This transcript has been edited for clarity.
Michael Wechsler, MD: Hello, and welcome to Medscape's InDiscussion series on moderate to severe asthma. I'm Dr Mike Wechsler, professor of medicine at National Jewish Health in Denver, Colorado. This is episode four of the first season. First, let me introduce my guest, Dr David Jackson. Today, we'll be discussing the topic of multidisciplinary approaches to patients with severe asthma. Dr Jackson is a consultant in severe asthma and the director of Guy's Severe Asthma Centre. He's also professor of medicine at King's College in London. Welcome to InDiscussion, David. Great to have you here. How are you doing today?
David Jackson, MRCP, PhD: Good. Many thanks for having me. Looking forward to today's discussion.
Wechsler: How is all the heat in London these days?
Jackson: Well, you know, it's normally a heat wave this side of the pond in London. We're known for blue skies and dry climates, but sadly, it's a bit gray today.
Wechsler: All right. Well, that's okay because we're going to focus on severe asthma and the multidisciplinary approaches. David, you and I met at a meeting a few years ago — just a random meeting at lunchtime — and you kept wondering why I was jumping in and out of the meeting. You were so kind to invite me to your home for dinner later that day for the first time. I'm grateful we've had this opportunity to catch up now on this podcast. Let's talk a little bit about difficult-to-control asthma vs severe asthma. How do you distinguish the two? There's a lot of severe asthma out there. There's a lot of difficult-to-control asthma. We have so many patients who are challenging for us. Tell us, how do you distinguish between the two concepts of difficult vs severe asthma?
Jackson: Thanks. I think it's quite confusing for a lot of physicians because the two terms are closely related but are distinct. Fundamentally, the main difference relates to if a person with poorly controlled symptoms and asthma genuinely has severe asthma, or if they have moderate asthma but there are other confounding variables — like they're not taking their inhaled steroids on a regular basis, their inhaler technique is suboptimal, or they have other comorbidities contributing to and driving their symptoms that's not their asthma.
Wechsler: We see these patients, and they're coughing, they're wheezing, they're short of breath. Generally, my first question is if they have asthma. Second, I find out if their asthma is well controlled. If it's not, my general approach is to query them about their inhaler adherence, evaluate them for comorbidities, and then treat their underlying asthma. Maybe we should walk through these steps a little bit, and we can talk about how you differentiate between patients with difficult-to-control asthma and severe asthma.
Jackson: I think the approach you've just outlined is absolutely right. The first step always when you see a patient — even when they have a label of asthma — is confirming the diagnosis. All too often, we see a patient who believes they've had asthma for many years. Maybe they've seen a family physician who told them they have asthma several years ago. But when you look again, the diagnosis is incorrect. There's obviously that famous study from Canada in JAMA several years ago that highlighted the huge proportion of patients with a label of asthma — I think it was like a third of patients overall — who didn't actually end up having asthma. It's incredibly important not to assume the patient in front of you has severe asthma, and that their symptoms are not controlled because of it. In many cases, it might be because their symptoms are not being driven by asthma at all.
Wechsler: David, tell me, what is on your differential diagnosis that is not asthma but appears like asthma?
Jackson: There's a very long list. But what I most often see in my clinic are patients who have persistent cough — often a nocturnal cough. We see this commonly with patients with bad reflux. What's interesting about gastroesophageal reflux is that it doesn't necessarily give patients symptoms of heartburn. They can just have a cough that is worse at night, which is classically what asthma does, because they lie down, which is what makes it worse. We see patients who have a cough because of a postnasal drip. We have patients who have a cough because of bronchiectasis with other respiratory symptoms. Sleep apnea, for example, can create breathlessness and a sensation of discomfort at night and a cough that can, in some respects, mimic patients with asthma. And then, of course, you have cardiac problems that cause breathlessness on exertion and a sense of tightness and discomfort. Often, that sort of pain is misidentified as the tightness of asthma. There are many conditions that can present like asthma. And then, of course, there are the conditions that patients with asthma also have that make their asthma worse and drive asthma-related inflammation. There's EGPA (eosinophilic granulomatosis with polyangiitis), formerly called Churg-Strauss syndrome. There's a sensitization to fungal allergens that drives diseases like ABPA (allergic bronchopulmonary aspergillosis) and other similar conditions. It is important that before escalating treatment, we really try to understand why the patient is still symptomatic on conventional asthma treatment.
