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Chest clinic
Case based discussions
Practical phenotyping of difficult asthma
  1. Angela Thomas1,
  2. Ruth H Green2,
  3. Robert M Niven3,
  4. Shiron Saha4,
  5. Ian Hall5,
  6. Liam G Heaney6,
  7. Ian Sabroe4,7
  1. 1Department of Respiratory Medicine, University Hospital of North Staffordshire, Stoke-on-Trent, UK
  2. 2Department of Respiratory Medicine, Glenfield Hospital, Leicester, UK
  3. 3North West Lung Centre, University Hospital of South Manchester, Wythenshawe Hospital, Manchester, UK
  4. 4Sheffield Thoracic Institute, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK
  5. 5Division of Therapeutics and Molecular Medicine, University Hospital of Nottingham, Nottingham, UK
  6. 6Centre for Infection and Immunity, School of Medicine, Dentistry and Biomedical Sciences, Queen's University Belfast, Belfast, UK
  7. 7Academic Unit of Respiratory Medicine, Department of Infection and Immunity, University of Sheffield, Sheffield, UK
  1. Correspondence to Professor Ian Sabroe, Academic Unit of Respiratory Medicine, Department of Infection and Immunity, Medical School, University of Sheffield, Beech Hill Road, Sheffield S10 2RX, UK; i.sabroe{at}sheffield.ac.uk

https://doi.org/10.1136/thoraxjnl-2013-203568

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    Key messages

    • The basics are important: in the poorly controlled asthmatic, examine and readdress adherence and inhaler technique.

    • In the poorly controlled asthmatic or a well-controlled patient on high levels of treatment, address other comorbidities or causes of lung disease, including smoking and obesity.

    • The number of specific asthma phenotypes remains uncertain, but divides reasonably clearly into eosinophilic and non-eosinophilic disease.

    • Historical data on blood eosinophilia, variability in lung function and airways pressure/PaCO2 during episodes of ventilation are important in the guidance of management and for providing for onward referral.

    Asthma comprises multiple but incompletely understood and characterised clinical phenotypes. We created two imaginary but typical cases and presented them to asthma specialists. This text summarises responses, which are presented in greater length in the online supplement.

    An overweight ex-smoker with airflow obstruction and moderately high treatment needs

    AT: What should I do with a 40-year-old woman, body mass index (BMI) 32, ex-smoker with 10 pack-year history, asthma as a child, with a 4-year history of episodic breathlessness, cough and wheeze? Exercise tolerance has become progressively more limited. She has received several courses of oral prednisolone with only temporary improvement and currently on combined inhaled corticosteroid (ICS) and long-acting β-agonist (LABA). Spirometry shows forced expiratory volume in the first second (FEV1) 2.08 (65%), forced vital capacity (FVC) 3.15 (80%), ratio 66%. Predicted values were 3.21/3.94. Her FeNO was 42 ppb.

    RG, RN, LH, IH: The most important thing to determine is if this is eosinophilic or non-eosinophilic asthma. These asthma phenotypes are discussed in the Commentary section below. To determine if eosinophilic disease is or has been present, we would look at historical blood counts in stable state and during exacerbations, induced sputum where available, and perhaps gain support from tests for atopy. We all suspect this first case is probably one of non-eosinophilic asthma. The measurement of FeNO is probably not …

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    Footnotes

    • Contributors AT and IS conceived the article. AT interviewed the participants and summarised the transcripts. The article was written by IS with contributions from all the authors.

    • Funding None.

    • Competing interests None.

    • Provenance and peer review Not commissioned; externally peer reviewed.