Professional Documents
Culture Documents
Azienda
Ospedaliera
Pisana
Universit degli
Studi di Pisa
Pierluigi Paggiaro
GINA International Executive Committee, Chairman GINA ITaly
Cardio-Thoracic and Vascular Department, University of Pisa
Bronchial Asthma
heterogeneity in clinical presentation
Large difference in clinical manifestations,
related to:
Severity of the disease
Heterogeneity of inducers and/or triggers
Level of adherence to therapeutical plan
Difference in:
Strategy of asthma treatment
Strategy in asthma management
Bronchial Asthma
heterogeneity in clinical presentation
Large difference in clinical manifestations,
related to:
Severity of the disease
Heterogeneity of inducers and/or triggers
Level of adherence to therapeutical plan
Difference in:
Strategy of asthma treatment
Strategy in asthma management
Bronchial Asthma
examples of special cases
According to severity
Mild-moderate vs severe (difficult to treat)
Frequent exacerbators vs chronic airway obstruction
Prevalence of comorbidities
No nasal polyps
(N=43)
Pre-BD FEV1, %
71.017.5 *
81.117.7
Sputum eosinophils, %
22.3 (0.4-95.6)
10.6 (0-84.1)
Sputum eosinophils 3%
89.5 *
63.9
ACT score
21 (10-24)
20 (7-25)
Poorly controlled, %
8 (38.1)
23 (53.5)
66.7
69.8
AQLQ score
4.63 (2.69-6.56)
4.92 (3.03-6.75)
Obesity
Obese
(N=22)
Normal weight
(N=42)
Pre-BD FEV1, %
77.723.5
77.914.8
Sputum eosinophils, %
8.3 (0-71.2)
17.4 (0-95.6)
Sputum eosinophils 3%
63.2
77.8
ACT
16.5 (7-25) *
21 (12-25)
Poorly controlled, %
72.7 *
35.7
77.3
64.3
AQLQ score
4.47 (3.03-6.16)
5.31 (2.69-6.75)*
GERD
GERD
(N=25)
No GERD
(N=39)
Pre-BD FEV1, %
77.416.5
78.119.3
Sputum eosinophils, %
14.9 (0-82.8)
15.8 (0-95.6)
Sputum eosinophils 3%
59.1
81.8
ACT
19 (7-25)
21 (10-25)
Poorly controlled, %
56.0
43.6
76.0
64.1
AQLQ score
4.42 (2.69-6.16) *
5.28 (3.19-6.75)
Poor control
Eosinophilic
phenotype
OR (CI 95%)
OR (CI 95%)
OR (CI 95%)
Obesity
5.3 (1.5-18.2) *
1.7 (0.6-5.3)
0.6 (0.2-1.9)
Nasal polyps
0.4 (0.1-1.5)
3.6 (1,2-11.3) *
5.5 (1.1-27.8) *
GERD
1.8 (0.6-5.8)
0.6 (0.2-1.8)
0.4 (0.1-1.5)
Age of onset
Early-onset asthma: more atopic, lower severity (?)
Exercise
In children and elite athletes (exercise-induced
bronchospasm)
Asthma phenotypes
Smoke
High risk for asthma developing
Prevalence in asthmatics: 20% smokers
Characteristics of asthma in smokers
Lower eosinophilic inflammation
Lower response to ICS
Greater FEV1 decline over time
Pedersen et al,
JACI 2007
Asthma phenoypes
Eosinophilic vs non-eosinophilic asthma
Eosinophilic phenotype
Allergen-induced asthma, children asthma
Severe asthma with frequent exacerbations (CSdependent asthma)
Asthma phenotypes
Implications for treatment
With current available drugs
High dose vs low dose ICS (non eosinophilic, smokers)
Eosinophil-driven strategies
LTRA (exercise asthma, aspirin-inuced asthma, asthma +
rhinitis)
Heterogeneity of the response also in unselected
asthmatics
Aims:
Evaluation of the level of asthma control
(symptoms, pulmonary function, exacerbations)
Factors related to poor asthma control
Relationship duration of treatment / level of
control
75
53,413,5
34,7/65,3
4,0/25,3/70,7
51(68,9)
28(38,4)
20(27,8)
Well-partially
controlled
221
51,513,9
38/62
3,6/28,1/67,4
142(65,1)
70(33)
51(23,6)
24(33,8)
25(33,3)
35(47,3)
8(11,3)
29,5(4-96)
64,119,8
39(18,6)*
43(19,5)*
69(32,5)*
15(7,1)
33(4-120)
78,319,7*
* p<0.05
No exacerbations
Exacerbations 1
167
51,613,2
39,5/60,5
3,6/28,1/67,1
108(65,9)
43 (27)
30 (18,5)
25(15)
28(16,9)
47 (29,4)
10(6,3)
32 (5-79)
77,818,6
22 (10-25)
125
52,514,4
34,4/65,6
3,2/25,6/71,2
80(64,5)
52 (43,3)*
43 (35,2) 3 *
35(29,4) 5*
38 (30,4)*
55(45,1)*
11 (9,2)
36 (4-120)
70,622,4*
20 (6-25)*
Novelli et al, ERS 2013
* p=0.003