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Rationale: Asthma poses a significant burden for U.S. patients and health systems, yet inpatient care quality is understudied. National chronic obstructive lung disease (COPD) readmission policies may affect inpatient asthma care through hospital responses to these policies because of imprecise diagnosis and identification of patients with COPD and asthma. Objectives: Evaluate inpatient care quality for patients hospitalized with asthma and potential collateral effects of the Medicare COPD Hospital Readmissions Reduction Program (HRRP). Methods: This was a retrospective cohort study of patients aged 18–54 years hospitalized for asthma across 924 U.S. hospitals (Premier Healthcare Database). Results: Care quality for patients with asthma was evaluated before HRRP implementation (n = 20,820; January 2010–September 2014) and after HRRP implementation (n = 26,885; October 2014–December 2018) using adherence to inpatient care guidelines (recommended, nonrecommended, and "ideal care" [all recommended with no nonrecommended care]). Between 2010 and 2018, at least 80% of patients received recommended care annually. Recommended care decreased similarly (rate of 0.02%/mo) after versus before HRRP (P = 0.8). Nonrecommended care decreased more rapidly after HRRP (rate of 0.29%/mo) versus before HRRP (rate of 0.17%/mo; P < 0.001), with changes driven largely by decreased antibiotic prescribing. Ideal care increased more rapidly after HRRP (rate of 0.25%/mo) versus before HRRP (rate of 0.17%/mo; P = 0.02), with changes driven largely by nonrecommended care improvements. Conclusions: Post-HRRP trends suggest asthma care improved with increased rates of guideline concordance in nonrecommended and ideal care. Although federal policies (e.g., HRRP) may have had positive collateral effects, such as with asthma care, parallel care efforts, including antibiotic stewardship, likely contributed to these improvements. [ABSTRACT FROM AUTHOR]

Background: The National Asthma Education and Prevention Program guidelines emphasize environmental control as an integral part of asthma management; however, limited national-level data exist on how clinicians implement environmental control recommendations. Objective: We analyzed data on clinicians’ self-reported use of recommended environmental control practices in a nationally representative sample (n = 1645) of primary care physicians, asthma specialists, and advanced practice providers from the National Asthma Survey of Physicians, a supplemental questionnaire to the 2012 National Ambulatory Medical Care Survey. Methods: We examined clinician and practice characteristics as well as clinicians’ decisions and strategies regarding environmental trigger assessment and environmental control across provider groups. Regression modeling was used to identify clinician and practice characteristics associated with implementation of guideline recommendations. Results: A higher percentage of specialists assessed asthma triggers at home, school, and/or work than primary care or advanced practice providers (almost always: 53.6% vs 29.4% and 23.7%, respectively, P < .001). Almost all clinicians (>93%) recommended avoidance of secondhand tobacco smoke, whereas recommendations regarding cooking appliances (eg, proper ventilation) were infrequent. Although assessment and recommendation practices differed between clinician groups, modeling results showed that clinicians who reported almost always assessing asthma control were 5- to 6-fold more likely to assess environmental asthma triggers. Use of asthma action plans was also strongly associated with implementation of environmental control recommendations. Conclusions: Environmental assessment and recommendations to patients varied among asthma care providers. High adherence to other key guideline components, such as assessing asthma control, was associated with environmental assessment and recommendation practices on environmental control.

Purpose of Review: A modified Delphi process was undertaken to provide a US expert-led consensus to guide clinical action on short-acting beta2-agonist (SABA) use. This comprised an online survey (Phase 1), forum discussion and statement development (Phase 2), and statement adjudication (Phase 3). Recent Findings: In Phase 1 (n = 100 clinicians), 12% routinely provided patients with ≥4 SABA prescriptions/year, 73% solicited SABA use frequency at every patient visit, and 21% did not consult asthma guidelines/expert reports. Phase 3 experts (n = 8) reached consensus (median Likert score, interquartile range) that use of ≥3 SABA canisters/year is associated with increased risk of exacerbation and asthma-related death (5, 4.75–5); SABA use history should be solicited at every patient visit (5, 4.75–5); usage patterns over time, not absolute thresholds, should guide response to SABA overuse (5, 4.5–5). Summary: Future asthma guidelines should include clear recommendations regarding SABA usage, using expert-led thresholds for action. [ABSTRACT FROM AUTHOR]

Asthma control is the main goal of management. Unfortunately, most asthma patients with moderate–severe asthma remain uncontrolled despite receiving standard treatment of inhaled corticosteroids (ICS) with long-acting β2 agonists (LABA). The addition of long-acting antimuscarinic agents (LAMA) has been shown to improve different aspects of asthma control, including symptoms, lung functions, and probably exacerbations. Such an option could be considered for low-T2 asthma phenotype. Umeclidinium and glycopyrronium bromide are other LAMA agents that have been recently made available in combination with ICS and LABA in single-inhaler triple therapy (SITT) devices. Here, we discuss the position of SITT as a new novel therapeutic option in asthma management and its clinical benefits, potential cost saving, and improved compliance.

Asthma control is the main goal of management. Unfortunately, most asthma patients with moderate–severe asthma remain uncontrolled despite receiving standard treatment of inhaled corticosteroids (ICS) with long-acting β2 agonists (LABA). The addition of long-acting antimuscarinic agents (LAMA) has been shown to improve different aspects of asthma control, including symptoms, lung functions, and probably exacerbations. Such an option could be considered for low-T2 asthma phenotype. Umeclidinium and glycopyrronium bromide are other LAMA agents that have been recently made available in combination with ICS and LABA in single-inhaler triple therapy (SITT) devices. Here, we discuss the position of SITT as a new novel therapeutic option in asthma management and its clinical benefits, potential cost saving, and improved compliance. [ABSTRACT FROM AUTHOR]

Background: International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β2-agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β2-agonist in acute asthma.Methods: We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β2-agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death.Results: Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I2=56%. The pooled Peto's OR for treatment failure with epinephrine versus selective β2-agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β2-agonist improved outcomes.Conclusion: The low-quality evidence available suggests that epinephrine and selective β2-agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β2-agonist improves outcome.Prospero Registration Number: CRD42017079472. [ABSTRACT FROM AUTHOR]

