Linking To And Excerpting From 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group”

Posted on March 10, 2025 by Tom Wade MD

Today, I review, link to, and excerpt from 2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group [PubMed Abstract] [Full-Text HTML] [Full-Text PDF]. J Allergy Clin Immunol. 2020 Dec;146(6):1217-1270. doi: 10.1016/j.jaci.2020.10.003.

The above article has been cited 225 times in PubMed.

All that follows is from the above resource.

Outline

Abstract

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 was coordinated and supported by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. It is designed to improve patient care and support informed decision making about asthma management in the clinical setting. This update addresses six priority topic areas as determined by the state of the science at the time of a needs assessment, and input from multiple stakeholders:A rigorous process was undertaken to develop these evidence-based guidelines. The Agency for Healthcare Research and Quality’s (AHRQ) Evidence-Based Practice Centers conducted systematic reviews on these topics, which were used by the Expert Panel Working Group as a basis for developing recommendations and guidance. The Expert Panel used GRADE (Grading of Recommendations, Assessment, Development and Evaluation), an internationally accepted framework, in consultation with an experienced methodology team for determining the certainty of evidence and the direction and strength of recommendations based on the evidence. Practical implementation guidance for each recommendation incorporates findings from NHLBI-led patient, caregiver, and clinician focus groups. To assist clincians in implementing these recommendations into patient care, the new recommendations have been integrated into the existing Expert Panel Report-3 (EPR-3) asthma management step diagram format.

Keywords: Asthma Guideline; NHLBI; allergen mitigation; asthma; bronchial thermoplasty; fractional exhaled nitric oxide; immunotherapy; inhaled corticosteroids; long-acting muscarinic antagonist.

PubMed Disclaimer

Section I: Introduction

 After a discussion and review of the responses to a public request for information on the need for and potential content of an update, the NHLBAC Asthma Expert Working Group (which included members of the EPR-3 expert panel) determined that a focused update on six priority topics was warranted. For each of the six priority topics, the NHLBAC Asthma Expert Working Group determined the key questions to address in the systematic reviews. For each key question, the working group of the NHLBAC identified the patient population, intervention, relevant comparators, and outcomes of interest.

The six priority topics identified for systematic review were as follows:

1.
Fractional exhaled nitric oxide (Feno) in diagnosis, medication selection, and monitoring of treatment response in asthma
2.
Remediation of indoor allergens (eg, house-dust mites/pets) in asthma management
3.
Adjustable medication dosing in recurrent wheezing and asthma
4.
Long-acting antimuscarinic agents in asthma management as add-ons to inhaled corticosteroids (ICSs)
5.
Immunotherapy and the management of asthma
6.
Bronchial thermoplasty (BT) in adult severe asthma
The NHLBAC Asthma Expert Working Group recommended that another 11 topics be acknowledged in the update but that no recommendations be developed for these topics because of the lack of sufficient new data for a systematic review of these topics at that time. These emerging topics are as follows:

•Adherence

•Asthma action plans
•Asthma heterogeneity
•Biologic agents
•Biomarkers (other than Feno)
•Classification of asthma severity
•Long-acting beta2-agonist (LABA) safety
•Physiological assessments
•Prevention of asthma onset
•Role of community health workers in asthma management
•Step down from maintenance therapy
Fig 1 Timeline for 2020 Asthma Guideline Update.
Topic Key question
Feno What is the diagnostic accuracy of Feno measurement(s) for making the diagnosis of asthma in individuals aged 5 y and older?
What is the clinical utility of Feno measurements in monitoring disease activity and asthma outcomes in individuals with asthma aged 5 y and older?
What is the clinical utility of Feno measurements to select medication options (including steroids) for individuals aged 5 y and older?
What is the clinical utility of Feno measurements to monitor response to treatment in individuals aged 5 y and older?
In children aged 0-4 years with recurrent wheezing, how accurate is Feno testing in predicting the future development of asthma at age 5 y and above?
Allergen mitigation Among individuals with asthma, what is the effectiveness of interventions to reduce or remove exposures to indoor inhalant allergens on asthma control, exacerbations, quality of life, and other relevant outcomes?
ICS What is the comparative effectiveness of intermittent ICS compared to no treatment, pharmacologic therapy, or nonpharmacologic therapy in children aged 0-4 y with recurrent wheezing?
What is the comparative effectiveness of intermittent ICS compared to ICS controller therapy in individuals 5 y and older with persistent asthma?
What is the comparative effectiveness of ICS with LABA used as both controller and quick-relief therapy compared to ICS with or without LABA used as controller therapy in individuals 5 y and older with persistent asthma?
LAMA What is the comparative effectiveness of LAMA compared to other controller therapy as add-on to ICS in individuals aged 12 y and older with uncontrolled, persistent asthma?
What is the comparative effectiveness of LAMA as add-on to ICS controller therapy compared to placebo or increased ICS dose in individuals aged 12 y and older with uncontrolled, persistent asthma?
What is the comparative effectiveness of LAMA as add-on to ICS-LABA compared to ICS-LABA as controller therapy in individuals aged 12 y and older with uncontrolled, persistent asthma?
Immunotherapy What is the evidence for the efficacy of SCIT in the treatment of asthma?
What is the evidence for the safety of SCIT in the treatment of asthma?
What is the evidence for the efficacy of SLIT, in tablet and aqueous form, for the treatment of asthma?
What is the evidence for the safety of SLIT, in tablet and aqueous form, for the treatment of asthma?
BT What are the benefits and harms of using BT in addition to standard treatment for the treatment of individuals aged 18 y and older with asthma?

