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Asthma in Adults and Adolescents

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General Information

Description

  • chronic inflammatory disorder of airways defined by history of respiratory symptoms (wheeze, shortness of breath, chest tightness, and cough) and variable expiratory airflow limitation1,2

Types

  • asthma phenotypes include1,2
    • allergic asthma
      • usually begins in childhood and associated with history of allergic diseases
      • often associated with eosinophilic inflammation
    • nonallergic asthma
      • not associated with allergies
      • may be associated with neutrophilic, eosinophilic, or paucigranulocytic inflammation
    • late-onset asthma - presents in adulthood and often nonallergic
    • asthma with fixed airflow limitation (due to airway wall remodeling)
    • asthma with obesity
    • cough variant asthma
    • exercise-induced asthma
    • occupational asthma

References

General references used

  1. British Thoracic Society and Scottish Intercollegiate Guidelines Network (BTS/SIGN) national clinical guideline on management of asthma. BTS/SIGN 2019 Jul PDFPictureAsPdf
  2. Global Initiative for Asthma (GINA) global strategy for asthma management and prevention. GINA 2019OpenInNew

Recommendation grading systems used

  • Global Initiative for Asthma (GINA) grading system
    • levels of evidence
      • Evidence A - randomized controlled trials (RCTs) and meta-analyses (rich body of data)
      • Evidence B - RCTs and meta-analyses (limited body of data)
      • Evidence C - nonrandomized trials; observational studies
      • Evidence D - consensus judgment of panel
    • Reference - GINA global strategy on asthma management and prevention (GINA 2019 PDFPictureAsPdf)
  • British Thoracic Society/Scottish Intercollegiate Guidelines Network (BTS/SIGN) definitions of grades of recommendation and levels of evidence
    • grades of recommendations
      • Grade A
        • at least 1 meta-analysis, systematic review, or randomized controlled trial (RCT) rated as 1++ and directly applicable to the target population, or
        • body of evidence consisting principally of studies rated as 1+, directly applicable to target population and demonstrating overall consistency of results
      • Grade B
        • body of evidence including studies rated as 2++, directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 1++ or 1+
      • Grade C
        • body of evidence including studies rated as 2+, directly applicable to target population and demonstrating overall consistency of results, or
        • extrapolated evidence from studies rated as 2++
      • Grade D
        • evidence level 3 or 4, or
        • extrapolated evidence from studies rated as 2+
      • Good Practice Point - recommended best practice based on clinical experience of guideline development group
    • levels of evidence
      • 1++ - high-quality meta-analyses, systematic reviews of RCTs, or RCTs with very low risk of bias
      • 1+ - well-conducted meta-analyses, systematic reviews of RCTs, or RCTs with low risk of bias
      • 1- - meta-analyses, systematic reviews of RCTs, or RCTs with high risk of bias
      • 2++
        • high-quality systematic reviews of case-control or cohort studies
        • high-quality case-control or cohort studies with very low risk of confounding or bias and high probability that relationship is causal
      • 2+ - well-conducted case-control or cohort studies with low risk of confounding or bias and moderate probability that relationship is causal
      • 2- - case-control or cohort studies with high risk of confounding or bias and significant risk that relationship is not causal
      • 3 - nonanalytical studies (for example, case reports, case series)
      • 4 - expert opinion
    • References
  • American Academy of Allergy, Asthma & Immunology/American College of Allergy, Asthma & Immunology (AAAAI/ACAAI) 2011 recommendation grading system
    • strength of recommendation
      • Grade A - based on Category I evidence
      • Grade B - based on Category II evidence or extrapolated from Category I evidence
      • Grade C - based on Category III evidence or extrapolated from Category I-II evidence
      • Grade D - based on Category IV evidence or extrapolated from Category I-III evidence
      • Grade NR - not rated
    • categories of evidence
      • Category Ia - evidence from meta-analysis of randomized controlled trials
      • Category Ib - evidence from ≥ 1 randomized controlled trial
      • Category IIa - evidence from ≥ 1 controlled study without randomization
      • Category IIb - evidence from ≥ 1 other type of quasi-experimental study
      • Category III - evidence from nonexperimental descriptive studies (for example, comparative studies)
      • Category IV - evidence from expert committee reports, clinical experience or opinions of respected authorities, or both
      • LB - laboratory based
      • NR - not rated
  • American Academy of Allergy, Asthma and Immunology/American College of Allergy, Asthma and Immunology (AAAAI/ACAAI) Joint Task Force on Practice Parameters (JTFPP) grading system for recommendations
    • strength of recommendation
      • Strong - benefits of approach clearly exceed harms, or harms clearly exceed benefits in a strong negative recommendation; supported by excellent quality evidence (Grade A or B) unless high-quality evidence is impossible to obtain
      • Moderate - benefits exceed the harms, or harms exceed benefits in negative recommendations; supported by Grade B or C evidence unless higher-quality evidence is impossible to obtain
      • Weak - existing evidence is suspect (Grade D) or well-done studies (Grade A, B, or C) show little advantage to 1 approach vs another
      • No recommendation - lack of pertinent evidence (Grade D); unclear balance between benefits and harms
    • level of evidence
      • Grade A - based on Category I evidence
      • Grade B - based on Category II evidence or extrapolated from Category I evidence
      • Grade C - based on Category III evidence or extrapolated from Category I-II evidence
      • Grade D - based on Category IV evidence or extrapolated from Category I-III evidence
      • Grade LB - laboratory based
      • Grade NR - not rated
    • categories of evidence
      • Category Ia - evidence from meta-analysis of randomized controlled trials
      • Category Ib - evidence from ≥ 1 randomized controlled trial
      • Category IIa - evidence from ≥ 1 controlled study without randomization
      • Category IIb - evidence from ≥ 1 other type of quasi-experimental study
      • Category III - evidence from nonexperimental descriptive studies (for example, comparative studies)
      • Category IV - evidence from expert committee reports, clinical experience or opinions of respected authorities, or both
    • Reference - AAAAI/ACAAI focused allergen immunotherapy practice parameter update on sublingual immunotherapy (28284533Ann Allergy Asthma Immunol 2017 Mar;118(3):276OpenInNew)