Abstract House-dust mites (HDM) allergy is the prevailing condition in subjects allergic to inhalants. Clinical studies with HDM extracts—either subcutaneous (SCIT) or sublingual (SLIT) have long been characterized by small sample size, varying allergen doses, and poorly defined endpoints assessing disease severity. In the last decade, well-designed, randomized, controlled studies recruiting thousands of patients have been conducted with newly developed HDM sublingual tablets (SQ®-HDM tablets). This drug is easily dispersible in the oral cavity due to the patented Zydis® technology and its allergen composition is balanced in terms of group I and group II major mite allergen content, reflecting the equal contribution of the two components to HDM sensitization. HDM is the most common allergen associated with asthma. Clinical efficacy of the SQ® HDM SLIT-tablet in HDM allergic asthma has been evaluated in randomized, double-blind, placebo-controlled trials. Both endpoints related to “present” asthma control (inhaled corticosteroid—ICS) as well as endpoints related to “future” asthma control (occurrence of asthma exacerbations) were included in these studies, in agreement with GINA (Global Initiative for Asthma) guidelines. Based on the positive results of these studies, SQ®-HDM SLIT-tablets were approved Europe-wide as registered drug for treating moderate-to-severe allergic rhinitis with or without allergic asthma and not well controlled HDM allergic asthma, associated with allergic rhinitis of any severity. GINA guidelines in 2017 included SLIT-tablet-based immunotherapy as an “add-on” treatment for asthmatic patients sensitized to HDM; indeed, allergen immunotherapy (AIT) is considered to be a complementary treatment option that targets the immunological of allergic diseases, representing the only treatment potentially disease-modifier or, at least, with a long-term efficacy. The availability of a safe, standardized, registered treatment for HDM respiratory allergies is pivotal in the immunotherapy field, pushing it out of a century-long limbo of amatorial interest towards the full dignity deserved by the only casual treatment of respiratory allergies.

Introduction: Work-related asthma accounts for ≥25% of asthma in working-age populations, though the relationship between work exposures and symptoms is frequently missed, leading to poor health and employment outcomes. We hypothesised that inhalable exposures at work are associated with poor asthma control in severe asthma (SA)., Methods: We searched the Birmingham (UK) Regional NHS SA Service clinical database (n=1453 records; 1 March 2004 to 1 March 2021) and undertook a cross-sectional study using baseline data collected at diagnosis. We included all employed patients aged 16-64 with documented current occupation (n=504), and collected socio-demographic, general health and asthma-specific data, including Asthma Control Questionnaire 7 (ACQ7) score. The Occupational Asthma Specific Job-Exposure Matrix (OAsJEM) was employed to determine the likelihood of exposure to respiratory sensitisers, irritants, cleaning agents and detergents; associations between exposures and ACQ7 were investigated using binary and multinomial regression., Results: Frequently reported occupations were care assistants (7%) and nurses (6%); 197/504 (39%) patients were exposed to an asthmagen, including respiratory sensitisers (30%), airway irritants (38%) and cleaning products/disinfectants (29%). ACQ7 score was available for 372/504 (74%) patients, of whom 14% had adequate control (ACQ7=0-1.5). After adjustment for major confounders there were no significant associations between inhaled asthmagens and ACQ7 score (either as binary or multinomial outcomes)., Conclusion: JEM-determined workplace exposures to inhaled asthmagens are not associated with asthma control in SA; 29-39% of patients may have current exposure to workplace asthmagens. Routine collection of lifetime occupational data including current job role and level of exposure, in the national asthma registry, would give further insights into this relationship., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Asthma is the most common chronic respiratory disease in the UK; however, the misdiagnosis rate is substantial. The lack of consistency in national guidelines and the paucity of data on the performance of diagnostic algorithms compound the challenges in asthma diagnosis. Asthma is a highly rhythmic disease, characterised by diurnal variability in clinical symptoms and pathogenesis. Asthma also varies day to day, seasonally and from year to year. As much as it is a hallmark for asthma, this variability also poses significant challenges to asthma diagnosis. Almost all established asthma diagnostic tools demonstrate diurnal variation, yet few are performed with standardised timing of measurements. The dichotomous interpretation of diagnostic outcomes using fixed cut-off values may further limit the accuracy of the tests, particularly when diurnal variability straddles cut-off values within a day, and careful interpretation beyond the 'positive' and 'negative' outcome is needed. The day-to-day and more long-term variations are less predictable and it is unclear whether performing asthma diagnostic tests during asymptomatic periods may influence diagnostic sensitivities. With the evolution of asthma diagnostic tools, home monitoring and digital apps, novel strategies are needed to bridge these gaps in knowledge, and circadian variability should be considered during the standardisation process. This review summarises the biological mechanisms of circadian rhythms in asthma and highlights novel data on the significance of time (the fourth dimension) in asthma diagnosis. [ABSTRACT FROM AUTHOR]

Regardless of existence of National asthma guidelines, adherence to major elements of guidelines among providers is suboptimal. The nonadherence contributes to poor clinical outcomes and quality of life of asthma patients. This project aims to improve the standard of care of asthma patients with increased providers' adherence to asthma guidelines through provider education, and implementation of practice guidelines and evidence-based resources. A pre-post implementation retrospective design was adopted along with the provision of provider education sessions and implementation of pediatric asthma management practice guidelines and asthma resources in the pediatric practice in Southern, New Jersey. Data were collected via retrospective chart review among 41 patients four-months pre-implementation and 38 patients three months post-implementation to assess the improvement of providers' adherence to seven elements of asthma guidelines. Descriptive statistics and chi-square tests were computed to evaluate providers' adherence. Results showed improvement from pre- to post-implementation in utilization of six of the seven key elements of guidelines among providers that include, the assessment and documentation of asthma control (4.9% to 39.5%), medication adherence (20% to 87.5%), medication delivery technique (7.3% to 18.4%), environmental triggers (14.6% to 44.7%), asthma action plan (4.9% to 28.9%), and follow-up visits (48.8% to 76.3%). In addition, the chi-square test showed a significant association between environmental triggers assessment from baseline to post-implementation, χ2 (1, n = 79) = 4.29, p =.038. Providing necessary resources and provider-focused education demonstrated a positive change in promoting best practice and facilitating providers' adherence. [ABSTRACT FROM AUTHOR]

