2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group - 03/12/20

Doi : 10.1016/j.jaci.2020.10.003

Expert Panel Working Group of the National Heart, Lung, and Blood Institute (NHLBI) administered and coordinated National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC)^∗
Members of the Expert Panel Working Group: Michelle M. Cloutier, MD (Chair of the Expert Panel Working Group; UCONN Health, Farmington, Conn), Alan P. Baptist, MD, MPH (University of Michigan, Ann Arbor, Mich), Kathryn V. Blake, PharmD (Nemours Children's Health System, Jacksonville, Fla), Edward G. Brooks, MD (University of Texas Health Science Center at San Antonio, San Antonio, Texas), Tyra Bryant-Stephens, MD (Children's Hospital of Philadelphia, Philadelphia, Pa), Emily DiMango, MD (Columbia University Irving Medical Center, New York, NY), Anne E. Dixon, MA, BM, BCh (University of Vermont, Burlington, Vt), Kurtis S. Elward, MD, MPH, FAAFP (Virginia Commonwealth University, Charlottesville, Va), Tina Hartert, MD, MPH (Vanderbilt University School of Medicine, Nashville, Tenn), Jerry A. Krishnan, MD, PhD (University of Illinois Hospital and Health Sciences System, Chicago, Ill), Robert F. Lemanske Jr, MD (University of Wisconsin - Madison, Madison, Wis), Daniel R. Ouellette, MD, FCCP (Henry Ford Health System, Detroit, Mich), Wilson D. Pace, MD, FAAFP (University of Colorado, Aurora, Colo), Michael Schatz, MD, MS (Kaiser Permanente, San Diego, Calif), Neil S. Skolnik, MD (Dr Skolnik withdrew from the Expert Panel on October 1, 2019; Abington - Jefferson Health, Jenkintown, Pa), James W. Stout, MD, MPH (University of Washington, Seattle, Wash), Stephen J. Teach, MD, MPH (George Washington University, Washington, DC), Craig A. Umscheid, MD, MSCE (University of Chicago, Chicago, Ill), and Colin G. Walsh, MD, MA (Dr Walsh withdrew from the Expert Panel on October 29, 2019; Vanderbilt University Medical Center, Nashville, Tenn).
Michelle M. Cloutier, MD, Alan P. Baptist, MD, MPH, Kathryn V. Blake, PharmD, Edward G. Brooks, MD, Tyra Bryant-Stephens, MD, Emily DiMango, MD, Anne E. Dixon, MA, BM, BCh, Kurtis S. Elward, MD, MPH, FAAFP, Tina Hartert, MD, MPH, Jerry A. Krishnan, MD, PhD, Robert F. Lemanske, MD, Daniel R. Ouellette, MD, FCCP, Wilson D. Pace, MD, FAAFP, Michael Schatz, MD, MS, Neil S. Skolnik, MD, James W. Stout, MD, MPH, Stephen J. Teach, MD, MPH, Craig A. Umscheid, MD, MSCE, Colin G. Walsh, MD, MA
National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda

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:

•	Fractional Exhaled Nitric Oxide Testing
•	Indoor Allergen Mitigation
•	Intermittent Inhaled Corticosteroids
•	Long-Acting Muscarinic Antagonists
•	Immunotherapy in the Treatment of Allergic Asthma
•	Bronchial Thermoplasty

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.

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Key words : NHLBI, Asthma Guideline, asthma, fractional exhaled nitric oxide, allergen mitigation, inhaled corticosteroids, long-acting muscarinic antagonist, bronchial thermoplasty, immunotherapy

Abbreviations used : ACP, ACQ, ACQ-5, ACQ-6, ACQ-7, ACT, AHRQ, AIR, BELT, BT, COI, EPC, EPR, EtD, FDA, Feno, GRADE, HEPA, ICS, ICS-LABA, JACI, LABA, LAMA, MID, NAEPP, NAEPPCC, NHLBAC, NHLBI, OR, ppb, RCT, RISA, RR, SABA, SCIT, SLIT, SMART, T2

Plan

Table of Contents

Preface

Foreword

Section I: Introduction

Background and rationale for focused updates

Methods

Systematic reviews of the literature

Updated reviews of the literature

Expert Panel processes

GRADE methodology

Focus groups with individuals with asthma and their caregivers

2020 focused updates to the 2007 Asthma Guidelines

Review and public comment

Limitations and research gaps

Recommendations

Integration of the new recommendations into asthma care

Section III: Recommendations for indoor allergen mitigation in management of asthma

Background

Definitions of terms used in this section

Question 3.1

Implementation guidance

Summary of the evidence

Single-component allergen mitigation interventions

Multicomponent allergen mitigation interventions

Rationale and discussion

Future research opportunities

Section V: Recommendations for the use of LAMAs for asthma

Background

Definitions of terms used in this section

Question 5.1

Question 5.2

Implementation guidance

Summary of the evidence

Rationale and discussion

Question 5.3

Implementation guidance

Summary of the evidence

Rationale and discussion

Future research opportunities

Section VI: The role of subcutaneous and sublingual immunotherapy in the treatment of allergic asthma

Background

Definition of terms used in this section

Question 6.1

Implementation guidance

Summary of the evidence

Rationale and discussion

Question 6.2

Implementation guidance

Summary of the evidence

Rationale and discussion

Overall summary for SCIT and SLIT

Future research opportunities

Section VII: Recommendations for the use of BT to improve asthma outcomes

Background

Definitions of terms used in this section

Question 7.1

Implementation guidance

Summary of the evidence

Rationale and discussion

Future research opportunities

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 funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. No additional funding was received. All authors volunteered their time.

