The role of allergy in severe asthma
Article first published online: 20 APR 2012
© 2012 Blackwell Publishing Ltd
Clinical & Experimental Allergy
Special Issue: Special Issue on Severe Asthma
Volume 42, Issue 5, pages 659–669, May 2012
How to Cite
Cite this as: J. L. Kennedy, P. W. Heymann and T. A. E. Platts-Mills, Clinical & Experimental Allergy, 2012 (42) 659–669.
- Issue published online: 20 APR 2012
- Article first published online: 20 APR 2012
- Manuscript Accepted: 5 DEC 2011
- Manuscript Revised: 18 NOV 2011
- Manuscript Received: 4 AUG 2011
- Cove Point Foundation. Grant Numbers: NIH AI-20565, 5T32 AI007496-17
- University of Virginia
- Phadia, Inc.
- acute asthma;
- fungal colonization;
- high titer IgE ab;
- severe asthma
The classification of asthma to identify forms which have different contributing causes is useful for all cases in which the disease requires regular treatment, but it is essential for the management of severe asthma. Many forms of the disease can occur, and complex mixtures are not uncommon; here we artificially separated the cases into four groups: (i) inhalant allergy, (ii) fungal sensitization with or without colonization (including ABPA); (iii) severe sinusitis with or without aspirin-exacerbated respiratory disease (AERD), and (iv) non-inflammatory cases, including those associated with severe obesity and vocal cord dysfunction (VCD). The reason for focusing on these groups is because they illustrate how much the specific management depends upon correct classification. Inhalant allergy can present as chronically severe asthma. However, severe attacks of asthma requiring hospital admission can occur in cases which are generally only mild or moderate. The best recognized and probably the most common cause of these acute episodes is acute infection with a rhinovirus. Recent evidence suggests that high titre IgE, particularly to dust mite, correlates to exacerbations of asthma related to rhinovirus infection. Although it is well recognized that the fungus Aspergillus can colonize the lungs and cause severe disease, it is less well recognized that those cases may not have full criteria for diagnosis of ABPA or may involve other fungi. Identifying fungal cases is important, because treatment with imidazole antifungals can provide significant benefit. Taken together, specific treatment using allergen avoidance, immunotherapy, anti-IgE, or antifungal treatment is an important part of the successful management of severe asthma, and each of these requires correctly identifying specific sensitization.