Background: There is conflicting research about the association between asthma and poor educational attainment that may be due to asthma definitions. Our study creates seven categories of current chronic and acute asthma to investigate if there is an association for poorer educational attainment at age 6-7 years, and the role of respiratory infections and school absence.Methods: This study used a population-based electronic cross-sectional birth cohort 1998-2005, in Wales, UK, using health and education administrative datasets. Current asthma or wheeze categories were developed using clinical management guidelines in general practice (GP) data, acute asthma was inpatient hospital admissions and respiratory infections were the count of GP visits, from birth to age 6-7 years. We used multilevel logistic regression grouped by schools to ascertain if asthma or wheeze was associated with not attaining the expected level in teacher assessment at Key Stage 1 (KS1) adjusting for sociodemographics, perinatal, other respiratory illness and school characteristics. We tested if absence from school was a mediator in this relationship using the difference method.Results: There were 85 906 children in this population representative cohort with 7-year follow-up. In adjusted multilevel logistic regression, only asthma inpatient hospital admission was associated with increased risk for not attaining the expected level at KS1 (adjusted OR 1.14 95% CI (1.02 to 1.27)). Lower respiratory tract infection (LRTI) GP contacts remained an independent predictor for not attaining the expected level of education. Absence from school was a potential mediator of the association between hospital admission and educational attainment.Conclusions: Clinicians and educators need to be aware that children who have inpatient hospital admissions for asthma or wheeze, or repeated LRTI, may require additional educational support for their educational outcomes. [ABSTRACT FROM AUTHOR]

As an asthma specialist, one is often asked to discuss the asthma guidelines. The challenge that one faces is deciding which guidelines to use as a resource for discussion or presentation. It often comes down to the following questions: What is the question? What message does one want to deliver? Where is the most current information? and Who is the target audience? This commentary will help answer those questions as it guides the reader through the new update of the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program guidelines and then outlines differences between 2 widely used strategies for the management of asthma: the Global Initiative for Asthma and the National Heart, Lung and Blood Institute/National Asthma Education and Prevention Program Guidelines for the Diagnosis and Management of Asthma. [ABSTRACT FROM AUTHOR]

Our aim is to review current asthma epidemiology, achievements from the last 10 years, and persistent challenges of asthma management and control in low-middle income countries (LMICs). Despite global efforts, asthma continues to be an important public health problem worldwide, particularly in poorly resourced settings. Several epidemiological studies in the last decades have shown significant variability in the prevalence of asthma globally, but generally a marked increase in LMICs resulting in significant morbidity and mortality. Poverty, air pollution, climate change, exposure to indoor allergens, urbanization and diet are some of the factors that contribute to inadequate control and poor outcomes in developing countries. Although asthma guidelines have been developed to raise awareness and improve asthma diagnosis and treatment, problems with underdiagnosis and undertreatment are still common. In addition, important social, financial, cultural and healthcare barriers are common obstacles in LMICs in achieving control. Given the high burden of asthma in these countries, adaptation and implementation of national asthma guidelines tailored to local needs should be a public health priority. Governmental commitment, education, better health system infrastructure, access to care and effective asthma medications are the cornerstone of achieving success. Conclusion. Asthma poses significant challenges to LMICs. Whilst there are ongoing efforts in improving asthma diagnosis and decreasing asthma burden in LMICs; reasons for inadequate asthma control are also common and difficult to tackle. Improving asthma diagnosis, access to appropriate treatment and decreasing risk factors should be key goals to reduce asthma morbidity and mortality worldwide. [ABSTRACT FROM AUTHOR]

House-dust mites (HDM) allergy is the prevailing condition in subjects allergic to inhalants. Clinical studies with HDM extracts—either subcutaneous (SCIT) or sublingual (SLIT) have long been characterized by small sample size, varying allergen doses, and poorly defined endpoints assessing disease severity. In the last decade, well-designed, randomized, controlled studies recruiting thousands of patients have been conducted with newly developed HDM sublingual tablets (SQ®-HDM tablets). This drug is easily dispersible in the oral cavity due to the patented Zydis® technology and its allergen composition is balanced in terms of group I and group II major mite allergen content, reflecting the equal contribution of the two components to HDM sensitization. HDM is the most common allergen associated with asthma. Clinical efficacy of the SQ® HDM SLIT-tablet in HDM allergic asthma has been evaluated in randomized, double-blind, placebo-controlled trials. Both endpoints related to "present" asthma control (inhaled corticosteroid—ICS) as well as endpoints related to "future" asthma control (occurrence of asthma exacerbations) were included in these studies, in agreement with GINA (Global Initiative for Asthma) guidelines. Based on the positive results of these studies, SQ®-HDM SLIT-tablets were approved Europe-wide as registered drug for treating moderate-to-severe allergic rhinitis with or without allergic asthma and not well controlled HDM allergic asthma, associated with allergic rhinitis of any severity. GINA guidelines in 2017 included SLIT-tablet-based immunotherapy as an "add-on" treatment for asthmatic patients sensitized to HDM; indeed, allergen immunotherapy (AIT) is considered to be a complementary treatment option that targets the immunological of allergic diseases, representing the only treatment potentially disease-modifier or, at least, with a long-term efficacy. The availability of a safe, standardized, registered treatment for HDM respiratory allergies is pivotal in the immunotherapy field, pushing it out of a century-long limbo of amatorial interest towards the full dignity deserved by the only casual treatment of respiratory allergies. [ABSTRACT FROM AUTHOR]

