Abstract
Purpose
Although the coexistence of asthma and bronchiectasis is common, the impacts of asthma on bronchiectastic patients (BE) have not been well evaluated because this issue using bronchiectasis cohorts has been investigated in only a few studies.
Methods
In the present study, 598 patients who were prospectively enrolled in the Korean bronchiectasis registry were evaluated. The clinical characteristics between BE with asthma and those without asthma were compared.
Results
Asthma was found in 22.4% of BE. BE with asthma had a higher body mass index (BMI) (P = 0.020), more dyspnea (P < 0.001), larger sputum volume (P = 0.015), and lower forced expiratory volume in 1 second (FEV1) (P < 0.001) than those without asthma. BE with asthma had a higher rate of previous pneumonia (P = 0.017) or measles (P = 0.037) than those without asthma. Regarding treatment, BE with asthma used inhaled corticosteroids, long-acting muscarinic antagonists, and leukotriene receptor antagonists more frequently than those without asthma. Although intergroup differences were not observed in disease severity of bronchiectasis (P = 0.230 for Bronchiectasis Severity Index and P = 0.089 for FACED), the Bronchiectasis Health Questionnaire (BHQ) scores indicating the quality of life, were significantly lower in BE with asthma than in those without asthma (61.6 vs. 64.8, P < 0.001). In a multivariable model adjusting for age, sex, body mass index, forced expiratory volume in 1 second %predicted, sputum volume, modified Medical Research Council dyspnea scale ≥ 2, and the number of involved lobes, asthma was associated with lower BHQ scores (β-coefficient = −2.579, P = 0.014).
Conclusions
BE with asthma have more respiratory symptoms, worse lung function, and poorer quality of life than those without asthma. A better understanding of the impacts of asthma in BE will guide appropriate management in this population.
Keywords: Asthma, bronchiectasis, quality of life, symptom exacerbations
INTRODUCTION
Non-cystic fibrosis bronchiectasis (hereafter referred to as bronchiectasis) is a chronic airway disease characterized by recurrent respiratory symptoms, such as cough, copious production of sputum, dyspnea, and recurrent or persistent infection.1,2 The prognosis of bronchiectasis is worse when it is accompanied by comorbidities.3 Furthermore, in prior studies, bronchiectasis-related comorbidities have been shown to be important determinants of disease severity, quality of life, exacerbations, and long-term prognosis, including mortality in bronchiectatic patients (BE).3,4,5
Overlap between bronchiectasis and chronic airway diseases, including asthma and chronic obstructive pulmonary disease (COPD), are common in BE.6 The prevalence of overlap was reported as 3%–29% for asthma and 14%–37% for COPD in BE.4,6,7,8,9,10,11 These conditions are significantly associated with an increased disease burden of bronchiectasis in terms of exacerbations and mortality.5,12 Thus, adequate management of comorbid airway diseases may be critical for improving treatment outcomes in BE.
Comorbid asthma has been suggested to further worsen the relevant exacerbation risk and mortality in BE.5,13,14 However, the impacts of asthma on the clinical characteristics of bronchiectasis have not been well elucidated except for exacerbations and mortality and most previous study results were derived from studies using asthma registries.15,16,17 Thus, limited information exists on the differences in demographics, pulmonary functions, and quality of life in BE with comorbid asthma.
Due to the high prevalence of asthma in BE and the impacts of asthma on the poorer prognosis of bronchiectasis,6,18 studies in which impacts of asthma on many aspects in BE are important. Accordingly, in the present study, the impacts of asthma on clinical characteristics including demographics, disease severity, treatment, quality of life, and acute exacerbation (AE) in BE were evaluated using a prospective multicenter bronchiectasis registry in Korea.