Synthesized Recommendation Grading System for DynaMed

  • DynaMed systematically monitors clinical evidence to continuously provide a synthesis of the most valid relevant evidence to support clinical decision-making (see 7-Step Evidence-Based MethodologyOpenInNew).
  • Guideline recommendations summarized in the body of a DynaMed topic are provided with the recommendation grading system used in the original guideline(s), and allow DynaMed users to quickly see where guidelines agree and where guidelines differ from each other and from the current evidence.
  • In DynaMed (DM), we synthesize the current evidence, current guidelines from leading authorities, and clinical expertise to provide recommendations to support clinical decision-making in the Overview & Recommendations section.
  • We use the Grading of Recommendations Assessment, Development and Evaluation (GRADE)OpenInNew to classify synthesized recommendations as Strong or Weak.
    • Strong recommendations are used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
    • Weak recommendations are used when, based on the available evidence, clinicians believe that desirable and undesirable consequences are finely balanced, or appreciable uncertainty exists about the magnitude of expected consequences (benefits and harms). Weak recommendations are used when clinicians disagree in judgments of relative benefit and harm, or have limited confidence in their judgments. Weak recommendations are also used when the range of patient values and preferences suggests that informed patients are likely to make different choices.
  • DynaMed (DM) synthesized recommendations (in the Overview & Recommendations section) are determined with a systematic methodology:
    • Recommendations are initially drafted by clinical editors (including ≥ 1 with methodological expertise and ≥ 1 with content domain expertise) aware of the best current evidence for benefits and harms, and the recommendations from guidelines.
    • Recommendations are phrased to match the strength of recommendation. Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients. Weak recommendations use "consider" or "suggested" phrasing.
    • Recommendations are explicitly labeled as Strong recommendations or Weak recommendations when a qualified group has explicitly deliberated on making such a recommendation. Group deliberation may occur during guideline development. When group deliberation occurs through DynaMed-initiated groups:
      • Clinical questions will be formulated using the PICO (Population, Intervention, Comparison, Outcome) framework for all outcomes of interest specific to the recommendation to be developed.
      • Systematic searches will be conducted for any clinical questions where systematic searches were not already completed through DynaMed content development.
      • Evidence will be summarized for recommendation panel review including for each outcome, the relative importance of the outcome, the estimated effects comparing intervention and comparison, the sample size, and the overall quality rating for the body of evidence.
      • Recommendation panel members will be selected to include at least 3 members that together have sufficient clinical expertise for the subject(s) pertinent to the recommendation, methodological expertise for the evidence being considered, and experience with guideline development.
      • All recommendation panel members must disclose any potential conflicts of interest (professional, intellectual, and financial), and will not be included for the specific panel if a significant conflict exists for the recommendation in question.
      • Panel members will make Strong recommendations if and only if there is consistent agreement in a high confidence in the likelihood that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. Panel members will make Weak recommendations if there is limited confidence (or inconsistent assessment or dissenting opinions) that desirable consequences outweigh undesirable consequences across the majority of expected patient values and preferences. No recommendation will be made if there is insufficient confidence to make a recommendation.
      • All steps in this process (including evidence summaries which were shared with the panel, and identification of panel members) will be transparent and accessible in support of the recommendation.
    • Recommendations are verified by ≥ 1 editor with methodological expertise, not involved in recommendation drafting or development, with explicit confirmation that Strong recommendations are adequately supported.
    • Recommendations are published only after consensus is established with agreement in phrasing and strength of recommendation by all editors.
    • If consensus cannot be reached then the recommendation can be published with a notation of "dissenting commentary" and the dissenting commentary is included in the topic details.
    • If recommendations are questioned during peer review or post publication by a qualified individual, or reevaluation is warranted based on new information detected through systematic literature surveillance, the recommendation is subject to additional internal review.

