ERS 2020 Articles

Rethinking asthma

Discover the latest updates in asthma diagnosis, treatment and management from ERS International Congress 2020 Virtual. From the contribution asthma phenotypes and endotypes could make in daily clinical practice to the latest research on the role of pharmacotherapy in the management of disease.

Despite significant advances in asthma diagnosis, treatment and management, the burden of asthma remains high¹. A hot topic at European Respiratory Society (ERS) 2020 this year was the need to rethink asthma, sharing the latest updates on diagnosis, treatment and management.

The following sessions are some of the highlights you may have missed, examining the role of existing therapies and addressing the concerns around the use of oral and inhaled corticosteroids. New treatments across the spectrum of asthma as well as the role that asthma phenotypes and endotypes may play in daily clinical practice were also featured.

Maximising the benefits of inhaled therapies in asthma

In this session, Professor Christine Jenkins alongside Professors Kenneth Chapman and Richard Van Zyl-Smit, addressed the current challenges in maximising the benefits of inhaled asthma therapies such as treatment mismatch (patients remaining uncontrolled despite use of long-acting β₂-agonist/inhaled corticosteroid [ICS/LABA]), low adherence and the misuse of inhaler devices.

The panel also shared new evidence and key clinical data related to new inhaled therapies – indacaterol/glycopyrronium/mometasone furoate (IND/GLY/MF) and IND/MF via Breezhaler^®.

Professor Kenneth Chapman explored uncontrolled asthma in the 21st century, sharing insights into the importance of asthma control, the relationship between exacerbations and control as well as adherence and persistence - two fundamental issues for improving control.

Two presentations by Professors Richard Van Zyl-Smit and Christine Jenkins focussed on maximising the potential of inhaled therapies. These presentations shared the results of the Novartis ‘PLATINUM’ programme which included the QUARTZ, PALLADIUM, IRIDIUM and ARGON studies. These studies characterised the efficacy and safety profile of IND/MF and IND/GLY/MF in patients with uncontrolled asthma.

Focusing on lung function, Professor Van Zyl-Smit demonstrated how once daily IND/MF showed sustained lung function benefits over twice-daily MF or twice-daily high-dose salmeterol/fluticasone propionate (SAL/FLU) and how once-daily IND/GLY/MF had sustained lung function benefits over IND/MF, twice-daily SAL/FLU and a free combination of SAL/FLU + tiotropium (TIO).

Professor Jenkins then described the secondary outcomes of the studies, including asthma control and asthma exacerbations.

She revealed that once-daily high-dose IND/GLY/MF significantly improved asthma control compared with both SAL/FLU and a free combination of SAL/FLU + TIO. Further, once-daily high-dose IND/GLY/MF significantly reduced the rate of all exacerbations compared with twice-daily SAL/FLU and moderate exacerbations compared with free combination SAL/FLU + TIO. Both IND/GLY/MF and IND/MF were well tolerated, with comparable safety across treatment arms.

Ending with a panel discussion, the faculty discussed key topics such as the extent to which complexity is driving poor adherence, the most important components that account for the efficacy of the new IND/GLY/MF combination regimen and the practicalities of stepping up and stepping down from these three drug regimens.

Rethinking asthma

This fascinating session, chaired by Professors Daiana Stolz and Thomas Geiser, aimed to give insights into management strategies and new treatments across the spectrum of asthma as well as present the evolution in our understanding of asthma phenotypes and endotypes and their relevance in daily clinical practice.

Until 2018, step one in the Global Initiative for Asthma (GINA) guidelines for the treatment of mild asthma was short-acting β₂-agonist (SABA), as needed. In the first presentation, Professor Roland Buhl shared the results of the open-label START trial and the benefits of moving to a fixed ICS/formoterol combination as needed for patients with mild asthma, to reduce exacerbations.

Professor Celeste Michala Porsbjerg discussed how to assess eligibility for biological treatments, how predictors of clinical effect have been identified for all available biologicals and the necessity of including predictors of clinical effect in pre-treatment assessments.