MATERIALS AND METHODS
Study design and participants
The present study included patients enrolled in the Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) registry between August 2018 and December 2019.10,19 The study population consisted of adult patients (≥ 18 years of age) with stable bronchiectasis confirmed with chest computed tomography. Exclusion criteria were as follows: patients with bronchiectasis due to cystic fibrosis, traction bronchiectasis associated with interstitial lung disease; patients actively being treated for infectious disease including pneumonia, pulmonary tuberculosis, or non-tuberculous mycobacterial pulmonary disease; or pregnant patients. The detailed registry protocol was previously described.19
Definition
At the time of registry enrollment, patients had stable bronchiectasis. The presence of asthma was determined using a questionnaire regarding comorbidities: “Does the patient have a self-reported or physician diagnosis of asthma?”
Regarding radiologic findings, cystic bronchiectasis was defined as when at least one lobe was involved due to cystic bronchiectasis. Modified Reiff score was used to assess radiological severity.20 Pre-bronchodilator spirometry with or without post-bronchodilator spirometry was performed; positive bronchodilator response was defined as an increase of ≥ 12% and ≥ 200 mL in forced expiratory volume in 1 second (FEV1) compared with pre-bronchodilator results.21 The bronchiectasis severity was evaluated using Bronchiectasis Severity Index (BSI) score1 and FACED score,22 and quality of life was assessed using the validated Korean version of Bronchiectasis Health Questionnaire (BHQ),23,24 Any AEs were defined as one or more exacerbations of respiratory symptoms.25 In the present study, severe AE was defined as requiring hospitalization or visiting the emergency room.26
Statistical analyses
Continuous data are presented as median with interquartile range (IQR) and were compared using the Mann-Whitney U test. Categorical data are presented as numbers (%) and were compared using Pearson’s χ2 test or Fisher’s exact test, as appropriate. P values < 0.05 in two-sided tests were considered to indicate statistical significance. To explore the effect of asthma on quality of life (BHQ scores) and the presence of any AEs in the previous year, both univariable and multivariable analyses were performed. Regarding variables for multivariable analyses, demographics and other variables that are significantly different between patients with and without asthma were selected. For BHQ scores analyses, multivariable linear regression analyses were performed; demographics (age, sex, and body mass index (BMI) were adjusted in Model 1; and in Model 2, sputum volume, modified Medical Research Council (mMRC) dyspnea scale ≥ 2, number of involved lobes, and FEV1%predicted were further adjusted in addition to the variables included in Model 1. In the multivariable logistic analyses for AE in the previous year, demographics (age, sex, and BMI) were adjusted in Model 1; in Model 2, sputum volume, mMRC dyspnea scale ≥ 2, number of involved lobes, FEV1%predicted, and BHQ scores were further adjusted in addition to the variables included in Model 1. Data were analyzed by using IBM SPSS Statistics for Windows, version 22.0 (IBM Corp., Armonk, NY, USA) and Stata (Release 16; StataCorp LP, College Station, TX, USA). Graphs were compiled using GraphPad Prism version 9.0.2 (GraphPad Software, San Diego, CA, USA).
Ethical statement
This study protocol was approved by the Institutional Review Board of all institutions participating in the KMBARC registry, including Hallym University Kangnam Sacred Heart Hospital (application No, 2018-07-16), and written informed consent was obtained from all patients.
RESULTS
Patient characteristics
In the present study, 598 BE were analyzed and divided into 2 groups into BE with asthma (n = 134, 22.4%) and those without asthma (n = 464, 77.6%). The characteristics of the patients are shown in Table 1. Among the 598 patients, 334 (55.9%) were female and the median age of all patients was 65.6 years (IQR, 59.8–71.5 years). BE with asthma had higher BMI (23.8 vs. 22.8 kg/m2, P = 0.020) and larger sputum volume (20 vs. 10 mL, P = 0.015) than those without asthma. More BE with asthma had mMRC dyspnea scale ≥ 2 than those without asthma (32.1% vs. 18.8%, P = 0.001). BE with asthma were diagnosed with bronchiectasis earlier than those without asthma (P < 0.001). Previous respiratory infections, including pneumonia (P = 0.017) or measles (P = 0.037) and concurrent COPD (P = 0.005), were also more frequent in BE with asthma than in those without asthma.