Reported disclosure of potential conflict of interest: Development of this report was funded by the National Heart, Lung, and Blood Institute of the National Institutes of Health. Members of the Expert Panel Working Group (“Expert Panel”) of the National Asthma Education and Prevention Program Coordinating Committee (NAEPPCC) completed financial disclosure forms and disclosed relevant financial interests described as conflicts of interest to each other before their discussions. Members of the Expert Panel were volunteers and received compensation only for travel expenses related to the panel’s in-person meetings. M. M. Cloutier reported that a family member was employed by Regeneron. The Expert Panel did not discuss any Regeneron or related products. M. M. Cloutier was not recused from any Expert Panel discussions. A. Baptist received grant funding from Novartis, AstraZeneca, Teva Pharmaceuticals Industries Ltd (Teva), and Takeda and was recused from drafting, discussing, or voting on sections of the report related to the inhaled corticosteroid recommendations. K. Blake received personal fees from Teva for participation on its Digital Technology Advisory Board and study drugs from Boehringer Ingelheim and GlaxoSmithKline for federally funded clinical trials and was not recused from any Expert Panel discussions. E. G. Brooks served on the Scientific Advisory Board for United Allergy Services until December 2019 and was recused from the initial drafting, discussions, and voting related to the immunotherapy recommendations. However, he participated in the final voting, discussions, and writing of this section of the report. T. Bryant-Stephens received mattress covers and air purifiers from the Asthma and Allergy Foundation of America and was not recused from any Expert Panel discussions. E. DiMango participated in an advisory board meeting for AstraZeneca, reported that a family member was formerly employed by Regeneron, and was not recused from any Expert Panel discussions. A. Dixon received a study medication from MitoQ, also received assistance from a medical writer from Boehringer Ingelheim for a manuscript published in 2019 that was not related to the update topics, and was not recused from any Expert Panel discussions. K. S. Elward had no conflicts of interest and was not recused from any Expert Panel discussions. T. Hartert participated in a Pfizer advisory board for a maternal respiratory syncytial virus vaccine and was not recused from any Expert Panel discussions. J. A. Krishnan participated in a data and safety monitoring committee for Sanofi, received funding from Inogen and ResMed for a study of portable oxygen concentrators, received personal fees from the Critical Path Institute, and was not recused from any Expert Panel discussions. R. F. Lemanske received personal fees from Siolta Therapeutics for a microbiome intervention and from the Food Allergy Research & Education Network and was not recused from any Expert Panel discussions. D. R. Ouellette had no conflicts of interest and was not recused from any Expert Panel discussions. W. Pace participated in a meeting sponsored by Mylan to discuss long-acting muscarinic antagonist (LAMA) therapy, received a study drug from Teva for a Patient-Centered Outcomes Research Institute–funded pragmatic clinical study, received a grant from Boehringer Ingelheim through Optimal Patient Care concerning Chronic Obstructive Pulmonary Disease, and was recused from participation in the final discussion, voting, and section writing related to LAMA therapy. M. Schatz received grant funding from Merck, Teva, and ALK-Abello, Inc, and was recused from the writing, discussion, and voting related to the immunotherapy recommendations. N. S. Skolnik received personal fees and nonfinancial support from AstraZeneca; personal fees from Teva, Eli Lilly and Company, Boehringer Ingelheim, Merck, Sanofi, Janssen Pharmaceuticals, Intarcia Therapeutics, GlaxoSmithKline, and Mylan; was recused from the writing, discussion, and voting related to the inhaled corticosteroids and LAMA recommendations; and withdrew from the Expert Panel on October 1, 2019. J. W. Stout received a training grant from the Patient-Centered Outcomes Research Institute, which distributed pillow and mattress dust covers; nonfinancial support for a new quality review design for the EasyOne Air spirometer (the EasyOne Air build was done with a combination of license revenue from the Spirometry 360 course, and his personal research and training account through his division); nonfinancial support for a smartphone spirometer application from Google, and development of an asynchronous and an abridged asynchronous online spirometer training course (asynchronous training was built with a combination of funding from AHRQ, the National Asthma Control Initiative [NACI], Spirometry 360 license revenue, and unrestricted funding from Astra-Zeneca); and was not recused from any Expert Panel discussions. S. Teach had no conflicts of interest and was not recused from any Expert Panel discussions. C. A. Umscheid received funding from the Agency for Healthcare Research and Quality for systematic reviews on allergen reduction and bronchial thermoplasty and was not recused from any Expert Panel discussions. C. G. Walsh had no conflicts of interest, was not recused from any Expert Panel discussions, and withdrew from the Expert Panel on October 29, 2019.