TABLE 2

Key Recommendations Given by 2 or More Asthma Guidelines and Primary Outcome of Treatment Recommendation

Strength of evidence for NHLBIaNHLBI 2007GINA 2014AAH 2014CTS 2012CPS 2012SIGN/BTS 2014ACCP 2005
AGREE II overall score (out of a possible 7)b 5446364
Recommendation topic
 Patient health literacyDid not addressRecommend forRecommend forDid not addressDid not addressDid not addressDid not address
 Control-based managementARecommend forRecommend forDid not addressRecommend forDid not addressDid not addressDid not address
 Treatment decisions based on patient characteristics, patient preferences, and practical issues (inhaler technique, adherence, cost)DRecommend forRecommend forRecommend forRecommend forDid not addressRecommend forDid not address
 First-line therapy: SABAARecommend forRecommend forRecommend forRecommend forDid not addressRecommend forDid not address
 Treating with low-dose ICS extremely effectiveARecommend forRecommend forRecommend forDid not addressDid not addressDid not addressDid not address
 With persistent symptoms and/or exacerbations: increase treatment if having symptoms even after starting low-dose ICS, first check inhaler techniqueDid not addressOptionalDid not addressRecommend forDid not addressDid not addressDid not address
 Adults and adolescents: start combo of ICS and LABA if ICS not enoughARecommend forRecommend forDid not addressRecommend forDid not addressOptionalDid not address
 Adults and adolescents with exacerbations despite other therapies: ICS and LABA as maintenance and reliever versus controller and SABADid not addressRecommend forDid not addressRecommend againstDid not addressDid not addressDid not address
 Patients 6–11 y: increase corticosteroid dose rather than ICS and LABAOptionalRecommend forDid not addressRecommend forDid not addressDid not addressDid not address
 (Step down) use least amount of medication for optimal controlDRecommend forOptionalRecommend forRecommend forDid not addressRecommend forDid not address
 Patients >6 y: inhaler skills trainingDid not addressRecommend forRecommend forDid not addressDid not addressRecommend forDid not address
 Patients >12 y: inhaler skills trainingDid not addressRecommend forRecommend forDid not addressDid not addressRecommend forDid not address
 Encourage adherence with controller medication (ICS) even when symptoms infrequentRecommend forRecommend forDid not addressDid not addressDid not addressDid not addressDid not address
 One or more risk factors for exacerbations: prescribe controller therapy (ICS)Recommend forRecommend forOptionalDid not addressDid not addressDid not addressDid not address
 One or more risk factor for exacerbation: identify and address modifiable risk factorsRecommend forRecommend forDid not addressRecommend forDid not addressDid not addressDid not address
 One or more risk factors for exacerbation: consider nonpharmacologic strategies to reduce symptomsDid not addressOptionalDid not addressDid not addressDid not addressOptionalDid not address
 Give advice on EIB prevention to those symptomaticRecommend forRecommend forDid not addressDid not addressDid not addressDid not addressDid not address
 EIB: prescribe controllers if risk factors, symptoms outside exerciseRecommend forRecommend forDid not addressDid not addressDid not addressDid not addressDid not address
 Patients >6 y: refer difficult-to-manage patients to specialists after addressing common treatment problemsDRecommend forRecommend forOptionalRecommend forRecommend forDid not addressDid not address
 Patients 0–5 y: refer difficult-to-manage patients to specialists after addressing common treatment problemsDRecommend forDid not addressOptionalRecommend forRecommend forDid not addressDid not address
 With exacerbation, start with repeated doses of SABA (most patients: MDI and spacer)ARecommend forRecommend forRecommend forDid not addressRecommend forDid not addressRecommend for
 With exacerbation, give oral steroids earlyRecommend forRecommend forRecommend forDid not addressDid not addressRecommend forRecommend for
 Patients >6 y: with exacerbation, give oral corticosteroidsRecommend forDid not addressOptionalRecommend forRecommend forDid not addressDid not address
 Patients <6 y: oral corticosteroidsDid not addressRecommend forRecommend againstDid not addressRecommend forDid not addressDid not address
 Patients 0–5 y: with exacerbation, give oxygen as neededDid not addressRecommend forRecommend forDid not addressRecommend forDid not addressDid not address
 Patients >6 y: with exacerbation, give oxygen as neededRecommend forRecommend forRecommend forDid not addressRecommend forRecommend forDid not address
 With severe exacerbation, ipratropium bromideARecommend forRecommend forRecommend forDid not addressDid not addressDid not addressDid not address
 With severe exacerbation, IV magnesium sulfateBOptionalOptionalOptionalDid not addressDid not addressRecommend forDid not address
 Patients 6–11 y: after exacerbation, start controller (ICS) or step up dose for 2–4 wkDid not addressRecommend forOptionalRecommend againstDid not addressDid not addressDid not address
 Patients >12 y: after exacerbation, start controller (ICS) or step up dose for 2–4 wkDid not addressRecommend forOptionalRecommend forDid not addressDid not addressDid not address
 Patients >6 y: antibioticsRecommend againstRecommend againstRecommend againstDid not addressDid not addressDid not addressDid not address
 All ages: antibioticsRecommend againstDid not addressRecommend againstDid not addressDid not addressDid not addressDid not address
 Patients 0–5 y: treat wheezing in children with SABADid not addressRecommend forRecommend forDid not addressDid not addressDid not addressDid not address
 Trial controller therapy (ICS) for children with frequent or severe wheezingARecommend forRecommend forOptionalDid not addressDid not addressDid not addressDid not address
 Patients 0–5 y: choice of inhaler device in kids by age and capability; preferred device: MDI + spacer with mask or mouthpieceARecommend forRecommend forRecommend forDid not addressDid not addressRecommend forDid not address
