Severe asthma, more than that?

Abstract

I was recently invited to write about the development of asthma management in the past decade. Biologic therapy came to my mind, and I was fascinated by the concept that asthma remission can potentially be achieved with this treatment (https://erj.ersjournals.com/content/early/2022/03/17/13993003.02583-2021). At the same time, I reflected on the management of one of my patients with severe asthma treated with biologics and the importance of looking for and managing comorbidities when treating patients with severe asthma. She was a young lady, and it was after more than a year of treatment with various agents for severe asthma, including high-dose inhaled corticosteroids, long-acting beta-agonist, anti-muscarinic agent, montelukast, azithromycin, systemic steroid and biologics (two biologics, started with one and then changed to the other with lack of effect) that we made the diagnosis of inducible laryngeal obstruction (ILO) (https://erj.ersjournals.com/content/50/3/1602221) that was causing the recurrent ‘asthma exacerbations’ and ICU admissions. Correct diagnosis is crucial for the treatment of asthma. However, having a confirmed diagnosis of asthma does not mean that it is the sole cause of respiratory symptoms/asthma exacerbations. This lady had features typical of asthma, including positive bronchodilator reversibility and her lung function varied with time with lower FEV1 at times of poor control or attacks. She also had Type-2 high asthma with high eosinophil blood count and exhaled nitric oxide levels. At the start of the illness, the patient improved with systemic steroid during hospitalisations. We did our usual workup for assessing comorbidities, such as looking for rhinitis and gastroesophageal reflux disease and excluded eosinophilic granulomatosis with polyangiitis. However, the young lady subsequently had more ‘asthma attacks’, and those episodes required ICU care, but no intubation was ever needed. Given the recurrent ICU admissions despite optimal pharmacotherapy for asthma, we have performed extensive investigations to exclude other diseases, including CT thorax, blood tests, echocardiogram and sleep study. During one of the ICU admissions, the patient was noted to have a low tidal and a high respiratory rate while on non-invasive pressure ventilation (NIV). Arterial blood gas taken during the ‘attacks’ showed respiratory acidosis with elevated pCO2 and normal alveolar-arterial gradient. The ‘attacks’ did not improve with asthma medications but responded to oxygen supplementation and NIV. We suspected ILO and were able to prove that by laryngoscopy. The patient had several ‘attacks’ of breathlessness afterwards, which were improved by benzodiazepines. We have thus stopped the unnecessary asthma medications for this patient, including biologics. The ILO was managed by speech therapist, psychologist, psychiatrist and ENT surgeon. Not every patient needs extensive investigations to search for comorbidities, but how far we need to go for patients with recurrent ‘asthma attacks’ would need clinical judgement and a personalized approach. Also, we have to think about ILO earlier in patients with severe asthma not responding well to therapy. We currently have potent medications, including biologics, for treating severe asthma, but we must ensure that these are given to the right patient. None declared.