Table 1. Baseline characteristics.
| Characteristics | BE with asthma (n = 134, 22.4%) | BE without asthma (n = 464, 77.6%) | P value | |
|---|---|---|---|---|
| Age (yr; n = 598) | 67 (61–73) | 65 (60–71) | 0.146 | |
| Sex (female; n = 598) | 82 (61.2) | 252 (54.3) | 0.157 | |
| BMI (kg/m2; n = 562) | 23.8 (21.0–25.7) | 22.8 (20.5–25.2) | 0.020 | |
| Smoking history (n = 598) | 0.151 | |||
| Never-smoker | 94 (70.1) | 293 (63.1) | ||
| Current- or ex-smoker | 40 (29.9) | 171 (36.9) | ||
| Sputum volume (mL; n = 581) | 20 (10–30) | 10 (5–30) | 0.015 | |
| mMRC dyspnea scale (n = 598) | 0.001 | |||
| < 2 | 91 (67.9) | 377 (81.2) | ||
| ≥ 2 | 43 (32.1) | 87 (18.8) | ||
| Comorbidities | ||||
| History of pneumonia (n = 597) | 67 (50.4) | 180 (38.8) | 0.017 | |
| History of measles (n = 550) | 34 (31.5) | 97 (21.9) | 0.037 | |
| History of pulmonary tuberculosis (n = 597) | 39 (29.3) | 159 (34.3) | 0.286 | |
| NTM-PD (n = 597) | 15 (11.3) | 47 (10.2) | 0.702 | |
| COPD (n = 598) | 65 (48.5) | 161 (37.4) | 0.005 | |
| Cardiovascular diseases (n = 598) | 49 (36.6) | 129 (27.8) | 0.054 | |
| Chronic kidney disease (n = 588) | 3 (2.3) | 9 (2.0) | 0.737 | |
| Diabetes mellitus (n = 597) | 15 (11.2) | 58 (12.5) | 0.678 | |
| Osteoporosis (n = 597) | 21 (15.7) | 49 (10.6) | 0.127 | |
| Depression (n = 596) | 7 (5.2) | 17 (3.7) | 0.423 | |
| Rheumatoid arthritis (n = 597) | 7 (5.3) | 30 (6.5) | 0.612 | |
| Gastrointestinal reflux disease (n = 597) | 23 (17.3) | 66 (14.2) | 0.381 | |
Values are presented as numbers (percentages) or medians (interquartile ranges).
BE, bronchiectatic patients; BMI, body mass index; mMRC, modified Medical Research Council; NTM-PD, non-tuberculous mycobacterial pulmonary disease; COPD, chronic obstructive pulmonary disease.
Fig. 1 shows the comparison of respiratory medications between the 2 groups. BE with asthma used inhalers, including inhaled corticosteroid (ICS) (11.3% vs. 1.9%, P < 0.001), ICS/long-acting beta agonist (LABA) (47.4% vs. 7.4%, P < 0.001), and long-acting muscarinic antagonist (LAMA) (20.3% vs. 11.5%, P = 0.009) as well as oral medications such as leukotriene receptor antagonists (19.5% vs. 5.2%, P < 0.001), more frequently than those without asthma.
Fig. 1. Comparison of treatment based on the presence or absence of asthma.
ICS, inhaled corticosteroid; LABA, long-acting beta-agonist; LAMA, long-acting muscarinnic antagonist; OCS, oral corticosteroid; LTRA, leukotriene receptor antagonist.
*P < 0.05.
Comparison of laboratory, radiographic, microbiologic, and pulmonary function test results in BE with and without asthma
Table 2 shows the comparison of laboratory, radiographic, pulmonary function, and microbiologic results between the 2 groups. BE with asthma tended to show higher eosinophil count (149.6/µL vs. 74.4/µL, P = 0.111) than those without asthma, albeit without statistical significance. Regarding radiological findings, BE without asthma had more involved lobes (P = 0.025), including more frequent involvement in the left upper lobe upper division (P = 0.008) and lingular division (P < 0.001) compared with those with asthma. However, the modified Reiff score did not differ between the 2 groups with a median score of 5 (IQR, 3–9; P = 0.406). BE with asthma had significantly lower FEV1%predicted (P = 0.003) and FEV1/forced vital capacity ratio (P < 0.001) than those without asthma. Intergroup differences in Pseudomonas isolation were not observed (P = 0.324).
