Seminars in respiratory and critical care medicine
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Semin Respir Crit Care Med · Oct 2022
Structural Inequities in Medicine that Contribute to Racial Inequities in Asthma Care.
Structural inequities in medicine have been present for centuries in the United States, but only recently are these being recognized as contributors to racial inequities in asthma care and asthma outcomes. This chapter provides a systematic review of structural factors such as racial bias in spirometry algorithms, the history of systemic racism in medicine, workforce/pipeline limitations to the presence of underrepresented minority health care providers, bias in research funding awards, and strategies to solve these problems.
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Asthma is a heterogeneous disease characterized by chronic airway inflammation that affects more than 300 million people worldwide. Clinically, asthma has a widely variable presentation and is defined based on a history of respiratory symptoms alongside airflow limitation. Imaging is not needed to confirm a diagnosis of asthma, and thus the use of imaging in asthma has historically been limited to excluding alternative diagnoses. ⋯ Techniques such as computed tomography, magnetic resonance imaging with gaseous contrast agents, and positron emission tomography enable assessment of the small airways. Others, such as optical coherence tomography and endobronchial ultrasound enable high-resolution imaging of the large airways accessible to bronchoscopy. These imaging techniques are providing new insights in the pathophysiology and treatments of asthma and are poised to impact the clinical management of asthma.
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Asthma represents one of the biggest global health concerns with increasing prevalence and influence on global health. Several distinct asthma phenotypes have been identified with one of the most common, earliest recognized, and described being the allergic asthma phenotype, in which allergens trigger asthma through mechanisms involving allergen-specific immunoglobulin E (IgE). Allergen-specific immunotherapy (AIT), in the forms of subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT), has been used for many decades as a tool for reducing IgE-mediated sensitization and controlling symptoms of allergic disease, most commonly for allergic rhinitis, and it remains the only currently available disease modifying therapy in atopic patients. ⋯ Patients with severe asthma are excluded from these trials. Importantly, patients with asthma, and in particular severe asthma, may have a higher rate of systemic adverse reactions to SCIT, including anaphylaxis; however, these events are overall rare. Future research in the area is needed to definitively assess the benefit of SCIT and SLIT for patients with asthma, comparing outcomes with different methods, addressing the role of AIT in severe asthma, significance of multiallergen AIT in allergic asthma, and safety concerns in asthma.
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In little over a generation, the ingenuity of scientists and clinician researchers has developed inhaled medications and pathway-specific biological agents that control the inflammation and physiology of asthma. Unfortunately, whether it is because of cost or difficulty understanding why or how to use inhaled medications, patients often do not take these medications. The consequences of poor treatment adherence, loss of control and exacerbations, are the same as if the condition remained untreated. ⋯ In this article, we discuss the rationale for and the delivery of successful interventions to improve medication adherence in asthma. We contextualize these interventions by describing the causes of poor treatment adherence and how adherence is assessed. Finally, future perspectives on the design of new interventions are described.
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Exposure and sensitization to environmental factors play a fundamental role in asthma development and is strongly associated with asthma morbidity. While hereditary factors are critical determinants of asthma, exposures to environmental factors are implicated in the phenotypic expression of asthma and have been strongly associated in the risk of its development. Significant interest has thus been geared toward potentially modifiable environmental exposures which may lead to the development of asthma. ⋯ In the home, multifaceted and multitargeted environmental control strategies have been shown to reduce home exposures and improve asthma outcomes. In addition to the home environment, assessment of the school, daycare, and workplace environments of patients with asthma is necessary to ensure appropriate environmental control measures in conjunction with medical care. This article will discuss the role of the environment on asthma, review targeted environmental therapy, and examine environmental control measures to suppress environmental exposures in the home and school setting.