Exploring the biology and treatment of responders and non-responders in asthma, Professor Marco Idzko specifically highlighted the need for a better understanding of immunology, further biomarkers for predicting therapy response and new treatments for T2-high and T2-low asthmatics.

Ending with an exciting pro-con debate, Professors Anke-Hilse Maitland-van der Zee and Parameswaran Nair debated whether severe neutrophilic asthma is a separate entity.

Arguing the case ‘for’, Professor Maitland-van der Zee explained the different causes of neutrophilia, the identification of more than one phenotype and the potential to identify sub-phenotypes and optimal treatment.

Advocating that neutrophilic asthma is not a separate entity, Professor Parameswaran Nair suggested that intense neutrophilia could be the result of an unrecognised airway infection and highlighted that targeting non-T2 pathways had so far not led to improvements in asthma control.

Notable mentions

A wide range of sessions and ePosters, on the hot topic of rethinking asthma, were presented at ERS 2020. Here are some other notable sessions and ePosters you may have missed:

‘Relevant Endpoints in Asthma Patients (REAP)’ chaired by Professor Kenneth Chapman, was an intriguing session focusing on the importance of selecting relevant endpoints for the treatment of patients with asthma.

Looking at the results of the Novartis ‘PLATINUM’ programme, there were also posters on the results of the IRIDIUM, PALLADIUM and ARGON with Professor Kenneth Chapman, Dr Matthias Krüll and Professor Christian Gessner.

This type of research is improving the understanding of asthma and allowing physicians to rethink the diagnosis, treatment and management strategies to help reduce the burden of disease.

References

1. Gruffydd-Jones K. Unmet needs in asthma. Ther Clin Risk Manag. 2019;15:409–421.

Digital health in airway disease

Find out the latest updates on digital health in airway disease including the potential role of digital technology to enhance the diagnosis, treatment and management of asthma from ERS International Congress 2020 Virtual.

Around the world, digital technology is becoming an ever-growing presence in daily life. The surge of these new technologies is also giving rise to new opportunities in the diagnosis and management of conditions such as asthma, chronic obstructive pulmonary disease (COPD) or interstitial lung disease (ILD).

The following sessions are some of the highlights you may have missed at European Respiratory Society (ERS) 2020, discussing topics such as enhancing asthma classification and precision medicine as well as a look at existing technology and what the future may bring for digital health.

AI: are the doctors still needed?

From playing chess to driving cars, artificial intelligence (AI) is beginning to change the world around us. In this session on the use of AI in respiratory medicine, Dr Marko Topalovic posed the question - with the development of AI, are doctors still needed?

To answer this, Dr Topalovic described what makes AI intelligent and how AI can use data from asthma, COPD or ILD patients to learn their characteristics. The ability to learn from large quantities of data has already given AI a large range of capabilities including aiding diagnoses, robot-assisted surgeries and medication management.

Dr Topalovic also shared the capabilities of AI in the three main fields that are pioneering AI research in respiratory medicine - thoracic imaging, histopathology and cytology, and physiological measurements.

But what lies in store for AI in the future? Do doctors still have a place in medicine? Ending the session on a positive note, Dr Topalovic also explained the various ways in which AI is a great tool to enhance the work carried out by doctors.

Digital health: a brave new world?

This symposium covered a wide range of updates on digital health from the utility of sensors, trackers and monitors to the promising role of artificial intelligence in future digital trials.

Dominique Hamerlijnck gave an overview of recent advances in using e-Health to help patients and the importance of trust in algorithms and the doctor-patient relationship.

To ensure that caregivers are fully taking advantage of technology and digital services, Professor Lars Kayser shared a new multi-dimensional model for eHealth literacy and the need to develop digital resources that are accessible.

Dr Omar Usmani identified the drivers of digital health in asthma and the different technologies utilised in asthma health, including asthma apps and ‘multi-featured digital health systems’. He also highlighted the current and future challenges for digital health in asthma.

