The National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group (hereinafter “panel”) of the National Heart, Lung, and Blood Institute recently published its 2020 Focused Updates to the Asthma Management Guidelines (https://www.nhlbi.nih.gov/asthmaguidelines).1  These are the first updates from the panel since 2007, a remarkably long interval given the advances in care of the last decade. Using the Grading Recommendations, Assessment, Development, and Evaluation platform,2  the panel made 19 recommendations across six topic areas: intermittent inhaled corticosteroid (ICS) therapy, long-acting muscarinic antagonist (LAMA) therapy, indoor allergen-mitigation strategies, immunotherapy, fractional exhaled nitric oxide (FeNO) testing, and bronchial thermoplasty.3  Of these, 18 are relevant to children and adolescents (Table 1). The panel made strong recommendations (to be implemented by clinicians for almost all their patients as standard of care) and conditional recommendations (intended for many individuals as part of a shared decision-making process involving the clinician, family, and patient). For pediatric clinicians, the most exciting updates are those affirming several treatment options for using ICS with long-acting β2-agonists (LABAs) and LAMAs. Those for allergen mitigation, immunotherapy, and FeNO testing provide useful clarifications but not transformative alternatives for care. Of note, the updates did not address biological therapies because at the time that a decision regarding which topics to update was made (2014), only one biologic (omalizumab) was available.

The updates’ most highly pediatric-relevant recommendations involve three treatment options: (1) intermittent ICS dosing with as-needed short-acting β2-agonist (SABA) for quick-relief therapy, (2) single maintenance and reliever therapy (SMART),4  and (3) add-on LAMA therapy. As always, before making any changes that step up care, clinicians should assess adherence, inhaler technique, environmental triggers, and comorbid conditions.

In children 0 to 4 years with intermittent asthma, clinicians may now conditionally recommend a short (7–10 days) course of daily ICS with as-needed SABA at the start of a viral respiratory tract infection for children who have had ≥3 lifetime episodes of viral-induced wheezing or ≥2 episodes in the past year and who are asymptomatic between episodes. Similarly, in those ≥12 years with mild persistent asthma, clinicians and families may jointly decide to use intermittent as-needed concomitant ICS with SABA instead of daily ICS with as-needed SABA.1  In deciding whether to implement this change, clinicians should consider the child’s previous adherence to daily therapy as part of shared decision-making. The challenge to clinicians will be reeducating families that have long been taught the importance of adherence to daily ICS.

For patients ≥4 years with mild to moderate persistent asthma who are likely adherent with daily ICS alone, a short-term increase in the ICS dose (eg, doubling, tripling, or quadrupling the daily dose) is not recommended. It may be considered for patients whose adherence is less certain.5 

SMART is treatment with ICS and a specific LABA (formoterol) for both daily and rescue therapy. It is strongly recommended as the preferred therapy for children ≥4 years who are not well controlled on a low- or medium-dose daily ICS alone.4  Formoterol is the LABA of choice because it has a rapid onset of action and can be used more than twice daily. For patients, SMART is a “double win,” reducing exacerbation rates and overall corticosteroid use.4  Individuals whose asthma is uncontrolled on daily ICS-LABA maintenance therapy should also receive the preferred SMART before moving to a higher-step level of therapy. Not only is SMART more effective than daily ICS, but it also reduces total exposure to ICS and effects on growth rates in young children; effects on growth are related to ICS dose equivalence and treatment duration. SMART is also attractive because only one device and technique are necessary, but families will need to be educated to stop using their SABA. In addition, insurers will need to modify their policies regarding medication dispensing for individuals on SMART because one inhaler per month may be insufficient.

These recommendations apply only to patients ≥12 years; LAMA therapy is approved for children 6 to 11 years of age but was not considered in the systematic reviews used to develop the recommendations. Daily ICS-LAMA is an alternative therapy after SMART (preferred choice) and after daily ICS-LABA (secondary choice) for moderate persistent disease. For severe persistent asthma, the preferred therapy for individuals not controlled on ICS-LABA is triple therapy with daily medium- to high-dose ICS-LABA plus add-on LAMA and as-needed SABA. This combination of three devices and techniques poses a unique challenge to patients.

