Co‐morbidities in severe asthma: Clinical impact and management

Abstract

Patients with severe asthma represent a minority of the total asthma population, but carry a majority of the morbidity and healthcare costs. Achieving better asthma control in this group of patients is therefore of key importance. Systematic assessment of patients with possible severe asthma to identify treatment barriers and triggers of asthma symptoms, including co-morbidities, improves asthma control and reduces healthcare costs and is recommended by international guidelines on management of severe asthma. This review provides the clinician with an overview of the prevalence and clinical impact of the most common co-morbidities in severe asthma, including chronic rhinosinusitis, nasal polyposis, allergic rhinitis, dysfunctional breathing, vocal cord dysfunction, anxiety and depression, obesity, obstructive sleep apnoea syndrome (OSAS), gastroesophageal reflux disease (GERD), bronchiectasis, allergic bronchopulmonary aspergillosis (ABPA) and eosinophilic granulomatous with polyangiitis (EGPA). Furthermore, the review offers a summary of recommended diagnostic and management approaches for each co-morbidity. Finally, the review links co-morbid conditions to specific phenotypes of severe asthma, in order to guide the clinician on which co-morbidities to look for in specific patients.

Nordic consensus statement on the systematic assessment and management of possible severe asthma in adults

“…Defined as ‘chronic changes in breathing pattern that result in dyspnoea and other symptoms, in the absence or in excess of the magnitude of physiological respiratory or cardiac disease’ [69], DB is observed in up to 52% of subjects with difficult asthma. DB seems to be most common in the obese and non-eosinophilic phenotypes of severe asthma [70,71]. Patients typically report very excessive dyspnea at relatively low levels of physical activity, that is dyspnea that is disproportionate with the objective level of asthma severity.…”

“…A potential vicious cycle may result as OSAS may induce asthma symptoms, and asthma increase the risk of OSAS [70]. Screening of patients for OSAS can be performed with validated questionnaires such as the, STOP-BANG or the Berlin Questionaire [81,82].…”

Impact of gastric reflux on asthma in clinical practice

“…1 The European Respiratory Society/American Thoracic Society (ERS/ATS) guidelines on severe asthma and the Global Initiative for Asthma (GINA) document recommend a systematic assessment of potential co-morbidities in all patients with possible severe asthma. 2,3 Co-morbidities may significantly affect asthma control, both aggravating and mimicking symptoms.…”

“…Although this issue has been recently investigated Porsbjerg and Menzies-Gow, 1 some pathophysiological aspects remain obscure. We now present our retrospectively conducted clinical study of 188 (107 females) consecutive outpatients with asthma.…”

Does CPAP for obstructive sleep apnoea improve asthma control?

“…Difficult‐to‐control asthma is even more common, and the key difference from severe asthma is that the poor control may be due to other factors, such as poor adherence or concomitant co‐morbidities. Increasingly, obstructive sleep apnoea (OSA) is being recognized as a common and important co‐morbidity in difficult‐to‐control asthma . OSA is the repetitive collapse of the upper airway during sleep and like asthma is very common in the general community.…”