Highlights from

ATS 2019

American Thoracic Society international conference

Dallas, USA 17-22 May 2019

Type-2 Inflammation in Asthma

Interview with Prof. Christian Bergmann

Prof. Karl-Christian Bergmann is Chair of Centre for Severe Asthma at the Charité, Berlin, Germany. Prof. Bergmann is a pulmonologist and allergist. In 2006, he opened the first Center for Second Opinion on the use of biologics. The system is being used successfully throughout Germany today.

What are the unmet needs in Type-2 inflammation in clinical practice?

Type-2 asthma is characterised by Type-2 inflammation and typically includes different forms of asthma, e.g. allergic asthma, exercise-induced asthma, late-onset asthma, and moderate-to-severe eosinophilic asthma. In Type-2 inflammation in asthma, the inflammatory response is amplified by recruited eosinophils via a positive feedback loop. The inflammatory mediators secreted by eosinophils and other inflammatory cells lead to tissue damage, creating a cycle of chronic inflammation. Understanding the allergic, eosinophilic, and mixed allergic/eosinophilic phenotypes has been greatly advanced in recent years and has underpinned new approaches to improve asthma control, such as biologics aimed at inhibiting interleukin signalling.

However, despite the fact that these recent advances in understanding the pathophysiology driving Type-2 inflammation has led to clinical trials applying this knowledge to return aberrant signals to physiological levels, the primary unmet need remains the timely and accurate identification of the individual disease status in a given patient. Each patient requires a thorough assessment, more extensive than is currently the norm. The disease can be complex, but important clues can be found in accurate phenotyping in order to adequately manage Type-2 asthma.

What would you like to see change in routine management of Type-2 asthma?

There are two things I would really like to see change. Firstly, I would like to stress the value of routine analysis of fractional exhaled nitric oxide (FeNO). FeNO is a marker for airway inflammation and is a non-invasive, safe, and simple method of quantifying the degree of asthma inflammation. It can be used to assess whether airway inflammation is contributing to poor asthma control, particularly in the presence of other contributors such as rhinosinusitis, anxiety, gastroesophageal reflux, obesity, or continued allergen exposure. Beyond aiding the identification of an eosinophilic asthma phenotype in a patient, FeNO can also help establish a baseline reading during a period of clinical stability for subsequent monitoring of chronic persistent Type-2 asthma. Rechecking the nitric oxide levels can also be a tool to verify that the steroid inhalers are adequately suppressing the nitric oxide level. Every ambulance should be equipped with a portable device to measure FeNO; although this is rarely the case, at least in Germany.

Secondly, the initial evaluation and assessment of a new patient with suspected Type-2 asthma is an essential element in achieving an optimal and individualised care plan. The physician needs to expect to spend at least 25-30 minutes with a new patient to properly understand the extent and nature of their specific disease with the aim to decrease acute exacerbations and reduce the frequency of corticosteroid treatments. A skilled multidisciplinary team may be required to get the full picture. Combined FeNO and spirometry are recommended in addition to a thorough physical examination, in addition to supplemental laboratory tests.

The added value of careful and thorough patient evaluation is that one can use the collective phenotypes to assign asthma endotypes, wherein a specific biological pathway is identified that explains the observable properties of a phenotype, with the goal to improve therapy.

Article image: Medicom

The content and interpretation of these conference highlights are the views and comments of the speakers/authors.