Bronchial Asthma Management in Children

- Methods

➡️Methods of search:

A comprehensive search for guidelines was undertaken to identify the most relevant guidelines to consider for adaptation. Using keywords: Management, Asthma, ICS, LABA, children 5 years and below, and children 6 years and above.

Inclusion / exclusion criteria followed in the search and retrieval of guidelines to be adapted:

• Selecting only evidence-based guidelines (guideline must include a report on systematic literature searches and explicit links between individual recommendations and their supporting evidence)

• Selecting only national and/or international guidelines

• Specific range of dates for publication (using Guidelines published or updated 2019 and later)

• Selecting peer reviewed publications only

• Selecting guidelines written in English language

• Excluding guidelines written by a single author not on behalf of an organization to be valid and comprehensive, a guideline ideally requires multidisciplinary input.

• Excluding guidelines published without references as the panel needs to know whether a thorough literature review was conducted and whether current evidence was used in the preparation of the recommendations.

All retrieved Guidelines were screened and appraised using AGREE II instrument (www.agreetrust.org) by at least three members. The panel decided a cut-off point or rank the guidelines (any guideline scoring above 60% on the rigor dimension was retained)

After reviewing all the previous criteria the GDG & methodologists recommended using 6 guidelines:

1. SIGN/BTS 158: British guideline on the management of asthma, 2019

2. Japanese pediatric guideline for the treatment and management of asthma (JPGL), 2020

3. Canadian Thoracic Society 2021 Guideline update: Diagnosis and management of asthma in preschoolers, children, and adults

4. European Respiratory Society clinical practice guidelines for the diagnosis of asthma in children aged 5–16 years, 2021

5. GINA Report 2024

We did Adolopment for these guidelines: (Adoption, Adaptation, and Development)

- Adoption for most of the guideline recommendations.

- Development of Good Practice Statement

➡️Contributors to the guideline development process:

➡️Guideline Development Group (GDG):

The GDG for the guideline on prevention and management of Bronchial Asthma included experts with a range of technical skills and diverse perspectives in the field of pulmonology.

The main functions of the GDG were adolopment of selected guidelines for Asthma (2019&2024) determining the scope of the guideline and guideline, reviewing the evidence, and formulating evidence-informed recommendations in case of changing strength of recommendations.

The protocol of this CPG adaptation Project was published in the official journal of the Guidelines International Network. (42-43)

➡️Guideline Methodologists:

There were guideline methodologists with expertise in guidelines development, GRADE and translation of evidence into recommendations. Methodologists provided orientation and overview of evidence-informed guideline development processes using the GRADE approach & also, provided AGREE II assessment of the source guidelines in conjunction with CDG.(44-45)

➡️External Review Group:

The External Review Group for this guideline comprises 3 clinical experts who have interest and expertise in the prevention and management of Asthma in children. They were identified by Egyptian Pediatric Clinical Practice Guidelines Committee (EPG) as people who can provide valuable insights during the guideline development process.

The External Review Group was asked to comment on (peer review) the final guideline to identify any criticism on the content and to comment on clarity and applicability as well as issues relating to implementation, dissemination, ethics, regulations, or monitoring, but not to change the recommendations formulated by the GDG. The members of the External Review Group were required to submit declarations of interest before the peer review process.

➡️Guideline Development Group meetings:

GDG meetings were organized virtually twice weekly. Due to the extensive scope of

the guideline, EPG Chair was responsible for the timetable and objectives of each meeting. GDG meetings were also attended by members of the methodologists and systematic. Working rules for each contributor type were outlined by the chair at the start of each meeting, covering aspects such as vocal rights, voting, and evidence to decision and recommendation formulating processes.

➡️Declarations of interests:

Prospective members of the GDG were asked to fill in and sign the standard WHO declaration of interest and confidentiality undertaking forms. All guideline members and methodologists were also asked to fill in and sign the standard WHO declaration-of-interests.

Members of the external review group will be asked to fill in and sign the standard WHO declaration-of-interests form before the peer review process.

➡️Evidence for the guideline:

We used the GRADE system (Grading of Recommendations, Assessment, Development and Evaluation) for assigning the quality of evidence and strength of recommendations that includes the following definitions [13]. Informed by the evidence required for the GRADE Evidence to Decision (EtD) table was done while considering changing strength of recommendations according to availability of some resources in the recommendations (we did this for only 2 recommendations).

Description of the interpretation of the GRADE four levels of certainty of evidence:

Table 1. Classification of the Quality of Evidence

High	We are very confident that the true effect lies close to that of the estimate of the effect.
Moderate	We are moderately confident in the effect estimate; the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.
Low	Our confidence in the effect estimate is limited; the true effect may be substantially different from the estimate of the effect.
Very Low	We have very little confidence in the effect estimate; the true effect is likely to be substantially different from the estimate of the effect.

➡️GRADE EtD criteria and considerations that link to the strength of recommendations:

Criteria Considerations:

Benefits and harms: When a new recommendation is developed, desirable effects (benefits) need to be weighed against undesirable effects (risks/harms), considering any previous recommendation or another alternative. The larger the gap or gradient in favor of the desirable effects over the undesirable effects, the more likely that a strong recommendation will be made.

Certainty of the evidence about the effects: The higher the certainty of the scientific evidence base, the more likely that a strong will be made.

Values and preferences: If there is no important uncertainty or variability in how much people value the main outcomes, it is likely that a strong recommendation will be made. Uncertainty or variability around these values that could likely lead to different decisions, is more likely to lead to a conditional recommendation.

Economic implications: Lower costs (monetary, infrastructure, equipment or human resources) or greater cost- effectiveness are more likely to support a strong recommendation.

Equity and human rights: If an intervention will reduce inequities, improve equity or contribute to the realization of human rights, the greater the likelihood of a strong recommendation.

Feasibility: The greater the feasibility of an intervention to all stakeholders, the greater the likelihood of a strong recommendation.

Acceptability: If a recommendation is widely supported by health workers and program managers and there is widespread acceptance for implementation within the health service, the likelihood of a strong recommendation is greater.

Table 2. Classification of the Strengths of Recommendations

Strong	The desirable effects of an intervention clearly outweigh the undesirable effects (or vice versa), so most patients should receive the recommended course of action.
Conditional	There is uncertainty about the trade-offs. The clinician and patient need to discuss the patient's values and preferences, and the decision should be individualized.

➡️Developing good practice statements (GPS):

The GDG also developed good practice statements for this guideline, which are actionable messages relevant to the guideline questions. The justification for each good practice statement was carefully considered by the GDG with an emphasis that they are clearly needed. Good practice statements were developed, guided by the following GRADE criteria:

1- Message is really necessary with regard to actual healthcare practice

2- Have large net positive consequence (relevant outcomes and downstream consequences) (GRADE EtD domains)

3- Collecting and summarizing the evidence is a poor use of time and resources

4- Include a well-documented, clear rationale connecting indirect evidence

5- Are clear and actionable statements.

The GDG collectively drafted and finalized good practice statements with relevant justifications and remarks to help with their interpretation, with close support and input from the consultant and guideline methodologists.