Table IA

Systematic review key questions
Outcome measure Range (points) Score interpretation MID
Asthma control
ACT 5-25 Well controlled: ≥20
Not well controlled: ≤19		 ≥12 y:
MID ≥3 points
Asthma Control Questionnaire-5 (ACQ-5)
Asthma Control Questionnaire-6 (ACQ-6)		 0-6 Uncontrolled: ≥1.5
Well controlled: <0.75		 ≥18 y:
MID ≥0.5 points
Asthma Control Questionnaire-7 (ACQ-7) 0-6 Uncontrolled: ≥1.5
Well controlled: <0.75		 ≥6 y:
MID ≥0.5 points
Asthma-related quality of life
Asthma Quality of Life Questionnaire
Asthma Quality of Life Questionnaire Mini (AQLQ-mini)		 1-7 Severe impairment = 1
No impairment = 7		 ≥18 y:
MID ≥0.5 points
Pediatric Asthma Quality of Life Questionnaire 1-7 Severe impairment = 1
No impairment = 7		 7-17 y:
MID ≥0.5 points
Other
Rescue medication use (daytime or nighttime) Continuous measure of puffs per unit of time NA ≥18 y:
MID = –0.81 puffs/d
Table IB

MIDs for asthma-control and asthma-related quality-of-life measures
NA, Not applicable/available.
Content area Question Judgment (pick one) Research evidence Additional considerations
Desirable effects How substantial are the desirable anticipated effects? Trivial, small, moderate, large, vary, don’t know
Undesirable effects How substantial are the undesirable anticipated effects? Large, moderate, small, trivial, vary, don’t know
Certainty of evidence What is the overall certainty of the evidence of the effects? Very low, low, moderate, high, no included studies
Values Is there important uncertainty about or variability in how much people value the main outcomes? Important uncertainty or variability, possibly important uncertainty or variability, probably no important uncertainty or variability, no important uncertainty or variability
Balance of effects Does the balance between desirable and undesirable effects favor the intervention or the comparison? Favors the comparison, probably favors the comparison, does not favor either the intervention or the comparison, probably favors the intervention, favors the intervention, varies, don’t know
Acceptability Is the intervention acceptable to key stakeholders? No, probably no, probably yes, yes, varies, don’t know
Feasibility Is the intervention feasible to implement? No, probably no, probably yes, yes, varies, don’t know
Equity What would be the impact on health equity? Reduced, probably reduced, probably no impact, probably increased, increased, varies, don’t know

Table IC

EtD table template
High We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate We are moderately confident in the effect estimate. The true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low Our confidence in the effect estimate is limited. The true effect may be substantially different from the estimate of the effect.
Very low We have very little confidence in the effect estimate. The true effect is likely to be substantially different from the estimate of the effect.

Table ID

Certainty of evidence of effects
Table IEImplications of strong and conditional recommendations∗
Implications Strong recommendation Conditional recommendation
For individuals with asthma Most individuals in this situation would want the recommended course of action and only a small proportion would not. Most individuals in this situation would want the suggested course of action, but many would not.
For clinicians Most individuals should receive the intervention. Formal decision aids are not likely to be needed to help individuals make decisions consistent with their values and preferences. Different choices will be appropriate for individuals consistent with their values and preferences. Use shared decision making. Decision aids may be useful in helping individuals make decisions consistent with their risks, values, and preferences.
For policymakers The recommendation can be adapted as policy or performance measure in most situations. Adherence to this recommendation according to the guideline could be used as a quality criterion or performance indicator. Policy making will require substantial debate and involvement of various stakeholders. Performance measures should assess whether decision making is documented.
For researchers The recommendation is supported by credible research or other convincing judgments that make additional research unlikely to alter the recommendation. On occasion, a strong recommendation is based on low or very low certainty in the evidence. In such instances, further research may provide important information that alters the recommendations. The recommendation is likely to be strengthened (for future updates or adaptation) by additional research. An evaluation of the conditions and criteria (and the related judgments, research evidence, and additional considerations) that determined the conditional (rather than strong) recommendation will help identify possible research gaps.
∗ Strong recommendations are indicated by statements that lead with “We recommend,” whereas conditional recommendations are indicated by statements that lead with “We conditionally recommend.”
This entry was posted in Asthma, Guidelines. Bookmark the permalink.