Recognition that about half of asthma deaths might be preventable if recommended guidelines are followed suggests that better implementation of established management strategies is needed. However, to achieve a further substantive reduction in asthma mortality, novel strategies will also be required. It is well established that asthma is a disease of chronic inflammation, with episodes of worsening inflammation associated with increased symptoms and/or exacerbations; however, current guidelines paradoxically recommend that initial treatment is only symptomatic, rather than directed at the underlying inflammatory mechanism. The "Treat to target" (TTT) approach has become a popular concept in the medical management of several common chronic conditions, including rheumatoid arthritis (RA), diabetes, hypertension and hyperlipidemia. For example, as part of a TTT approach, rheumatologists recommend methotrexate for RA with onset within 6 months. Applying the TTT approach to asthma, the primary target could be clinical remission and the primary goals as follows: eliminate symptoms and exacerbation risk; prevent airway remodeling; and normalize lung function. To construct a TTT algorithm for chronic asthma, the proposal is to eradicate short-acting β2-agonists (SABA) at all asthma severity levels and replace SABA with "Anti-Inflammatory Reliever Therapy" (AIR), using inhaled corticosteroids (ICS)/SABA or ICS/formoterol. For individuals with equal to or less than 12 months' history of symptoms, fewer than two symptoms per month, no exacerbations in the last 12 months and normal lung function, the recommendation is early initiation of ICS/SABA or ICS/formoterol as AIR. [ABSTRACT FROM AUTHOR]

Most pediatric asthma guidelines offer evidence-based or best practice approaches to the management of asthma exacerbations but struggle with evidence-based approaches for severe acute asthma (SAA). We aimed to investigate current practices in children with SAA admitted to European pediatric intensive care units (PICUs), in particular, adjunct therapies, use of an asthma severity score, and availability of a SAA guideline. We designed a cross-sectional electronic survey across European PICUs. Thirty-seven PICUs from 11 European countries responded. In 8 PICUs (22%), a guideline for SAA management was unavailable. Inhaled beta-agonists and anticholinergics, combined with systemic steroids and IV MgSO4 was central in SAA treatment. Seven PICUs (30%) used a loading dose of a short-acting beta-agonist. Eighteen PICUs (49%) used an asthma severity score, with 8 different scores applied. Seventeen PICUs (46%) observed an increasing trend in SAA admissions.Conclusion: Variations in the treatment of children with SAA mainly existed in the use of adjunct therapies and asthma severity scores. Importantly, in 22% of the PICUs, a SAA guideline was unavailable. Standardizing SAA guidelines across PICUs in Europe may improve quality of care. However, the limited number of PICUs represented and the data compilation method are constraining our findings.What is Known:• Recent reports demonstrate increasing numbers of children with SAA requiring PICU admission in several countries across the world.• Most pediatric guidelines offer evidence-based approaches to the management of asthma exacerbations, but struggle with evidence-based approaches for SAA beyond these initial steps.What is New:• A large arsenal of adjunct therapies and 8 different asthma scores were used.• In a large number of PICUs, a written guideline for SAA management is lacking. [ABSTRACT FROM AUTHOR]

Background: Airway obstruction is defined by spirometry as a low forced expiratory volume in 1 s (FEV 1 ) to forced vital capacity (FVC) ratio. This impaired ratio may originate from a low FEV 1 (classic) or a normal FEV 1 in combination with a large FVC (dysanaptic). The clinical implications of dysanaptic obstruction during childhood and adolescence in the general population remain unclear., Aims: To investigate the association between airway obstruction with a low or normal FEV 1 in childhood and adolescence, and asthma, wheezing and bronchial hyperresponsiveness (BHR)., Methods: In the BAMSE (Barn/Child, Allergy, Milieu, Stockholm, Epidemiology; Sweden) and PIAMA (Prevention and Incidence of Asthma and Mite Allergy; the Netherlands) birth cohorts, obstruction (FEV 1 :FVC ratio less than the lower limit of normal, LLN) at ages 8, 12 (PIAMA only) or 16 years was classified as classic (FEV 1 1 ≥LLN) obstruction. Cross-sectional and longitudinal associations between these two types of obstruction and respiratory health outcomes were estimated by cohort-adjusted logistic regression on pooled data., Results: The prevalence of classic obstruction at ages 8, 12 and 16 in the two cohorts was 1.5%, 1.1% and 1.5%, respectively. Dysanaptic obstruction was slightly more prevalent: 3.9%, 2.5% and 4.6%, respectively. Obstruction, regardless of FEV 1 , was consistently associated with higher odds of asthma (dysanaptic obstruction: OR 2.29, 95% CI 1.40 to 3.74), wheezing, asthma medication use and BHR compared with the normal lung function group. Approximately one-third of the subjects with dysanaptic obstruction in childhood remained dysanaptic during adolescence., Clinical Implications: Children and adolescents with airway obstruction had, regardless of their FEV 1 level, a higher prevalence of asthma and wheezing. Follow-up and treatment at these ages should be guided by the presence of airway obstruction., Competing Interests: Competing interests: GHK reports grant support from the Netherlands Lung Foundation, TEVA the Netherlands, GSK, Vertex, Ubbo Emmius Foundation, European Union (H2020) and ZonMW outside the submitted work. GHK reports lecture and/or advisory fees from GSK, AstraZeneca and PureIMS (money to institution). EM reports lecture and/or advisory board fees from ALK, Airsonett, AstraZeneca, Chiesi, Novartis and Sanofi outside the submitted work. GW reports lecture fees from Sanofi outside the submitted work., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Multicenter randomized controlled trials (RCTs) for asthma management that incorporate usual-care regimens could benefit from standardized application of evidence-based guidelines. We sought to evaluate performance of a computerized decision support tool, the Asthma Control Evaluation and Treatment (ACET) Program, to standardize usual-care regimens for asthma management in RCTs. Children and adolescents with persistent uncontrolled asthma living in urban census tracts were recruited into 3 multicenter RCTs (each with a usual-care arm) between 2004 and 2014. A computerized decision support tool scored asthma control and assigned an appropriate treatment step based on published guidelines. Control-level determinants (symptoms, rescue medication use, pulmonary function measure, and adherence estimates) were collected at visits and entered into the ACET Program. Changes in control levels and treatment steps were examined during the trials. At screening, more than half of the participants were rated as having symptoms that were not controlled or poorly controlled. The proportion of participants who gained good control between screening and randomization increased significantly in all 3 trials. Between 51% and 70% had symptoms that were well controlled by randomization. The proportion of well-controlled participants remained constant or improved slightly from randomization until the last posttreatment visit. Nighttime symptoms were the most common control-level determinant; there were few (<1%) instances of complete overlap of factors. FEV 1 was the driver of control-level assignment in 30% of determinations. The ACET Program decision support tool facilitated standardized asthma assessment and treatment in multicenter RCTs and was associated with attaining and maintaining good asthma control in most participants. [ABSTRACT FROM AUTHOR]