Table 2. Laboratory, radiographic, pulmonary function test, and microbiological results.
| Variables | BE with asthma (n = 134, 22.4%) | BE without asthma (n = 464, 77.6%) | P value | ||
|---|---|---|---|---|---|
| Laboratory findings | |||||
| WBC (/µL; n = 387) | 7,300 (5,900–9,200) | 6,800 (5,600–8,600) | 0.299 | ||
| Eosinophil, count (/µL; n = 59) | 149.6 (74.5–264.3) | 74.4 (19.2–161.5) | 0.111 | ||
| Eosinophil ≥ 300/µL (n = 59) | 3 (25.0) | 3 (6.4) | 0.092 | ||
| Hemoglobin (g/dL; n = 383) | 13.4 (12.1–14.3) | 13.1 (12.2–14.1) | 0.528 | ||
| Platelet (/µL; n = 383) | 250 (192–288) | 248 (209–300) | 0.617 | ||
| ESR (n = 156) | 30 (12–51) | 26 (14–48) | 0.745 | ||
| CRP (n = 313) | 0.90 (0.11–2.58) | 0.39 (0.15–1.42) | 0.082 | ||
| Total IgE (n = 119) | 77.8 (29.6–233.0) | 53.8 (14.2–160.1) | 0.249 | ||
| Radiologic findings (n = 582) | |||||
| Cystic bronchiectasis in any lobes | 63 (47.0) | 208 (44.8) | 0.826 | ||
| No. of involved lobes | 3 (2–4) | 3 (2–5) | 0.025 | ||
| Involved lobe | |||||
| RUL | 55 (42.3) | 192 (42.5) | 0.972 | ||
| RML | 76 (58.5) | 285 (63.1) | 0.342 | ||
| RLL | 81 (62.3) | 265 (58.6) | 0.451 | ||
| LUL upper division | 35 (26.9) | 179 (39.6) | 0.008 | ||
| LUL lingular division | 46 (35.4) | 265 (58.6) | < 0.001 | ||
| LLL | 99 (76.2) | 338 (74.8) | 0.749 | ||
| Modified Reiff score | 5 (3–9) | 5 (3–9) | 0.406 | ||
| Pulmonary function tests (n = 532) | |||||
| FEV1 (L) | 1.40 (1.04–1.83) | 1.66 (1.30–2.07) | < 0.001 | ||
| FEV1 %predicted | 56.7 (46.3–71.3) | 64.1 (50.2–78.7) | 0.003 | ||
| FVC (L) | 2.31 (1.92–2.81) | 2.52 (2.01–3.10) | 0.018 | ||
| FVC %predicted | 72.1 (61.1–80.1) | 73.1 (62.9–84.5) | 0.378 | ||
| FEV1/FVC | 60.5 (50.2–70.2) | 67.3 (57.9–75.0) | < 0.001 | ||
| FEV1/FVC < 0.7 | 92 (74.8) | 232 (56.7) | < 0.001 | ||
| Positive bronchodilator response (n = 464) | 7 (6.3) | 11 (3.1) | 0.157 | ||
| Microbiological findings | |||||
| Pseudomonas aeruginosa colonization (n = 372) | 23 (33.3) | 83 (27.4) | 0.324 | ||
Values are presented as numbers (percentages) or medians (interquartile ranges).
BE, bronchiectatic patients; WBC, white blood cell; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein; Ig, immunoglobulin; RUL, right upper lobe; RML, right middle lobe; RLL, right lower lobe; LUL, left upper lobe; LLL, left lower lobe; FEV1, forced expiratory volume in 1 second; FVC, forced vital capacity.
