Asthma Management Guidelines Research Articles

Development and Utilization of a Diagnostic Support Tool for Asthma within the Electronic Medical Record.

Asthma in childhood is a common and costly chronic disease. Quality asthma care can lead to better control of asthma thus decreasing use of health services. The gold standard for pediatric asthma diagnosis and management is the National Heart, Lung and Blood Institute (NHLBI) guidelines for Diagnosis and Management of Asthma which center on precisely establishing the severity of asthma, as this precise classification delineates appropriate therapy. However, navigating these guidelines is a challenge for primary care providers that creates a barrier to providing quality care. We aim to improve precision in asthma severity classification in the community healthcare setting through the development of an electronic asthma decision support tool (eADST) incorporating NHLBI guidelines embedded within the electronic health record system. We developed an algorithm for the eADST to guide the health care provider to the appropriate classification and subsequent therapy. We engaged our health system's electronic health record informatics team and together developed and revised the tool. We launched the tool in three academic community clinics and measured precision in asthma classification in the twelve months prior to the availability of the tool and the twelve months following the launch. We found a significant improvement in precision of asthma severity classification following the launch, a necessary first step in improvement of asthma care. The next step will be to evaluate the impact of the tool on asthma outcomes.

Paediatric asthma and non-allergic comorbidities: A review of current risk and proposed mechanisms.

It is increasingly recognized that children with asthma are at a higher risk of other non‐allergic concurrent diseases than the non‐asthma population. A plethora of recent research has reported on these comorbidities and progress has been made in understanding the mechanisms for comorbidity. The goal of this review was to assess the most recent evidence (2016–2021) on the extent of common comorbidities (obesity, depression and anxiety, neurodevelopmental disorders, sleep disorders and autoimmune diseases) and the latest mechanistic research, highlighting knowledge gaps requiring further investigation. We found that the majority of recent studies from around the world demonstrate that children with asthma are at an increased risk of having at least one of the studied comorbidities. A range of potential mechanisms were identified including common early life risk factors, common genetic factors, causal relationships, asthma medication and embryologic origins. Studies varied in their selection of population, asthma definition and outcome definitions. Next, steps in future studies should include using objective measures of asthma, such as lung function and immunological data, as well as investigating asthma phenotypes and endotypes. Larger complex genetic analyses are needed, including genome‐wide association studies, gene expression–functional as well as pathway analyses or Mendelian randomization techniques; and identification of gene–environment interactions, such as epi‐genetic studies or twin analyses, including omics and early life exposure data. Importantly, research should have relevance to clinical and public health translation including clinical practice, asthma management guidelines and intervention studies aimed at reducing comorbidities.

Understanding the Updates in the Asthma Guidelines.

Asthma is a chronic inflammatory lung disease that affects millions of Americans, with variable symptoms of bronchospasm and obstruction among individuals over time. The National Heart, Lung, and Blood Institute (NHLBI) published the 2020 Focused Updates to the Asthma Management Guidelines based on the latest research since the 2007 Expert Panel Report-3 (EPR-3). The following article reviews the 21 new recommendations on the six core topics in asthma: use of intermittent inhaled corticosteroids, long-acting muscarinic antagonist therapy, use of the fractional exhaled nitric oxide test in asthma diagnosis and monitoring, indoor allergen mitigation, immunotherapy, and bronchial thermoplasty. The Grading of Recommendations Assessment, Development, and Evaluation (GRADE) approach was used to rate recommendations as strong or conditional based on the evidence. The recommendations were based on systematic reviews of the literature and focused on patient-centered critical outcomes of asthma exacerbations, asthma control, and asthma-related quality of life. Understanding the recommendations with consideration of individual values through shared decision-making may improve asthma outcomes.

Evaluation of Knowledge, Practice and Adherence of General Practitioners and Community Pharmacists to Asthma Guidelines in Malaysia

Asthma is a heterogeneous disease that inflames and narrows the airways. It is identified with respiratory symptoms such as wheezing, shortness of breath, chest tightness and cough. It has also been established that adherence to evidence-based guidelines may raise asthma control to optimal levels in both diagnosis and medical intervention. The objectives are to assess the knowledge, practice and adherence to asthma-management guidelines of general practitioners (GPs) and community pharmacists (CPs) in Pulau Pinang, Malaysia. A cross-sectional study was conducted in Pulau Pinang using a validated self-administered questionnaire. The knowledge, practice and adherence to asthmamanagement guidelines of GPs and CPs were captured using a 30-item questionnaire that prompted their responses using a mixture of closed-ended and Likert scale techniques. The questionnaires, together with a self-addressed stamped envelope for return, were mailed to 236 CPs and 300 GPs. The knowledge of both CPs and GPs on asthma was slightly above average, and there was no significant difference between the two groups (65.9% for CPs and 67.2% for GPs, p = 0.933). Overall, GPs have better practice than CPs, with a mean score of 4 or higher for most practice questions. GPs have a significantly higher tendency to follow the asthma guidelines (71.9%), whereas less than half of the CPs (46.4%) adhere to them. Only 40.6% of GPs and 3.5% of CPs mentioned the name of the guidelines they followed. Our findings show that although CPs and GPs have similar levels of knowledge, GPs have better practice and adherence to guidelines than CPs.