Looking at how AI could improve the future of clinical trials, Professor Konstantinos Kostikas shared the drawbacks of complex clinical trials and the potential for AI to transform clinical trial design, from study preparation to execution, and improve clinical trial success rates.

Closing the session, Dr Vitalii Poberezhets provided clinicians with the patient perspective on the utility of sensors, trackers and monitoring.

The new reality: better asthma care supported by digital health solutions

In this Novartis-sponsored industry symposium, Professors David Price, Konstantinos Kostikas and Dr Holger Woehrle explored how digital solutions have the potential to address unmet needs in inhaled asthma therapies, especially in adherence.

Professor Price presented data to highlight the ongoing burden of asthma and COPD, including increasing mortality rates, exacerbations occurring across all severities and risks caused by systemic corticosteroid exposure. He also identified the key drivers of poor adherence and inhaler technique and provided an introduction to the digital solutions that could overcome these challenges.

Professor Kostikas outlined the utility of a variety of mobile devices for asthma in the digital era. These included the portable Bluetooth AirNext^® and AsthmaTuner^® portable spirometers for diagnosis and ongoing remote monitoring of asthma patients as well as add-on sensors such as the Propeller^® Sensor that can be attached to the BREEZHALER^® device. Add on sensors with associated apps can provide the patient with inhalation confirmation, medication reminders, and allows the patient to share a data report on their asthma control and medication use with HCPs.

Dr Woehrle set out the difficulties caused by the differences in the use of new technologies between younger and older generations. He also summarised the pros and cons of big data in medicine, lessons learned from the field of respiratory sleep medicine and the push for digital asthma care during the COVID-19 pandemic. Finally, he presented the non-interventional ADITION study that aims to describe the change in asthma control achieved with the indacaterol/glycopyrronium/mometasome furoate BREEZHALER^® sensor system and fixed-dose combination therapy (long-acting β₂-agonist/long-acting muscarinic antagonist/inhaled corticosteroid) under real-life conditions.

At the end of the session, Professors Price and Kostikas and Dr Woehrle answered key questions in a panel discussion such as how different digital health solutions will fit together, how AI will integrate into clinical practice and the complications that could arise from digital health solutions.

Notable mentions

Professor Christer Janson presented an intriguing ePoster exploring the results of the ARCTIC study. This study was designed to develop a machine learning model to predict an immediate risk of exacerbation in asthma patients, as well as describe the factors that influence that risk.

Another topical session was the ‘Insights from wearable respiratory sensors and AI’ chaired by Professors Hilary Pinnock and Richard Costello. This session covered a range of subjects, such as the use of AI for respiratory signals, using health patches in respiration monitoring and COVID-19 surveillance with a new radar app.

These advancements and others in various new technologies are currently evolving standard medical care and have the potential to revolutionise personalised medicine in the future.

The environmental impact of asthma and COPD therapy

Many inhalers for conditions such as asthma contain propellants that are known to be potent greenhouse gases, but is the global warming potential of these inhalers having a significant impact?

Currently, it is estimated that hydrofluoroalkane (HFA) propellants used by pressurized metered dose inhalers (pMDI) contribute towards 3.9% of the NHS carbon footprint¹. A hot topic at European Respiratory Society (ERS) International Congress 2020 Virtual was the renewed debate on whether pMDIs have a notable impact on global warming.

Questions that have arisen this year include: how do you balance the health of a patient with the impact on the environment and what is the global warming potential of each inhaler type? The following sessions are some of the highlights you may have missed at ERS 2020 discussing the environmental concerns that should be considered by physicians and their patients when deciding on the best treatment options.

Protecting the planet: time for action!

Without immediate action, the damage caused by climate change will be irreversible with the least developed countries being impacted hardest². In this thought-provoking Novartis industry symposium, Professors Rachel Huxley, Ashley Woodcock and Kai Beeh discussed the need to assess the global warming potential of inhalers and the importance of reducing greenhouse gas emissions.

Professor Huxley shared data on the social, economic and health impacts of air pollution and global warming, especially in exacerbating asthma and potentially contributing to new-onset asthma.

