Page 51 - Škrgat, Sabina, ed. 2022. Severe Asthma - Basic and Clinical Views. Koper: University of Primorska Press. Severe Asthma Forum, 1
P. 51
hma Psychologists, Asthma Pharmacists, endotype to define the core type of asthma 51
Speech & Language Therapists and Dieti- that is present. In parallel, they need to assess
tians. Patients referred into such services will factors such as adherence to treatments and the multi-disciplinary team approach to specialist adult difficult asthma care
generally undergo comprehensive assessment issues of inhaler technique to identify if such
at the point of referral followed by appropri- treatment related factors explain why that pa-
ate pharmacotherapeutic treatment chang- tient’s asthma is not well controlled. Their
es. They then have regular follow-up with ap- assessment must also search for all possible
propriate members of the MDT as dictated aggravating comorbidities that might a) neg-
by individual need. Such MDT’s typically re- atively impact on asthma control or b) them-
view cases on a regular (often weekly) basis in selves drive symptoms of breathing difficulty
a meeting setting to achieve group consensus that lead to a misperception of those symp-
on appropriate treatment steps culminating in toms as being driven by asthma when they
approval for higher level biologic treatments are not. In order to achieve this understand-
once the MDT is satisfied that other appropri- ing they will need to undertake and interpret
ate actions have been addressed. This struc- a range of objective measures to aid asthma
tured pathway meets the important goal of characterization including blood tests (full
ensuring that all other facets of patient need blood count, Total IgE, aspergillus serology),
are met rather than simply escalating to high- allergy skin prick tests to a standard aeroaller-
er and higher asthma therapies in the hope of gen panel appropriate for that locality, lung
improving refractory breathing difficulties. function testing (spirometry with bronchodi-
It should therefore maximise the chances of lator reversibility plus gas transfers), measures
improving healthcare status and facilitate ra- of airway inflammation (Fractional Exhaled
tional use of higher-level costly biologic medi- Nitric Oxide [FeNO] +/- induced sputum
cations where they are truly indicated. differential counts) plus radiological imaging
(chest radiography +/- High Resolution Com-
In the following sections we review the puted Tomography [HRCT] chest). They will
roles of different MDT members involved in also need to undertake a range of screening
difficult asthma care. assessments for comorbid conditions and their
severity using standardised disease monitor-
The Asthma Specialist Physician ing tools such as the Nijmegen Questionnaire
(to assess breathing pattern disorder), HADS
In the Specialist clinic setting, a Consultant (Hospital Anxiety and Depression) score (to
(or equivalently experienced) Respiratory assess psychological comorbidity status), Ep-
Physician with subspecialist expertise and ex- worth score (to assess for sleep apnoea) and
perience in managing difficult asthma plays SNOT-22 (to assess for rhinitis).39-42 The use
a central role in directing patient treatment of such questionnaires as a standard compo-
and overseeing an individualized approach nent of the assessment process has been asso-
to multidisciplinary patient care. In simple ciated with significantly better identification
terms they might be viewed as the conductor of asthma-related comorbidities though it can
of the MDT orchestra. Their role will initial- be time consuming and onerous for the pa-
ly focus on establishing that the patient does tient in the short-term.43
indeed have asthma. This basic step is impor-
tant as it has been shown that after a thor- Following the initial comprehensive eval-
ough evaluation process a not insubstantial uation process, the Specialist Asthma Phy-
minority of patients (5-12%) may be deemed sician needs to determine appropriate asth-
to not have a diagnosis of asthma.37,38 If asth- ma focused pharmacotherapeutic strategies
ma seems probable, the Physician then must and establish potential timelines to consider
determine patient asthma phenotype and/or higher level biologic asthma therapies should
Speech & Language Therapists and Dieti- that is present. In parallel, they need to assess
tians. Patients referred into such services will factors such as adherence to treatments and the multi-disciplinary team approach to specialist adult difficult asthma care
generally undergo comprehensive assessment issues of inhaler technique to identify if such
at the point of referral followed by appropri- treatment related factors explain why that pa-
ate pharmacotherapeutic treatment chang- tient’s asthma is not well controlled. Their
es. They then have regular follow-up with ap- assessment must also search for all possible
propriate members of the MDT as dictated aggravating comorbidities that might a) neg-
by individual need. Such MDT’s typically re- atively impact on asthma control or b) them-
view cases on a regular (often weekly) basis in selves drive symptoms of breathing difficulty
a meeting setting to achieve group consensus that lead to a misperception of those symp-
on appropriate treatment steps culminating in toms as being driven by asthma when they
approval for higher level biologic treatments are not. In order to achieve this understand-
once the MDT is satisfied that other appropri- ing they will need to undertake and interpret
ate actions have been addressed. This struc- a range of objective measures to aid asthma
tured pathway meets the important goal of characterization including blood tests (full
ensuring that all other facets of patient need blood count, Total IgE, aspergillus serology),
are met rather than simply escalating to high- allergy skin prick tests to a standard aeroaller-
er and higher asthma therapies in the hope of gen panel appropriate for that locality, lung
improving refractory breathing difficulties. function testing (spirometry with bronchodi-
It should therefore maximise the chances of lator reversibility plus gas transfers), measures
improving healthcare status and facilitate ra- of airway inflammation (Fractional Exhaled
tional use of higher-level costly biologic medi- Nitric Oxide [FeNO] +/- induced sputum
cations where they are truly indicated. differential counts) plus radiological imaging
(chest radiography +/- High Resolution Com-
In the following sections we review the puted Tomography [HRCT] chest). They will
roles of different MDT members involved in also need to undertake a range of screening
difficult asthma care. assessments for comorbid conditions and their
severity using standardised disease monitor-
The Asthma Specialist Physician ing tools such as the Nijmegen Questionnaire
(to assess breathing pattern disorder), HADS
In the Specialist clinic setting, a Consultant (Hospital Anxiety and Depression) score (to
(or equivalently experienced) Respiratory assess psychological comorbidity status), Ep-
Physician with subspecialist expertise and ex- worth score (to assess for sleep apnoea) and
perience in managing difficult asthma plays SNOT-22 (to assess for rhinitis).39-42 The use
a central role in directing patient treatment of such questionnaires as a standard compo-
and overseeing an individualized approach nent of the assessment process has been asso-
to multidisciplinary patient care. In simple ciated with significantly better identification
terms they might be viewed as the conductor of asthma-related comorbidities though it can
of the MDT orchestra. Their role will initial- be time consuming and onerous for the pa-
ly focus on establishing that the patient does tient in the short-term.43
indeed have asthma. This basic step is impor-
tant as it has been shown that after a thor- Following the initial comprehensive eval-
ough evaluation process a not insubstantial uation process, the Specialist Asthma Phy-
minority of patients (5-12%) may be deemed sician needs to determine appropriate asth-
to not have a diagnosis of asthma.37,38 If asth- ma focused pharmacotherapeutic strategies
ma seems probable, the Physician then must and establish potential timelines to consider
determine patient asthma phenotype and/or higher level biologic asthma therapies should