Perceptions towards childhood asthma and barriers to its management among patients, caregivers and healthcare providers: a qualitative study from Ethiopia

BackgroundThe management of asthma, which is one of the major causes of childhood morbidity and mortality has been affected by non-adherence to recommended treatment regimens with severe consequences. The aim of the present study was therefore to explore the perceptions of the children with asthma, their caregivers and their healthcare providers towards asthma and barriers to long term childhood asthma management in an institutional setting in Addis Ababa, Ethiopia.MethodsA qualitative descriptive design was followed for the present study that used individual interviews as a data collection method. The study participants were 23 pairs of children with asthma that had treatment follow-ups in two tertiary hospitals and their caregivers and eight healthcare providers who cared for these children. The data was analyzed using thematic analysis approach.ResultsThe study findings revealed that the children’s reported adherence to the recommended treatment regimens was low and they along with their caregivers were facing physical, emotional and social burdens related to asthma. Some of the influencing factors affecting childhood asthma management were found to be the low-level implementation of the asthma management guidelines by the healthcare providers, limited awareness about asthma and its management by the children and their caregivers, use of traditional home remedies and religious healing on a complementary and alternative basis and inadequate education received from healthcare professionals. Further identified barriers to the adherence of especially inhaled corticosteroids appear to be the low necessity beliefs towards chronic administration of treatment regimens and concerns related with difficulty of administration, fear of side effects and general negative attitude towards it, in addition to their low availability and affordability.ConclusionsLow awareness of the biomedical treatment regimens and use of traditional home remedies and religious healing by the children with asthma and their caregivers, the low-level implementation of the asthma management guidelines as well as low access to medications may among other things contribute to the low adherence of the children to their recommended regimens. The findings support the need for implementation of asthma management guidelines, institution of strong asthma care and education programs that are sensitive to local and individual patients’ and caregiver perceptions and experiences including emotional distress, the need to institute chronic care approach and ways to address patients’ medication access issues.

SMART - is it practical in the United States?

The 2020 focused updates to the asthma management guidelines by the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group advocate for inhaled corticosteroid (ICS)-formoterol combinations as single maintenance and reliever therapy (SMART) for patients with persistent asthma. We review the rationale, the evidence supporting SMART use in asthma, and barriers limiting its wide adoption in the United States. A growing body of evidence supports the use of SMART over the conventional use of controller medicaments with an as-needed short-acting β2 agonist for rescue therapy for the purpose of reducing the risk of asthma exacerbation and maintaining asthma control in adolescents and adults with persistent disease. Lack of US Food and Drug Administration approval, inconsistent insurance coverage, and limited options of ICS-formoterol combination available for use as SMART represent obstacles to wider integration of SMART in clinical practice. SMART represents a paradigm shift in asthma management. By identifying and addressing the current and anticipated barriers to implementing SMART, its adoption by providers is likely to increase in the United States.

The Racial and Ethnic Makeup of the Asthma Clinical Trials informing the 2020 NHLBI asthma guidelines update

Black/African American and Hispanic people in the United States are disproportionately impacted by asthma with increased prevalence, morbidity, and mortality. However, these groups are often under-represented in asthma clinical and translational research studies which is a barrier to achieving health equity. We describe the racial/ethnic makeup of participants in clinical trials which informed the recent 2020 National Heart, Lung, and Blood Institute (NHLBI) asthma management guidelines focused update.

Asthma in the Americas: An Update: A Joint Perspective from the Brazilian Thoracic Society, Canadian Thoracic Society, Latin American Thoracic Society, and American Thoracic Society.