Highlighting considerations for inhaler choice, Professor Woodcock described the importance of the Montreal Protocol in 1987 which set out a road map for the phase out of chlorofluorocarbons (CFCs) in order to protect the ozone layer. We now face the challenge of phasing out hydrofluorocarbons, given the impact they continue to have on global warming.

Professor Beeh emphasised the importance of offering information about the environmental impact of inhaler devices, examined the specific carbon footprint of a range of devices including metered-dose and dry powder inhalers (MDIs and DPIs) and discussed the need for inhalers with a small impact on the environment.

Finishing on a panel discussion, the faculty answered questions on a variety of topics including whether or not it is too late to tackle these environmental issues, if there is enough awareness and education on environmental implications of inhalers and what the future holds for DPIs and MDIs.

Is the global warming potential of inhaler propellants significant?

In this pro/con session, Professors Christer Janson and Dr Omar Usmani debated whether the global warming potential of inhaler propellants is significant.

Halocarbon compounds, such as CFCs, have caused concern for a number of decades due to their global warming potential as anthropogenic greenhouse gases and ozone-depleting properties. With the phasing out of CFCs under the Montreal Protocol, hydrofluorocarbons (HFCs) became a widely used replacement. But despite an ozone depletion potential of 0, HFCs are still potent greenhouse gases.

Is reducing the use of HFCs important for reducing global warming?

In support of this claim, Professor Christer Janson shared the data on the global warming potential of HFCs, as well as a cradle-to-grave analysis that compared the impact of pMDIs and DPIs.

To give perspective on the situation, Professor Janson also compared the difference made by switching from pMDIs to DPIs to real world examples such as switching from a meat-based diet to a plant-based diet or changing from a petrol car to a hybrid car.

So, what is the impact of HFCs from inhalers on global warming? Concluding the presentation, Professor Janson described how uncontrolled HFC use has the potential to increase global surface temperatures by 0.5 degrees and how switching from pMDIs to equally effective DPIs could be a ‘low hanging fruit’ for health care workers to influence the environment in a positive way.

But what about patient choice, clinical effectiveness and patient safety?

Opposing the claim that we should reduce the use of HFC-containing pMDIs, Dr Omar Usmani stressed the moral obligation to protect the planet but highlighted the dangers of switching inhalers in currently stable patients.

With a focus on patient choice and the oath ‘first do no harm’, Dr Usmani shared the view that inhaler devices should not be considered interchangeable. The trend towards precision medicine requires unrestricted patient choice and the ability of physicians to tailor appropriate treatment to their patients.

Advocating the use of pMDIs, Dr Usmani then shared data on the differences in disease outcomes between pMDIs and DPIs and that in certain situations, and for specific patients, pMDIs may still be valuable.

In closing, Dr Usmani suggested that there is a need to look at the whole life cycle of an inhaler from its creation to disposal, that globally switching away from pMDIs will cause difficulties and that while HFCs do have an impact on global warming there is a need to think before we switch.

Climate change is a huge and present danger to the health and lives of many people around the world. It also disproportionately impacts the poorest and most vulnerable in society, such as people with pre-existing respiratory disease². Every effort must be made to minimise the release of greenhouse gases into the atmosphere to protect future generations from the consequences of climate change.

References

1. Wilkinson AJK, Braggins R, Steinbach I, Smith J. Costs of switching to low global warming potential inhalers. An economic and carbon footprint analysis of NHS prescription data in England. BMJ Open. 2019;9(10):28763.
2. Eckstein D, Künzel V, Schäfer L, Winges M. Global Climate Risk Index. 2020. http://germanwatch.org/en/17307. Accessed 9 September 2020.

Latest insights in respiratory management

Find out the latest insights in asthma and COPD management from ERS International Congress 2020 Virtual, sharing updates in prevention, risk mitigation, diagnostics, treatment and management strategies.

Effective respiratory management is essential for improving the quality of life of patients with respiratory disease. At the European Respiratory Society (ERS) 2020, a wide range of engaging sessions provided the latest insights in respiratory management.