Wechsler: Right. One other entity you didn't mention is COPD. How do you distinguish someone with COPD and someone with asthma? Because a lot of patients tell me they have asthma. But it turns out they didn't have any childhood allergies, and they didn't have any childhood symptoms. Many of them might actually have evidence of emphysema on imaging. How do you make that distinction?
Jackson: That's a good question. The truth is that COPD, in the vast majority of patients, especially in the Western world, will relate to a history of smoking. But a patient with asthma who never smoked could develop COPD. We see a number of patients that have both asthma and COPD. They've had asthma since childhood, smoke in adulthood, and now they've developed COPD. Similarly, we have patients who have smoked for many years and, like nonsmokers, develop adult-onset asthma. It can be very confusing. There are always two elements to remember. The first relates to the reversibility of airflow obstruction, and the second relates to the immunology of asthma and whether it is evident in the patient in front of you who you think may have COPD. When I talk about immunology, I'm really talking about evidence of type 2 (T2) airway inflammation identified by fractional exhaled nitric oxide (FeNO) and blood eosinophil count. Fundamentally, the same treatment approach is appropriate whether or not the patient has asthma or COPD if they have evidence of ongoing T2 inflammation.
Wechsler: We've talked a little bit about all of these conditions, and one of the key things we want to discuss today is the multidisciplinary approaches. Asthma, I think, is somewhat unique in that we often work with many of our colleagues to help manage the comorbidities, diagnose some of the more complicated entities, and try to evaluate our patients, in addition to working with them on the adherence component. I want to discuss with you all the different types of specialists you use in your practice, starting from the ground up. In your practice, it's not just you. Who else is working with you and with the patients on a day-to-day basis to address the underlying asthma needs? Nurses, nurse practitioners, physician assistants, asthma educators — who's a part of your practice?
Jackson: I'm very fortunate at our center in London that we have a large multidisciplinary team. If you were to come to our clinic, you would have a single corridor, and the rooms along this corridor are filled with a couple of physicians like myself and a couple of nurses who are specialists in asthma care. We have pharmacists whose main role is to support patients' inhaler adherence, which we know is such a common problem for why patients have ongoing symptoms despite having been prescribed appropriate treatment. We have a speech-language therapist who supports patients who have laryngeal dysfunction. These patients often called it vocal cord dysfunction. They have a sudden onset of symptoms — tightness that focused in the throat area that was different from asthma. This could be common in patients with asthma but also common in those without asthma. We have a respiratory physiotherapist who supports patients with breathing pattern disorders if they are hyperventilating or breathing in a slightly abnormal way, which frequently occurs in patients with psychological problems. And for that reason, we also have a clinical psychologist on our corridor as well. The clinical psychologist is very important, not only for patients who have psychological morbidities but also to support patients who have chronic diseases. Now that we have biologics that are injectable, she also sees patients who have needle phobia. Other members of the multidisciplinary team who aren't always with us include, for example, a dietitian. Obesity is very important. There's no question that if patients who are very obese are able to lose weight, their symptoms can improve. There's not a set team that everybody should have, but there are clearly different comorbidities that need support.
Wechsler: Do you employ an asthma educator in your practice to work with patients on either inhaler technique or adherence? Tell me a little bit about that.
Jackson: In the UK, the asthma educator is fulfilled by a number of people, to be honest. But the asthma nurse — the clinical nurse specialist — is the main person who fulfills this role. She has the time to follow in the initial consultation with the physician, sit with the patient, and go through the key elements of asthma care, creating an asthma action plan. Regarding the importance of adherence and inhaler technique, it's our asthma nurses who are in many ways the backbone of our clinics supporting patients in this way.
Wechsler: In my practice, I've got the same setup. We have nurses and nurse practitioners, physical therapists, speech therapists, dietitians, and psychologists, as well. All of these people contribute in different ways to our understanding of asthma. In fact, I was talking to one of our psychologists yesterday who's evaluating the comorbidity of depression in asthma and sleep disturbances and asthma. There's a huge amount of insomnia and depression that's going on, and our psychologist is working in that regard. The other person who's sitting down the hall from me who we share office space with is our allergist. In your practice, do you also have allergists, and how do patients get referred to you as a respiratory pulmonologist vs referred to the allergist? How do you work hand in hand with the allergists in your practice?