Comparison of bronchiectasis severity, quality of life, and AEs in the previous year in BE with and without asthma
Bronchiectasis severity measured using the BSI (median 6; IQR, 4–9) and FACED (median 2; IQR, 1–3) scores were comparable between the 2 groups (P = 0.230 for BSI and P = 0.089 for FACED). However, BE with asthma showed significantly lower total BHQ scores than those without asthma (61.6 vs. 64.8, P < 0.001). Items regarding fatigue (P = 0.020), slower than others (P = 0.007), shortness of breath (P < 0.001), sleep disruption (P = 0.007), and coughing (P = 0.048), showed significant difference between the 2 groups (Fig. 2). The proportion of experiencing any AEs and severe AEs in the previous year did not differ between the 2 groups (55.2% vs. 53.9% for any AEs, P = 0.783; 23.9% vs. 21.6% for severe AEs, P = 0.567). However, the rate of AEs treated with antibiotics among the BE with AEs requiring secondary care was lower in BE with asthma than in those without asthma (77.3% vs. 94.1%, P = 0.026) (Table 3).
Fig. 2. Comparison of each BHQ item score based on the presence or absence of asthma.
BHQ, Bronchiectasis Health Questionnaire.
*P < 0.05.
Table 3. Bronchiectasis severity, quality of life, and acute exacerbations.
| Variables | BE with asthma (n = 134, 22.4%) | BE without asthma (n = 464, 77.6%) | P value | ||
|---|---|---|---|---|---|
| Disease severity | |||||
| BSI (n = 581) | 6 (4–10) | 6 (4–9) | 0.230 | ||
| FACED (n = 467) | 2 (1–3) | 2 (1–3) | 0.089 | ||
| Quality of life (n = 591) | |||||
| BHQ | 61.6 (54.8–66.6) | 64.8 (57.4–70.8) | < 0.001 | ||
| AEs in the previous year | |||||
| Any AEs (n = 598) | 74 (55.2) | 250 (53.9) | 0.783 | ||
| Severe AEs (n = 598) | 32 (23.9) | 100 (21.6) | 0.567 | ||
| AEs not requiring secondary or tertiary care (n = 598) | 41 (30.6) | 140 (30.2) | 0.925 | ||
| AEs requiring secondary or tertiary care, except for ER visit or admission (n = 462) | 22 (23.2) | 101 (27.5) | 0.391 | ||
| Use of antibiotics | 17/22 (77.3) | 95/101 (94.1) | 0.026 | ||
| AEs requiring visiting ER without admission (n = 598) | 10 (7.5) | 35 (7.5) | 0.975 | ||
| Use of antibiotics | 9/10 (90.0) | 26/32 (81.3) | > 0.999 | ||
| AEs requiring admission (n = 598) | 27 (20.1) | 82 (17.7) | 0.526 | ||
| Use of antibiotics | 26/27 (96.3) | 69/72 (95.8) | > 0.999 | ||
Values are presented as numbers (percentages) or medians (interquartile ranges).
BE, bronchiectatic patients; BSI, Bronchiectasis Severity Index; BHQ, Bronchiectasis Health Questionnaire; AE, acute exacerbation; ER, emergency room.
Effects of asthma on quality of life and AEs
The relationship between asthma and quality of life measured based on the BHQ scores was investigated using multivariable linear regression analyses. Asthma was significantly associated with a lower BHQ score (β-coefficient = −3.957, P < 0.001). After adjusting for potential confounders, asthma remained associated with lower total BHQ scores (β-coefficient = −4.105, P < 0.001 in Model 1 and β-coefficient = −2.579, P = 0.014 in Model 2). Other factors that were significantly associated with BHQ included BMI (β-coefficient = 0.329, P = 0.012) in Model 1, and sputum volume (β-coefficient = −0.049, P < 0.001) and mMRC dyspnea scale ≥ 2 (β-coefficient = −6.913, P < 0.001) in Model 2 (Table 4).
