This is part of the MD Magazine® Peer Exchange, “Precision Medicine in the Treatment of Severe Asthma.” Click here for Segment 2 and learn more about recognizing the burden of uncontrolled persistent asthma.
Peter Salgo, MD: Hello. Thank you for joining us for this MD Magazine® Peer Exchange entitled, “Precision Medicine in the Treatment of Severe Asthma.” A greater understanding of the molecular pathways associated with asthma has led to new therapeutic strategies, and that requires a more individualized approach. This MD Magazine® Peer Exchange panel of experts is going to provide an overview of recent advances and is going to discuss best practices in patient assessment and treatment, with a focus on the role for newer biologic therapies in the overall management of severe disease.
I’m Dr Peter Salgo. I’m a professor of medicine and anesthesiology at Columbia University College of Physicians and Surgeons. I’m also an associate director of Surgical Intensive Care at the NewYork-Presbyterian Hospital in New York City.
Joining me for this discussion are Dr Neal Jain, director of research for Arizona Allergy and Immunology Research and co-owner of San Tan Allergy & Asthma in Gilbert, Arizona; Dr David Rosenstreich, director of the Division of Allergy and Immunology at the Albert Einstein College of Medicine Montefiore Medical Center in New York, New York; and Dr Raffi Tachdjian, assistant professor of medicine and pediatrics at the David Geffen School of Medicine at UCLA, in Los Angeles, California. Thank you all for joining us. Let’s get to work, shall we?
Asthma is a tricky disease. When I was in medical school, asthma was asthma. But nothing stays that way forever. Now it looks like it’s pretty heterogeneous. How do you define asthma?
Neal Jain, MD: The classic textbook definition would be that it’s a chronic disease of the airways that typically manifests by airway inflammation whereby there is at least some reversible airflow obstruction.
Peter Salgo, MD: Now, that’s a clinical definition?
Neal Jain, MD: Absolutely.
Peter Salgo, MD: The more I think about it, I think it’s more of a lab definition. From a clinician’s perspective, if someone comes in wheezing, what is that person thinking? Asthma?
Raffi Tachdjian, MD: Right.
Peter Salgo, MD: Is that so far from correct?
Raffi Tachdjian, MD: Well, you can also look at the cardinal signs and go to the textbook with it—with wheezing, chest tightness, shortness of breath, or cough. But in essence, part of it is your gut feeling of, How often is this getting in the way of life, and what is the impact on the person’s health?
Peter Salgo, MD: One of the things I have noticed is that a lot of people with asthma present more with a cough than with a wheeze. Why is that?
Neal Jain, MD: One of the challenges in asthma, alluding to sort of what you were just mentioning, is that asthma can be variable. People will have coughing. They’ll have wheezing. They’ll have shortness of breath. Those symptoms can occur at various times—sometimes with activity, sometimes without. And because there are other conditions that can manifest similarly, it makes it a challenge. People come in with wheezing for a variety of reasons. They come in with a cough for a variety of reasons. Trying to know whether or not it is asthma is a challenge that we’re all faced with.
Peter Salgo, MD: Now, the other thing I hear about all the time is expiratory airflow limitation. Why couldn’t inspiratory airflow limitation be asthma as well? Or can it?
David Rosenstreich, MD: Well, it’s airway obstruction. The airways are narrowed. It’s easier to breathe in than it is to breathe out. You pick it up more on the breathing out. The patients actually don’t perceive that. They rarely perceive whether it’s in or out. They just feel that their chest is tight.
That’s primarily what they come in with. It’s, I think, the leading symptom they feel. They feel discomfort. They feel that their chest is tight. They know they’re just not getting enough air, and that’s how they show up.
Neal Jain, MD: From an inspiratory/expiratory standpoint, typically we’re taught that inspiratory airflow obstruction is something that’s related to your upper airway. That has to do with the dynamics and the physiology of our airways, whereas lower airway obstruction is going to manifest as expiratory difficulty.
Peter Salgo, MD: If you think about the pressure relationships and the thorax and the upper airway, if you increase the volume, you will dilate your airways below the glottis. That makes it easier. And then, if you try to breathe in with an obstruction above the glottis, that’s going to flap shut.
Transcript edited for clarity.