Reviews and feature article
2020 Focused Updates to the Asthma Management Guidelines: A Report from the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group

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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.

Key words

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

Abbreviations used

ACP
American College of Physicians
ACQ
Asthma Control Questionnaire
ACQ-5
5-question Asthma Control Questionnaire
ACQ-6
6-question Asthma Control Questionnaire
ACQ-7
7-question Asthma Control Questionnaire
ACT
Asthma Control Test
AHRQ
Agency for Healthcare Research and Quality
AIR
Asthma Intervention Research
BELT
Blacks and Exacerbations on LABA vs Tiotropium
BT
Bronchial thermoplasty
COI
Conflict of interest
EPC
Evidence-Based Practice Center
EPR
Expert Panel Report
EtD
Evidence to decision
FDA
US Food and Drug Administration
Feno
Fractional exhaled nitric oxide
GRADE
Grading of Recommendations, Assessment, Development, and Evaluation
HEPA
High-efficiency particulate air (a type of filter)
ICS
Inhaled corticosteroid
ICS-LABA
Inhaled corticosteroid and long-acting beta2-agonist combination, typically in a single device
JACI
Journal of Allergy and Clinical Immunology
LABA
Long-acting beta2-agonist
LAMA
Long-acting muscarinic antagonist
MID
Minimally important difference
NAEPP
National Asthma Education and Prevention Program
NAEPPCC
National Asthma Education and Prevention Program Coordinating Committee
NHLBAC
National Heart, Lung, and Blood Advisory Council
NHLBI
National Heart, Lung, and Blood Institute
OR
Odds ratio
ppb
Parts per billion
RCT
Randomized controlled trial
RISA
Research In Severe Asthma
RR
Relative risk
SABA
Short-acting beta2-agonist
SCIT
Subcutaneous immunotherapy
SLIT
Sublingual immunotherapy
SMART
Single maintenance and reliever therapy
T2
Type 2

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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.

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).