Table 4. Effect of asthma on the quality of life measured by Bronchiectasis Health Questionnaire.
| Variables | β-coefficient (95% CI) for asthma | P value | |
|---|---|---|---|
| Unadjusted model | |||
| Asthma | −3.957 (−5.978, −1.935) | < 0.001 | |
| Model 1 | |||
| Asthma | −4.105 (−6.203, −2.007) | < 0.001 | |
| Age | 0.065 (−0.033, 0.164) | 0.194 | |
| Female | −1.133 (−2.909, 0.642) | 0.210 | |
| BMI | 0.329 (0.072, 0.586) | 0.012 | |
| Model 2 | |||
| Asthma | −2.579 (−4.644, −0.514) | 0.014 | |
| Age | 0.041 (−0.059, 0.141) | 0.418 | |
| Female | −1.628 (−3.377, 0.120) | 0.068 | |
| BMI | 0.066 (−0.186, 0.319) | 0.606 | |
| FEV1 %predicted | 0.035 (−0.019, 0.088) | 0.202 | |
| Sputum volume | −0.049 (−0.067, −0.031) | < 0.001 | |
| mMRC dyspnea scale ≥ 2 | −6.913 (−9.170, −4.655) | < 0.001 | |
| No. of involved lobes | −0.537 (−1.130, 0.056) | 0.076 | |
Model 1: adjusted for age, sex, and BMI. Model 2: adjusted for variables included in Model 1, FEV1%predicted, sputum volume, mMRC dyspnea scale ≥ 2, and number of involved lobes.
CI, confidence interval; FEV1, forced expiratory volume in 1 second; mMRC, modified Medical Research Council; BMI, body mass index.
The effect of asthma on any AEs and severe AEs in the previous 12 months was evaluated using univariable and multivariable logistic regression analyses. A significant association was not observed between asthma and the number of any AEs and severe AEs (P = 0.528 and P = 0.149, respectively). After adjusting for other clinical variables, a significant association was not observed between asthma and the frequency of any AEs and severe AEs (Models 1 and 2). Factors that were significantly associated with any AEs included female sex (odds ratio [OR], 1.595, P = 0.042) in Model 1, and female sex (OR, 1.984, P = 0.003), the number of involved lobes (OR, 1.251, P = 0.004), and BHQ score (OR, 0.975, P = 0.032) in Model 2. In addition, factors that were significantly associated with severe AEs included female sex (OR, 3.144, P = 0.007) and FEV1%predicted (OR, 0.966, P = 0.010) in Model 2 (Table 5).
Table 5. Effects of asthma on acute exacerbations in the previous year.
| Variables | Any AEs | Severe AEs | |||
|---|---|---|---|---|---|
| OR (95% CI) | P value | OR (95% CI) | P value | ||
| Unadjusted model | |||||
| Asthma | 1.159 (0.732, 1.836) | 0.528 | 1.630 (0.840, 3.161) | 0.149 | |
| Model 1 | |||||
| Asthma | 1.134 (0.698, 1.845) | 0.611 | 1.748 (0.883, 3.461) | 0.109 | |
| Age | 0.991 (0.969, 1.014) | 0.449 | 1.015 (0.980, 1.052) | 0.391 | |
| Female | 1.595 (1.075, 2.366) | 0.042 | 1.736 (0.889, 3.390) | 0.106 | |
| BMI | 0.964 (0.911, 1.021) | 0.212 | 0.908 (0.825, 1.000) | 0.050 | |
| Model 2 | |||||
| Asthma | 1.039 (0.602, 1.796) | 0.890 | 1.112 (0.478, 2.588) | 0.806 | |
| Age | 0.995 (0.969, 1.021) | 0.695 | 1.015 (0.972, 1.061) | 0.501 | |
| Female | 1.984 (1.264, 3.115) | 0.003 | 3.144 (1.370, 7.212) | 0.007 | |
| BMI | 0.986 (0.925, 1.052) | 0.676 | 0.978 (0.877, 1.089) | 0.681 | |
| FEV1 %predicted | 0.996 (0.984, 1.009) | 0.588 | 0.966 (0.940, 0.992) | 0.010 | |
| Sputum volume | 1.000 (0.995, 1.005) | 0.967 | 0.996 (0.986, 1.006) | 0.426 | |
| mMRC dyspnea scale ≥ 2 | 1.225 (0.667, 2.249) | 0.513 | 1.464 (0.601, 3.564) | 0.401 | |
| No. of involved lobes | 1.251 (1.073, 1.459) | 0.004 | 1.151 (0.890, 1.489) | 0.285 | |
| BHQ scores | 0.975 (0.953, 0.998) | 0.032 | 0.985 (0.949, 1.023) | 0.436 | |
Model 1: adjusted for age, sex, and BMI. Model 2: adjusted for variables included in Model 1, FEV1%predicted, sputum volume, mMRC dyspnea scale ≥ 2, number of involved lobes, and BHQ scores.
