Bronchial Asthma

This guideline offers evidence-based recommendations on the management and follow-up of bronchial asthma in adults and adolescents (12 years and older). It is intended to give healthcare professionals practical, guideline-driven guidance that improves asthma control, reduces exacerbations and limits treatment-related harm, while remaining applicable across the differing service levels of the Egyptian health system.

Section 1: Diagnosis of Asthma in Adults and Adolescents

1.1.1 We recommend beginning the diagnostic assessment of every patient with suspected asthma with a thorough history, documenting typical respiratory symptoms (wheeze, shortness of breath, chest tightness or cough) that vary over time and in intensity, are often worse at night or on waking, and are triggered by viral infections, exercise, allergen exposure, changes in weather or laughter. (Good practice statement)

1.2.1 We recommend a physical examination for every patient with suspected asthma, recognizing that the examination is often normal. (Good practice statement)

1.3.1 We recommend confirming excessive variability in expiratory lung function, preferably by spirometry with bronchodilator responsiveness testing, and documenting it before controller treatment is started; any one of the criteria described in this section confirms it. (Good practice statement)

1.4.1 We recommend using Type 2 biomarkers (FeNO, blood eosinophil count and, where available, induced-sputum eosinophils) and allergy tests to support, but not to exclude, a diagnosis of Type 2 (eosinophilic and/or allergic) asthma in patients with typical symptoms. (Strong recommendation)

1.5.1 We do not recommend routine chest imaging for the diagnosis of asthma, or for predicting treatment outcomes or lung-function decline. (Good practice statement)

1.6.1 We recommend that, in patients already taking ICS-containing treatment, confirmation of the diagnosis of asthma be guided by the patient’s symptoms and lung function, following the pathway described in this section. (Good practice statement)

Section 2: Assessment of Asthma in Adults and Adolescents

2.1.1 We recommend assessing, for every patient, symptom control and risk factors on current treatment, treatment issues (particularly inhaler technique and adherence), multimorbidity, and the patient’s goals and preferences. (Good practice statement)

2.1.2 We recommend investigating for impaired perception of airflow limitation when there are few symptoms but low lung function, and for alternative diagnoses when there are frequent symptoms despite good lung function. (Good practice statement)

2.2.1 We recommend assessing symptom control over the previous 4 weeks (and over the whole period since the last review) at every visit, using a validated tool such as the GINA symptom control tool, the ACQ-5 or the ACT, and selecting the initial treatment step according to the ACT score (see Section 4 and Annex 1). (Strong recommendation)

2.4.1 We recommend, at every review, observing the patient using their inhaler and correcting and re-checking technique if necessary, assessing medication adherence and barriers to adherence (including adherence to other interventions such as smoking cessation), and reviewing and updating the written asthma action plan if the level of asthma control or treatment has changed. (Strong recommendation)

2.5.1 We advise assessing for multimorbidity – rhinitis, rhinosinusitis, gastroesophageal reflux, obesity, obstructive sleep apnea, depression and anxiety – which can contribute to symptoms and poor quality of life, and sometimes to poor asthma control (see Section 6.1). (Conditional recommendation)

2.6.1 We recommend measuring FEV₁ and bronchodilator responsiveness during follow-up to help predict the risk of exacerbations. (Strong recommendation)

2.7.1 We recommend routinely prescribing ICS-containing treatment to reduce the patient’s risk of severe exacerbations, and treating any modifiable risk factors or comorbidities using pharmacological or non-pharmacological strategies. (Strong recommendation)

2.8.1 We recommend that patients with poor symptom control and/or exacerbations despite ICS-containing treatment be assessed systematically, in the order described in this section, before treatment is stepped up further. (Good practice statement)

2.10.1 We advise adding FeNO measurement as an adjunct to the evaluation of adults and adolescents in whom the diagnosis of asthma remains uncertain after history, clinical findings, clinical course and spirometry (including bronchodilator responsiveness testing), or in whom spirometry cannot be performed. (Conditional recommendation)

2.10.2 We advise adding FeNO measurement, as part of an ongoing asthma monitoring and management strategy that includes frequent assessments, in adults and adolescents with persistent allergic asthma when there is uncertainty in choosing, monitoring or adjusting anti-inflammatory therapy based on history, clinical findings and spirometry. (Conditional recommendation)

2.10.3 We do not recommend using FeNO measurement alone to assess asthma control, predict future exacerbations or assess exacerbation severity; FeNO should be used for these purposes only as part of an ongoing asthma monitoring and management strategy. (Strong recommendation)

2.11.1 We advise against allergen mitigation interventions as part of routine asthma management in patients who are not sensitized to specific indoor allergens or who have no symptoms related to exposure to specific indoor allergens. (Conditional recommendation)

