A Multidimensional approach to Severe Asthma Management: the need for Pulmonary Rehabilitation among candidates for Biologic Therapy.

BACKGROUND: Despite optimized pharmacological therapy, a significant subset of severe asthma patients remains poorly controlled. Lack of control is often driven by complex, non-inflammatory "treatable traits" that require a multidimensional management strategy beyond traditional airway targeting. OBJECTIVE: To characterize clinical, functional, and inflammatory profile of severe asthma patients at the time of prescribing biologic therapy and identify potential candidates to ARM (Assessment-Rehabilitate-Maintenance) pulmonary rehabilitation (PR) program. METHODS: This retrospective study analyzed 195 consecutive adults meeting GINA criteria for severe asthma admitted to our outpatient clinic between January 1, 2015, and December 31, 2025. ARM-program candidacy was predefined by the coexistence of: FEV1 < 80% predicted, mMRC ≥ 2, ACT < 20, and ≥2 annual exacerbations. RESULTS: The median age of the cohort was 55 years and 60% of patients were female. A substantial disease burden was detected (median ACT: 16; annual exacerbations: 3). Females showed significantly higher maintenance oral corticosteroid (OCS) dependence (35.9% vs. 21.8%, p = 0.036) and increased risk of air trapping (RV/TLC: 42.0% vs. 38.5%, p = 0.035). 47 patients (24%) met ARM candidacy criteria, showing higher OCS use (42.6% vs. 26.4%; p = 0.035), and a four-fold higher prevalence of anxiety/depression (12.8% vs. 3.4%; p = 0.015) compared with non-candidates. CONCLUSIONS: At the time of biologic prescription, a significant proportion of severe asthma patients present a multidimensional burden, including dyspnea, frequent exacerbations, and psychological comorbidities and are potential candidates to ARM PR program. Prospective studies are needed to validate patient selection criteria and support whether pulmonary rehabilitation-may improve clinical and functional outcomes in target subgroup.