Counsel patients about potential side effects, and assess and monitor for risk of adrenal suppression and corticosteroid-induced osteoporosis. Provide relevant lifestyle counseling and prescription of therapy for prevention of osteoporosis (where appropriate) in patients expected to be treated for 3 months. As per SIGN 2019 guidelines, offer daily oral corticosteroids (at the lowest dose providing adequate control) in selected patients not controlled on high-dose therapies. B Immunosuppressants: as per ERS 2014 guidelines, avoid using methotrexate in adult and pediatric patients with severe asthma. D 6. Nonpharmacologic interventions Smoking cessation: https://web.pathway.md/diseases/recoid4eeyMVLDPrX 15/26 6/23/23, 3:13 AM Asthma Pathway As per GINA 2022 guidelines, advise smoking cessation at every visit in smoker patients with asthma. Provide access to counseling and smoking cessation programs if available. A Show 2 more As per SIGN 2019 guidelines, counsel patients with asthma and parents/carers of pediatric patients with asthma about the dangers of smoking and second-hand tobacco smoke exposure, and advise quitting smoking. B Physical activity: encourage patients with asthma to engage in regular physical activity for its general health benefits, A including improvement in cardiopulmonary fitness as well as for a small benefit for asthma control and lung function, including with swimming in young patients with asthma. B Show 3 more Dietary modifications: advise patients with asthma to follow a diet high in fruit and vegetables for its general health benefits. A Show 2 more Weight loss: As per GINA 2022 guidelines: Include weight reduction in the treatment plan of patients with asthma and obesity. B Advise a weight reduction program combined with twice-weekly aerobic and strength exercises for symptom control in adult patients with asthma and obesity. B As per SIGN 2019 guidelines, consider offering weight-loss interventions (including dietary and exercise-based programs) to improve asthma control in adult and pediatric patients with overweight or obesity. C Breathing exercises: As per GINA 2022 guidelines, consider offering breathing exercises as an adjunct to pharmacotherapy to improve symptoms and quality of life, but not for reducing exacerbation risk or improving lung function. B As per SIGN 2019 guidelines, consider offering breathing exercise programs (including face-to- face physiotherapist-delivered methods and audiovisual programs) as an adjuvant to pharmacotherapy to improve quality of life and reduce symptoms in adult patients with asthma. B Stress management: encourage patients to identify goals and strategies to deal with emotional stress if it makes their asthma worse. B Show 2 more Vitamin D supplements: insufficient evidence to support the use of vitamin D supplements for improving disease control or reducing exacerbations in patients with asthma. I Avoidance of indoor allergens: As per GINA 2022 guidelines, do not advise routine allergen avoidance in patients with asthma. D Show 2 more https://web.pathway.md/diseases/recoid4eeyMVLDPrX 16/26 6/23/23, 3:13 AM Asthma Pathway As per NHLBI 2020 guidelines, avoid offering allergen mitigation interventions as part of routine asthma management in patients with asthma not having sensitization to specific indoor allergens or not having symptoms related to exposure to specific indoor allergens. D Show 2 more As per SIGN 2019 guidelines: Do not advise using routine physical or chemical methods of reducing house dust mite levels in the home (including acaricides, mattress covers, vacuum cleaning, heating, ventilation, freezing, washing, air filtration, and ionizers) for the management of asthma. D Do not advise using air ionizers for the treatment of asthma. D Avoidance of outdoor allergens: advise reducing exposure to outdoor allergens in sensitized patients by closing windows and doors, remaining indoors, and using air conditioning when pollen and mold counts are highest. B Avoidance of weather conditions: consider advising staying indoors in a climate-controlled environment and avoiding strenuous outdoor physical activity during unfavorable weather conditions (such as very cold weather or low humidity). Advise avoiding polluted environments during viral infections, if feasible. C Avoidance of air pollution: Advise using non-polluting heating and cooking sources, and vent sources of pollutants outdoors where possible. B Consider advising staying indoors in a climate-controlled environment and avoiding strenuous outdoor physical activity during high air pollution. Advise avoiding polluted environments during viral infections, if feasible. C Avoidance of occupational exposure: As per GINA 2022 guidelines: Identify and eliminate occupational sensitizers as soon as possible and remove any further exposure to these agents in the management of patients with occupational asthma. A Advise using non-powdered low-allergen gloves instead of powdered latex gloves to minimize latex sensitization. A As per SIGN 2019 guidelines, advise relocation away from exposure as soon as the diagnosis of work-related asthma