Asthma affects a large number of people living in the Americas, a vast and diverse geographic region comprising 35 nations in the Caribbean and North, Central, and South America. The marked variability in the prevalence, morbidity, and mortality from asthma across and within nations in the Americas offers a unique opportunity to improve our understanding of the risk factors and management of asthma phenotypes and endotypes in children and adults. Moreover, a better assessment of the causes and treatment of asthma in less economically developed regions in the Americas would help diagnose and treat individuals migrating from those areas to Canada and the United States. In this focused review, we first assess the epidemiology of asthma, review known and potential risk factors, and examine commonalities and differences in asthma management across the Americas. We then discuss future directions in research and health policies to improve the prevention, diagnosis, and management of pediatric and adult asthma in the Americas, including standardized and periodic assessment of asthma burden across the region; large-scale longitudinal studies including omics and comprehensive environmental data on racially and ethnically diverse populations; and dissemination and implementation of guidelines for asthma management across the spectrum of disease severity. New initiatives should recognize differences in socioeconomic development and health care systems across the region while paying particular attention to novel or more impactful risk factors for asthma in the Americas, including indoor pollutants such as biomass fuel, tobacco use, infectious agents and the microbiome, and psychosocial stressor and chronic stress.

Secondary adrenal suppression related to high doses of inhaled corticosteroids in patients with severe asthma

Asthma management guidelines recommend inhaled corticosteroids (ICS) as first-line therapy. Although long-time ICS use in patients with asthma has a more favorable safety profile than oral corticosteroids (OCS), it is still associated with adrenal suppression (AS) even in the absence of OCS use.1,2 Subsequent secondary adrenal insufficiency (AI) has been reported. Still, there are limited data on the magnitude of the effect in patients with severe asthma treated with high ICS doses.1

Currently Available Inhaled Therapies in Asthma and Advances in Drug Delivery and Devices.

Medications delivered in the inhaled form remains the cornerstone of medical management of asthma. There have been considerable advances in the development of inhaled medications and devices over the past several decades. Clinicians also have access to regularly updated international guidelines for management of asthma. Despite this, a substantial proportion of children with asthma continue to have persistent poor asthma control and considerable morbidity even in well-resourced settings. The wide selection of medications and devices may complicate clinical decision making. The ideal inhaler would be one that the patient can and will use as advised. One cannot overemphasize the importance of medication adherence and a correct inhaler technique in achieving optimal asthma control. Clinicians who manage children with asthma should have a good understanding of inhaled medications and devices commercially available for the management of asthma and this would help them select the right medication and device for the right patient. This review aims to provide an overview of physiologic basis of inhaler therapy, commonly used inhaled therapies, and the advances in the field of inhaler devices including emerging technologies.

Implementing asthma management guidelines in public primary care clinics in Malaysia

Implementing asthma guideline recommendations is challenging in low- and middle-income countries. We aimed to explore healthcare provider (HCP) perspectives on the provision of recommended care. Twenty-six HCPs from six public primary care clinics in a semi-urban district of Malaysia were purposively sampled based on roles and experience. Focus group discussions were guided by a semi-structured interview guide and analysed thematically. HCPs had access to guidelines and training but highlighted multiple infrastructure-related challenges to implementing recommended care. Diagnosis and review of asthma control were hampered by limited access to spirometry and limited asthma control test (ACT) use, respectively. Treatment decisions were limited by poor availability of inhaled combination therapy (ICS/LABA) and free spacer devices. Imposed Ministry of Health programmes involving other non-communicable diseases were prioritised over asthma. Ministerial policies need practical resources and organisational support if quality improvement programmes are to facilitate better management of asthma in public primary care clinics.

Treatment Decisions in Children With Asthma in a Real-Life Clinical Setting: The Swiss Paediatric Airway Cohort

Asthma treatment should be modified according to symptom control and future risk, but there are scarce data on what drives treatment adjustments in routine tertiary care. We studied factors that drive asthma treatment adjustment in pediatric outpatient clinics. We performed a cross-sectional analysis of the Swiss Paediatric Airway Cohort, a clinical cohort of 0- to 16-year-old children seen by pediatric pulmonologists. We collected information on diagnosis, treatment, lung function, and FeNO from hospital records; and on symptoms, sociodemographic, and environmental factors from a parental questionnaire. We used reported symptoms to classify asthma control and categorized treatment according to the 2020 Global Initiative for Asthma guidelines. We used multivariable logistic regression to study factors associated with treatment adjustment (step-up or down vs no change). We included 551 children diagnosed with asthma (mean age, 10 years; 37% female). At the clinical visit, most children were prescribed Global Initiative for Asthma step 3 (35%). Compared with previsit treatment, 252 children remained on the same step (47%), 227 were stepped up (42%), and 58 were stepped down (11%). Female sex (adjusted odds ratio [aOR]= 1.61; 95% confidence interval [CI], 1.05-2.47), poor asthma control (aOR= 3.08; 95% CI, 1.72-5.54), and lower FEV1 Z-score (aOR= 0.70; 95% CI, 0.56-0.86 per one Z-score increase) were independently associated with treatment step-up, and low FeNO (aOR= 2.34; 95% CI, 1.23-4.45) was associated with treatment step-down, with marked heterogeneity between clinics. In this tertiary care real-life study, we identified main drivers for asthma treatment adjustment. These findings may help improve both asthma management guidelines and clinical practice.