DynaMed Editorial Process

Special acknowledgements

  • The American College of Physicians (Marjorie Lazoff, MD, FACP; ACP Deputy Editor, Clinical Decision Resource) provided review in a collaborative effort to ensure DynaMed provides the most valid and clinically relevant information in internal medicine.
  • DynaMed topics are written and edited through the collaborative efforts of the above individuals. Deputy Editors, Section Editors, and Topic Editors are active in clinical or academic medical practice. Recommendations Editors are actively involved in development and/or evaluation of guidelines.
  • Editorial Team role definitions
    Topic Editors define the scope and focus of each topic by formulating a set of clinical questions and suggesting important guidelines, clinical trials, and other data to be addressed within each topic. Topic Editors also serve as consultants for the internal DynaMed Editorial Team during the writing and editing process, and review the final topic drafts prior to publication.
    Section Editors have similar responsibilities to Topic Editors but have a broader role that includes the review of multiple topics, oversight of Topic Editors, and systematic surveillance of the medical literature.
    Recommendations Editors provide explicit review of DynaMed Overview and Recommendations sections to ensure that all recommendations are sound, supported, and evidence-based. This process is described in "Synthesized Recommendation Grading."
    Deputy Editors are employees of DynaMed and oversee DynaMed internal publishing groups. Each is responsible for all content published within that group, including supervising topic development at all stages of the writing and editing process, final review of all topics prior to publication, and direction of an internal team.

How to cite

National Library of Medicine, or "Vancouver style" (International Committee of Medical Journal Editors):

  • DynaMed [Internet]. Ipswich (MA): EBSCO Information Services. 1995 - . Record No. T114449, Asthma in Adults and Adolescents; [updated 2018 Nov 30, cited place cited date here]. Available from https://www.dynamed.com/topics/dmp~AN~T114449. Registration and login required.
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    Overview and Recommendations

    • Background

    • Evaluation

    • Management

  • Related Summaries

  • KeyboardArrowRight

    General Information

    • Description

    • Types

  • KeyboardArrowRight

    Epidemiology

    • Incidence/Prevalence

    • Risk factors

    • Associated conditions

  • KeyboardArrowRight

    Etiology and Pathogenesis

    • Causes

    • Pathogenesis

  • KeyboardArrowRight

    History and Physical

    • KeyboardArrowRight

      History

      • Chief concern (CC)

      • History of present illness (HPI)

      • Medication history

      • Past medical history (PMH)

      • Family history (FH)

      • Social history (SH)

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      Physical

      • General physical

      • Skin

      • HEENT

      • Chest

      • Cardiac

      • Lungs

    • Severity assessment

  • KeyboardArrowRight

    Diagnosis

    • Making the diagnosis

    • Differential diagnosis

    • Testing overview

    • Blood tests

    • Imaging studies

    • KeyboardArrowRight

      Pulmonary function tests

      • Spirometry

      • Bronchial provocation testing

      • Peak expiratory flow rate (PEFR)

