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Severe asthma is characterized by frequent disease symptoms and exacerbations. The life of patients with severe asthma is largely influenced by the disease. Severe asthma requires multi-drug therapy, as well as proper education and cooperation with the patient. The greater the patient's knowledge and awareness of severe asthma, the greater the chance of improving their condition. Find out what severe asthma is, when it is possible to diagnose severe asthma and what are the current guidelines and current therapy models for the treatment of severe asthma.
Severe (difficult) asthmais a form of asthma in which the disease is not controlled by standard pharmacotherapy. There are 5 levels of therapy in the treatment of asthma. The first is low-dose medication therapy only in the event of symptoms. Subsequent stages require the use of medications also between asthma attacks, and the higher the grade, the greater the doses of medications. In the last, 5th stage, drugs in the highest doses and all currently available methods of treating asthma are used.
Severe asthma is the form of the disease that requires the most intensive treatment - that is, stage 4 or 5 therapy. Unfortunately, there are cases in which, despite such advanced therapy, the disease cannot be controlled. Asthma symptoms keep recurring, and there is a significant limitation of life activity due to the disease. Over time, asthma attacks may stop being reversible. Many years of uncontrolled asthma may cause permanent bronchial remodeling and irreversible damage to lung function.
Severe asthma - diagnosis
Severe asthma is diagnosed in those patients in whom control over the disease is very difficult - they require constant increase in the doses of anti-asthma medications and the use of additional methods of treatment. Before a diagnosis of severe asthma is made, it is important to make sure that the course of the disease is not caused by other factors.
One of the most common reasons for the lack of asthma control isfailure to follow the doctor's recommendations- lack of regular use of medications in the right doses.
Another common problem isinappropriate medication technique . Most drugs used in treatmentasthma is inhaled. During a medical visit, it is always worth making sure that you are inhaling drugs correctly, and then take care of the inhalation technique each time you take drugs.
Treatment-resistant asthma is an indication for in-depth diagnostics of the respiratory system. Lack of disease control may result from other comorbidities that worsen its course.
One of the most common conditions with asthma ischronic obstructive pulmonary disease (COPD) . This disease affects smokers in most cases, and its coexistence with asthma makes effective treatment difficult.
The diagnosis of COPD is performed using a spirometry test (spirometry). Spirometry should be performed regularly in patients with asthma. Asthma spirometry results between attacks may be normal - test deviations occur in exacerbations of the disease. In COPD, spirometry shows a constant, irreversible deterioration in airflow to the lungs.
Imaging tests are also used to exclude other diseases of the respiratory system, among which the most accessible is a chest X-ray. In the most advanced cases of asthma, careful imaging (CT scan of the chest) can reveal permanent remodeling of the bronchial wall.
A group of additional tests that may be helpful in the diagnosis of severe asthma are allergy tests. They are performed in the case of probable allergic asthma, usually in the earlier stages of the disease.
However, if a patient with severe asthma has not had any tests so far, it is worth doing them. The tests include skin prick tests as well as testing for specific antibodies against various allergens in the blood.
Confirmation of an allergy to specific allergens may indicate to the patient what factors should be avoided (if possible). In some patients with severe allergic asthma, sublingual immunotherapy (so-called "desensitization") is possible.
Severe asthma - treatment
Severe asthma requires intensive treatment to prevent the development of irreversible complications of the disease. The therapy of severe asthma combines non-pharmacological treatment with the use of drugs with various mechanisms of action. Asthma unresponsive to such treatment may be an indication for invasive therapy, currently available in experimental research.
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severe asthma - lifestyle
Adjusting the lifestyle to strict recommendations can in many cases improve the functioning of patients with severe asthma. Asthma at any stage of its advancementit is an indication for regular physical exercise, adapted to the patient's abilities. Moderate physical activity should be preceded by a warm-up.
In case your asthma symptoms worsen after exercise, take a dose of a bronchodilator before training. Patients with overweight or obesity should absolutely strive to reduce body weight through a properly selected diet and physical activity. Weight normalization can greatly improve respiratory function.
Patients with severe asthma should absolutely avoid smoking. Smoking increases the incidence of asthma exacerbations, worsens the response to treatment, and carries the risk of other respiratory diseases (COPD, cancer).
If you are allergic to inhalation allergens, avoid contact with sensitizing agents if possible. In the case of the so-called aspirin-induced asthma, asthma attacks may appear after taking aspirin or similar drugs from the group of so-called NSAIDs (non-steroidal anti-inflammatory drugs). Confirmed aspirin-induced asthma is an indication for absolute avoidance of the above-mentioned. drugs.
In the treatment of severe asthma, a holistic approach to the patient plays a huge role. In addition to strictly anti-asthma therapy, it is worth considering other conditions coexisting with asthma.
In addition to the aforementioned obesity, many other diseases can make it difficult or even impossible to effectively treat asthma. They include, among others gastroesophageal reflux disease, mental disorders (depression) or obstructive sleep apnea. Optimal management of comorbidities increases the chances of achieving asthma control.
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severe asthma - basic treatment
Standard treatment of asthma includes two categories of medications: anti-inflammatory drugs that target the cause of the disease, and bronchodilators to reduce symptoms. The most important group of anti-inflammatory drugs in asthma are glucocorticosteroids (GKS).
Severe asthma requires high doses of inhaled glucocorticosteroids. The inhaled route of administration increases the effectiveness of treatment (the drug goes straight to the respiratory system - where it should work), and at the same time reduces the risk of side effects (the drug is not distributed throughout the body).
Some patients with severe asthma require systemic administration of glucocorticosteroids, i.e. by the oral route. The anti-inflammatory effect of the drug is stronger then, but the chronic use of glucocorticoids in this form significantly increases the risk of side effects (see section 5 - complications). For this reason, he avoids todaythe use of oral glucocorticosteroids, increasingly replacing them with newly available biological drugs.