The following sessions are highlights you may have missed on this topic including asthma management in adolescent and young adult patients, the need to consider a gender perspective in severe asthma patients and the impact of fear, anxiety and wellbeing in chronic lung diseases.

Successfully managing adolescent and young adult patients with asthma

In this expert view, Professor Graham Roberts described the challenges faced by adolescents and young adults with asthma and their at-risk status as patients.

These challenges included an increased rate of mortality as well as being overlooked in terms of service provision and training for healthcare professionals. Psychological factors also play a role with social anxiety, depression and stress impacting adolescents and young adults with asthma.

These issues were further explained in the ‘fear and anxiety, psychological wellbeing and prevention of psychological distress in chronic lung diseases’ session below.

So how can we better support adolescents? The need to have an adolescent-specific approach to asthma management was emphasised by Professor Roberts and included various options such as direct appropriate education, simple treatment regimens and methods for enabling adolescents and young adults to better self-manage their asthma.

Professor Roberts also shared the possibility of working in collaboration with colleagues to develop an adolescent and young adult clinic and the benefits of seeing adolescents on their own.

A ‘gender phenotype’ does really exist in severe asthma

The difference in clinical and functional features in severe asthma between is poorly understood. In an intriguing ePoster, Sonia Rizzello describes her study into the clinical, functional and biological features of patients with severe asthma according to their gender.

Examining a variety of factors including quality of life, asthma control and lung function, Rizzello et al. revealed a significantly higher lung hyperinflation in female patients with severe asthma. Studies such as this further reinforce the need for a gender perspective in investigating severe asthma patients.

Fear and anxiety, psychological wellbeing and prevention of psychological distress in chronic lung diseases

Chaired by Professors Marion Delcroix and Thierry Troosters, this comprehensive session identified fear anxiety as important risk factors and explored various approaches to minimise these risks.

The session opened with a patient perspective video of a 59-year-old man with idiopathic pulmonary fibrosis (IPF), who was given a 3–5 year life expectancy at age 53. In this video, the patient revealed the emotional and psychological strain of living with a chronic lung disease and gave advice for healthcare professionals for treating these issues.

Chronic obstructive pulmonary disease (COPD) is often associated with psychological comorbidities. In this presentation, Dr Thomas Reijnders described the negative effect of disease-specific fears on pulmonary rehabilitation and physical activity in daily life.

Dr Karen Heslop-Marshall highlighted the importance of addressing psychological well-being and the benefits of cognitive behavioural therapy (CBT) delivered by respiratory nurses. She also shared results from the Newcastle COPD CBT study, which found that CBT delivered by respiratory nurses improves symptoms of anxiety and reduces attendance to A&E and hospital admissions.

Describing the relationship between physical and psychological health, Debra Reynolds-Sandford discussed the importance of empathy and shared how to increase empathy and psychologically focused skills in patient centred care.

Professor Kathleen Lindell shared the recently completed study ‘Integrating early palliative care for patients with IPF and their caregivers’. This study analysed the feasibility of the ‘SUPPORT’ intervention for IPF and caregivers and its impact on stress, symptom burden, quality of life, and completion of advanced care planning.

Notable mentions

Two other notable sessions you may have missed at ERS 2020 were the ‘from symptoms to diagnosis in primary care’ primary care sessions. A wide array of respiratory management updates were covered including, choosing the most effective diagnostic work up, an overview of the epidemiology of respiratory diseases, pharmacotherapy in patients with multi-morbid COPD and methods of managing airway diseases in pregnancy.

Research into risk factors, new management strategies and gender differences in asthma is helping to advance the diagnosis, treatment and management of respiratory diseases and making a real difference to patient lives.

Early life origins of respiratory illness

Explore research into the complex mechanisms and pathways involved in the relationship between early-life events and chronic respiratory diseases that is opening up new opportunities for the treatment and management of respiratory illness.

Chronic obstructive respiratory disorders, such as asthma and chronic obstructive pulmonary disease (COPD), begin in early life. Various factors have an impact on respiratory health, including genetic predisposition and environmental exposures. Some of these factors may be modifiable, such as smoke exposure and diet, while others are more difficult to influence, such as early exposure to viruses or allergens.