Jackson: It's interesting because different countries have slightly different setups. It just so happens that in the UK, patients with the most severe asthma are managed by pulmonologists, not by allergists, so we're fairly unique in that regard. There's always a bit of a mix from country to country, but the UK is polarized toward pulmonology when it comes to severe asthma care. That's not to say we don't work with allergists; it's just that in the context of the main clinicians, the healthcare professionals looking after the severe asthma patients are really the pulmonologists. We've got a very good allergy department we work closely with. Clearly, in many patients with asthma, they have allergy-related comorbidities that need care. Similarly, we work with ENT folks for the same reason. Nasal polyps are incredibly common, and severe asthma is very debilitating. It's very important to have access to a good ENT colleague who can support that part of patient care.
Wechsler: It's a great segue to talking about the multitude of specialists involved in asthma care. And it's such a fascinating field because there are so many specialists that are involved. With our ENT doctors, it isn't just the nasal polyps but also all the other related diseases, the chronic rhinosinusitis, and the allergic rhinitis. And ENT doctors also help with evaluation of laryngeal vocal cord dysfunction and paradoxical vocal cord movement that can affect our patients. Tell me the interrelationship you have with your ENT doctors and what role they fulfill in that regard.
Jackson: I think it's absolutely right to say that they have a key role, both from the point of view of sinonasal disease but also laryngeal disease. I think they are ideal for diagnosing the problem. But actually, I think allied healthcare professionals, like the speech-language therapists, are in many ways more important for the day-to-day management of some of the laryngeal problems, going over the exercises that are necessary. In many cases, there isn't a quick fix from a medicine or a surgical procedure. Like with breathing pattern disorders and physiotherapists, they really need to work with the patients over a period of time. We work with the ENT surgeons to diagnose the problems and then with the therapists to support the patients in managing the problems.
Wechsler: Right. ENT doctors play a really important role in our practice, as well. They educate patients on exercises that can really help mitigate the symptoms that can contribute to the paradoxical vocal cord motion seen by many of these patients. And the speech therapists also are helpful for the many patients who have aspiration issues and who have significant cough as a result of not swallowing appropriately. What about reflux? What kind of workup do you do for your patients to evaluate them for some of the gastrointestinal diseases that contribute to severe asthma? And what role does the gastroenterologist play in your practice in the management of patients with severe asthma?
Jackson: The identification of reflux is really important. Often when you see a patient who is very symptomatic, they are coughing in front of you, but when you look at the spirometry, it's fairly normal. You look at their FeNO, and it's fairly normal, and you're thinking, hang on a minute — why are you coughing so much? Because the asthma markers that would be abnormal if their cough was really being triggered by poorly controlled asthma are not there. And for patients in whom we suspect reflux, we often would initially do an esophageal manometry. So, we pass a 24-hour pH probe and assess the level of the acidity in their esophagus as a first test. And we would then normally refer the patient with those esophageal manometry, pH probe, and esophagram results to the gastroenterologist so they have the results in front of them. Usually before that, we would at least give a trial of a proton pump inhibitor, such as omeprazole or lansoprazole, just to see if it is enough to control the suspected reflux. Sometimes we will pick up a hiatus hernia by chance on a CT scan we've done on the chest. That also gives you the clue there's likely to be some reflux contributing to their symptoms.
Wechsler: It's so important to do these kinds of evaluations because I find that in many of my patients, it isn't the asthma that's the problem, it's all these other diseases. And patients get started on all sorts of biologic therapies for what's perceived to be severe asthma with a lot of symptoms. But it's oftentimes the aspiration, the reflux, or the chronic rhinosinusitis that can really be a problem for these patients. It's so important to do that extensive workup. That's what we do here, as well. Now, what about patients with sleep apnea, and what role do some of the sleep specialists play in evaluating those patients? Maybe you can tell us how sleep apnea in and of itself can contribute to severe asthma.
Jackson: Sleep apnea is incredibly common, especially in patients who are obese. And it is something we always need to think about, especially when the patients describe disturbed sleep or excessive fatigue during the day, and poor sleep quality at night. Many patients will say they suddenly wake up in the middle of the night, and you really have to try and tease apart whether it's their asthma waking them up or something else. The standard overnight oximetry and sleep studies done by our colleagues in the sleep medicine department are very important in helping identify this, and we will always refer to them for this test if there's a high suspicion of sleep apnea. Again, I think biomarkers are important here simply because the type of patient who wakes up frequently at night due to their asthma usually has high T2 biomarkers. One of the first things a patient does when they take prednisolone to suppress their T2 inflammation is stop waking up at night. The steroids will cause insomnia. But separate from that, they stop waking up frequently. When you have a patient who describes waking up frequently gasping in the middle of the night, yet their FeNO is 15 ppb or 20 ppb, you think about what else is going on that may be driving this. And sleep apnea is a very important differential in that setting.