2.11.2 We advise a multicomponent, allergen-specific mitigation intervention for patients whose symptoms are related to exposure to identified indoor allergens, confirmed by history taking or allergy testing. (Conditional recommendation)

2.11.3 We advise integrated pest management, alone or as part of a multicomponent allergen-specific mitigation intervention, for patients who are sensitized to, or have symptoms related to exposure to, pests (cockroach and rodent). (Conditional recommendation)

2.11.4 We advise impermeable pillow and mattress covers for patients who are sensitized to, or have symptoms related to exposure to, house dust mite only as part of a multicomponent allergen mitigation intervention, not as a single-component intervention. (Conditional recommendation)

Section 3: Principles of Asthma Management in Adults and Adolescents

3.1.1 We recommend establishing an effective patient–healthcare provider partnership using communication strategies that include eliciting the patient’s understanding of and concerns about asthma, shared decision-making about treatment options, checking the patient’s understanding of the asthma management plan, and asking about the patient’s goals and preferences. (Strong recommendation)

3.2.1 We recommend that the long-term goal of asthma management for every patient be to achieve the best possible long-term outcomes, which include:

•    long-term asthma symptom control, with few or no asthma symptoms, no sleep disturbance due to asthma and unimpaired physical activity;

•    long-term asthma risk minimization, with no exacerbations, improved or stable personal best lung function, no requirement for maintenance oral corticosteroids and no medication side-effects. (Strong recommendation)

3.2.2 We recommend recognizing that the patient’s personal goals for their asthma may differ from these medical goals, and negotiating individualized treatment targets in partnership with the patient. (Strong recommendation)

3.3.1.1 We recommend that patients with asthma:

•    avoid active smoking and be supported to stop smoking;

•    avoid exposure to second-hand (environmental) tobacco smoke;

•    avoid e-cigarette use and vaping exposure. (Strong recommendation)

3.3.1.2 We advise that allergen avoidance strategies be tailored to the individual patient on the basis of confirmed sensitization; they are most effective when combined with ICS treatment. General advice includes:

•    house dust mite avoidance measures: washing bed linen weekly in hot water, use of allergen-impermeable mattress and pillow covers, and removal of bedroom carpeting;

•    pet allergen avoidance: removing the pet from the home or keeping it out of the bedroom;

•    workplace allergen avoidance: identifying and removing occupational exposure. (Conditional recommendation)

3.3.1.3 We recommend that patients with asthma and obesity be offered weight reduction programs (through diet, exercise or behavioral modification), as weight reduction can improve asthma control and reduce exacerbation risk. (Strong recommendation)

3.3.1.4 We recommend that patients with asthma be encouraged to engage in regular physical activity and exercise, as it improves fitness and overall health; patients with exercise-induced bronchoconstriction should use appropriate pre-exercise medication. (Strong recommendation)

3.3.1.5 We advise exclusive breastfeeding for at least the first 3–4 months, which may have modest protective effects against the development of asthma in children at high risk of atopy. (Conditional recommendation)

3.3.1.6 We recommend assessment and treatment of gastroesophageal reflux disease (GERD), if present, as uncontrolled GERD can contribute to asthma symptoms and exacerbations. (Strong recommendation)

Section 4: Pharmacological Treatment and Treatment Regimens for Adults and Adolescents

4.1 We recommend, at Step 1, as-needed low-dose ICS-formoterol or as-needed low-dose ICS-SABA. (Strong recommendation)

4.2 We recommend, at Step 2, low-dose maintenance ICS. (Strong recommendation)

4.3 We recommend, at Step 3, low-dose maintenance ICS-LABA. (Strong recommendation)

4.4 We recommend, at Step 4, medium-dose maintenance ICS-LABA plus add-on LAMA plus add-on theophylline or LTRA. (Strong recommendation)

4.5 We recommend, at Step 5, high-dose maintenance ICS-LABA plus add-on LAMA plus add-on theophylline or LTRA. (Strong recommendation)

4.6 We advise, at Step 5 if the patient remains uncontrolled, three short courses of oral corticosteroids per year, each for 5–7 days at a maximum dose of prednisolone 20 mg, taking into account the side-effects of oral corticosteroids. (Conditional recommendation)

4.7 We recommend, at Step 5 if the patient remains uncontrolled after the above, assessment of phenotyping for biologic therapy, with referral to a severe asthma clinic to diagnose and prescribe treatment for committee approval. (Strong recommendation)

4.8 We recommend, as the reliever at Steps 2–5, as-needed low-dose ICS-formoterol or as-needed low-dose ICS-SABA. When low-dose ICS-formoterol is used as the reliever, the maintenance medication should be the same molecule, medication and device. (Strong recommendation)