AE, acute exacerbation; OR, odds ratio; CI, confidence interval; BMI, body mass index; FEV1, forced expiratory volume in 1 second; mMRC, modified medical research council; BHQ, Bronchiectasis Health Questionnaire.
DISCUSSION
In the present study, the clinical impacts of asthma in BE were evaluated. BE with asthma had more respiratory symptoms including a larger amount of sputum and more severe dyspnea and lower lung function than those without asthma. Inhalers such as ICS, ICS/LABA, and LAMA and leukotriene receptor antagonists were more frequently used in BE with asthma than in those without asthma. Although significant intergroup differences in radiological extent, disease severity scores, and exacerbation history were not observed, BE with asthma showed significantly poorer quality of life than those without asthma.
BE with asthma showed different clinical characteristics, including higher BMI, more respiratory symptoms, and more use of inhaler treatment compared with those without asthma. Similar findings were also observed in a previous research performed in China.27 However, data regarding the characteristics of bronchiectatic population with asthma are limited. Because bronchiectasis-asthma overlap is not yet clearly defined,2,6,18,28 the diagnosis of asthma in BE is challenging since it is made at the discretion of attending physicians. However, the present study provided meaningful results showing the clinical characteristics of asthma in terms of bronchiectasis cohorts in actual clinics. However, BE with asthma-like features and patients with long-confirmed asthma history plus concomitant bronchiectasis may be different populations,6 which was not distinguished in this study. Thus, further studies using various cohorts (bronchiectasis and asthma cohorts) are warranted to characterize bronchiectasis-asthma overlap.
Notably, the existence of asthma was independently associated with a poorer quality of life in BE even when adjusting for potentially confounding factors. In agreement with our results, in a previous study, the EMBARC cohort showed a similar result when the quality of life was measured using a different tool (quality of life-bronchiectasis scale).29 The present study also provided detailed aspects of quality of life because the score for BHQ each item was evaluated, which supports previous findings. BE with asthma were more hampered by the following than those without asthma: dyspnea, sleep disruption, coughing, tiredness, and much slower in performing tasks. The impaired dyspnea, sleep disruption, and coughing indicate that more attention should be given to the proper control of respiratory symptoms in BE with asthma. Furthermore, the present study results provide insights into pulmonary rehabilitation potentially benefitting tiredness and slow task performance, which may improve quality of life and long-term outcomes in BE with asthma.
Unexpectedly, asthma was not significantly associated with an increased rate of AEs in the prior year in BE. Conversely, identified asthma was considered a relevant risk factor for bronchiectasis exacerbation in previous studies.13,18,29 In studies with asthmatic patients, bronchiectasis was also associated with increased risk of exacerbations.11,17,30 The discordant result of our study might be explained by the following reasons: exacerbation was assessed during a relatively short period (initial questionnaires on exacerbations in a previous year); regional differences in study populations affected different clinical outcomes18; a very high proportion of regular asthma-related medications, especially ICS, may have affected the results. Proper therapeutic intervention such as asthma medication in asthma-bronchiectasis overlap patients may reduce the risk of exacerbations requiring antibiotics,2,28 and because we used the definition of AE for bronchiectasis, mild AEs requiring a short-acting beta agonist only might not have been counted.
