“Severe asthma is much more than just a disease of the airways, it affects many aspects of the person’s life“ said Professor Vanessa McDonald from the School of Nursing and Midwifery at the University of Newcastle. “Despite a greater understanding of the respiratory condition and more treatments available to manage severe asthma,^1,2 recent data shows us that the impact of this disease on patients’ quality of life has gone largely unchanged over at least a decade.”^3,4

It’s time to start changing the way we approach severe asthma

We need to talk the same talk

“Living well with severe asthma is a challenge for patients, even in today’s times where we have treatments that reduce the risk of exacerbation or hospitalisation.” Prof. McDonald immediately corrected herself, making the point “I should say reducing the risk of attack. We’ve recently published data that demonstrated the terminology we use when we talk about severe asthma matters to patients. People living with severe asthma describe severe exacerbations as ‘attacks’¹ and while clinically we describe them as the former, some patients feel this term trivialises their experience.”^5,6

Be cognisant of the extra-pulmonary impact

Prof. McDonald noted how important it is to recognise that people with severe asthma are not just battling the disease itself, they’re often battling comorbidities that place a significant burden on their quality of life. “People with severe asthma face many challenges. Going right back to basics, think about diagnosis – this is often delayed meaning people may experience cycles of hope and failure before they arrive at a diagnosis. People with severe asthma also talk about fear of their next attack and how this impacts their ability to be active and socialise, which ultimately impacts their relationships, mental health and physical condition.¹ People with severe asthma describe the impact as relentless, unable to switch it off completely. Despite they are also resilient and discuss how they adapt and make the most of things, despite that it continues to impact every aspect of their life on a daily basis.”^1,7  This highlights the need for multidimensional approaches to care.

Severe asthma during COVID-19

Prof. McDonald said COVID-19 was a particularly stressful time for people with severe asthma and that we may see the impact of this crisis on patients for some time to come. “Patients with severe asthma often live with a heightened sense of anxiety in relation to their fear of the next attack,” she explained. “Patients will be worried about the risk the COVID-19 poses on them and may feel even more socially isolated and economically vulnerable than they were. It can also be a self-perpetuating cycle in that patients may decrease their already limited physical activity, which in turn impacts not only their asthma, but comorbidities as well. In times like this we need to make a point of checking in regularly on the holistic management of people with severe asthma.”

Adopt a treatable traits approach

“There’s now evidence to suggest taking a personalised approach to severe asthma patient care achieves good outcomes,” explained Prof. McDonald. “We undertook a randomised controlled trial (RCT) to evaluate the effect of multidimensional assessment and targeted management in severe asthma.⁸ Importantly we didn’t just look at pulmonary interventions, we also looked at extrapulmonary treatments, risk factor modification, education and treatment adherence initiatives.  Importantly the implementation of the treatment plan was supported by a case-manager.⁸ There were a couple of important findings:⁸

• The burden of severe asthma is multi-dimensional, with patients exhibiting around 10 traits per person within the pulmonary, extra-pulmonary and risk-factor domains
• When these traits are targeted with personalised interventions it results in significant improvements in patients’ health-related quality of life.

“With patients expressing many traits, identifying the traits to prioritise is an important clinical question”. Prof. McDonald explained “identifying traits that impact future risk of attacks and quality of life is important as is having these conversations with the patients”. Including patients in the discussion about what’s most important or most troubling for them can help guide the management plan. When you tackle the individual problems, be it oral corticosteroid burden or weight gain, inflammation or smoking, you and the patient can be focussed on improving those traits. What’s also great is that with each success you can build patient hope and trust, which are important for the success of ongoing management.”

Personalised models of care

“We know that the impacts of severe asthma also extend beyond the individual  patient,⁸ it also impacts their family and healthcare system. With better identification of severe asthma there is a greater demand on severe asthma health services. In adopting a personalised approach, some aspects of care may be better delivered in the community using multidisciplinary teams across primary and tertiary care,” explained Prof. McDonald.

Prof. McDonald noted community-based multidisciplinary care could enable an increased capacity in the tertiary sector. However, she also emphasised that “community-based care requires implementation of systems to monitor and promote adherence to treatment. This is to ensure patients take treatments as intended and are not lost to follow up by specialist services.”

Reflecting on expanding healthcare services for severe asthma, Prof. McDonald acknowledged that support programs may play a role. “Access to support programs can help in the optimisation of severe asthma services for patients in the community,” she noted. “The key is always going to be personalising the approach and seeing how the treatment and delivery suits the person in front of you.”

This article was developed by the Limbic at the request of and with funding from GSK.

References

1. McDonald VM, Kennington E, Hyland ME. Understanding the experience of people living with severe asthma. In: Chung KF, Israel E, Gibson PG, eds. Severe Asthma (ERS Monograph). Sheffield, European Respiratory Society, 2019; pp. 16–29.
2. Holguin F, et al. Eur Respir J 2020; 55: 1900588.
3. Stubbs MA, et al. Breathe 2019;15: e40–e49.
4. Katsaounou P, et al. ERJ Open Res 2018; 4: 00076-2018.
5. Jones KA, et al. Journal of Asthma. 2019;DOI: 10.1080/02770903.2019.1665064.
6. Pavord ID, et al. Lancet. 2017.
7. Foster JM, et al. Eur Respir J 2017; 50: 1700765.
8. McDonald VM, et al. Eur Respir J 2020; 55: 1901509.