Severe or therapy-resistant asthma is increasingly recognised as a major unmet need. A Task Force, supported by the European Respiratory Society and American Thoracic Society, reviewed the definition and provided recommendations and guidelines on the evaluation and treatment of severe asthma in children and adults. A literature review was performed, followed by discussion by an expert committee according to the GRADE (Grading of Recommendations, Assessment, Development and Evaluation) approach for development of specific clinical recommendations. When the diagnosis of asthma is confirmed and comorbidities addressed, severe asthma is defined as asthma that requires treatment with high dose inhaled corticosteroids plus a second controller and/or systemic corticosteroids to prevent it from becoming “uncontrolled” or that remains “uncontrolled” despite this therapy. Severe asthma is a heterogeneous condition consisting of phenotypes such as eosinophilic asthma. Specific recommendations on the use of sputum eosinophil count and exhaled nitric oxide to guide therapy, as well as treatment with anti-IgE antibody, methotrexate, macrolide antibiotics, antifungal agents and bronchial thermoplasty are provided. Coordinated research efforts for improved phenotyping will provide safe and effective biomarker-driven approaches to severe asthma therapy.

/pdf/international-ers-ats-guidelines-on-definition-evaluation-sedelwbk4v.pdf

International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma

Background: Dyspnea is a common, distressing symptom of cardiopulmonary and neuromuscular diseases. Since the ATS published a consensus statement on dyspnea in 1999, there has been enormous growth in knowledge about the neurophysiology of dyspnea and increasing interest in dyspnea as a patient-reported outcome.Purpose: The purpose of this document is to update the 1999 ATS Consensus Statement on dyspnea.Methods: An interdisciplinary committee of experts representing ATS assemblies on Nursing, Clinical Problems, Sleep and Respiratory Neurobiology, Pulmonary Rehabilitation, and Behavioral Science determined the overall scope of this update through group consensus. Focused literature reviews in key topic areas were conducted by committee members with relevant expertise. The final content of this statement was agreed upon by all members.Results: Progress has been made in clarifying mechanisms underlying several qualitatively and mechanistically distinct breathing sensations. Brain imaging studies have consist...

/pdf/an-official-american-thoracic-society-statement-update-on-1ya95r8mpq.pdf

An Official American Thoracic Society Statement: Update on the Mechanisms, Assessment, and Management of Dyspnea

The GRADE (Grades of Recommendation, Assessment, Development, and Evaluation) approach provides guidance to grading the quality of underlying evidence and the strength of recommendations in health care. The GRADE system's conceptual underpinnings allow for a detailed stepwise process that defines what role the quality of the available evidence plays in the development of health care recommendations. The merit of GRADE is not that it eliminates judgments or disagreements about evidence and recommendations, but rather that it makes them transparent. This first article in a three-part series describes the GRADE framework in relation to grading the quality of evidence about interventions based on examples from the field of allergy and asthma. In the GRADE system, the quality of evidence reflects the extent to which a guideline panel's confidence in an estimate of the effect is adequate to support a particular recommendation. The system classifies quality of evidence as high, moderate, low, or very low according to factors that include the study methodology, consistency and precision of the results, and directness of the evidence.

https://onlinelibrary.wiley.com/doi/pdf/10.1111/j.1398-9995.2009.01973.x

Grading quality of evidence and strength of recommendations in clinical practice guidelines. Part 1 of 3. An overview of the GRADE approach and grading quality of evidence about interventions.

Anxiety disorders and comorbid medical illness

Adolescents with a chronic condition: challenges living, challenges treating.

Rationale: Dyspnoea is a debilitating and distressing symptom that is reflected in different verbal descriptors. Evidence suggests that dyspnoea, like pain perception, consists of sensory quality and affective components. The objective of this study was to develop an instrument that measures overall dyspnoea severity using descriptors that reflect its different aspects. Methods: 81 dyspnoea descriptors were administered to 123 patients with chronic obstructive pulmonary disease (COPD), 129 with interstitial lung disease and 106 with chronic heart failure. These were reduced to 34 items using hierarchical methods. Rasch analysis informed decisions regarding further item removal and fit to the unidimensional model. Principal component analysis (PCA) explored the underlying structure of the final item set. Validity and reliability of the new instrument were further assessed in a separate group of 53 patients with COPD. Results: After removal of items with hierarchical methods (n = 47) and items that failed to fit the Rasch model (n = 22), 12 were retained. The ‘‘Dyspnoea-12’’ had good internal reliability (Cronbach’s alpha = 0.9) and fit to the Rasch model (x 2 p = 0.08). Items patterned into two groups called ‘‘physical’’(n = 7) and ‘‘affective’’(n = 5). In the separate validation study, Dyspnoea-12 correlated with the Hospital Anxiety and Depression Scale (anxiety r = 0.51; depression r = 0.44, p,0.001, respectively), 6-minute walk distance (r = 20.38, p,0.01) and MRC (Medical Research Council) grade (r = 0.48, p,0.01), and had good stability over time (intraclass correlation coefficient = 0.9, p,0.001). Conclusion: Dyspnoea-12 fulfills modern psychometric requirements for measurement. It provides a global score of breathlessness severity that incorporates both ‘‘physical’’ and ‘‘affective’’ aspects, and can measure dyspnoea in a variety of diseases.

