La prise en charge de l'asthme léger et très léger chez les enfants d'âge préscolaire, les enfants et les adolescents.

Le présent point de pratique résume la mise à jour des lignes directrices de la Société canadienne de thoracologie publiée en 2021 sur le diagnostic et la prise en charge de l'asthme chez les enfants d'âge préscolaire, les enfants et les adultes. Ces nouvelles recommandations incluent, parmi les critères de contrôle de l'asthme, une diminution de la fréquence des symptômes diurnes et de l'utilisation de médicaments pour soulager l'asthme à un maximum de deux fois par semaine. Elles comprennent également l'évaluation du risque d'exacerbation de l'asthme, la non-utilisation de bêta-agonistes à courte durée d'action seuls au besoin chez les patients à plus fort risque d'exacerbation et la possibilité d'administrer du budésonide-formotérol au besoin aux jeunes de 12 ans ou plus qui sont incapables de prendre des corticostéroïdes inhalés au quotidien malgré une éducation sur l'asthme et un soutien importants. La préférence pour la prise quotidienne de corticostéroïdes inhalés afin de traiter l'asthme léger chez les enfants et la recommandation d'éviter les courts traitements intermittents de corticostéroïdes inhalés ne changent pas.

[Pesticide exposure and chronic respiratory diseases]. / Exposition aux pesticides et maladies respiratoires chroniques.

INTRODUCTION: Pesticides are used worldwide, mainly in agriculture as a means of controlling pests and protecting crops. That said, the entire world population is ultimately subject to pesticide exposure (consumption of fruits and vegetables, living near treated fields…), with varying degrees of toxicity involved. STATE OF THE ART: In recent decades, epidemiological studies have contributed to the identification of chemical pesticide families with detrimental effects on human health: cognitive disorders, Parkinson's disease, prostate cancer… and impairment in respiratory functioning. Current scientific evidence points to the implication of the active substances in insecticides, herbicides and fungicides in chronic respiratory diseases, two examples being chronic obstructive pulmonary disease (COPD) in exposed workers, and asthmatic wheezing in children during prenatal or postnatal exposure. PERSPECTIVES: The safety of individuals exposed to pesticides is of key importance in public health. Further epidemiological investigations are needed to identify the chemical families affecting certain populations. CONCLUSIONS: The scientific literature suggests strong links between pesticide exposure and respiratory health. Whether it be environmental or occupational, pesticide exposure can lead to respiratory disorders and symptoms of varying severity.

[Adverse events in biologics for severe asthma]. / Effets indésirables des biothérapies de l'asthme sévère.

INTRODUCTION: Asthma is a pathology that remains severe and is inadequately controlled in 4% of patients. Identification of multiple pathophysiological mechanisms has led to the development of biomedicines, of which there are currently five available in France, with a safety profile that appears favorable but remains uncertain due to a lack of real-life experience with these new molecules. STATE OF KNOWLEDGE: Although relatively benign, the adverse effects of biologics are diverse. Headache, joint pain, skin reactions at the injection site, fever and asthenia are commonly observed during the different treatments. Ophthalmological complications seem restricted to dupilumab, with numerous cases of keratitis and conjunctivitis in patients with atopic dermatitis. Several respiratory complications have also been observed, essentially consisting in pharyngitis and other upper respiratory infections. Hypereosinophilia may occur, mainly with dupilumab, requiring investigation of systemic repercussions or vasculitis. Allergic reactions are uncommon but require careful monitoring during initial injections. CONCLUSION: Biologics for severe asthma are recent drugs with a favorable safety profile, but with little real-life experience, justifying increased vigilance by prescribing physicians.

[An epidemiological and evolutionary profile of occupational asthma of Tunisian workers]. / Profil épidémiologique et évolutif de l'asthme professionnel des travailleurs tunisiens.

