Multimorbidity in Difficult Asthma: The Need for Personalised and Non-Pharmacological Approaches to Address a Difficult Breathing Syndrome

Judit Varkonyi-Sepp, Anna Freeman, Ben Ainsworth, Latha Perunthadambil Kadalayil, Hans Michael Haitchi, Ramesh J Kurukulaaratchy, Judit Varkonyi-Sepp, Anna Freeman, Ben Ainsworth, Latha Perunthadambil Kadalayil, Hans Michael Haitchi, Ramesh J Kurukulaaratchy

Abstract

Three to ten percent of people living with asthma have difficult-to-treat asthma that remains poorly controlled despite maximum levels of guideline-based pharmacotherapy. This may result from a combination of multiple adverse health issues including aggravating comorbidities, inadequate treatment, suboptimal inhaler technique and/or poor adherence that may individually or collectively contribute to poor asthma control. Many of these are potentially "treatable traits" that can be pulmonary, extrapulmonary, behavioural or environmental factors. Whilst evidence-based guidelines lead clinicians in pharmacological treatment of pulmonary and many extrapulmonary traits, multiple comorbidities increase the burden of polypharmacy for the patient with asthma. Many of the treatable traits can be addressed with non-pharmacological approaches. In the current healthcare model, these are delivered by separate and often disjointed specialist services. This leaves the patients feeling lost in a fragmented healthcare system where clinical outcomes remain suboptimal even with the best current practice applied in each discipline. Our review aims to address this challenge calling for a paradigm change to conceptualise difficult-to-treat asthma as a multimorbid condition of a "Difficult Breathing Syndrome" that consequently needs a holistic personalised care attitude by combining pharmacotherapy with the non-pharmacological approaches. Therefore, we propose a roadmap for an evidence-based multi-disciplinary stepped care model to deliver this.

Keywords: asthma; co-morbidity; difficult breathing syndrome; holistic treatment; multimorbidity; non-pharmacological; personalized; therapy; treatable traits; treatment.

Conflict of interest statement

The authors declare no conflict of interest, apart from B.A. who is a member of the UK Taskforce for Lung Health, has received honoraria for educational talks from Astra-Zeneca and sits on advisory boards for the Medito Foundation, earGym and Roche Ltd.

Figures

Figure 1
Figure 1
Schematic diagram of the “Difficult Breathing Syndrome” in difficult asthma. T2—Type 2 inflammation, ABPA—Allergic Bronchopulmonary Aspergillosis, SAFS—Severe Asthma with Fungal Sensitisation, COPD—Chronic Obstructive Pulmonary Disease, GORD—Gastro-oesophageal reflux disease.
Figure 2
Figure 2
Treatable Traits in the Wessex AsThma CoHort of difficult asthma (WATCH) study. ABPA—Allergic Bronchopulmonary Aspergillosis, SAFS—Severe Asthma with Fungal Sensitisation, COPD—Chronic Obstructive Pulmonary Disease, GORD—Gastro-oesophageal reflux disease, OSAHS—Obstructive Sleep Apnoea-Hypopnoea Syndrome, ILO—Inducible Laryngeal Obstruction.
Figure 3
Figure 3
The interaction of emotional, cognitive and behavioural processes with examples in the context of Difficult Breathing Syndrome. Based on Yii and Koch’s framework [40].
Figure 4
Figure 4
Non-pharmacological treatment approaches for the treatable traits of asthma and “Difficult Breathing Syndrome”.

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