In contrast to the panel’s recommendations for pharmacologic therapies, its recommendations for allergen mitigation are less notable. In fact, the panel conditionally recommends against it as part of routine asthma care.1  Mitigation should be used only for individuals who are exposed to a specific allergen to which they are either sensitized or become symptomatic after exposure. When used, multicomponent tailored intervention strategies should be used. For example, dust-mite mitigation might include a combination of dust-mite impermeable pillow and mattress covers, frequent damp dusting, and HEPA vacuums. The exception is integrated pest management, which is recommended either alone or as part of a multicomponent intervention strategy.

Subcutaneous immunotherapy (SCIT) or sublingual immunotherapy (SLIT) (in liquid or tablet form) reduces the immunoglobulin E–mediated allergic response associated with asthma. The panel defines a narrow role for SCIT as an adjunct to standard pharmacotherapy in individuals aged ≥5 years with mild to moderate allergic asthma for whom a potential decrease in long-term medication is important.1  SCIT should not be administered in individuals with severe asthma or any individuals with persistent asthma whose asthma is not under control at the time the injections are administered. Clinicians should administer SCIT in a clinical setting that has the capacity to monitor and treat reactions, which are frequent and of wide-ranging severity. SCIT should not be administered at home. The panel recommends against the use of SLIT in asthma treatment,1  but it may benefit individuals with certain comorbid conditions, such as allergic rhinitis with or without conjunctivitis.

Like immunotherapy, the panel recommends a narrow role for FeNO testing in asthma management. Nitric oxide in exhaled breath is an indirect measure of type 2 (or eosinophilic) airway inflammation. Measurement is safe and noninvasive; the biggest barrier to office-based implementation is purchasing the equipment. Results can be difficult to interpret, however, because levels are confounded by different conditions (eg, ICS use, allergic rhinitis, or smoking). FeNO testing should not be used alone to diagnose or manage asthma.1  FeNO measurement may support a diagnosis of asthma in individuals ≥5 years for whom the diagnosis remains uncertain after completion of a history, physical examination, and spirometry with bronchodilator responsiveness. In children ≥5 years with an established diagnosis of asthma, FeNO measurements every 2 to 3 months can supplement history, clinical findings, and spirometry in an ongoing asthma monitoring and management strategy. FeNO monitoring is not recommended to assess adherence to treatment (typically for ICS). FeNO testing should not be used in children aged 0 to 4 years with recurrent wheezing to predict the future development of asthma.

The 2020 Focused Asthma Updates provide recommendations across multiple domains of asthma care. Those related to intermittent ICS may reduce asthma impairment and risk with lower overall exposure to ICS. Patients, caregivers, clinicians, payers, and institutions will need to adapt to these changes. Clinicians may wish to update their quality measures to adapt, for example, to recommendations for SMART, targeted allergen mitigation, and immunotherapy. Finally, the panel should move quickly to address several topics that were emerging at the time the revision process began, including personalized management with biological therapies and primary asthma prevention, an especially important area for pediatricians.

We thank the members of the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group and the National Heart, Lung, and Blood Institute leadership and staff for their support and contribution.

Drs Cloutier and Lemanske conceptualized and designed the study; and all authors drafted portions of the initial manuscript, reviewed and revised the manuscript, and approved the final manuscript as submitted and agree to be accountable for all aspects of the work.

FUNDING: The 2020 Focused Updates to the Asthma Management Guidelines report was funded by the National Heart, Lung, and Blood Institute (NHLBI) of the National Institutes of Health. No additional funding was received for this article. All authors volunteered their time. The NHLBI was not involved in the development of this article. Funded by the National institutes of Health (NIH).

FeNO

fractional exhaled nitric oxide

ICS

inhaled corticosteroid

LABA

long-acting β2-agonist

LAMA

long-acting muscarinic antagonist

SABA

short-acting β2-agonist

SCIT

subcutaneous immunotherapy

SLIT

sublingual immunotherapy

SMART

single maintenance and reliever therapy

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Competing Interests

POTENTIAL CONFLICT OF INTEREST: Dr Cloutier reports a family member who is employed by Regeneron. Dr Teach reports research funding from the NIH NHLBI, the NIH National Institute of Allergy and Infectious Diseases, the NIH Eunice Kennedy Shriver National Institute of Child Health and Human Development, and EJF Philanthropies and royalty payments from UpToDate. Dr Lemanske has received personal fees from Siolta Therapeutics for a microbiome intervention and from the Food Allergy Research and Education Network. Dr Blake reports research funding from the NIH NHLBI, the NIH National Human Genome Research Institute, and Propeller Health. All authors were members of the National Asthma Education and Prevention Program Coordinating Committee Expert Panel Working Group.

FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.