is confirmed, ideally within 12 months of the first work-related symptoms of asthma. B As per ERS 2012 guidelines, inform patients: the risk of work-related asthma is higher in case of atopy or preexisting asthma or pre- employment sensitization B persistence of exposure to the causal agent is likely to result in a deterioration of asthma symptoms and airway obstruction B complete avoidance of exposure is associated with the highest probability of improvement, but may not lead to a complete recovery from asthma. B Show 4 more https://web.pathway.md/diseases/recoid4eeyMVLDPrX 17/26 6/23/23, 3:13 AM Asthma Pathway Avoidance of exacarbating medications: ask patients about asthma and previous reactions always before prescribing NSAIDs, and advise discontinuing them if asthma worsens. B Recognize that aspirin and NSAIDs are not generally contraindicated unless there is a history of previous reactions to these agents. A Show 3 more 7. Therapeutic procedures Bronchial thermoplasty: As per GINA 2022 guidelines, consider offering bronchial thermoplasty, if available, as step 5 in adult patients with uncontrolled asthma despite optimized therapeutic regimens and referral to an asthma specialty center. C As per NHLBI 2020 guidelines, consider offering bronchial thermoplasty in 18 years old patients with persistent asthma placing a low value on harms (short-term worsening symptoms and unknown long-term side effects) and a high value on potential benefits (improvement in quality of life, a small reduction in exacerbations). C As per CTS 2017 guidelines: Insufficient evidence regarding the precise role of bronchial thermoplasty in 18 years old patients with severe asthma. I Perform bronchial thermoplasty in highly specialized centers because of the complexity of the procedure and the occurrence of severe events, such as hospitalizations due to asthma worsening, atelectasis, and pneumonia. E As per ERS 2014 guidelines, offer bronchial thermoplasty in adult patients with severe asthma only in the context of an IRB-approved independent systematic registry or a clinical trial. B 8. Perioperative care Perioperative management: Ensure achieving good asthma control preoperatively in patients scheduled for elective surgery, especially in patients with more severe asthma, uncontrolled symptoms, exacerbation history, or persistent airflow limitation. B Weigh the risks of performing surgery without achieving good asthma control against the need for immediate surgery in patients requiring emergency surgery. Administer perioperative hydrocortisone in patients on long-term high-dose ICSs or receiving oral corticosteroids for > 2 weeks during the previous 6 months, because of the risk of adrenal crisis in the context of surgery. B 9. Specific circumstances https://web.pathway.md/diseases/recoid4eeyMVLDPrX 18/26 6/23/23, 3:13 AM Asthma Pathway Pediatric patients (diagnosis): do not diagnose asthma solely based on symptoms D or improvement in symptoms after a trial of preventer medication. D Pediatric patients (pulmonary function testing): obtain spirometry as part of the diagnostic evaluation of 5-16 years old patients with suspected asthma. B Show 2 more Pediatric patients (FeNO testing): obtain measurement of fractional exhaled nitric oxide as part of the diagnostic evaluation of 5-16 years old patients with suspected asthma. B Pediatric patients (allergen testing): Do not obtain skin prick tests for aeroallergens in the diagnostic evaluation of asthma. D Do not obtain serum total or specific IgE tests in the diagnostic evaluation of asthma. D Pediatric patients (bronchial challenge tests): Obtain a direct bronchial challenge test using methacholine for the evaluation of asthma in 5-16 years old patients, if asthma diagnosis could not be confirmed with first-line objective tests. B Obtain an indirect bronchial challenge test using a treadmill or a bicycle for the evaluation of asthma with exercise-related symptoms in 5-16 years old patients, if asthma diagnosis could not be confirmed with first-line objective tests. B Pediatric patients (indications for treatment): Consider offering watchful waiting in asymptomatic pediatric patients with an intermediate probability of asthma unable to perform spirometry. C Offer a carefully monitored initiation of treatment in symptomatic pediatric patients with an intermediate probability of asthma unable to perform spirometry. B Pediatric patients, treatment guidance: As per GINA 2022 guidelines, offer fractional exhaled nitric oxide-guided treatment to reduce exacerbation rates in pediatric patients with asthma. A As per BTS/SIGN 2019 guidelines, do not use pulmonary function measurements to guide management in < 5 years old patients with asthma. D As per ERS/ATS 2014 guidelines, consider using clinical criteria alone rather than clinical criteria and sputum eosinophil counts to guide treatment in pediatric patients with severe asthma. C Pediatric patients (stepwise management): Use the following track as the preferred stepwise approach to the management of asthma in pediatric patients aged 6-11 years, with an as-needed short-acting -agonist or