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Parenchymal destruction in asthma: Fixed airflow obstruction and lung function trajectory

Published:August 23, 2021DOI:https://doi.org/10.1016/j.jaci.2021.07.042

      Background

      Fixed airflow obstruction (FAO) in asthma, particularly in nonsmokers, is generally believed to be caused by airway remodeling. However, parenchymal destruction may also contribute to FAO and longitudinal decline in forced expiratory volume in 1 second (FEV1).

      Objectives

      To evaluate parenchymal destruction, we used emphysema indices, exponent D, and low-attenuation area percentage (LAA%) on computed tomography (CT), and test whether the parenchymal destruction and airway disease are independently associated with FAO and FEV1 decline in both smoking and nonsmoking asthma.

      Methods

      Exponent D, LAA%, wall area percentage at segmental airways, and airway fractal dimension (AFD) in those with asthma were measured on inspiratory CT and compared to those in patients with chronic obstructive pulmonary disease (COPD).

      Results

      Exponent D was lower and LAA% was higher in COPD (n = 42) and asthma with FAO (n = 101) than in asthma without FAO (n = 88). The decreased exponent D and increased LAA% were associated with FAO regardless of smoking status or asthma severity. In multivariable analysis, decreased exponent D and increased LAA% were associated with an increased odds ratio of FAO and decreased FEV1, irrespective of wall area percentage and airway fractal dimension. Moreover, decreased exponent D affected the longitudinal decline in FEV1 in those with severe asthma, independent of smoking status.

      Conclusions

      Patients with asthma with FAO showed parenchymal destruction regardless of smoking status and asthma severity. Parenchymal destruction was associated with an accelerated FEV1 decline, suggesting the involvements of both airway and parenchyma in the pathophysiology of a subgroup of asthma.

      Graphical abstract

      Key words

      Abbreviations used:

      AFD (Airway fractal dimension), BMI (Body mass index), BSA (Body surface area), COPD (Chronic obstructive pulmonary disease), CT (Computed tomography), DLCO (Carbon monoxide diffusing capacity), FAO (Fixed airflow obstruction), FEV1 (Forced expiratory volume in 1 second), FVC (Forced vital capacity), Hi-CARAT (Hokkaido-based Investigative Cohort Analysis for Refractory Asthma), HU (Hounsfield unit), ICS (Inhaled corticosteroids), Kco (Transfer coefficient), LA (Airway luminal area), LAA%950 and -910 (LAA% calculated as volume percentages of low-attenuation voxels less than −950 and less than −910 HU), LAA (Low-attenuation area), LAC (Low-attenuation cluster), TLC (Total lung capacity), WA% (Wall area percentage), WA (Airway wall area)
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