Background: Inhaled corticosteroids have been widely reported as a preventive measure against the development of severe forms of COVID-19 not only in patients with asthma., Methods: In 654 Czech and Slovak patients with asthma who developed COVID-19, we investigated whether the correct use of inhaler containing corticosteroids was associated with a less severe course of COVID-19 and whether this had an impact on the need for hospitalisation, measurable lung functions and quality of life (QoL)., Results: Of the studied cohort 51.4% had moderate persistent, 29.9% mild persistent and 7.2% severe persistent asthma. We found a significant adverse effect of poor inhaler adherence on COVID-19 severity (p=0.049). We also observed a lower hospitalisation rate in patients adequately taking the inhaler with OR of 0.83. Vital capacity and forced expiratory lung volume deterioration caused by COVID-19 were significantly reversed, by approximately twofold to threefold, in individuals who inhaled correctly., Conclusion: Higher quality of inhalation technique of corticosteroids measured by adherence to an inhaled medication application technique (A-AppIT) score had a significant positive effect on reversal of the vital capacity and forced expiratory lung volume in 1 s worsening (p=0.027 and p<0.0001, respectively) due to COVID-19. Scoring higher in the A-AppIT was also associated with significantly improved QoL. All measured variables concordantly and without exception showed a positive improvement in response to better adherence. We suggest that corticosteroids provide protection against the worsening of lungs in patients with COVID-19 and that correct and easily assessable adherence to corticosteroids with appropriate inhalation technique play an important role in preventing severe form of COVID-19., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

We have a unique opportunity to significantly reduce the worldwide burden of asthma in children and affect respiratory outcomes in adults. However, this will require a paradigm shift that is directed at altering the natural history of asthma, reducing asthma exacerbations, and preventing long-term adverse outcomes of childhood asthma. Attention should continue to be directed toward minimizing risk, as well as impairment, with a goal to achieve optimal control. Based on several National Institutes of Health studies conducted over the last 10 years, we now have the tools necessary to accomplish this goal. The tools include assessment of lung function over time or defining trajectories of lung growth, the Composite Asthma Severity Index score, a panel of useful biomarkers, the Seasonal Asthma Exacerbation Prediction Index score, and rapidly advancing technology that includes adherence monitoring. Future guideline revisions should consider incorporating recommendations to follow spirometry over time and defining trajectories of lung growth to assess risk for reduced lung growth and early decline, asthma burden by using biomarkers to select and monitor therapy, assessment of social determinants of health, evaluation of risk for seasonal exacerbations, and consideration of electronic adherence monitoring for difficult-to-manage asthma. Guidelines should continue to include a core dedicated to the diagnosis and treatment of intermittent and mild and moderate persistent asthma and include additional sections dedicated to the management of severe asthma. [ABSTRACT FROM AUTHOR]

Background: Childhood asthma is a substantial health burden in Thailand. Due to a lack of pediatric respiratory specialists (pediatric pulmonologists and allergists; RS), most Thai children are cared for by general pediatricians (pediatric primary care providers (PCP)). Objectives:We investigated whether current practices of Thai pediatricians complied with asthma guidelines and compared practices (diagnosis and treatments) provided by PCP and RS. Methods: A cross-sectional study was conducted using electronic surveys including four case scenarios of different asthma phenotypes distributed to Thai pediatricians. Asthma diagnosis andmanagement were evaluated for compliance with standard guidelines. The practices of PCP and RS were compared. Results: From 800 surveys distributed, there were 405 respondents (51%).Most respondents (81%)were PCP, who preferred to use clinical diagnosis rather than laboratory investigations to diagnose asthma. For acute asthmatic attacks, 58% of the pediatricians prescribed a systemic corticosteroid. For uncontrolled asthma, 89% of the pediatricians prescribed at least one controller. For exercise-induced bronchospasm, 55% of the pediatricians chose an inhaled bronchodilator, while 38% chose a leukotriene receptor antagonist (LTRA). For virusinduced wheeze, 40% of the respondents chose an LTRA, while 15% chose inhaled corticosteroids (ICS). PCP prescribed more oral bronchodilators (31% vs. 18%, p = 0.02), antibiotics (20% vs. 6%, p < 0.001), and antihistamines (13% vs. 0%, p = 0.02) than RS for the management of an acute asthmatic attack. Conclusions: Most of the Thai pediatrician's practices toward diagnosis and treatment of acute asthmatic attack and uncontrolled asthma conform to the guidelines. PCP prescribed more oral bronchodilators, antibiotics, and antihistamines than RS. [ABSTRACT FROM AUTHOR]