INTRODUCTION: This study aims to identify the epidemiological and occupational characteristics of patients with occupational asthma (OA) and to assess their clinical evolution and occupational outcomes. METHODS: We carried out a descriptive epidemiological study over a period of five years (from 2012 to 2016) about the OA cases in the private sector reported in the Tunisian region of Zaghouan. RESULTS: All in all, 165 OA cases were reported during the study period, representing an annual incidence of 733.3 cases per 1,000,000 workers in the private sector. Our study population was composed predominantly (85.5%) of women, whose mean age was 41.5±6.8years. More than three quarters of the affected persons were working in the automobile industry, and most illnesses (77%) were attributable to isocyanates. The mean time to onset of the respiratory symptoms was longer for low molecular weight agents (13.6±3.1years) compared to high molecular weight agents (12.0±3.9years) (P=0.0006). The majority of OA cases (66.7%) lost their jobs. Job loss was significantly more frequent among asthmatic women and workers with OA due to isocyanates. Among the 62 cases of OA for whom risk factors were eliminated, 45 nonetheless remained symptomatic. CONCLUSION: Effective prevention strategies involving the various actors need to be implemented in work environments so as to reduce the frequency and the medico-legal repercussions of a disabling condition.

[Modeling T2 high severe asthma using human induced pluripotent stem cells (hiPSC)]. / Modélisation de l'asthme sévère par la technologie des cellules humaines souches pluripotentes induites (hiPSC).

Severe asthma patients with persistent airflow obstruction are characterized by functional obstruction due to mucus plugs containing mucins, fibrin, and eosinophil derived Charcot- Leyden crystals. The molecular mechanisms underlying this endotype are not clearly understood. Developing new models is crucial to respiratory research insofar as critical differences exist between human and rodent airway epithelium. We (and other teams) have shown that it is possible to reconstitute in vitro a complex and functional airway epithelium displaying all the features described in vivo from human-induced pluripotent stem cells (hiPSC). Our aim is to establish a human in vitro model of severe asthma that will recapitulate airway epithelium remodeling and mucus plugs.

[Written action plans for asthma control: How are they used by pulmonologists in France?] / Les plans d'action écrits pour l'asthme : quel usage en font les pneumologues en France ?

INTRODUCTION: Despite evidence of the benefits of the written asthma action plans (WAP) in asthma control, they remain poorly applied. The aim of our study was to assess the practices of French-speaking pulmonologists and paediatricians in their use of WAP for asthma control and to analyse the contents of several WAPs routinely consulted in treatment of asthma patients. METHODS: Members of three French medical societies (SPLF, G2A, SP2A) were requested to share their WAPs for asthma patients and to participate in an online survey about the possible influence of these documents on their practices. RESULTS: Most (95%) of the 41 WAPs taken into consideration were symptom-based and 34% included peak expiratory flow measurement. All of these action plans were in full compliance with current guidelines. Among the 110 survey respondents, while 65% systematically provided a WAP to their asthma patients, only 30% often or always supplemented the written document with therapeutic education sessions. In almost every case, it was the doctor who presented the WAP to the patient, generally devoting to less than 10minutes to explanation of what they were handing out. CONCLUSIONS: In France, WAPs are generally presented to the patient by the physician, which probably limits the time devoted to explanation of their contents. Furthermore, WAPs are rarely reinforced with therapeutic education. The current study suggests ways of improving the utilization of WAPs in asthma care and treatment.

FACTORS OF NON-CONTROL OF ASTHMA IN LOMÉ. / Facteurs de non contrôle de l'asthme à Lomé.

Introduction: L'absence de contrôle de l'asthme fait partie des causes d'exacerbation sévère d'asthme. Les objectifs de ce travail étaient de déterminer la prévalence de l'asthme non contrôlé au centre hospitalier universitaire (CHU) Sylvanus Olympio de Lomé et de décrire les facteurs de non contrôle à Lomé. Méthodes: Il s'est agi d'une étude transversale prospective et descriptive par questionnaire administré à des patients asthmatiques ayant consulté ou ayant été hospitalisés dans le service de Pneumo-Phtisiologie du CHU Sylvanus Olympio de Lomé du 1erjanvier 2019 au 31décembre 2020. Résultats: Nous avons recruté 80 patients. L'âge moyen des patients était de 46,49 +/-19,73 ans avec une prédominance féminine (68%). L'asthme était non ou partiellement contrôlé chez 75% des patients. L'asthme était significativement moins contrôlé chez les patients qui avaient un bas revenu mensuel (p=0,012), qui disposaient à domicile de fauteuils bourrés en tissus (p=0,049), et qui subissaient une pollution de l'air dans leur milieu (p=0,03). Conclusion: Notre étude a révélé que l'asthme non contrôlé est très fréquent au CHU Sylvanus Olympio. Plusieurs facteurs de non contrôle de l'asthme, surtout modifiables, y ont été identifiés. Une sensibilisation de la population, une éducation thérapeutique des patients, et une prise en charge gratuite de l'asthme amélioreront le contrôle de l'asthme et la morbi-mortalité liée à l'asthme.

