Airway Restriction in Asthma: Characterization, Causes, and Further Insights
In a significant development for individuals living with severe asthma, new treatment options and strategies are being explored to manage Asthma with Fixed Airflow Obstruction (FAO). This subtype of severe asthma is characterised by persistent airway eosinophilic inflammation, leading to structural changes in the bronchial walls and a chronic and unchanging restriction in a person's ability to exhale air from the lungs.
Individuals with severe asthma may experience a range of symptoms, including shortness of breath, wheezing, coughing, and chest tightness. FAO can also cause airflow issues, even without other symptoms. Worsening symptoms, difficulty in performing daily activities, frequent exacerbations, a decline in lung function, needing to use a rescue inhaler more frequently, and respiratory infections that worsen symptoms are signs to seek medical attention.
Current treatment approaches focus on optimizing inhaled therapies and, where appropriate, using biologic agents alongside precision medicine strategies. One key approach is the use of Single-inhaler Triple Therapy (SITT), combining inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and long-acting muscarinic antagonists (LAMA), specifically with extrafine formulations such as beclomethasone–formoterol–glycopyrronium. This therapy improves symptoms, lung function (small airway function), and inflammation control, helping a substantial proportion of patients to achieve sustained disease control without escalation to biologics.
Inhaled corticosteroids and bronchodilators (LABAs and LAMAs) remain foundational for managing persistent symptoms and airflow limitation. In severe asthma with fixed obstruction, airway smooth muscle may respond variably, but steroid and bronchodilator treatment is still effective in vitro and in practice.
Biologic therapies targeting eosinophilic inflammation, such as anti-IL-5, anti-IL-5 receptor, anti-IgE, anti-TSLP, and anti-IL-4/IL-13, are effective for reducing exacerbations and improving control in severe eosinophilic asthma. However, not all asthma phenotypes, especially low-T2 asthma, currently have approved biologics.
Early intervention and personalized treatment through biomarker-guided strategies help optimize therapy choice and improve outcomes. Monitoring for biomarkers like blood eosinophil counts, FeNO levels, and lung function parameters assists in tailoring treatments, dose adjustments, and determining biologic eligibility.
The use of oral corticosteroids (OCS) is minimized due to side effects, with newer therapies aiming to reduce OCS dependence. The ability to maintain control with inhaled therapies alone is a novel goal termed "Steady Quiet Asthma."
Emerging non-steroidal treatments, like the antifibrotic Pirfenidone (investigated mainly in COPD), show promise in reducing inflammation without the drawbacks of steroids, though their role in asthma with fixed obstruction is not yet established.
It is crucial to note that, while novel treatments for FAO, such as biological therapies like omalizumab, may reduce symptom flares (exacerbations), they do not significantly improve lung function. Furthermore, no specific treatments are currently available that directly target the remodeling of airways and lung tissue in FAO.
In conclusion, management strategies for asthma with fixed airflow obstruction centre on optimized inhaled triple therapy, selectively adding biologics based on the asthma phenotype, and precision medicine approaches using biomarkers to guide therapy and improve disease control. Early recognition and appropriate management are essential to prevent asthma symptoms from worsening and decrease the risk of developing severe asthma with FAO.
For those living with asthma and allergies, resources are available offering evidence-based information. A dedicated hub provides valuable insights and guidance for effective management.
- New treatment options and strategies are being explored for severe eosinophilic asthma, a subtype that includes persistent airway eosinophilic inflammation.
- Severe asthma symptoms can include shortness of breath, wheezing, coughing, chest tightness, airflow issues, and respiratory infections that worsen symptoms.
- Current treatment approaches for severe asthma focus on optimizing inhaled therapies, including Single-inhaler Triple Therapy (SITT).
- SITT combines inhaled corticosteroids (ICS), long-acting beta-agonists (LABA), and long-acting muscarinic antagonists (LAMA).
- Inhaled corticosteroids and bronchodilators remain foundational for managing persistent symptoms and airflow limitation in severe asthma.
- Biologic therapies that target eosinophilic inflammation, such as anti-IL-5, anti-IL-5 receptor, and anti-IgE, are effective for reducing exacerbations and improving control in severe eosinophilic asthma.
- Monitoring biomarkers like blood eosinophil counts, FeNO levels, and lung function parameters can assist in tailoring treatments and dose adjustments.
- Minimizing the use of oral corticosteroids (OCS) and aiming to reduce OCS dependence are goals in severe asthma treatment.
- Emerging non-steroidal treatments, such as Pirfenidone, show promise in reducing inflammation without the drawbacks of steroids in asthma with fixed obstruction.
- Novel treatments for FAO may reduce symptom flares, but they do not significantly improve lung function or directly target airway and lung tissue remodeling.
- Strategies for managing asthma with fixed airflow obstruction include optimized inhaled triple therapy, selectively adding biologics, and precision medicine approaches using biomarkers.
- Early recognition and appropriate management are essential to prevent asthma symptoms from worsening and decrease the risk of developing severe asthma with FAO.
- Resources providing evidence-based information for those living with asthma and allergies are available online.
- Effective management of asthma requires a dedicated approach covering health and wellness, fitness and exercise, nutrition, and mental health.
- Other chronic diseases beyond severe eosinophilic asthma require attention for overall health maintenance, including cervical cancer screenings, skin care, eye health, hearing, digestive health, aging, autoimmune disorders, neurological disorders, and men's health.