Background: The Global Initiative for Asthma and National Asthma Education and Prevention Program recently made paradigm-shifting recommendations regarding inhaler management in asthma. The Global Initiative for Asthma now recommends that combination inhaled corticosteroid (ICS)-formoterol inhalers replace short-acting β-agonists as the preferred reliever therapy at all steps of asthma management. Although the most recent guidelines of the National Asthma Education and Prevention Program did not review reliever ICS-formoterol usage in mild asthma, they similarly recommended single maintenance and reliever therapy (SMART) at steps 3 and 4 of asthma management. Despite these recommendations, many clinicians-particularly in the United States-are not prescribing new inhaler paradigms. Clinician-level reasons for this implementation gap remain largely unexplored., Objective: To gain an in-depth understanding of the facilitators and barriers to prescribing reliever ICS-formoterol inhalers and SMART in the United States., Methods: Community and academic primary care providers, pulmonologists, and allergists who reported regularly caring for adults with asthma were interviewed. Interviews were recorded, transcribed, qualitatively coded, and analyzed using the Consolidated Framework for Implementation Research. Interviews were continued until theme saturation., Results: Among 20 interviewed clinicians, only 6 clinicians described regularly prescribing ICS-formoterol inhalers as a reliever inhaler (either alone or within SMART). Significant barriers to new inhaler approaches included concerns surrounding a lack of Food and Drug Administration labeling for ICS-formoterol as a reliever therapy, a lack of awareness regarding a patient's formulary-preferred ICS-long-acting β-agonist choices, the high cost of combination inhalers, and time constraints. Facilitators to using new inhaler approaches included clinicians' beliefs that the latest inhaler recommendations are simpler and more congruent with real-world patients' behavior, and that a potential change in management strategy would offer a valuable opportunity for shared decision making., Conclusions: Although new guidelines exist in asthma, many clinicians described significant barriers to using them including medicolegal issues, pharmaceutical formulary confusion, and high drug costs. Nonetheless, most clinicians believed that the latest inhaler approaches would be more intuitive for their patients and would offer an opportunity for patient-centered collaboration and care. Stakeholders may find these results useful in future attempts to increase the real-world adoption of recent asthma recommendations., (Copyright © 2023 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Despite the development and dissemination of guidelines for the diagnosis and management of asthma, a gap remains between current recommendations and actual practice. Objectives: To assess the physicians’ knowledge, practice and adherence to The Global Initiative for Asthma (GINA) guidelines before and after dissemination of guidelines and to identify causes of non adherence to these guidelines. Materials and Methods: A pretest-posttest design was used to evaluate GINA guidelines dissemination intervention. The study included all chest physician categories working in all chest hospitals in Alexandria. Total sample size included sixty chest physicians. An interview questionnaire was designed to collect data related to knowledge and practices of physicians in diagnosis and management of bronchial asthma and to their agreement with GINA guidelines and barriers to implementation of the guidelines. In addition, seven different case scenarios were used to assess the ability of the respondents to classify control and management of asthma. Results: Poor practice (70%) was more marked than poor knowledge (45%) before guidelines dissemination. After guidelines dissemination, poor practice was still high (41.7%) while poor knowledge Fell to zero. Written asthma plan was used poorly by the studied physicians before as well as after guideline dissemination (3.3% and 16.7%, respectively). The reasons for non adherence of chest physicians to asthma guidelines were namely; lack of agreement with specific guidelines (26%); external barriers including lack of time, equipment or clinical space, educational materials staff support and reimbursement for services (25.6%) and poor patients’ adherence to asthma guidelines (16.4%). Conclusion and Recommendations: Even though, Alexandria chest physicians, had improvement in their level of knowledge after GINA guidelines dissemination yet, their practice and adherence to asthma guidelines was still low. To overcome barriers of physicians' non adherence, educational programs and strategies are needed to ensure actual dissemination and implementation of the guidelines.

Purpose of Review: Over the past decade, the most important advance in the field of asthma has been the widespread recognition that asthma is a heterogeneous disease driven by multiple molecular processes. Recent Findings: The most well-established molecular mechanism in asthma is increased airway type-2 inflammation, and consequently, non-invasive biomarkers of increased airway type-2 inflammation, such as blood eosinophil counts or blood periostin levels, have proven important in stratifying asthma patients in clinical trials of type-2 cytokine inhibitors. However, it remains ambiguous how well these non-invasive biomarkers represent airway measures of type-2 inflammation in asthma. As a result, the utility of these biomarkers to assist with asthma management or as research tools to better understand asthma pathogenesis remains unclear. Summary: This article reviews primary data assessing biomarkers of airway type-2 inflammation in asthma and describes how the use of biomarkers can advance a precision medicine approach to asthma treatment. [ABSTRACT FROM AUTHOR]

Objective: The objective of this review is to explore how current research measures the effectiveness of inhaled corticosteroids (ICS) in smokers with asthma.Data sources: PubMed, CINAHL and PsycINFO databases were searched for combinations of terms relating to asthma, tobacco use and ICS effectiveness.Study selections: The search was limited to articles published between 2004 and 2015, in English language. Studies met inclusion criteria if reporting the use of guideline-based asthma control indicators to measure the therapeutic effects of ICS or ICS combination therapies. This review did not exclude articles based on study design. Data were extracted and summarized to describe how indicators were measured across studies in order to characterize and describe the effects of ICS in smokers.Results: Thirteen studies were included in this review. Six of these 13 studies used only one indicator to measure asthma control in smokers and ICS was found to improve asthma in only one of six of these studies. Of studies evaluating combination therapy, three of four studies reported a therapeutic benefit to smokers. In these studies of combination therapy multiple indicators of control were measured to assess drug effects.Conclusions: To assess the therapeutic benefit of ICS drugs in smokers, multiple indicators should be measured to determine if current therapy is improving asthma control. Asthma therapy should then be adjusted based on the patient’s current asthma status. The development of clinical treatment guidelines for asthmatic smokers may help clinicians make best-practice, evidence-based recommendations in order to optimize care for these patients. [ABSTRACT FROM PUBLISHER]

Management of asthma in adults has advanced in the past 10 years. Central to these advances has been further clarification of type (T) 2 mechanisms of airway inflammation and utilization of T2 biomarkers, that is, eosinophils and fractional exhaled nitric oxide. In addition, epithelial cells are emerging as significant contributors to inflammation through generation of alarmins to initiate local injury as well as downstream pathways. Five new biologics, mepolizumab, benralizumab, reslizumab, dupilumab, and tezepelumab, were approved to join omalizumab and revolutionize severe asthma treatment. These biologics significantly prevent exacerbations to spare systemic corticosteroids use and their side effects. Guidelines attest to the effectiveness of inhaled corticosteroids/long-acting β-agonists (formoterol) for both maintenance and rescue therapy. Focused updates to the Expert Panel Report addressed limited but specific questions relevant to asthma control. Future guidelines should include phenotype/endotype-directed therapeutics to gain more precision-directed treatment., (Copyright © 2022 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Problem: Improved patient asthma outcomes have been demonstrated through the use of a symptom- based written asthma action plan (AAP) in reducing acute care visits (Gibson & Powell, 2004). However, despite the research and guideline recommendations that support the use of AAPs, these plans are routinely not used by providers. The aim of this quality improvement (QI) project was to improve provider compliance in the use of a symptom-based AAP. Methods: A QI project was conducted in an outpatient setting involving an educational in-service on the use of an AAP. A retrospective medical record review was conducted following an educational in-service to assess the use and completeness of the AAP (N = 42). The rate of proportional change in compliance in the use of an AAP after the educational in-service and system procedural change was analyzed and reported. Results: A statistically significant improvement in provider compliance to the use and completion of a symptom-based AAP was found at 8 weeks following an educational in-service and system procedural change. Discussion: This QI project demonstrated the effectiveness of an educational in-service in improving provider compliance in the use of and the completion of a symptom-based AAP. [ABSTRACT FROM AUTHOR]