Notably, BE with asthma showed lower frequency of exacerbation requiring antibiotics than BE without asthma (77.3% vs. 94.1%). Clinicians might prescribe systemic corticosteroids instead of antibiotics when their BE with asthma experience AEs. Currently, biomarkers do not exist to guide the use of antibiotics or corticosteroids for the treatment of BE with asthma. Because identifying therapeutic traits can improve the clinical outcomes of BE,31,32 evaluating whether eosinophilic endotypes are higher in BE with asthma than in BE without asthma is important. Because the KMBARC is an ongoing registry, future longitudinal data could help elucidate the exacerbation risk and appropriate treatment strategies when considering eosinophilic endotypes in BE with asthma.
The current study had several limitations. First, the study population was limited to Korean patients. Thus, the results of this study should be carefully adapted to different clinical settings considering geographic and racial/ethnic diversity. Second, some values were missing, including microbiological data. Third, the diagnosis of asthma was based on physicians' diagnosis and patients' reports in this study. Thus, there is a possibility that BE with more symptoms may have reported having asthma, which could lead to an error of circular reasoning. In addition, a recall bias could affect the asthma diagnosis. However, the study results have the advantage of reflecting real practice.
In conclusion, BE with asthma had more respiratory symptoms, lower lung functions, and poorer quality of life, which was not reflected by disease severity, than those without asthma. A better understanding of the impacts of asthma in BE will guide appropriate management in this population. Further studies are warranted to gain a better understanding of BE with asthma.
ACKNOWLEDGMENTS
The authors would like to thank members of the Korean Multicenter Bronchiectasis Audit and Research Collaboration (KMBARC) registry for collecting data: An-Soo Jang, Bumhee Yang, Byoung Soo Kwon, Chang Youl Lee, Chang-Hoon Lee, Changhwan Kim, Chin Kook Rhee, Deog Kyeom Kim, Eun Hye Lee, Eun Kyung Kim, Hyun Kuk Kim, Hyun-Kyung Lee, Ina Jeong, Jae Ha Lee, Jae Seung Lee, Jae Sung Choi, Ji Soo Choi, Ji Ye Jung, Ji-Ho Lee, Ji-Hyun Lee, Junghyun Kim, Jung-Kyu Lee, Juok Na, Ki Uk Kim, Kwang Ha Yoo, Sang Ha Kim, Sang Haak Lee, Se Hee Lee, Seung Jun Lee, Seung Won Ra, Shinhee Park, Sooim Sin, Soo-Jung Um, So-Young Park, Sung-Yoon Kang, Tae-Hyung Kim, Woo Jin Kim, Yee Hyung Kim, Yong Bum Park, Yoonki Hong, Youlim Kim, Young-Jae Cho, Young-Soon Yoon, Yu-Il Kim, and Yun-Jeong Jeong.
Part of this article was presented in the form of an abstract at the American Thoracic Society International Conference 2020.
This work was supported by a National Research Foundation of Korea (NRF) grant funded by the Ministry of Science, Information, and Communications Technologies (No. 2020R1F1A1070468 and 2021M3E5D1A01015176 to HL) and the Korean Ministry of Education (No. 2021R1I1A3052416 to HC). This work was also supported by the Korea Medical Device Development Fund grant funded by the Korean government (the Ministry of Science and ICT, the Ministry of Trade, Industry and Energy, the Ministry of Health & Welfare, the Ministry of Food and Drug Safety) (No. Project Number: 1711138447, KMDF_PR_20200901_0214). The funders had no role in the design of the study, the collection and analysis of the data, or the preparation of the manuscript.
Footnotes
Disclosures: There are no financial or other issues that might lead to a conflict of interest.
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