THE PHARMACIST'S ROLE IN ASTHMA MANAGEMENT IN AFRICA: A SURVEY OF PHARMACISTS IN TOGO. / Rôle du pharmacien dans la prise en charge de l'asthme en Afrique: une enquête auprès des pharmaciens du Togo.

Introduction: La prise en charge de l'asthme nécessite le concours de l'entourage des asthmatiques et de plusieurs partenaires de soins dont les pharmaciens. Les objectifs de l'étude était d'apprécier l'attitude des pharmaciens dans la délivrance des médicaments de l'asthme et d'évaluer leur connaissance sur la technique d'utilisation des aérosols doseurs pressurisés. Méthodes: Il s'est agi d'une enquête transversale réalisée du 5 janvier au 31 mars 2015 par auto- questionnaire auprès de pharmaciens d'officines privées de la ville de Lomé. Toutes les pharmacies privées figurant sur la liste actualisée de la direction générale des pharmacies du Togo étaient retenues. Les pharmaciens non répondeurs après six passages de l'investigateur étaient exclus. L'analyse des données a été faite sur un micro-ordinateur grâce à un logiciel Epi- info version 3.3.2. Résultats: Le taux de participation était de 76,36 %. Tous les pharmaciens ont affirmé recevoir la visite d'un asthmatique à l'officine en période de crise et ou en inter crise. Les asthmatiques se présentaient à l'officine sans aucune prescription médicale. Les médicaments de l'asthme sont délivrés sans exigence d'une ordonnance médicale surtout en période critique. Une prise en charge de la crise d'asthme est assurée par le pharmacien dans 51,20 % des cas à l'officine. L'aérosol doseur était la forme de médicaments la plus proposée. Seulement 27,38 % des pharmaciens ont une maîtrise parfaite de la technique d'utilisation. Les pharmaciens avaient prodigué des conseils aux patients sur la nécessité du traitement de fond, la régularité du suivi médical, l'éviction des allergènes et de la fumée du tabac. Conclusion: Les pharmaciens loin de se limiter seulement à la délivrance des médicaments, doivent s'impliquer dans l'éducation des malades asthmatiques. Mots clés: Asthme-Pharmacien-Education-Togo.

[Anti-IL-5 in severe asthma associated with eosinophilic granulomatosis with polyangiitis. Real-life study]. / Anti-IL-5 dans l'asthme sévère associé à une granulomatose éosinophilique avec polyangéite. Étude en vie réelle.

INTRODUCTION: Eosinophilic granulomatosis with polyangiitis (EGPA) is a form of necrotizing vasculitis affecting small vessels and typically characterized by severe glucocorticoid (GC)-dependent eosinophilic asthma. While mepolizumab, which is indicated at a dose of 100mg/4weeks in severe eosinophilic asthma, has been shown to be an effective treatment for EGPA-related asthma at a dose of 300mg/4weeks, it was only recently approved at this dose. METHODS: This retrospective, single-center, observational study was conducted to investigate over a 5-year period (2014-2019) the effect of mepolizumab 100mg/4weeks at 12months in patients with EGPA and glucocorticoid-dependant severe asthma. Response to treatment was defined as reduction in daily dose of oral corticosteroids to at most 5mg/day or reduction in annual exacerbation by at least 50%. RESULTS: Thirty patients were included, of whom twenty-three were treated (two were not fully evaluable). Among the 21 evaluable treated patients, 13 (62%) had responded at 12months. At baseline, non-responders had lower FEV1 levels and lower blood eosinophil levels than responders. CONCLUSIONS: Mepolizumab at a "severe asthma" dose (100mg/4weeks) is effective in treatment of GC-dependent severe asthma in most patients with EGPA.

[Bronchial diseases and heroin use. A systematic review]. / Pathologies bronchiques et usage d'héroïne. Revue systématique.

