American journal of respiratory and critical care medicine
-
Am. J. Respir. Crit. Care Med. · Jun 2020
Randomized Controlled Trial Observational StudyThe Relationship Between Symptoms, Exacerbations and Treatment Response in Bronchiectasis.
Rationale: Bronchiectasis guidelines regard treatment to prevent exacerbation and treatment of daily symptoms as separate objectives. Objectives: We hypothesized that patients with greater symptoms would be at higher risk of exacerbations and therefore that a treatment aimed at reducing daily symptoms would also reduce exacerbations in highly symptomatic patients. Methods: Our study comprised an observational cohort of 333 patients from the East of Scotland (2012-2016). ⋯ Inhaled mannitol treatment improved the time to first exacerbation (hazard ratio, 0.56; 95% CI, 0.40-0.77; P < 0.001), and the proportion of patients remaining exacerbation free for 12 months of treatment was higher in the mannitol group (32.7% vs. 14.6%; RR, 2.84; 95% CI, 1.40-5.76; P = 0.003), but only in highly symptomatic patients. In contrast, no benefit was evident in patients with lower symptom burden. Conclusions: Highly symptomatic patients have increased risk of exacerbations, and exacerbation benefit with inhaled mannitol was only evident in patients with high symptom burden.
-
The stepwise approach to pharmacological treatment in adult asthma mandates that asthma treatment is progressively stepped up to achieve symptom control and reduce the risk of exacerbations and stepped down after a period of prolonged control. This review proposes that in adults without good asthma control, well-controlled asthma can only be achieved in approximately 70% of patients across the strata of severity, and only if there is a progressive increase in inhaled corticosteroid/long-acting β2 agonist therapy to a maintenance inhaled corticosteroid dose that causes the same magnitude of systemic side effects as oral prednisone at a 5-mg daily dose. ⋯ Finally, it is widely assumed that asthma symptom control equates to elimination of risk of asthma attacks, an assumption that may not apply to many patients, particularly those with more severe asthma. We propose that further research be undertaken to determine the optimal levels of asthma control and the potential value of different treatment targets, such as control of type-2 airway inflammation, that can be achieved with currently available treatment, based on efficacy, side effects, and cost.