Archivos de Bronconeumología 59 (2023) 190–192 www.archbronconeumol.org Letter to the Director What’s New in the 2022 Consensus for Severe to 10 scale that measures factors such as efficacy, adverse effects, Asthma in Adults ease of use, impact on daily activities, and general opinion. In terms of treatment, after confirming the diagnosis of SUCA To the Director, and assessing comorbidities, one of 2 new phenotypes will be assigned: T2-high and T2-low asthma. In T2-high asthma, A 2022 update of the consensus for severe asthma in adults the dichotomy of blood eosinophilia >300/␮l and 150–300/␮l was recently published in the Open Respiratory Journal.1 This doc- has been maintained, but a group with FENO >50 ppb and ument was drawn up by 15 authors with the participation of 78 eosinophilia <150/␮l has been added. The T2-low group includes expert asthma panellists who validated the recommendations and not only eosinophilia <150/␮l, but also FENO values <25 ppb, conclusions of the consensus in a 2-round Delphi process. while induced sputum should be obtained for phenotyping This document updates the recommendations published in if possible (Fig. 1). A specific algorithm for patients receiv- 2020.2 New developments include a definition of severe uncon- ing CGCs has also been developed, with current or historical trolled asthma (SUCA), as follows: “when poor disease control eosinophilia levels ≥150/␮l being considered significant (Fig. 1). persists despite treatment over the preceding year with a combina- The publication includes guidelines for the withdrawal of oral cor- tion of high-dose inhaled glucocorticoids/long-acting ␤2 agonists ticosteroids and new recommendations on smoking, inhalation and long-acting anticholinergics, or if maintenance systemic glu- devices, environmental pollution, and climate change. The effects cocorticoids are required (treatment lasting 6 months per year of SARS-Cov-2 and recommended vaccination guidelines are also regardless of dose, or cumulative dose >1 g of prednisone or equiv- addressed. alent regardless of duration)”. Attention is given to the role of respiratory nursing in patient Another new feature is the assessment of response to education, the evaluation of control and therapeutic compliance, monoclonal antibody therapy (mAB) using the EXACTO multidi- mAB follow-up, and the identification and training of patients who mensional scale (EXacerbations, ACT, systemic CorticosTeroids and may be candidates for self-administration at home. Obstruction-FEV1), with two scores ranging from 0 to 10 or 0 to Finally, the document assesses the organization of asthma care 7 depending on whether the patient is receiving continuous sys- units, the allocation of technical and human resources, accredited temic glucocorticoids (CGC) or not, respectively.3 Furthermore, the training, teaching and research, the importance of a multidisci- SNOT 22 questionnaire and a visual analogue scale are proposed plinary approach, referral criteria and health outcome indicators.4,5 for patients with chronic rhinosinusitis with nasal polyposis. Taken We hope this revised consensus will be useful to all professionals together, these indices provide a useful assessment of single-airway who treat asthma patients and that it attracts the same interest as super-responders. Finally, patient satisfaction is assessed using a 0 the previous reviews. https://doi.org/10.1016/j.arbres.2022.09.012 0300-2896/© 2022 SEPAR. Published by Elsevier España, S.L.U. All rights reserved. F.J. Alvarez-Gutiérrez, M. Blanco-Aparicio, F. Casas-Maldonado et al. Archivos de Bronconeumología 59 (2023) 190–192 Fig. 1. SUCA treatment algorithm. ACT: asthma control test; ACQ: asthma control questionnaire; CRSwNP: chronic rhinosinusitis with nasal polyposis; EGPA: eosinophilic granulomatosis with polyangiitis; FENO: exhaled nitric oxide fraction; HES: hypereosinophilic syndrome; IAT: inhaler adhesion test; IGC: inhaled glucocorticoids; LABA: long-acting ␤2 bronchodilators; LAMA: long-acting anticholinergic agents; OCS: oral corticosteroids; PMNs: polymorphonuclear neutrophils; SNOT 22: Sino-Nasal Outcome Test 22; SUCA: severe uncontrolled asthma; VAS: visual analogue scale. 