low-dose ICS-formoterol as the preferred reliever in all steps: Situation Guidance Offer low-dose ICS whenever short-acting - agonist is taken A Steps 1. Symptoms < 2 days per month Step 2. Symptoms 2 days, but less than daily Offer low-dose ICS daily A Offer low-dose ICS-long-acting -agonist Step 3. Symptoms most days, or waking with asthma 1 per week https://web.pathway.md/diseases/recoid4eeyMVLDPrX 19/26 6/23/23, 3:13 AM Asthma Pathway Offer medium-dose ICS A ; offer very low- dose ICS-formoterol maintenance and reliever B Offer medium-dose maintenance ICS-long- acting -agonist Step 4. Symptoms most days, or waking with asthma 1 per week, and low lung function Offer low-dose ICS-formoterol maintenance and reliever therapy Refer for expert advice Consider administering a short course of oral corticosteroids in patients presenting with severely uncontrolled asthma Refer for phenotypic assessment Step 5. Offer higher-dose ICS-long-acting -agonist Offer add-on therapy with anti-IgE and anti- interleukin 4 receptor therapies A Pregnant patients: recognize that the advantages of actively treating asthma in pregnancy markedly outweigh any potential risks of usual controller and reliever medications. A Show 2 more Perimenstrual patients: consider prescribing oral contraceptives and/or leukotriene receptor antagonists in addition to the usual strategies for asthma treatment in perimenstrual patients. C Athletes: Discuss preventative measures to avoid high exposure to air pollutants, allergens (if sensitized), and chlorine levels in pools, particularly during training periods, with athletes. B Advise avoiding training in extreme cold or pollution. B Patients with exercise-induced bronchoconstriction: As per GINA 2022 guidelines, counsel patients with asthma about the prevention of exercise- induced bronchoconstriction with regular ICSs. A Show 2 more As per SIGN 2019 guidelines: Consider adding any of the following if exercise is a specific problem in otherwise well- controlled patients taking ICSs: leukotriene receptor antagonist long-acting -agonists sodium cromoglicate or nedocromil sodium theophylline. C Offer inhaled short-acting -agonists immediately before exercise. A Patients with aspirin-exacerbated respiratory disease: https://web.pathway.md/diseases/recoid4eeyMVLDPrX 20/26 6/23/23, 3:13 AM Asthma Pathway Advise avoiding aspirin or NSAID-containing products and other medications inhibiting COX-1 in patients with aspirin-exacerbated respiratory disease. Consider preferring a COX-2 inhibitor (such as celecoxib or etoricoxib) or acetaminophen, with appropriate healthcare provider supervision and observation for at least 2 hours after administration, when an NSAID is indicated for other medical conditions. B Administer ICSs as the mainstay of asthma treatment in patients with aspirin-exacerbated respiratory disease, recognizing that oral corticosteroids are sometimes required and leukotriene receptor antagonists may also be useful. B Patients with chronic cough: consider obtaining noninvasive measurement of airway inflammation in adult and adolescent patients with chronic cough due to asthma. Recognize that the presence of eosinophilic airway inflammation is likely to be associated with a more favorable response to corticosteroids. C Show 3 more Patients with allergic bronchopulmonary aspergillosis: As per SIGN 2019 guidelines, consider offering a 4-month trial of itraconazole in adult patients with allergic bronchopulmonary aspergillosis. C As per IDSA 2016 guidelines, consider initiating oral itraconazole with therapeutic drug monitoring in symptomatic patients with asthma and bronchiectasis or mucoid impaction despite oral or ICS therapy. C As per ERS 2014 guidelines: Consider initiating antifungal agents in adult patients with severe asthma and recurrent exacerbations of allergic bronchopulmonary aspergillosis. C Avoid using antifungal agents for the treatment of asthma in adult and pediatric patients with severe asthma without allergic bronchopulmonary aspergillosis, irrespective of sensitization to fungi (positive skin prick test or fungus-specific IgE in serum). D Patients with cardiac arrest: obtain prompt evaluation for tension pneumothorax in patients with asthma with cardiac arrest, sudden elevation in peak inspiratory pressures, or difficulty ventilating. B Show 2 more 10. Patient education Self-management education: as per GINA 2022 guidelines, establish a partnership between the patients with asthma (or the parent/carer) and healthcare providers for effective asthma management, and allow the patients to gain the knowledge, confidence, and skills to assume a major role in the management of their asthma. Recognize that self-management education reduces asthma morbidity in both adult and pediatric patients. A Show 2 more Asthma action plans: As per GINA 2022 guidelines: https://web.pathway.md/diseases/recoid4eeyMVLDPrX 21/26 6/23/23, 3:13 AM Asthma Pathway Include both a step up in ICSs and the addition of oral corticosteroids, and peak expiratory flow-based plans (based on personal best rather than percent predicted peak expiratory flow) in written