The second group of primary medications used in the treatment of asthma are bronchodilators. First-line drugs are the so-called long-acting beta-agonists, inhaled.
By stimulating the receptors in the airways, they dilate the bronchi and reduce the feeling of breathlessness. In severe asthma, an additional, second bronchodilator drug - tiotropium, belonging to the anticholinergic drugs - is often added to the therapy.
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severe asthma - biological drugs
One of the breakthroughs in the treatment of severe asthma was the introduction of the so-called biological drugs. These aretargeted drugsthat target specific biological mechanisms underlying asthma. Consequently,biological drugsare not intended for every patient.
In order for biological therapy to have sense and a chance of success, it is necessary to properly qualify candidates for treatment. Currently, two biological drugs have been registered for the treatment of severe asthma in Poland. They are available under the drug program "Treatment of severe IgE-dependent allergic asthma and severe eosinophilic asthma".
Omalizumab, available from 2013, was the first to be introduced on the Polish market. Omalizumab is an antibody directed against IgE molecules. IgE is a group of antibodies that are involved in allergic reactions.
The concentration and activity of IgE may be increased in patients prone to allergies, including patients with severe asthma. If the mechanism of asthma development is IgE-mediated, then in the event of failure of standard treatment, the patient may be enrolled in the Omalizumab treatment program.
The second drug available in Poland from 2022 is Mepolizumab. It works by blocking one of the inflammatory molecules called interleukin 5 (IL-5). IL-5 is a protein that stimulates the development of cells responsible for allergic reactions - eosinophils. In the case of elevated blood eosinophils levels in a patient with severe asthma, there is a good chance that treatment with Mepolizumab will be effective.
Both of the drugs mentioned above are available under the drug program. This means that the medicine cannot simply be purchased at a pharmacy. To receive treatment, you must go to a severe asthma management center and then enter the program. The condition for eligibility is insufficient disease control with standard treatment, severe course and frequent exacerbations of asthma, as well as confirmation of a specificthe mechanism of the development of asthma (IgE-dependent or eosinophilic, respectively).
It is also worth knowing about additional criteria for excluding people from participating in the program - for example smoking, pregnancy or coexisting cancer.
By default, participation in a drug program lasts 24 months. During this time, the drug is administered subcutaneously every 2-4 weeks. There are also regular check-ups to assess the response to treatment.
If therapy is unsuccessful, treatment may be interrupted. If, however, after completing the therapy, the patient's condition deteriorates again, he or she may be included in the next program.
The patient remains under observation for one year after the end of the therapy. If asthma control is maintained during this time, participation in the drug program will be terminated.
The guidelines of the World Initiative Against Asthma (GINA) allow the use of other biological drugs in severe asthma, including Benralizumab, Reslizumab, Dupilumab. These are agents registered for use in the European Union, and in the case of Reslizumab - also in Poland. Unfortunately, they are not yet available as part of drug programs financed by the National He alth Fund.
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severe asthma - immunotherapy
Sublingual immunotherapy, commonly known as "desensitization", can be used in strictly defined cases of allergic asthma.
Immunotherapy is currently recommended as an adjunct to standard grade 3 and 4 asthma therapy. The most severe, grade 5, is associated with advanced respiratory dysfunction and is an indication for other therapies (see above).
It is worth remembering that immunotherapy is specific - desensitization is carried out for a specific allergen. The current recommendations regarding immunotherapy in the treatment of asthma indicate that patients allergic to house dust mites, with coexisting allergic diseases (mainly allergic rhinitis) should be eligible for treatment.
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severe asthma - invasive treatment
Invasive treatment is one of the newest methods of asthma therapy, reserved only for the most severe cases. This form of therapy is only considered when all other available treatments have failed.
The treatment used in the treatment of severe asthma is the so-called bronchial thermoplasty. This method involves inserting a bronchoscope into the lumen of the bronchus and then destroying the inside of the bronchial wall with high temperature. The damaged bronchial musculature cannot contract, which allowsreduce asthma symptoms.
Bronchial thermoplasty is currently performed in few centers in Poland. Studies on the long-term safety and effectiveness of the method are ongoing, although the preliminary results are encouraging. Perhaps in the future, bronchial thermoplasty will become one of the routine treatments for severe asthma.
Severe asthma - complications
Complications of severe asthma may result from the progression of the disease as well as from treatment. Severe asthma is associated with frequent exacerbations of the disease, which often require hospitalization.
Serious exacerbations of asthma may cause drops in blood oxygenation (saturation), complications in the respiratory system (including pneumothorax), and in extreme cases severe respiratory failure.
Long-term, uncontrolled asthma may cause permanent bronchial remodeling. In this situation, the symptoms of asthma are no longer fully reversible and the flow of air to the lungs is permanently restricted. Then, irreversible changes in the functioning of the respiratory system occur.
The second group of complications associated with severe asthma are drug-related complications. In the past, the vast majority of these were associated with systemic (oral) glucocorticoid use.
Chronic steroid therapy was associated with the risk of developing the so-called Cushing's syndrome. Cushing's syndrome is manifested by the formation of skin stretch marks, obesity, muscle atrophy, osteoporosis, hypertension and diabetes. For this reason, systemic glucocorticoid therapy is used very carefully in severe asthma.
Currently, it is used only for a short time in the treatment of severe exacerbations of the disease. In the treatment of chronic asthma, oral glucocorticosteroids have in many cases been replaced by new biological drugs.
- Bronchial asthma - symptoms, causes and effective treatment
- Atopic (allergic) asthma: causes, treatment and prevention
- Steroid-resistant asthma - causes and treatment