Page 128 - Škrgat, Sabina, ed. 2022. Severe Asthma - Basic and Clinical Views. Koper: University of Primorska Press. Severe Asthma Forum, 1
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compatible with asthma, around 32% of the h istory should determine asthma immediate-
asthma was confirmed by further examina- ly. Respiratory symptoms were present from
severe asthma forum 1: severe asthma - basic and clinical views tion i.e. methacholine challenge testing, skin childhood, they had sensitisation to perenni-
prick tests and serum IgE measurement (4). al allergens, they were treated for asthma in
Although in older patients >65 years, a low- youth, or have eosinophilia etc. “Lack of care-
er percentage of underdiagnosed asthma was ful history taking is intellectually lazy, it is too
found - in 15% of them. This fact is very im- expensive, so should be condemned.”7
portant, because, in older patients with typi-
cal asthma symptoms, asthma is a rarely per- “Poor perceivers” are those patients with
ceived physician-diagnosed disease, even in asthma who do not report symptoms when
those patients who had< 10 pack-years of their FEV1 dropped by 20%8. In the group
smoking or no history of congestive heart fail- with an established asthma diagnosis in this
ure5. Independent risk factors for asthma mis- study of 1155 subjects, 6% were poor perceiv-
diagnosis are spirometry underutilization and ers of dyspnea, while in the group which did
missing data on pack-years of smoking6. not have physician-diagnosed asthma despite
verified airways obstruction, 26% were poor
An even bigger problem is the diagnosis perceivers. Both under and overdiagnosis of
of severe asthma. There is a significant delay asthma lead to significant risks to patients,
in some severe asthma patients until the right and every effort should be undertaken to es-
diagnosis of severe asthma is established. The tablish a proper diagnosis9.
most logical possible explanations are twofold:
the appearance of disease with atypical pres- It is usually stated that 5-10% of all asth-
entations of asthma in persons with parallel ma patients have severe asthma10. Since 2016,
conditions (like obesity), and secondly - some the Global initiative for asthma (GINA) has
patients are “poor perceivers” (although there stated that asthma is a heterogeneous dis-
are also medical professionals failing to rec- ease11. Asthma heterogeneity can be seen in
ognize the disease). There are asthma patients diverse clinical presentations, different re-
that never have wheezing, some never cough, sponses to treatment, and different patho-
but most of them have dyspnea. As dyspnea physiological features and findings due to
can be a manifestation of many diseases, the various pathogenic mechanisms, which lead
most often from cardiac origin, it is not sur- to multiple asthma phenotypes.
prising that some patients for many years do
not perform any pulmonary diagnostics. Of Here Comes the Second Controversy:
course, heart diseases are the most common Where are Those Patients With Severe
pathology in the elderly, so they are often pres- Asthma Hiding?
ent as a comorbidity, but are not necessarily
the leading etiology. As many patients smoke There is an unmet need for standardisa-
and their obstructive disease is presented for tion of the referral pathway leading to early
the first time during an exacerbation, they im- identification of patients with severe or diffi-
mediately receive a COPD diagnosis, which cult-to-treat asthma12.. A possible solution for
has been going on for years. From person- better referral to asthma specialists is better
al experience, a certain number of “COPD” communication with emergency departments
patients disclosed their asthma features af- (ER).Patients discharged from the emergency
ter usage of a single or dual bronchodilator departments after an acute asthma exacerba-
therapy in COPD became more regular, and tion episode should be referred to an asthma
somewhat earlier patients were advised to dis- specialist, either a pulmonologist, allergist or
continue ICS from their therapy. The fact is pediatrician. Another possibility is also better
that in most of those patients careful medical access to the general practitioner’s (GP’s) pool
of “problematic“ asthma patients. Patients are
asthma was confirmed by further examina- ly. Respiratory symptoms were present from
severe asthma forum 1: severe asthma - basic and clinical views tion i.e. methacholine challenge testing, skin childhood, they had sensitisation to perenni-
prick tests and serum IgE measurement (4). al allergens, they were treated for asthma in
Although in older patients >65 years, a low- youth, or have eosinophilia etc. “Lack of care-
er percentage of underdiagnosed asthma was ful history taking is intellectually lazy, it is too
found - in 15% of them. This fact is very im- expensive, so should be condemned.”7
portant, because, in older patients with typi-
cal asthma symptoms, asthma is a rarely per- “Poor perceivers” are those patients with
ceived physician-diagnosed disease, even in asthma who do not report symptoms when
those patients who had< 10 pack-years of their FEV1 dropped by 20%8. In the group
smoking or no history of congestive heart fail- with an established asthma diagnosis in this
ure5. Independent risk factors for asthma mis- study of 1155 subjects, 6% were poor perceiv-
diagnosis are spirometry underutilization and ers of dyspnea, while in the group which did
missing data on pack-years of smoking6. not have physician-diagnosed asthma despite
verified airways obstruction, 26% were poor
An even bigger problem is the diagnosis perceivers. Both under and overdiagnosis of
of severe asthma. There is a significant delay asthma lead to significant risks to patients,
in some severe asthma patients until the right and every effort should be undertaken to es-
diagnosis of severe asthma is established. The tablish a proper diagnosis9.
most logical possible explanations are twofold:
the appearance of disease with atypical pres- It is usually stated that 5-10% of all asth-
entations of asthma in persons with parallel ma patients have severe asthma10. Since 2016,
conditions (like obesity), and secondly - some the Global initiative for asthma (GINA) has
patients are “poor perceivers” (although there stated that asthma is a heterogeneous dis-
are also medical professionals failing to rec- ease11. Asthma heterogeneity can be seen in
ognize the disease). There are asthma patients diverse clinical presentations, different re-
that never have wheezing, some never cough, sponses to treatment, and different patho-
but most of them have dyspnea. As dyspnea physiological features and findings due to
can be a manifestation of many diseases, the various pathogenic mechanisms, which lead
most often from cardiac origin, it is not sur- to multiple asthma phenotypes.
prising that some patients for many years do
not perform any pulmonary diagnostics. Of Here Comes the Second Controversy:
course, heart diseases are the most common Where are Those Patients With Severe
pathology in the elderly, so they are often pres- Asthma Hiding?
ent as a comorbidity, but are not necessarily
the leading etiology. As many patients smoke There is an unmet need for standardisa-
and their obstructive disease is presented for tion of the referral pathway leading to early
the first time during an exacerbation, they im- identification of patients with severe or diffi-
mediately receive a COPD diagnosis, which cult-to-treat asthma12.. A possible solution for
has been going on for years. From person- better referral to asthma specialists is better
al experience, a certain number of “COPD” communication with emergency departments
patients disclosed their asthma features af- (ER).Patients discharged from the emergency
ter usage of a single or dual bronchodilator departments after an acute asthma exacerba-
therapy in COPD became more regular, and tion episode should be referred to an asthma
somewhat earlier patients were advised to dis- specialist, either a pulmonologist, allergist or
continue ICS from their therapy. The fact is pediatrician. Another possibility is also better
that in most of those patients careful medical access to the general practitioner’s (GP’s) pool
of “problematic“ asthma patients. Patients are