INTRODUCTION: Heroin use can cause respiratory complications including asthma, chronic obstructive pulmonary disease (COPD) and bronchiectasis (BD). OBJECTIVES: A general review of the literature presenting the data on the relationships between heroin consumption and bronchial complications, while underlining the difficulties of diagnosis and management. DOCUMENTARY SOURCES: Medline, 1980-2022, keywords "asthma" or "bronchospasm" or "COPD" or "bronchiectasis" and "heroin" or "opiate" or "opiates", with limits pertaining to "Title/Abstract". Concerning asthma, 26 studies were included, as were 16 for COPD and 5 for BD. RESULTS: Asthma and COPD are more prevalent among heroin addicts, who are less compliant than other patients with their treatment. The authors found a positive association between frequency of asthma exacerbations, admission to intensive care and heroin inhalation. Late diagnosis of COPD worsens the course of the disease; emphysema and BD are poor prognostic factors. CONCLUSION: Bronchial diseases in heroin users can be identified by means of respiratory function exploration and chest CT scans. These tests should be performed frequently in view of optimizing their care, which includes their weaning themselves from addictive substances.

[Level of knowledge on occupational asthma and asthmagens: Assessment among healthcare workers by a validated questionnaire]. / Niveau de connaissance sur l'asthme professionnel et les agents asthmogènes : évaluation auprès du personnel de santé par un questionnaire validé.

INTRODUCTION: The health system is one of the professional sectors perhaps most at risk of occupational asthma. The aims of this study were to evaluate the level of knowledge of health care workers (HCWs) on occupational asthma and asthmogenic agents and to pave the way to effective educational action on the subject. METHODS: A multicenter transversal study including 180 HCWs was carried out between July and December 2020. A validated questionnaire addressed four dimensions: knowledge of asthmatic disease, knowledge of occupational asthma, knowledge of prognosis of occupational asthma and knowledge on the prevention of occupational asthma. RESULTS: The average total score was 13.71/18 (76.17%). There was no correlation between average total score and age, educational level, seniority or status of paramedical staff. Mean total scores were significantly higher for participants with no fixed work schedule and those practicing in non-university structures. The difficulty indexes for the four aforementioned dimensions were 82.22%, 77.56%, 53.52% and 66.67% respectively. CONCLUSIONS: Knowledge gaps affect all professional categories but to different degrees. A review of the level of knowledge of persons in each category would be the first step on the road to planned educational action.

[Allergenic and chemical pollutants of indoor environments and asthma: Characterization, assessment and eviction]. / Polluants allergéniques et chimiques de l'environnement intérieur et asthme : caractérisation, évaluation et éviction.

The environment of an asthmatic patient can contain numerous sources of pollutants that degrade the quality of indoor air and have major repercussions on the occurrence and control of asthma. Assessment and improvement of the quality of indoor air should be assigned a major role in pneumology and allergology consultations. Characterization of an asthmatic's environment entails a search for biological pollutants with mite allergens, mildew, and allergens resulting from the proximity of pets. It is important to evaluate the chemical pollution represented by exposure to volatile organic compounds, which are increasingly present in our lodgings. Active or second-hand smoking must in all circumstances be sought out and quantified. Assessment of the environment is mediated by several methods, of which the application depends not only on the pollutant sought out, but also on enzyme-linked immunosorbent assay (ELISA), which has an essential role in quantification of biological pollutants. Attempts at expulsion of the different indoor environment pollutants is mediated by indoor environment advisors, whose efforts are aimed at obtaining reliable evaluation and control of indoor air. Implemented as a form of tertiary prevention, their methods are conducive to improved asthma control, in adults as well as children.

[Hyperventilation syndrome, definition, diagnostic and therapy]. / Le syndrome d'hyperventilation, définition, diagnostic et thérapeutique.

Hyperventilation syndrome (HVS) is a frequent disorder of which the etiology is unclear. Diagnosis is based on the ruling out of organic disease and, more positively, on results of the Nijmegen questionnaire, reproduction of symptoms during the hyperventilation provocation test (HPVT), and detected hypocapnia. Treatment is based on targeted respiratory physiotherapy consisting in voluntary hypoventilation and instructions to the patient on regular respiratory exercise over an appreciable period of time. Additional research is needed to evaluate the validity of current investigative tools leading to the diagnosis of hyperventilation syndrome and to appraise the efficacy of current respiratory physiotherapy methods.

[Lung manifestations of sickle-cell disease]. / Manifestations respiratoires de la drépanocytose.