An understanding of these critical early stages and mechanisms can help determine early disease biomarkers and risk profiles that are predictive of chronic respiratory conditions.

The following sessions from European Respiratory Society (ERS) International Congress 2020 Virtual explore this relevant topic, from physical activity in childhood to the relationship between reduced size during foetal life and early time to onset of asthma symptoms.

Physical activity and childhood asthma

A rise in asthma prevalence over recent decades has coincided with a global increase in obesity and a decrease in physical activity levels¹. Does this mean there is a link between asthma and physical activity?

In this session, Dr Marianna Eijkemans described the well-established link between obesity and asthma in adults and children. She also explored the multifactorial pathophysiology of asthma and the role of inflammation and environmental factors such as diet, vitamin D intake and physical activity.

However, the potential link between physical activity and asthma remains unclear. Sharing the various potential causes, Dr Eijkemans explored the possibility of physical limitations due to asthmatic symptoms, fear of asthma attack and the potential for physical activity to influence the inflammatory state.

Ending with a clinical year in review, Dr Eijkemans also shared several notable articles that investigated the link between physical activity levels and asthma in children.

This session revealed the importance of considering environmental factors when treating childhood asthma, such as diet and physical activity. However, the potential association between physical activity and asthma is still very much the subject of debate.

Reduced antenatal and birth size and time to onset of asthma

In this ePoster session, Professor Stephen Turner described his study into the potential relation between reduced size during foetal life and early time to onset of asthma symptoms. By comparing routinely acquired foetal, neonatal and maternal data collected between 1987 and 2015 with asthma-related hospital admission and prescribing data, Professor Turner revealed that small for gestational age (SGA) is a strong predictor of early onset asthma.

Respiratory diseases in children and adults

This thought-provoking session covered the early life origins of asthma and COPD with Professors Sejal Saglani and Alvar Agusti, as well as risk factors for cystic fibrosis (CF) and lower respiratory tract infections with Professor Stephen Stick and Dr Jessica Rademacher.

Since early wheezing and asthma-like symptoms are associated with a much higher incidence of COPD in later life, Professor Saglani highlighted the promising possibility of a window of intervention between the ages of one and six.

But the key question is, what is the intervention and in which scenarios should you intervene? Professor Saglani shared prominent risk factors, including viral and allergen exposure, and also discussed the potential benefits of manipulating the airway microbiome.

On a similar theme, Professor Agusti discussed the early life origins of COPD. He also highlighted the necessity of understanding and preventing the early factors that influence lung function and the importance of earlier diagnosis and intervention.

Discussing the early risk factors for CF lung disease progression, Professor Stephen Stick explored the vicious cycle of inflammation and structural lung damage involved in CF as well as the gradual accumulation of pathogenic bacteria, exacerbations from potential viral infection and the roll of the dice caused by gene modifiers.

Respiratory tract infections are a significant cause of paediatric and adult morbidity and mortality. In the final presentation, Dr Jessica Rademacher described the influence of early-life respiratory tract infections on lung function and asthma, the overuse of antibiotics and the need for better diagnostics and antimicrobial stewardship around the world.

Notable mentions

Some other notable sessions at ERS 2020 included ‘Does exposure long before conception influence future respiratory health?’ and ‘chronic respiratory diseases and their origins in early life: how physiology meets clinical medicine’. These sessions featured interesting data on the effects of exposures, lifestyles and behaviours before conception on asthma and respiratory health. In addition to this, the session touched on the impact of improvements in antenatal and neonatal care on long-term effects of early life risk factors.

Research into the relationship between early-life events and chronic respiratory diseases is giving rise to a better understanding of how these diseases evolve over time, leading to improvements in our ability to treat and prevent them.

References

1. Eijkemans M, Mommers M, Draaisma JMT, Thijs C, Prins MH. Physical activity and asthma: a systematic review and meta-analysis. PLoS One. 2012;7(12).