https://thorax.bmj.com/content/thoraxjnl/65/1/21.full.pdf

Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12

1. A review of the impact of pre-operative education on recovery from surgery

Background
Many people have asthma, and for some their symptoms may be triggered by psychological factors. In addition, compliance with medical therapy may have a psychological dimension. Therefore, psychological interventions aim to reduce the burden of symptoms and improve management of the disease.

Objectives
To assess the effectiveness of psychological interventions for adults with asthma.

Search strategy
The Cochrane Airways Group Specialised Register and PsycINFO were searched with pre-defined terms up until May 2007.

Selection criteria
Randomised controlled trials published in any language assessing the effects of a psychological intervention compared with a form of control in adult participants were included in the review. Our primary outcome was healthcare resource defined as: hospitalisation, emergency room visits and/or GP visits

Data collection and analysis
Two reviewers assessed the relevance of abstracts identified by electronic searching and retrieved agreed studies for further scrutiny. The studies that met the inclusion criteria were assembled and data extracted.

Main results
Fifteen studies, involving 687 participants, were included in the review. Study quality was poor and sample sizes were frequently small. However, some pooled effects were analysed. Three studies measured our primary outcome but individually did not report significant differences between treatment and control. The use of 'as needed' medications was reduced in two studies, (47 patients), by relaxation therapy (OR 4.47, CI 1.22 to 16.44). There was no significant difference in FEV1 for relaxation therapy in four studies of 150 patients, (SMD -0.01, CI -0.41 to 0.40). Quality of life, measured using the Asthma Quality of Life Questionnaire in two studies, (48 patients), showed a positive effect following CBT (WMD 0.71, CI 0.23 to 1.19). Peak Expiratory Flow outcome data in two studies, (51 patients), indicated a significant difference in favour of bio-feedback therapy (SMD 0.66, CI 0.09 to 1.23) but no significant difference following relaxation therapy (WMD 43 L/min, CI -5 to 92 L/min). There was no statistically significant improvement in depression levels following relaxation therapy (SMD 0.17, CI -0.25 to 0.59). The remainder of the findings between studies were conflicting. This may have been due to the different types of interventions used and the deficiencies in trial design.

Authors' conclusions
This review was unable to draw firm conclusions for the role of psychological interventions in asthma due to the absence of an adequate evidence base. Larger, well-conducted and reported randomised trials are required in this area, in order to determine the effects of these techniques in the treatment of asthma in adults.

Psychological interventions for adults with asthma.

Psychological interventions for adults with asthma: A systematic review

Background. Dyspnea is a prominent symptom in asthma. The Dyspnea-12 (D-12), an instrument that quantifies breathlessness using 12 descriptors that tap the physical and affective aspects, has shown promise for the measurement of dyspnea in cardiorespiratory disease. Objective. We report the results of a study designed to test the validity and reliability of the D-12 in a population of patients with asthma. Methods. This cross-sectional study included 102 patients with asthma. Subjects completed the D-12, Hospital Anxiety and Depression scale, St. George’s Respiratory Questionnaire (SGRQ), and Medical Research Council scale. Confirmatory factor analysis confirmed the two-component structure of the D-12 (i.e., seven items that tap the physical aspects of breathlessness and five items that tap the affective aspects). Results. The D-12 subscales had excellent internal reliability (Cronbach’s alpha for the “physical” score was 0.94 and the affective score was 0.95). The D-12 physical component was more strongl...

Caroline Shuldham

Papers

Quantification of dyspnoea using descriptors: development and initial testing of the Dyspnoea-12

1. A review of the impact of pre-operative education on recovery from surgery

Psychological interventions for adults with asthma.

Psychological interventions for adults with asthma: A systematic review

Assessment of dyspnea in asthma: Validation of the dyspnea-12