      • Nitric oxide breath test

      • Other testing

    • KeyboardArrowRight

      Other diagnostic testing

      • Allergy testing

  • KeyboardArrowRight

    Management

    • Management overview

    • KeyboardArrowRight

      Diet

      • n-3 fatty acids (fish oil)

      • Tartrazine exclusion

      • Salt restriction

      • Monosodium glutamate avoidance

      • Calorie restriction

    • KeyboardArrowRight

      Activity

      • Exercise

    • Counseling

    • KeyboardArrowRight

      Medications

      • KeyboardArrowRight

        Stepwise medication management of asthma

        • Global Initiative for Asthma (GINA) stepwise management

      • Short-acting beta-2 agonists (SABAs)

      • Inhaled corticosteroids

      • Systemic corticosteroids

      • Intranasal steroids

      • Long-acting beta-2 agonists (LABAs)

      • Triple combination therapy

      • Mast cell stabilizers

      • Antileukotrienes

      • Methylxanthines

      • Immunotherapy

      • Biologics

      • KeyboardArrowRight

        Anticholinergic agents

        • Ipratropium

        • Tiotropium

      • KeyboardArrowRight

        Antimicrobial agents

        • Antifungal agents in asthma patients with fungal sensitization

        • Macrolide antibiotics

      • Oxygen

      • Other medications

      • Vaccinations

    • Consultation and referral

    • KeyboardArrowRight

      Other management

      • Smoking cessation

      • Chronotherapy

      • Allergen avoidance (environmental control)

      • Antireflux therapy

      • Self-management

      • Asthma education

      • Enhancing patient adherence to asthma therapy

      • Weight loss

      • Bronchial thermoplasty

      • Asthma alternative treatments

      • Depression management

    • KeyboardArrowRight

      Follow-up

      • Monitoring

      • Tests that may guide therapy

      • Shared decision making (SDM)

      • Health services delivery for asthma care

  • KeyboardArrowRight

    Complications and Prognosis

    • Complications

    • Prognosis

  • KeyboardArrowRight

    Prevention and Screening

    • Prevention

    • Screening

  • KeyboardArrowRight

    Quality Improvement

    • Physician Quality Reporting System Quality Measures

    • Quality and Outcomes Framework Indicators

    • Choosing Wisely

    • Choosing Wisely Canada

    • Choosing Wisely Italy

    • Quality improvement evidence

  • KeyboardArrowRight

    Guidelines and Resources

    • KeyboardArrowRight

      Guidelines

      • International guidelines

      • United States guidelines

      • United Kingdom guidelines

      • Canadian guidelines

      • European guidelines

      • Asian guidelines

      • Central and South American guidelines

      • Australian and New Zealand guidelines

    • Review articles

    • MEDLINE search

  • Patient Information

  • KeyboardArrowRight

    ICD Codes

    • ICD-10 codes

  • KeyboardArrowRight

    References

    • General references used

    • Recommendation grading systems used

    • Synthesized Recommendation Grading System for DynaMed

    • DynaMed Editorial Process

    • Special acknowledgements

    • How to cite

Topic Editor
Jonathan Ilowite MD
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Affiliations

Assistant Professor, Donald and Barbara Zucker School of Medicine, Hofstra/Northwell; New York, United States; Attending, Internal Medicine, Pulmonary Disease, and Critical Care Medicine, Northwell Health; New York, United States

Conflicts of Interest

Dr. Ilowite declares no relevant financial conflicts of interest.

Recommendations Editor
Esther Jolanda van Zuuren MD
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Affiliations

Head of Allergy, Dermatology, and Venereology, Leiden University Medical Centre; Netherlands

Conflicts of Interest

Dr. van Zuuren declares no relevant financial conflicts of interest.

Deputy Editor
Terence K. Trow MD, FACP, FCCP
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Affiliations

Deputy Editor of Pulmonary, Critical Care, and Sleep Medicine; Connecticut, United States; Ex-Director of the Yale Pulmonary Vascular Disease Program, Associate Clinical Professor of Medicine, Yale University School of Medicine; Connecticut, United States

Conflicts of Interest

Dr. Trow declares no relevant financial conflicts of interest.

Produced in collaboration with American College of Physicians

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Spirometry findings pre and post bronchodilator

Spirometry findings pre and post bronchodilator

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