 Patients >5 y: choice of inhaler device in kids by age and capability; preferred device MDI + spacer with mask or mouthpieceARecommend forDid not addressRecommend forRecommend forRecommend forRecommend forOptional
 Exacerbation: home use of SABADid not addressRecommend forRecommend forDid not addressDid not addressDid not addressDid not address
 Exacerbation: parent-initiated oral corticosteroidsDid not addressOptionalRecommend againstRecommend againstDid not addressDid not addressDid not address
 With exacerbation, dosing of SABA (2–6 puffs every 20 min for first h)Did not addressRecommend forRecommend forDid not addressDid not addressDid not addressDid not address
 Patients 0–5 y: oral prednisoneDid not addressRecommend forRecommend forDid not addressRecommend forDid not addressDid not address
 Patients >6 y: oral prednisoneDid not addressDid not addressRecommend forRecommend forRecommend forDid not addressDid not address
 Patients >12 y: oral prednisoneDid not addressDid not addressRecommend forRecommend forRecommend forDid not addressDid not address
 Patients >2 y: intermittent or mild persistent: LTRA (montelukast) as first choice controller medicineBOptionalRecommend againstOptionalDid not addressDid not addressRecommend forDid not address
 Patients >2 y :moderate to severe persistent symptoms, ICS as first-choice controller medicineARecommend forRecommend forOptionalDid not addressDid not addressDid not addressDid not address
 Patients <2 y: sodium cromoglycateBOptionalDid not addressOptionalDid not addressDid not addressDid not addressDid not address
 Patients >2 y: sodium cromoglycateBOptionalDid not addressOptionalDid not addressDid not addressDid not addressDid not address
 Patients 5–11 y: regular use of theophyllineAOptionalDid not addressRecommend againstDid not addressDid not addressDid not addressDid not address
 Ipratropium for regular useDOptionalDid not addressRecommend againstDid not addressDid not addressDid not addressDid not address
 Patients <6 y: oral corticosteroids with severe exacerbationDid not addressDid not addressRecommend forDid not addressDid not addressOptionalDid not address
 Needing β2 agonist >2 × per wk: prescribe controller therapy (ICS)CRecommend forDid not addressOptionalDid not addressDid not addressDid not addressDid not address
 OmalizumabBRecommend forDid not addressOptionalDid not addressDid not addressDid not addressDid not address
 Cleaning spacerDid not addressDid not addressRecommend forDid not addressRecommend forDid not addressDid not address
 All children: precautions with inhaled corticosteroids (ICS)BRecommend forDid not addressRecommend forDid not addressDid not addressDid not addressDid not address
 All ages: precautions with inhaled corticosteroids (ICS)BRecommend forDid not addressRecommend forDid not addressDid not addressDid not addressDid not address
 NebulizerDid not addressDid not addressOptionalDid not addressDid not addressOptionalRecommend for
 Patients: demonstrate techniqueBRecommend forDid not addressRecommend forDid not addressRecommend forDid not addressDid not address
 With severe exacerbation, intermittent nebulizer SABADid not addressDid not addressRecommend forDid not addressDid not addressDid not addressRecommend for
 With life-threatening asthma, continuous nebulizer of SABADid not addressDid not addressRecommend forDid not addressDid not addressDid not addressRecommend for
 Add-on therapy to salbutamol (SABA)Did not addressDid not addressOptionalDid not addressOptionalDid not addressDid not address
 IV salbutamol dosing guideDid not addressDid not addressRecommend forDid not addressDid not addressDid not addressDid not address
 Uncontrolled with medium dose ICS: add adjunctive therapy (usually LABA)BRecommend forDid not addressDid not addressRecommend forDid not addressOptionalDid not address
 Patients >12 y: third-line option: LTRA or increase ICSAOptionalDid not addressDid not addressOptionalDid not addressDid not addressDid not address
 Patients >16 y: ICS and/or LABA as reliever for mild intermittent asthma not on controllerDRecommend againstDid not addressDid not addressRecommend againstDid not addressDid not addressDid not address
 Patients <16 y: ICS and/or LABA as reliever when not on controller therapyDRecommend againstDid not addressDid not addressOptionalDid not addressDid not addressDid not address
 Children and adults: ICS and/or LABA as reliever when on ICS monotherapyDRecommend againstDid not addressDid not addressAbstainDid not addressDid not addressDid not address
 Mild persistent asthma: daily ICS versus intermittent ICSARecommend forDid not addressDid not addressRecommend forDid not addressDid not addressDid not address
 Patients <12 y: ICS and/or LABA adjustable maintenance dosing versus increasing ICS adjustable maintenance dosingDid not addressDid not addressDid not addressAbstainDid not addressRecommend againstDid not address
 ICS and/or LABA AMD versus increased ICS doseDid not addressDid not addressDid not addressAbstainRecommend forRecommend againstDid not address
 LABA as monotherapyRecommend againstDid not addressDid not addressRecommend againstDid not addressDid not addressDid not address
 ICS effectiveARecommend forDid not addressDid not addressDid not addressDid not addressRecommend forDid not address
  • AMD, adjustable maintenance dosing; MDI, metered dose inhaler;—, not reported.

  • a The level of evidence is given for the NHLBI guideline in letters per the system of evidence reporting in the NHLBI guideline when it was reported.24 Evidence Category A: RCTs, rich body of data; Evidence Category B: RCTs, limited body of data; Evidence Category C: nonrandomized trials and observational studies; Evidence Category D: panel consensus judgment.

  • b AGREE II scoring instrument to assess guideline quality and reporting: this tool has overall guideline assessments (overall score above), as well as 23 individual questions.