Clinical guideline highlights for the hospitalist: Focused updates to pediatric asthma management.

2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC) Expert Panel Working Group1 RELEASE DATE: Online: December 3, 2020 PRIOR VERSIONS: 1991, 1997, 2002, 2007 DEVELOPER: NAEPPCC Expert Panel Working Group (referred to as "the Expert Panel") of the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health FUNDING SOURCE: NHLBI of the National Institutes of Health TARGET POPULATION: Adults and children with asthma and recurrent wheezing.

A questionnaire validated using local treatment guidelines may better predict future asthma risk: MARGIN study.

Asthma patients often feel satisfied with their current treatment, even when they have been diagnosed as uncontrolled by physicians. The present study investigated the differences in the evaluation of asthma control levels between patients and physicians, and the prediction of future risks. Asthma patients receiving inhaled corticosteroid/long-acting beta-2 agonists for 4 weeks or more were enrolled and followed-up for 24 weeks. Asthma control levels were evaluated using the following guidelines: Asthma Prevention and Management Guideline, Japan (JGL) and Global Initiative for Asthma (GINA) by physicians, and the Japan Asthma Control Survey (JACS) and a 6-item Asthma Control Questionnaire (ACQ6) by patients, at weeks 0 and 24. Analysis for predictive factors influencing exacerbation was performed using JGL, GINA, JACS, and ACQ6 at week 0. A total of 420 patients were enrolled. Comparison of the distribution of asthma control levels assessed by physicians and patients showed no statistically significant difference between JGL and JACS (P=0.19), suggesting a symmetric distribution, while ACQ6 demonstrated a significant difference versus JGL and GINA (both P<0.001). The predictive factors for exacerbation were unscheduled visits based on GINA (rate ratio; 0.25, 95% CI; 0.14, 0.44), and the use of oral steroids on 3 consecutive days based on JGL (rate ratio; 0.42, 95% CI 0.22, 0.82) and JACS (rate ratio; 0.22, 95% CI; 0.13, 0,40). Our study suggests that evaluation based on treatment guidelines and the questionnaire validated according to the local treatment guidelines is important for improved assessment of asthma control levels and the reduction of future risk. UMIN000030419.

Summary of the 2020 focused updates to U.S. asthma management guidelines: What has changed and what hasn't?

Despite the availability of effective medications, the majority of pediatric and adult patients with persistent asthma have uncontrolled symptoms. This has been attributed to patient nonadherence and poor self-management, but clinicians also contribute through inaccurate assessment of asthma and lack of familiarity with best practice guidelines for medication management. Thus, improving patient outcomes will require improving clinical management by health care providers, including utilization of evidence-based practice guidelines. In this report, we briefly summarize key points of the national guidelines for asthma management and delineate important changes enacted by 2020 Expert Panel Report-4 updates. These include revised recommendations on the use of fractional exhaled nitric oxide testing, indoor allergen mitigation, bronchial thermoplasty, adjunctive immunotherapy, and important modifications to medication management that are likely to have widespread impact on prescribing throughout the United States. In particular, for all patients aged five years and older taking stepwise therapy levels 3-4, it is now recommended to use Single Maintenance and Reliever Therapy, whereas the use of intermittent inhaled corticosteroids (ICSs) administered at the same time as short-acting beta agonist is recommended for step 2 to reduce symptom burden, improve control, and minimize total ICS dose.

Obesity in asthma: Intricately linked and often overlooked

In December 2020, the National Asthma Education and Prevention Program Coordinating Committee (coordinated by the National Heart, Lung, and Blood Institute) published a much-anticipated update to the Asthma Management Guidelines.1 Previously updated in 2007, the guidelines inform evidence-based care for clinicians caring for adults and children with asthma. Primary topics discussed in the recent update include the following: use of fractional exhaled nitric oxide testing, indoor allergen mitigation, use of intermittent inhaled corticosteroids and long-acting muscarinic antagonists, and adjunctive treatment modalities (eg, immunotherapy).

The Role of Pediatric Health-care Providers in Promoting Students' Asthma Health.