Wechsler: So, we discussed all these different comorbidities. We've talked about reflux, sinus disease, and obstructive sleep apnea. We talked about how to distinguish severe asthma from difficult-to-control asthma. What about some of the "zebras," and who are some of the specialists you work with? You mentioned EGPA — eosinophilic granulomatosis with polyangiitis. First, for our listeners, what is EGPA specifically, and who are the other doctors who might help you in terms of the management of patients with EGPA?
Jackson: EGPA is classically thought of as a vasculitis. It is grouped with some of the other vasculitides, like granulomatous polyangiitis, formally known as Wegener's granulomatosis, and is a small-to-medium vessel vasculitis. It's a multiorgan disease. What really distinguishes it from the other vasculitides is the presence of fairly profound eosinophilia in tissues. But what is important about EGPA and why we're talking about it today is because the vast majority of people with EGPA have bad asthma, and very commonly they have bad asthma with a significant sinonasal disease. They can look in many respects like some of your severe asthma patients who have nasal polyps, are very eosinophilic, and have steroid-responsive disease but are not able to control their asthma in the absence of systemic steroids. For these type of patients, when there's a suspicion of EGPA, it's really important to involve your rheumatology colleagues if you don't have expertise in this area. In many respects, these patients should be managed by rheumatology to ensure they get the best possible care.
Wechsler: Right. For many of these patients, they're going to be administered an anti–IL-5 therapy, which we feel very comfortable giving because it's been approved for patients with severe asthma or severe asthma with eosinophilia. But there are many other different approaches, such as or use of other immunosuppressants. It's important to think about all these patients with hypereosinophilia because they're another subset of patients you might be referring out for further evaluation. When might you refer patients with eosinophilia to an infectious disease specialist or to a hematologist to do a bone marrow evaluation?
Jackson: I think you do this when you have a patient who has a very high blood eosinophil count. Most of the patients who have, for example, an eosinophil count driven by a helminth infection will have a clonal eosinophilia problem. The eosinophil counts are several thousand in the vast majority of patients and not usually in the 1000-1500 cells/µL range. They're in most cases, much, much higher. When you're thinking about infectious diseases, these are patients who will usually have some gastrointestinal upset. They have a history of foreign travel. But it's important to remember that strongyloidiasis is frequently subclinical. So it is important to screen for it by serology when you think it's a possibility. And I think it's good practice to do it in almost everybody who has traveled to an area that is known to have helminth infections. Once it's been diagnosed, it's important to refer to infectious diseases, so the care team can then look at other potential pathogens or helminth infections that also may be present. In the context of primary eosinophilia when the count is very, very high, when the features don't really fit with just EGPA or just asthma, and there is that suspicion there, it's important to contact your hematology colleagues to discuss whether it's possible it is a primary hypereosinophilia that needs a bone marrow evaluation because the treatment algorithm will differ.
Wechsler: Wow. We've gone over so much today. David, it's been so great discussing all of this with you. I think the main take-home points we've learned today are that asthma is such a complicated entity, and we need a whole team in order to help manage our patients with severe and/or difficult-to-control asthma. We have to look at the differential diagnosis to make sure it is asthma. We need to address all the comorbidities like reflux, sinus disease, obstructive sleep apnea, and other issues. And we need to work with other specialists to help us tease out some of the "zebras" that are associated with patients with severe asthma. These are really exciting times for the management of asthma because we have all these biologic therapies, but it's also so important to go back to the basics. I think that's what we've learned today and what you focused on. Any closing thoughts, Dave, in that regard?
Jackson: I think it is exactly as you've said. When you see a patient who is not responding to high-dose inhaled steroids, bearing in mind that probably at least 95% of patients with asthma should respond to high-dose inhaled steroids, the first assumption is not that they have severe asthma. We need to confirm that the reason they aren't responding is not simply because it's a misdiagnosis or comorbidity, or most commonly, suboptimal adherence to inhaled therapy.
Wechsler: Thank you so much, Dave. Great comments. It's been a fabulous discussion. I'd like to thank our listeners for joining us today. We've had international expert Dr David Jackson discussing with us multidisciplinary approaches for moderate to severe asthma. Thank you all for joining us today for episode four, and I look forward to another great discussion in episode five. This is Mike Wechsler for InDiscussion.
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Cite this: Team Effort: A Multidisciplinary Approach to Severe Asthma Control - Medscape - Oct 04, 2022.