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Review
. 2021 Dec 15;47(6):e20210273.
doi: 10.36416/1806-3756/e20210273. eCollection 2021.

2021 Brazilian Thoracic Association recommendations for the management of severe asthma

[Article in English, Portuguese]
Regina Maria de Carvalho-Pinto  1 , José Eduardo Delfini Cançado  2 , Marcia Margaret Menezes Pizzichini  3 , Jussara Fiterman  4 , Adalberto Sperb Rubin  5   6 , Alcindo Cerci Neto  7   8 , Álvaro Augusto Cruz  9   10 , Ana Luisa Godoy Fernandes  11 , Ana Maria Silva Araujo  12 , Daniela Cavalet Blanco  13 , Gediel Cordeiro Junior  14   15 , Lilian Serrasqueiro Ballini Caetano  11 , Marcelo Fouad Rabahi  16 , Marcelo Bezerra de Menezes  17 , Maria Alenita de Oliveira  18 , Marina Andrade Lima  19 , Paulo Márcio Pitrez  20
Affiliations
Review

2021 Brazilian Thoracic Association recommendations for the management of severe asthma

[Article in English, Portuguese]
Regina Maria de Carvalho-Pinto et al. J Bras Pneumol. .

Abstract
in English, Portuguese

Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.

Os avanços no entendimento de que a asma grave é uma doença complexa e heterogênea, e os progressos que ocorreram no conhecimento de sua fisiopatologia, com a identificação de diferentes fenótipos e endotipos, permitiram novas abordagens para seu diagnóstico e caracterização, bem como resultaram em mudanças consideráveis em seu manejo farmacológico. Nesse contexto, se estabelece a definição de asma grave, diferenciando-a da asma de difícil controle. As presentes recomendações abordam esse tópico e revisam os avanços referentes a fenotipagem, uso de biomarcadores e novos tratamentos para asma grave. Ênfase é dada para tópicos voltados para a seleção personalizada do paciente e do imunobiológico, bem como para a importância da avaliação da resposta ao tratamento. Estas recomendações se aplicam a adultos e crianças com asma grave e destinam-se a médicos envolvidos no tratamento da doença. Um painel de 17 pneumologistas brasileiros foi convidado a revisar as evidências recentes referentes ao diagnóstico e manejo da asma grave, adaptadas à realidade brasileira. A cada um dos especialistas coube revisar um tópico ou questão relevante em relação ao tema. Em uma segunda fase, quatro especialistas discutiram e estruturaram os textos elaborados, e, na última fase, todos revisaram e aprovaram o presente manuscrito e suas recomendações.

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Figures

Figure 1
Figure 1. Flow chart of severe asthma diagnosis and phenotyping. ACQ: Asthma Control Questionnaire; ACT: Asthma Control Test; VCD: vocal cord dysfunction; GERD: gastroesophageal reflux disease; OSA: obstructive sleep apnea; ABPA: allergic bronchopulmonary aspergillosis; ICS: inhaled corticosteroid; LABA: long-acting β2-agonist; LAMA: long-acting muscarinic antagonist; OCS: oral corticosteroid; EosIS: eosinophils in induced sputum; EosPB: eosinophils in peripheral blood; FeNO: fractional exhaled nitric oxide.
Figure 2
Figure 2. Inflammatory mechanisms of T2-high asthma phenotype. The figure schematically represents the main cells and cytokines involved in the adaptive and innate inflammatory response of the T2-high phenotype in severe asthma. In genetically susceptible individuals, inhalation of allergens (adaptive immunity), smoke, bacteria, and viruses (innate immunity) initiates and perpetuates the T2-high inflammatory cascade. TSLP: thymic stromal lymphopoietin; TCR: T-cell receptor; MHC2: major histocompatibility complex class 2; GATA3: transcription factor encoded by the GATA3 gene; ILC2: group 2 innate lymphoid cells; PGD2: prostaglandin D2; ECP: eosinophil cationic protein; MBP: major basic protein; EPO: eosinophil peroxidase.
Figure 3
Figure 3. Assessment of response to treatment with biologicals. ACQ: Asthma Control Questionnaire; ACT: Asthma Control Test; OCS: oral corticosteroid.
See this image and copyright information in PMC

Comment in

References

    1. Ray A, Camiolo M, Fitzpatrick A, Gauthier M, Wenzel SE. Are We Meeting the Promise of Endotypes and Precision Medicine in Asthma . Physiol. Rev. 2020;100(3):983–1017. doi: 10.1152/physrev.00023.2019. - DOI - PMC - PubMed
    1. J Bras Pneumol 2020 Brazilian Thoracic Association recommendations for the management of asthma. J Bras Pneumol. 2020;46(1):e20190307. doi: 10.1590/1806-3713/e20190307. - DOI - PMC - PubMed
    1. Chung KF, Wenzel SE, Brozek JL, Bush A, Castro M, Sterk PJ. International ERS/ATS guidelines on definition, evaluation and treatment of severe asthma [published correction appears in Eur Respir. 2014;43(4):1216–1216. doi: 10.1183/09031936.00202013. - DOI - PubMed
    1. Global Initiative for Asthma [homepage on the internet] Global Strategy for Asthma Management and Prevention. Bethesda: Global Initiative for Asthma; c2021. https://ginasthma.org/wp-content/uploads/2021/05/GINA-Main-Report-2021-V...
    1. Bousquet J, Mantzouranis E, Cruz AA, Aït-Khaled N, Baena-Cagnani CE, Bleecker ER. Uniform definition of asthma severity, control, and exacerbations document presented for the World Health Organization Consultation on Severe Asthma. J Allergy Clin Immunol. 2010;126(5):926–938. doi: 10.1016/j.jaci.2010.07.019. - DOI - PubMed