cross-sectionally and longitudinally.  

This longitudinal report in the asthmatic cohort shows that small airway disease is an independent predictor of future exacerbation risk. A composite of impulse oscillometry biomarkers, the ordinal score, significantly predicted asthma exacerbations in a model with other known predictors, including GINA severity score, history of previous exacerbations and blood eosinophils. Therefore, measurement of small airway function by impulse oscillometry is a valuable addition to clinical practice because it can assist the clinician in understanding the risk of an asthma exacerbation in their patients along with routinely collected information on treatment intensity and blood eosinophils. 

Kole et al (2022) conducted a post-hoc analysis of the ATLANTIS study in The Lancet Respiratory Medicine. The authors found that PAL occurs not only among patients with severe asthma (GINA steps 4-5), but also in a considerable number of patients with less severe asthma (GINA steps 1-2). Patients with asthma who have PAL have asthma for a longer period are more often male and are current smokers, than those without PAL. Patients with PAL have more severe small airways dysfunction shown by larger ventilation heterogeneity of the conductive and acinar airways. They also have a distinct type of inflammation characterised by a higher proportion of eosinophils in sputum and blood, a higher blood monocyte count, and lower proportion of sputum macrophages. PAL was associated with a higher risk of having an asthma exacerbation independent of age, sex, smoking status, level of eosinophilic inflammation in blood, and severity of disease.  

According to the authors and the results, the PAL phenotype occurs across the full spectrum of asthma severity. Not only is it present in people with less severe asthma, but it is also an important predictor of exacerbations. In severe asthma, it has been shown that patients with PAL respond well to add-on treatment with long-acting muscarinic antagonist (LAMA). People with mild asthma (GINA steps 1 and 2) could increase treatment intensity with the aim of reducing the risk of exacerbations. 

Ulmeanu et al (2022) confirmed real-world benefits that inhaled corticosteroid/ long-acting β2-agonist (ICS/LABA) combination of beclomethasone dipropionate and formoterol can provide to poorly controlled and uncontrolled adult asthma patients treated previously with non-extra-fine medications. HFA solutions can be manipulated to extra fine particle size distribution, permitting precise control of delivered dose and optimised drug delivery to allow the drugs to penetrate the deeper regions of the lung more effectively. 

The results of this observational study demonstrate the effectiveness and safety of beclomethasone dipropionate and formoterol (100/6µg) pressurised metered dose inhalers in Romanian adult asthma patients uncontrolled with non-extra-fine medication in a real-world setting, leading to clinically and statistically improvements in asthma control and pulmonary function.  

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