4.9 We advise adding a leukotriene receptor antagonist (LTRA) or theophylline at Steps 4–5 if the patient has multiple allergic rhinitis or exercise-induced asthma, and monitoring regularly for side-effects. (Conditional recommendation)

4.10 We advise that allergen immunotherapy is an available option in mild and moderate asthma when the patient has one or two perennial allergies, especially to house dust mite. (Conditional recommendation)

4.11.1 We recommend that all healthcare providers assess asthma control, adherence and inhaler technique at every visit, not only when the patient presents because of their asthma. (Strong recommendation)

4.11.2 We recommend that patients be seen 1–3 months after starting treatment and every 3–12 months thereafter, with the frequency of visits determined by the patient’s initial level of control, response to treatment and level of engagement in self-management. (Strong recommendation)

4.11.3 We recommend scheduling a review visit within 1 week after an exacerbation. (Strong recommendation)

4.12.1 We recommend day-to-day adjustment using an anti-inflammatory reliever (AIR): for patients whose reliever inhaler is budesonide-formoterol or beclometasone-formoterol (with or without maintenance ICS-formoterol), the patient adjusts the number of as-needed doses of ICS-formoterol from day to day according to their symptoms. This strategy reduces the risk of a severe exacerbation requiring oral corticosteroids within the next 3–4 weeks. (Strong recommendation)

4.12.2 We recommend a short-term step-up (an increase in maintenance ICS dose for 1–2 weeks) where necessary, for example during viral infections or seasonal allergen exposure. This may be initiated by the patient according to their written asthma action plan, or by the healthcare provider. (Strong recommendation)

4.12.3 We recommend that a sustained step-up (for at least 2–3 months) be considered only after confirming that the symptoms are due to asthma, that inhaler technique and adherence are satisfactory, and that modifiable risk factors such as smoking have been addressed. Any step-up should be regarded as a therapeutic trial; if there is no response after 2–3 months, treatment should be reduced to the previous level and alternative treatments or referral considered. (Strong recommendation)

4.13.1 We recommend considering stepping down treatment once good asthma control has been achieved and maintained, and lung function has been stable, for 3 months or more. If the patient has risk factors for exacerbations (for example, a history of exacerbations in the past year or persistent airflow limitation), step down only with close supervision. (Strong recommendation)

4.13.2 We recommend choosing an appropriate time to step down (no respiratory infection, patient not travelling, not pregnant). (Strong recommendation)

4.13.3 We recommend approaching each step-down as a therapeutic trial: engage the patient in the process; document their asthma status (symptom control, lung function and risk factors); provide clear instructions and a written asthma action plan; ensure that the patient has sufficient medication to resume the previous dose if necessary; monitor symptoms and/or PEF; and schedule a follow-up visit. (Strong recommendation)

4.13.4 We recommend stepping down ICS doses by 25–50% at 3-month intervals, which is feasible and safe for most patients. Options for stepping down by current step are given in Annex 4. (Strong recommendation)

4.13.5 We do not recommend complete cessation of ICS in adults and adolescents, as the risk of exacerbations is increased with SABA-only treatment. (Strong recommendation)

4.13.6 We do not recommend stepping down too far or too quickly, as exacerbation risk may increase even if symptoms remain reasonably controlled. (Strong recommendation)

4.14.1 We advise that allergen-specific immunotherapy may be a treatment option where allergy plays a prominent role, including asthma with allergic rhinoconjunctivitis. Two approaches are available: subcutaneous immunotherapy (SCIT) and sublingual immunotherapy (SLIT). (Conditional recommendation)

4.14.2 We advise that, compared with pharmacological and avoidance options, the potential benefits of SCIT be weighed against the risk of adverse effects and the inconvenience and cost of the prolonged course of therapy, including the minimum half-hour wait required after each injection. (Conditional recommendation)

4.14.3 We advise that, for adult patients with allergic rhinitis who are sensitized to house dust mite and have persisting asthma symptoms despite low- to medium-dose ICS-containing therapy, adding SLIT be considered, but only if FEV₁ is >70% predicted. (Conditional recommendation)

4.14.4 We advise that, as for any treatment, the potential benefits of SLIT for the individual patient be weighed against the risk of adverse effects and the cost to the patient and the health system. (Conditional recommendation)

4.14.5 We advise against allergen immunotherapy in patients sensitized to mold, as there is insufficient evidence about its safety and efficacy in this group. (Conditional recommendation)

Section 5: Guided Asthma Self-Management Education and Skills Training

5.1.1 We recommend demonstrating correct inhaler technique to every patient at the initial prescription and at every follow-up visit, as poor technique significantly reduces treatment efficacy; technique should be assessed using a device-specific checklist. (Strong recommendation)

