Early Diagnosis of Bronchiectasis Critical in
Type 2 Severe Asthma

Pam Harrison

December 10, 2021

Type 2 inflammation likely has a causative role in the development of bronchiectasis (BE) in patients with type 2-high severe asthma (T2-SA), and its early diagnosis is critical to improve outcomes in patients with this dual diagnosis, a prospective, observational, multicenter study suggested.

In a cohort of 113 patients with T2-SA, the prevalence of BE was confirmed in 44.2% of patients, Claudia Crimi, MD, AOU Policlinico "G.Rodolico-San Marco," Catania, Italy, and colleagues reported in the Journal of Asthma and Allergy. Moreover, chronic rhinosinusitis (CRS) was significantly more prevalent in T2-SA plus BE patients at 84% compared with those without BE at 58.7% (P = .004) as was chronic rhinosinusitis with nasal polyps (CRSwNP) at 54% vs 42.9% (P = .0165), researchers added.

In addition, 58% of patients in the T2-SA plus BE group (compared with only 23.8% of patients in the T2-SA alone group) reported chronic mucus hypersecretion (P = .0004), whereas a greater proportion of BE patients at 56% were on maintenance oral corticosteroids (OCS) compared with 34.9% of patients without BE (P = .0357), investigators note.

T2-SA plus BE patients also reported a higher number of asthma exacerbations in the previous year (10 per year) compared with 6 exacerbations in patients without BE (P = .048). "It has been hypothesized that the long-term eosinophils-mediated inflammatory damage, promoted by T2-inflammaion, induces tissues changes and airway remodeling, playing a primary role in the pathogenesis of BE," the researchers observed.

"Our results confirm and expand the current knowledge reporting that T2-SA with coexisting BE was frequently associated with CRS with and without nasal polyposis, chronic sputum production, chronic OCS intake, and a higher exacerbations rate," they added.

High-Dose ICS

The mean age of the cohort was 55 years but the mean age at disease onset was younger at 32.3 years. Almost 60% of the cohort were women and all patients were on high-dose inhaled corticosteroids/long-acting beta agonists (LABAs). On multivariate analysis, the presence of CRS, chronic sputum production, and daily OCS intake were all strongly predictive of the presence of comorbid BE in T2-SA patients, as investigators reported.

Results from high-resolution chest tomography (HRCT) showed that the majority of patients (76%) had mild BE whereas 24% had moderate BE, with a median of three affected lobes. As assessed by the Bronchiectasis Severity Index (BSI) — which has been shown to be an excellent predictor of mortality and hospital admissions as well as exacerbations of asthma — only 12% of patients had clinically severe BE, the researchers noted.

There was also a significant, inverse relationship between the BSI score and levels of asthma control as assessed by the asthma control test (ACT) (P < .0001). On the other hand, no significant association was seen between the BSI score and duration of asthma or the risk of asthma exacerbations. As the authors point out, mucus hyperproduction is a clinical hallmark of both T2-SA and BE and in patients with both conditions, mucus hypersecretion predictably would occur.

Indeed, almost 60% of patients with BE in this study reported chronic mucus hypersecretion, often purulent or muco-purulent. "The persistent accumulation of mucus can limit airflow, worsen asthma symptoms, trigger asthma exacerbations, and reduce asthma control with standard inhaled high-dose
ICS + LABA, often making chronic oral corticosteroid intake necessary," the authors point out.

"Data obtained from this prospective observational study confirm the hypothesis that a dangerous liaison closely links T2-SA and BE," they emphasized.

Need for Aggressive Treatment

Asked to comment on the study, Hugh Windom, MD, an allergy and immunology specialist in Sarasota, Florida, felt that this observational study of poorly controlled, severe type 2 asthma adds to our knowledge of the chronic lung pathology resulting from long-standing, unabated asthma. "A similar analysis of other forms of severe asthma would be helpful to establish these findings as being unique to type 2 asthma," Windom told Medscape Medical News in an email.

"Early and aggressive treatment of persistent asthma is standard of care, and this study reinforces why it is so critical to modulate airway inflammation with one or some of the many medications now available," he added.

No funding was received for this research. Crimi has disclosed no relevant financial relationships. Windom declared he has received research funds from Novartis, Sanofi, Verona, and Teva.

J Asthma and Allergy. Published online November 30, 2021. Full text

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