Asthma guidelines focus on day-to-day control of symptoms. However, asthma attacks remain common. They continue to cause mortality and considerable morbidity, and are a major financial burden to the UK National Health Service (NHS) and the wider community. Asthma attacks have chronic consequences, being associated with loss of lung function and significant psychological morbidity. In this article we argue that addressing daily symptom control is only one aspect of asthma treatment, and that there should be a more explicit focus on reducing the risk of asthma attacks. Management of future risk by general practitioners is already central to other conditions such as ischaemic heart disease and chronic renal impairment. We therefore propose a revised approach that separately considers the related domains of daily control and future risk of asthma attack. We believe this approach will have advantages over the current 'stepwise' approach to asthma management. It should encourage individualised treatment, including non-pharmacological measures, and thus may lead to more efficacious and less harmful management strategies. We speculate that this type of approach has the potential to reduce morbidity and healthcare costs related to asthma attacks. [ABSTRACT FROM AUTHOR]

Objective Asthma is one of the commonest causes of morbidity and mortality in childhood. The goals of the present study were to design a valid medication assessment tool for evaluating the quality of medication use according to recommendations of updated asthma guidelines for children aged from 5 to 12 years, and to quantify adherence to guideline recommendations. Setting Two primary care settings in Scotland, UK. Methods Recommendations related to the long-term management of asthmatic children in the British Thoracic Society/Scottish Intercollegiate Guidelines Network and Global Initiative for Asthma guidelines were identified and corresponding criteria were created. These criteria were incorporated to generate an assessment tool named MAT ASTHMA-PAED. Two phases of field-testing were undertaken and the tool was also subject to examination by a focus group of specialist practitioners. Thereafter, MAT ASTHMA-PAED was modified accordingly. Main outcome measure Applicability and adherence to each criterion and overall adherence to the MAT ASTHMA-PAED. Results The MAT ASTHMA-PAED field-testing was undertaken in two primary care practices in Scotland, United Kingdom and 77 asthmatic children were recruited. Results of the pilot study field-testing showed a high overall adherence of 70.0 % (95 % CI: 58.7-81.3 %) to the guidelines. Low adherence (<50 %) was seen for 4 criteria, whereas 8 criteria were considered high-adherence criteria (>70 %). The final MAT ASTHMA-PAED comprised of 25 criteria was produced based on the results of field testing and the opinions from the focus group. Conclusion Although high utility of MAT ASTHMA-PAED criteria was found, there were gaps in the implementation of certain recommendations, particularly in relation to demonstrated satisfactory technique of inhaler. Moreover, further studies assessing the use of oral steroids and exercise-induced asthma, and wider implementation of MAT ASTHMA-PAED are required. [ABSTRACT FROM AUTHOR]

Background: Current asthma management guidelines are based on the level of asthma control. The impact of asthma control on health care resources and quality of life (QoL) is insufficiently studied. EUCOAST study was designed to describe costs and QoL in adult patients according to level of asthma control in France and Spain. Methods: An observational cost of illness study was conducted simultaneously in both countries among patients age greater or equal to 18 with a diagnosis of asthma for at least 12 months. Patients were recruited prospectively by GPs in 2010 in four waves to avoid a seasonal bias. Health care resources utilization of the three months before the inclusion was collected through physician questionnaires. Asthma control was evaluated using 2009 GINA criteria over a 3-month period. QoL was assessed using EQ-5D-3L®. Results: 2,671 patients (France: 1,154; Spain: 1,517) were enrolled. Asthma was controlled in 40.6% [95% CI: 37.7% - 43.4%] and 29.9% [95% CI: 27.6% - 32.3%] of French and Spanish patients respectively. For all types of costs, the percentage of patients using health care resources varied significantly according to the level of asthma control. The average cost (euros/3-months/patient) of controlled asthma was €85.4 (SD: 153.5) in France compared with €314.0 (SD: 2,160.4) for partially controlled asthma and €537.9 (SD: 2,355.7) for uncontrolled asthma (p<0.0001). In Spain, the corresponding figures were €152.6 (SD: 162.1), €241.2 (SD: 266.8), and €556.8 (SD: 762.4). EQ-5D-3L® score was higher (p<0.0001) in patients with controlled asthma compared to partially controlled and uncontrolled asthma in both countries (respectively 0.88; 0.78; 0.63 in France and 0.89; 0.82; 0.69 in Spain). Conclusions: In both countries, patients presenting with uncontrolled asthma had a significantly higher asthma costs and lower scores of Qol compared to the others. [ABSTRACT FROM AUTHOR]

Background: It is important to control asthma during pregnancy. However, some studies indicate that women stop or change their asthma medications when they become pregnant. Objective: We used a population database to analyze changes in prescriptions for asthma medications to patients before, during, and after pregnancy. Methods: We collected information from a pregnancy database that is part of the population-based pharmacy prescription InterAction Database from the northern Netherlands. Our study cohort comprised 25,709 pregnancies for which prescription data were available. We collected data over a study period of 1 year before pregnancy until 6 months after birth and analyzed data from pregnant women who received at least 1 prescription for asthma medication during the study period (n = 2072), identifying all prescriptions for asthma medication and oral corticosteroids. Results: Prescriptions for asthma medications did not change during pregnancies from 1994-2003. However, during the 2004-2009 period, there was a significant decrease (P = .017) in prescriptions for asthma medications during the first months of pregnancy compared with the months before pregnancy, especially prescriptions of long-acting bronchodilators. Although most asthma prescriptions continued throughout pregnancy, prescriptions for controller therapies were reduced by 30% during the first months of pregnancy. Conclusions: Many women stop or reduce their use of asthma medications when they become pregnant. Strategies to safely control asthma during pregnancy are needed. [Copyright &y& Elsevier]

