Building Hope by Restoring Breathing in Airways Diseases

Prof Agustí opened the session by explaining the new challenges in airway diseases including the changing paradigm of our understanding of chronic obstructive pulmonary disease (COPD) that considers the entire lung function trajectory from birth to death, the complexity and heterogeneity of the disease, and the need to diagnose and treat COPD earlier in life. Prof Siddiqui then explained that all of the airways, including small airways, are critically important in the pathophysiology of asthma and COPD. The world’s largest multi-centre ATLANTIS study focussed on small airways dysfunction (SAD) confirmed that a simple combination of different assessments like oscillometry and spirometry could identify patients with the SAD phenotype. The prevalence of airway dysfunction in the full asthma cohort was 91%. Prof Papi discussed that exacerbations are a crucial event in the natural history of COPD and that they drive several health-related outcomes. He reviewed the clinical evidence to demonstrate the benefits of triple therapy in general and specifically of the extrafine fixed triple combination (beclometasone dipropionate, formoterol fumarate, glycopyrronium bromide) to consistently reduce the risk of exacerbations, and improve lung function and quality of life (QoL) with a favourable benefit-to-harm ratio. Furthermore, triple therapy showed promising signals in terms of improved survival. Prof Celli debated that inhaled corticosteroid (ICS) should be given to many patients because scientific trials have shown that: 1) ICS combined with bronchodilator (BD) are effective in improving health status and reducing exacerbations; 2) they also impact lung function decline and mortality; 3) ICS increase pneumonia risk (depending on type, dose, airflow limitation, BMI, and age) but have no untoward effect on mortality or hospitalisations for pneumonia; 4) blood eosinophil count (BEC) (<100 cell/µL) helps select patients unlikely to respond to ICS; and 5) ‘many’ COPD patients benefit from ICS combined with BD. Prof Singh focused on the fact that the magnitude of clinical benefit in preventing COPD exacerbations varies between individual patients, underlining the importance for clinicians of making the right decision for each patient when prescribing ICS, by balancing the potential risk/benefit. He concluded the debate by outlining that ICS have benefits in patients at increased exacerbation risk, and that the size of the benefits varies with BEC and the number/type of exacerbation.