The Role of Pediatric Health-care Providers in Promoting Students' Asthma Health.

Pan-Canadian standards for severe asthma in electronic medical records

Rationale: Integration of guidelines for severe asthma (SA) management into electronic medical records (EMRs) may greatly enhance asthma care and outcomes. Objectives: We aimed: 1) to develop an algorithm to identify SA patients in primary care EMRs using pan-Canadian standardized data elements and decision support that prompts adherence with best practice guidelines and 2) to develop EMR data standards for SA for use primarily by specialists. Methods: A draft algorithm and list of elements were prepared, based upon the Canadian Thoracic Society criteria for suspected SA, Pan-Canadian Respiratory Standards Initiative for Electronic Health Records (PRESTINE) Asthma and Chronic Obstructive Pulmonary Disease (COPD) Working Group Report and published SA registries. Using a modified Delphi process, a working group (WG) of 18 experts voted on algorithm steps, elements and data definitions. Consensus was defined a priori as ≥ 60%. The algorithm, data elements and definitions were revised based on external stakeholder review. Measurements and Main Results: The WG devised a 4-step algorithm to identify SA and identified minor revisions to PRESTINE Core asthma elements necessary for the algorithm. PRESTINE Core asthma elements were deemed Core for SA. The WG identified 108 Core and 48 Optional elements for SA. Of those, 26 Core elements and 15 Optional elements were unique to SA. Conclusions: An algorithm has been proposed that will identify SA patients in primary care EMRs based upon PRESTINE Core asthma elements. This initiative has also identified SA EMR elements for use primarily by specialists.

National Asthma Education and Prevention Program 2020 Guidelines: What's Important for Primary Care.

• The 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group provides updated recommendations for 6 topics related to the management of individuals with asthma. • The classification of asthma severity and asthma control, as well as the concept of utilizing a stepwise approach to pharmacologic treatment, were not updated from the Expert Panel Report 3, released in 2007. • However, important updates in preferred therapies for intermittent and persistent asthma at treatment steps 1 through 5 were suggested. • Recommendations regarding biologic therapy were not included in the 2020 update, as only evidence and US Food and Drug Administration approvals through October 2018 were considered. • The most recent 2021 Global Initiative for Asthma guidelines are not included in this review but can be used in a complementary manner to assist primary care clinicians to optimize decisions regarding the care of patients with asthma.

The 2020 Focused Updates to the NIH Asthma Management Guidelines: Key Points for Pediatricians.

* Abbreviations: FeNO — : fractional exhaled nitric oxide ICS — : inhaled corticosteroid LABA — : long-acting β2-agonist LAMA — : long-acting muscarinic antagonist SABA — : short-acting β2-agonist SCIT — : subcutaneous immunotherapy SLIT — : sublingual immunotherapy SMART — : single maintenance and reliever therapy The National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (hereinafter “panel”) of the National Heart, Lung, and Blood Institute recently published its 2020 Focused Updates to the Asthma Management Guidelines (https://www.nhlbi.nih.gov/asthmaguidelines).1 These are the first updates from the panel since 2007, a remarkably long interval given the advances in care of the last decade. Using the Grading Recommendations, Assessment, Development, and Evaluation platform,2 the panel made 19 recommendations across six topic areas: intermittent inhaled corticosteroid (ICS) therapy, long-acting muscarinic antagonist (LAMA) therapy, indoor allergen-mitigation strategies, immunotherapy, fractional exhaled nitric oxide (FeNO) testing, and bronchial thermoplasty.3 Of these, 18 are relevant to children and adolescents (Table 1). The panel made strong recommendations (to be implemented by clinicians for almost all their patients as standard of care) and conditional recommendations (intended for many individuals as part of a shared decision-making process involving the clinician, family, and patient). For pediatric clinicians, the most exciting updates are those affirming several treatment options for using ICS with long-acting β2-agonists (LABAs) and LAMAs. Those for allergen mitigation, immunotherapy, and FeNO testing provide useful clarifications but not transformative alternatives for care. Of note, the updates did not address biological therapies because at the time that a decision regarding which topics to update was made (2014), only one biologic (omalizumab) was available. View this table: TABLE 1 New Recommendations of the 2020 Focused Updates by Age Group The updates’ most highly pediatric-relevant recommendations involve three treatment options: (1) intermittent ICS dosing with as-needed short-acting β2-agonist (SABA) for quick-relief therapy, (2) single maintenance and reliever … Address correspondence to Stephen J. Teach, MD, MPH, Children’s National Hospital, 111 Michigan Ave NW, Washington, DC 20010. E-mail: steach{at}childrensnational.org