Sickle-cell disease is an autosomal recessive genetic disorder of hemoglobin that causes systemic damage. Hypoxia is the main actor of sickle-cell disease. It initiates acutely the pathogenic cascade leading to tissue damages that in turn induce chronic hypoxia. Lung lesions represent the major risk of morbidity and mortality. Management of sickle-cell disease requires a tight collaboration between hematologists, intensivists and chest physicians. Recurrent episodes of thrombosis and hemolysis characterize the disease. New therapeutic protocols, associating hydroxyurea, transfusion program and stem cell transplantation in severe cases allow a prolonged survival until the fifth decade. However, recurrent pain, crisis, frequent hospital admissions due to infection, anemia or acute chest syndrome and chronic complications leading to organ deficiencies degrade the patients' quality of life. In low-income countries where the majority of sickle-cell patients are living, the disease is still associated with a high mortality in childhood. This paper focuses on acute chest syndrome and chronic lung manifestations.

[Availability and affordability of diagnosis and treatment for asthma and COPD in Ouagadougou, Burkina Faso]. / Disponibilité et accessibilité financière aux moyens diagnostiques et thérapeutiques de l'asthme et de la bronchopneumopathie chronique obstructive dans la ville de Ouagadougou, Burkina Faso.

INTRODUCTION: Chronic respiratory diseases, particularly asthma and Chronic Obstructive Pulmonary Disease (COPD), pose a significant threat to public health. This study aims to determine the accessibility and affordability of means of diagnosis and treatment. METHODS: This was a cross-sectional study covering the period from August to December 2021 in Ouagadougou, Burkina Faso. This study involved 107 health centers and 135 pharmacies. The World Health Organization/Health Action International definition was used as a benchmark for accessibility to medicines. RESULTS: Out of 107 health centers, 29 (27.1%) had a spirometer. The average cost of spirometry represented 19.88 days of salary for a patient paid at the minimum wage. The most widely available drugs were salbutamol in a pressurized metered dose inhaler (pMDI) (88.1%) and prednisone 20mg tablet (87.4%). No disease-modifying drug was available in public pharmacies. Affordable drugs were salbutamol 4mg tablet and aminophylline 100mg tablet. CONCLUSION: The means of diagnosis and treatment of asthma and COPD are insufficiently available, especially in the public sector, which is characterized by a nearly total absence of basic treatment.

[The impact of specialized management on allergic asthma outcomes]. / Impact de la prise en charge pneumo-allergologique sur l'évolution de l'asthme allergique.

INTRODUCTION: Allergic asthma has variable characteristics depending on the region of occurrence. Management is often organized without easy access to a specialized pneumo-allergological evaluation. OBJECTIVES: PRIMARY: To characterize allergic asthma in patients followed at the Nancy University Hospital. SECONDARY: To estimate the impact at 12 months of the proposed specialized management. METHOD: Retrospective study including allergic asthmatic adults conducted between 01/01/2016 and 31/12/2018. Parameters studied (aside from descriptive parameters): asthma control score ACQ-7 (Asthma Control Questionnaire) and lung function at inclusion and at one year. RESULTS: One hundred and fifteen patients were included (age 42±16 years, women 63%, non-smokers 70%). Even though asthma symptoms arose at 19±18 years, the specialized consultation was performed 21±17.5 years later. Frequent sensitizations involved house dust mites (49%), cat dander (43%), grasses (43%). Patients tended to underestimate the frequency of their allergies (mites 36% P=0.011, pollens 36% P=0.001, pet dander 42% P=0.003, molds 80% P=0.007). At 1-year follow-up both the ACQ-7 score (1.3±1.3 vs. 0.8±0.9; P=0.007) and the forced expiratory volume per second (81.3±20.8% vs. 86.2±21.9%; P=0.002) had improved. CONCLUSION: The specificities of allergic asthmatics followed up in Nancy: late age of asthma onset of asthma and specialized consultation; predominant sensitization to cat dander and Betulaceae pollens; underestimation of allergies by the patient. Specialized care seems to important in the management of allergic asthma. While access to specialized care remains problematic, it could be facilitated by the creation of dedicated networks.

[Production of innervated bronchial epithelium from a blood sample]. / Fabrication d'un épithélium bronchique innervé à partir d'une prise de sang.