asthma action plans. A Recognize that the efficacy of self-management education is similar regardless of whether patients self-adjust their medications according to an individual written plan or whether the medication adjustments are made by a doctor. A 11. Preventative measures Avoidance of occupational exposure: eliminate exposure as the best preventive measure to reduce the disease burden of work-related asthma and the preferred approach for primary prevention. A Show 3 more Avoidance of smoke exposure: advise current and prospective parents regarding the many adverse effects of smoking on their children, including increased wheezing in infancy and increased risk of persistent asthma. B Weight loss: Advise weight reduction in patients with obesity to promote general health and to reduce subsequent respiratory symptoms consistent with asthma. B Offer weight-loss programs in pediatric patients with overweight or obesity to reduce the likelihood of respiratory symptoms suggestive of asthma. B Breastfeeding: As per GINA 2022 guidelines: Recognize that breastfeeding decreases wheezing episodes in early life but does not prevent the development of persistent asthma. B Encourage breastfeeding for all of its other positive benefits regardless of its effect on the development of asthma. A As per SIGN 2019 guidelines, encourage breastfeeding for its various benefits, including a potential protective effect in relation to early asthma. B Routine immunizations: offer annual influenza vaccination in patients with moderate-to-severe asthma. B Show 2 more 12. Follow-up and surveillance Indications for specialist referral: as per GINA 2022 guidelines, refer for expert advice in the following cases, where available: Situation Guidance https://web.pathway.md/diseases/recoid4eeyMVLDPrX 22/26 6/23/23, 3:13 AM Asthma Pathway Difficulty confirming the diagnosis of asthma Symptoms of chronic infection, or features suggesting a cardiac or other nonpulmonary cause (immediate referral) Diagnosis is unclear even after a trial of therapy with inhaled or systemic corticosteroids Features of both asthma and COPD, if there is doubt about priorities for treatment Refer for confirmatory testing and identification of sensitizing or irritant agent, specific advice about eliminating exposure, and pharmacological treatment Suspected occupational asthma Uncontrolled symptoms, ongoing exacerbations, or low lung function despite correct inhaler (medium-dose ICS-long- acting -agonist) technique and good adherence (identify and treat modifiable risk factors and comorbidities before referral, depending on the clinical context) Persistent or severely uncontrolled asthma or frequent exacerbations Frequent asthma-related healthcare utilization (such as multiple emergency department visits or urgent primary care visits) Near-fatal asthma attack (ICU admission, or mechanical ventilation for asthma) at any time in the past Any risk factors for asthma-related death Suspected or confirmed anaphylaxis or food allergy Significant side effects from treatment Evidence of, or risk of, significant treatment side effects Need for long-term oral corticosteroid use Frequent courses of oral corticosteroids ( 2 courses per year) Aspirin-exacerbated respiratory disease Symptoms suggesting complications or subtypes of asthma Allergic bronchopulmonary aspergillosis Doubts about the diagnosis of asthma (such as respiratory symptoms not responding well to treatment in a prematurely born child) Additional reasons for referral in pediatric patients aged 6-11 years Symptoms or exacerbations remain uncontrolled despite medium-dose ICSs with https://web.pathway.md/diseases/recoid4eeyMVLDPrX 23/26 6/23/23, 3:13 AM Asthma Pathway correct inhaler technique and good adherence Suspected side effects of treatment (such as growth delay) Concerns about the patient's welfare or well- being. Serial pulmonary function testing: obtain pulmonary function testing after 3-6 months of controller treatment to assess the patient's personal best FEV in 1 second, and periodically thereafter (at least every 1-2 years in adult patients, but more frequently in higher risk patients including with exacerbations and at risk of decline in lung function and in pediatric patients based on asthma severity and clinical course). B Show 2 more Serial FeNO testing: do not obtain routine fractional expiratory nitric oxide testing to monitor asthma in adult or pediatric patients, except in specialist asthma clinics. D Serial sputum testing: do not obtain routine sputum eosinophilia testing to monitor asthma in adult or pediatric patients. D References 1. David Smith, Ingrid Du Rand, Charlotte Louise Addy et al. British Thoracic Society guideline for the use of long-term macrolides in adults with respiratory disease. Thorax. 2020 May;75 5 370 404. Open 2. Global Initiative for Asthma. 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Federico Martin n-Torres, Antonio Rodr guez-N ez, Jose Mar a Martin n-S nchez. Heliox therapy in infants with acute bronchiolitis. Pediatrics. 2002 Jan;109 1 68 73. Open https://web.pathway.md/diseases/recoid4eeyMVLDPrX 26/26