Predicting Exacerbation of Asthma

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: On that point of recurrence, I’m going to turn it back to you, Dr Siri. What are the factors that influence the recurrence of these exacerbations? Are we at a point in history where we can start predicting or have tools to catch these earlier before they completely exacerbate and are out of our hands? Not just emergency care—they might be in the intensive care unit.

Dareen D. Siri, MD, FAAAAI, FACAAI: Many things could predict exacerbation rates. One is environmental triggers. We talked about seasonal asthma, for example. They could be allergic triggers, mites, pollutants irritants, and occupational hazards for some patients. There can be other factors, like tobacco smoke. We see a lot of respiratory infections during the fall, winter, and post–COVID-19 there may be more in the spring. We’re seeing things such as viral infections, a lot of colds, cases of the flu, and things like that.

Beyond that, there’s also this layer of undertreatment, whether it’s from nonadherence to medication, patients not understanding the full concept of preventive medications, and not relaying that information to their primary care doctor and specialists. As a result, we undertreat them. That can be a major risk factor for severe exacerbations. There are also psychological implications. There are patients who are depressed. Maybe they’re not doing the things that they want to do. Maybe this is a burden that they hadn’t thought about. We always have to think about the patient perspective and their psychology.

Besides that, the most important factors when we treat—and we’re talking about type 2 inflammation—are comorbid diseases. CRS [chronic rhinosinusitis] with nasal polyps is a huge trigger for many of our patients when they have sinusitis and nasal polyps. When that exacerbates, it tracks along with asthma exacerbations, whether it’s a consequence or a correlation. That’s huge. Also, gastroesophageal reflux disease, obesity, and even allergies. Those comorbidities have to be taken into account when we think about things that may lend to the fact that the patient might have more severe exacerbations.

Objectively, we can measure lung function. From a specialist perspective that can be spirometry, which measures force export volume in 1 second. It also measures volume and speed by tidal volume and forced exhalations. Every patient with moderate to severe asthma deserves spirometry every year, as demonstrated by the guidelines. But it’s hard in a primary care setting. It’s difficult for primary care doctors to have access to spirometry. I don’t think it’s a difficult technology to incorporate in their office, but it would be really useful for patients. If they can’t get it through the hospital or a specialist, they can incorporate it in their office. As a surrogate, they may do peak expiratory flow rate, which may be helpful because a fall in peak expiratory flow could represent that a patient is heading for an exacerbation. Biomarkers are another way to look at whether a patient may have a risk for severe exacerbations and certain symptoms. This is easy to do in a primary care setting. We have validated questionnaires like the Asthma Control Test and the Asthma Control Questionnaire. This can be implemented easily in primary care or specialist setting to follow a patient to see if they’re at risk for a severe exacerbation.

Raffi Tachdjian, MD, MPH, FAAAAI, FACAAI: Kudos for enunciating and spelling out all the acronyms that take forever to do. You did it flawlessly. Thank you.

Transcript edited for clarity