Asthma is a frequent respiratory disease, with severe asthma occurring in 3 to 5% of cases. Chronic inflammation of the bronchial epithelium is essential to its pathophysiology. When activated by the bronchial environment, the peripheral sensory nervous system contributes to inflammation of the airways. However, due to a lack of reliable models, the mechanisms of action remain largely unknown. Using induced pluripotent stem cells reprogrammed from blood cells, we have set up a model of bronchial epithelium innervated by sensory neurons. This model will ensure better understanding of the mechanisms of action underlying neurogenic inflammation.

[Digital adaptation of a therapeutic education program in the context of Covid-19]. / Adaptation numérique d'un programme d'éducation thérapeutique dans le contexte de la Covid-19.

The context of containment due to the Covid-19 epidemic forced professionals to suspend their face-to-face therapeutic education programs. For young patients with asthma, the situation was made even more complex by anxiety-provoking communications (which turned out to be inaccurate) about the possible aggravating role of corticosteroids in the event of Covid-19, which led to untimely discontinuations and sometimes to a decrease in their therapeutic adherence, exposing them to an increased risk of poor control of their disease. Faced with the feeling of abandonment felt by some families in this singular context, a team at Trousseau Hospital in Paris decided to rethink and adapt its distance therapeutic education workshops.

[General practitioners' management of childhood asthma in Sfax, Tunisia]. / Prise en charge de l'asthme de l'enfant par le médecin de première ligne au Gouvernorat de Sfax, Tunisie.

AIMS: To study primary care physicians' attitudes toward childhood asthma management and their adherence to international guidelines. METHODS: Cross-sectional, descriptive and analytical survey conducted among 400 primary care physicians practicing in the governorate of Sfax. Data collection was done through a self-administered questionnaire with 36 questions. RESULTS: the participation rate was 53.75%. The average age was 49.72years and the sex ratio=1.52. 56.3% reported that they assisted in childhood asthma medical education between 2019 and 2020. Poor knowledge was found in 53.3% of practitioners. It concerns in 60.5% of cases the long-term asthma treatment. We found that 49.8% of doctors did not use the GINA guidelines in their daily practice. These guidelines were considered too complex by 45.8%. Oral salbutamol was prescribed by 10.2% of physicians in childhood asthma exacerbation and 64.2% antibiotics as therapy for childhood febrile asthma exacerbation. The practice of prescribing antihistamines as long-term therapy is still present in 28.8% of physicians. In front of exercise-induced asthma, sports exemptions were given by 33% of participants. Adherence to asthma guidelines was found in 34,41%. Physicians who are aged between 35 and 45years and who used GINA guidelines had better childhood asthma management score than other physicians. CONCLUSION: Despite guidelines, childhood asthma is still underdiagnosis and undertreated. Our study revealed difficulties faced by primary care physicians in the management of childhood asthma.

[Markers of severity and predictors of response to treatment in severe asthma]. / Marqueurs de sévérité et marqueurs prédictifs de réponse au traitement dans l'asthme sévère.

Asthma is a multifactorial disease with complex pathophysiology. Knowledge of its immunopathology and inflammatory mechanisms is progressing and has led to the development over recent years of increasingly targeted therapeutic strategies. The objective of this review is to pinpoint the different predictive markers of asthma severity and therapeutic response. Obesity, nasal polyposis, gastroesophageal reflux disease and intolerance to aspirin have all been considered as clinical markers associated with asthma severity, as have functional markers such as bronchial obstruction, low FEV1, small daily variations in FEV1, and high FeNO. While sinonasal polyposis and allergic comorbidities are associated with better response to omalizumab, nasal polyposis or long-term systemic steroid use are associated with better response to antibodies targeting the IL5 pathway. Elevated total IgE concentrations and eosinophil counts are classic biological markers regularly found in severe asthma. Blood eosinophils are predictive biomarkers of response to anti-IgE, anti-IL5, anti-IL5R and anti-IL4R biotherapies. Dupilumab is particularly effective in a subgroup of patients with marked type 2 inflammation (long-term systemic corticosteroid therapy, eosinophilia≥150/µl or FENO>20 ppb). Chest imaging may help to identify severe patients by seeking out bronchial wall thickening and bronchial dilation. Study of the patient's environment is crucial insofar as exposure to tobacco, dust mites and molds, as well as outdoor and indoor air pollutants (cleaning products), can trigger asthma exacerbation. Wider and more systematic use of markers of severity or response to treatment could foster increasingly targeted and tailored approaches to severe asthma.