1 Mepolizumab is indicated if current Eos ≥150/␮l and ≥300/␮l in the previous 12 months; this drug is also indicated for eosinophilic granulomatosis with polyangiitis and hypereosinophilic syndrome. 2 Dupilumab is indicated if Eos ≥300/␮l and/or FENO ≥50 ppb and Eos between 150 and 300 and FENO ≥25 ppb. At least 3 FENO measurements should be used. 3 Reslizumab is indicated if EOS ≥400/␮l. 4 Compassionate use of omalizumab may be considered in case of IgE levels ≥75 U/L and Eos levels <150 cells/␮L. 5 In T2-high asthma, azithromycin may be selected in case of a lack of response, intolerance, or allergic reactions with monoclonal antibodies. 191 F.J. Alvarez-Gutiérrez, M. Blanco-Aparicio, F. Casas-Maldonado et al. Archivos de Bronconeumología 59 (2023) 190–192 References c Servicio de Neumología, Hospital Universitario Clínico San Cecilio, Granada, Spain 1. Álvarez-Gutiérrez FJ, Blanco-Aparicio M, Casas-Maldonado F, Plaza V, González- d Servicio de Neumología y Alergia, Hospital de la Santa Creu i Sant Barcala FJ, Carretero-Gracia JA, et al. Documento de consenso de asma grave en adultos. Actualización 2022. Open Respir Arch. 2022;4:100192. Pau de Barcelona, Barcelona, Spain http://dx.doi.org/10.1016/j.opresp.2022.100192. e Servicio de Neumología, Hospital Clínico Universitario de Santiago 2. Álvarez-Gutiérrez FJ, Blanco-Aparicio M, Plaza V, Cisneros C, García- Rivero JL, Padilla A, et al. Documento de consenso de asma grave de Compostela, Santiago de Compostela, A Coruña, Spain f Servicio de Neumología, Hospital Royo Villanova, Zaragoza, Spain en adultos. Actualización 2020. Open Respir Arch. 2020;2:158–74, http://dx.doi.org/10.1016/j.opresp.2020.03.005. g Servicio de Neumología, Hospital Universitario Los Arcos del Mar 3. Casas-Maldonado F, Baynova K, Soto-Campos G, González-Barcala F, Blanco- Aparicio M, González Ramírez A, et al. EXACTO scale: multidimensional tool for Menor, Pozo Aledo, Murcia, Spain h Servicio de Neumología, Hospital Universitario La Princesa, FIB La assessing the response to treatment with monoclonal antibodies in severe uncon- trolled asthma. Prague: EACCI Hybrid Congress; 2022. Princesa, Madrid, Spain 4. Carretero Gracia JÁ, Rodríguez Fernández F, Gómez Sáenz JT, Molina París i Servicio de a Neumología y Cirugía Torácica, Unidad de J, Gómez Ruiz F, López Carrasco V, et al. Criterios de derivación en asma: actualización documento de consenso. Open Respir Arch. 2021;3:100131, Investigación, Hospital Universitario Nuestra Señora de Candelaria, http://dx.doi.org/10.1016/j.opresp.2021.100131. Santa Cruz de Tenerife, Tenerife, Spain 5. Pinera-Salmeron P, Alvarez-Gutierrez FJ, Dominguez-Ortega J, Alvarez C, Blanco- j Servei de Pneumologia, Corporació Parc Taulí, Sabadell, Barcelona, Aparicio M, Davila I, et al. Referral recommendations for adult emergency department patients with exacerbated asthma. Emergencias. 2020;32:258–68 Spain [article in English, Spanish]. k Servicio de Neumología, Hospital Universitario Dr Peset, Valencia, Spain Francisco Javier Alvarez-Gutiérrez a,∗ , l Servicio de Neumología, Hospital Vall d’Hebron, Departamento de Marina Blanco-Aparicio b , Francisco Casas-Maldonado c , Biología Celular, Fisiología e Inmunología, Universidad Autònoma de Vicente Plaza d , Francisco Javier González-Barcala e , Barcelona, Barcelona, Spain José Ángel Carretero-Gracia f , Manuel Castilla-Martínez g , m Unidad de Asma, Hospital Costa del Sol, Marbella, Málaga, Spain Carolina Cisneros h , David Diaz-Pérez i , n Servicio de Neumología, Hospital Universitario y Politécnico La Fe, Christian Domingo-Ribas j , Eva Martínez-Moragon k , Valencia, Spain Xavier Muñoz l , Alicia Padilla-Galo m , Miguel Perpiña-Tordera n , o Unidad de Gestión Clínica de Neumología y Alergia, Hospital Gregorio Soto-Campos o Universitario de Jerez, Jerez de la Frontera, Cádiz, Spain a Unidad de Asma, UMQER, Hospital Universitario Virgen del Rocío, Corresponding author. Seville, Spain E-mail address: Fjavieralvarez2008@gmail.com b Servicio de Neumología, Hospital Universitario A Coruña, A Coruña, (F.J. Alvarez-Gutiérrez). Spain 192