The use of real-world evidence (RWE) studies, including pragmatic randomised controlled trials (RCTs; randomised RWE studies), to aid the development of treatment guidelines, is gradually becoming a mainstay within clinical practice. RWE is an integral part of patient-driven decision-making and offers important value to add complimentary evidence to traditional RCTs; these provide a more well-rounded view of the benefits to patient-reported outcomes and improve the external validity of a given treatment versus findings from traditional RCTs alone. Discussions in recent scientific workshops explored the importance of pragmatic RCTs in optimising guideline development and patient care in chronic obstructive pulmonary disease (COPD) and asthma. The Salford Lung Study in patients with COPD (NCT01551758) and asthma (NCT01706198) were the world's first prelicence pragmatic RCTs that compared novel investigational treatments with existing COPD and asthma treatments and, more recently (2021), RWE studies have been used by the American Thoracic Society and the US Food and Drug Administration to support the approval of an immunosuppressant drug in patients receiving lung transplants. This highlights the importance of RWE data in supporting clinical guideline development and emphasises the advantages for the use of pragmatic RCTs in guiding clinical practice., Competing Interests: Competing interests: NDB reports grants and personal fees from GSK, Novartis and Almirall/AstraZeneca, and congress attendance fees from Boehringer-Ingelheim. KN and GC are employees of and shareholders in GSK. NGS is a former employee of GSK. RS reports previous honoraria/sponsorship for consultancy work, lecturing and educational events unrelated to this workshop from GSK, Cogora, Pharman, Chiesi, Boehringer Ingelheim, Teva, AstraZeneca and the Centre for Pharmacy Postgraduate Education, and is a member of the National Institute for Health and Care Excellence COPD guidelines committee and the British Thoracic Society specialist advisory group. ADS reports grants, personal fees and other financial activities from AstraZeneca, Bayer, GSK, Gilead, Novartis, Pfizer, Teva and Chiesi., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Over the past 20 years, there has been a concerted effort in the United States to reduce morbidity related to chronic disease, including asthma. Attention was initially directed toward asthma in response to the recognition that asthma mortality was increasing and that the burden of disease was significant. These efforts to address asthma mortality led to many new initiatives to develop clinical practice guidelines, implement the asthma guidelines into clinical practice, conduct research to fill the gaps in the guidelines, and continuously revise the asthma guidelines as more information became available. An assessment of our progress shows significant accomplishments in relation to reducing asthma mortality and hospitalizations. Consequently, we are now at a crossroads in asthma care. Although we have recognized some remarkable accomplishments in reducing asthma mortality and morbidity, the availability of new tools to monitor disease activity, including biomarkers and epigenetic markers, along with information technology systems to monitor asthma control hold some promise in identifying gaps in disease management. These advances should prompt the evolution of new strategies and new treatments to further reduce disease burden. It now becomes imperative to continue a focus on ways to further reduce the burden of asthma and prevent its onset. [ABSTRACT FROM AUTHOR]

For children living in inner cities, asthma tends to be more frequent and severe. To characterize, understand, and treat children with asthma living in the inner city more effectively, the National Institute of Allergy and Infectious Diseases established an Inner-City Asthma Program in 1991. In addition, the revised National Asthma Education and Prevention Program Expert Panel 3 report was introduced with new concepts for asthma management that are now centered on asthma control. The purpose of this review is to highlight features of the National Institute of Allergy and Infectious Diseases Inner-City Asthma Consortium Asthma Control Evaluation study that enhance our knowledge regarding the application of the asthma guidelines and to provide a summary of lessons learned from that important study. We recognized that asthma symptoms and exacerbations are theoretically linked to underlying inflammation of airways but are not direct indicators of inflammation. Based on the observations from the Asthma Control Evaluation study, we were impressed that a systematic guidelines-based approach improved asthma control significantly over the course of the 1-year treatment period. [Copyright &y& Elsevier]

Abstract: Background: Asthma management guidelines state that a low-dose inhaled corticosteroid (ICS) is the preferred treatment for mild persistent asthma and that coadministration of a long-acting β2-agonist (LABA) should be reserved for patients whose asthma is uncontrolled by single-entity ICS. However, it appears that many patients in the United States with mild persistent asthma are initially treated with combinations of fluticasone propionate/salmeterol (FPS). Objective: The aim of this study was to examine whether use of FPS was consistent with asthma management guidelines. Methods: A commercial insurance database was analyzed retrospectively to identify patients aged 12 to 62 years who had ≥1 pharmacy claim for FPS between October 1, 2004, and September 30, 2006. An index date corresponding to the date of the first FPS pharmacy claim was assigned to each patient. Medical and pharmacy claims data were analyzed for the 365-day period before the index date (preindex period). The severity of patients'' asthma was inferred from their history of claims. Patients were identified as having more severe asthma if, during the preindex period, they either received >365 doses of short-acting β2-agonists (SABAs), an oral corticosteroid (OCS), or an emergency department (ED) asthma visit with an OCS prescription, or were hospitalized for their asthma. Results: Among 87,459 patients with new FPS claims, 60.8% were female, and the mean age was 37.3 years. Of these patients, 60,453 (69.1%) had no preindex ICS pharmacy claim or claims that would indicate moderate or severe asthma. In the preindex period, only 6.3% had received an ICS, 7.4% had >365 SABA doses, 22.7% had used an OCS, 1.1% had an ED visit with an OCS prescription, and 1.5% had been hospitalized. Conclusion: More than two thirds of the patients who initiated FPS treatment had neither received an ICS prescription before their first FPS pharmacy claim nor had evidence of asthma severity that would appear to warrant the use of an ICS/LABA combination. [Copyright &y& Elsevier]

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