Section 6: Managing Asthma with Multimorbidity and in Specific Populations

6.1.1 We recommend screening all patients with asthma for comorbidities that may contribute to respiratory symptoms or poor asthma control, including:

•    allergic rhinitis;

•    chronic rhinosinusitis;

•    gastroesophageal reflux disease (GERD);

•    obstructive sleep apnea;

•    obesity;

•    anxiety/depression;

•    confirmed food allergy. (Strong recommendation)

6.1.2.1 We recommend assessing all patients with asthma for symptoms of allergic rhinitis (itching, sneezing, nasal congestion), as allergic rhinitis is a risk factor for exacerbations. Treatment options include:

•    intranasal corticosteroids (preferred);

•    antihistamines (oral or nasal);

•    allergen avoidance;

•    allergen immunotherapy (in selected cases). (Strong recommendation)

6.1.2.2 We recommend integrated management of asthma and allergic rhinitis, as treatment of rhinitis can improve asthma control and reduce exacerbations. (Strong recommendation)

6.1.3.1 We recommend assessing for chronic rhinosinusitis (facial pain/pressure, nasal congestion, post-nasal drip) and nasal polyps (especially in patients with severe asthma), as these are risk factors for exacerbations. (Strong recommendation)

6.1.3.2 We recommend treatment with intranasal corticosteroids for chronic rhinosinusitis and nasal polyps. For patients with severe asthma and chronic rhinosinusitis with nasal polyps (CRSwNP), biologic therapy (omalizumab, dupilumab) may be beneficial for both conditions and should be considered. (Strong recommendation)

6.1.3.3 We advise considering CT of the paranasal sinuses for patients with suspected chronic rhinosinusitis with nasal polyps, as the findings may help guide the choice of biologic therapy in severe asthma. (Conditional recommendation)

6.1.4.1 We recommend considering GERD as a possible cause of dry cough in patients with confirmed asthma, and treating symptomatic reflux (e.g., with a trial of a proton pump inhibitor such as omeprazole 20–40 mg daily, or equivalent). (Strong recommendation)

6.1.4.2 We do not recommend routine testing for GERD (e.g., 24-hour pH monitoring) in patients with uncontrolled asthma who have no reflux symptoms, or anti-reflux therapy to improve asthma control in patients without symptomatic reflux. (Strong recommendation)

6.1.4.3 We recommend counseling on GERD management, including:

•    elevating the head of the bed;

•    avoiding large meals, late-evening eating and trigger foods;

•    weight reduction if obese;

•    avoiding medications that relax the lower esophageal sphincter (anticholinergics, LABAs and beta-blockers may worsen reflux in some patients). (Strong recommendation)

6.1.5.1 We recommend screening for symptoms of obstructive sleep apnea (OSA) (loud snoring, witnessed apneas, daytime sleepiness, unrefreshing sleep) in patients with:

•    uncontrolled asthma despite optimization;

•    severe asthma;

•    obesity;

•    risk factors for OSA. (Strong recommendation)

6.1.5.2 We advise referring patients with suspected OSA for a sleep study (polysomnography) and, if OSA is confirmed, offering continuous positive airway pressure (CPAP) or other treatment, as treatment of OSA can improve asthma control. (Conditional recommendation)

6.1.6.1 We recommend assessing body mass index (BMI) and counseling on weight management for all patients with asthma and obesity, as obesity is a risk factor for:

•    uncontrolled asthma;

•    exacerbations;

•    impaired lung function. (Strong recommendation)

6.1.6.2 We recommend offering structured weight reduction programs involving diet modification, regular physical activity and behavioral support, as weight loss can significantly improve asthma control and reduce symptoms and exacerbations. (Strong recommendation)

6.1.7.1 We recommend screening for anxiety and depression in patients with asthma, particularly those with:

•    uncontrolled asthma;

•    frequent exacerbations;

•    poor quality of life;

•    risk factors for mental health disorders. (Strong recommendation)

6.1.7.2 We advise referring patients with anxiety or depression to mental health specialists for assessment and treatment (cognitive behavioral therapy, pharmacotherapy), as treatment of psychological comorbidities can improve asthma control. (Conditional recommendation)

6.1.8.1 We advise considering AERD (also called NSAID-exacerbated respiratory disease) in patients with asthma, chronic rhinosinusitis and nasal polyps who react to NSAIDs or aspirin; the diagnosis is confirmed by an aspirin challenge test under controlled conditions. (Conditional recommendation)

6.1.8.2 We recommend that the management of AERD include:

•    avoidance of NSAIDs and aspirin (unless high-dose aspirin desensitization has been performed);

•    use of paracetamol (acetaminophen) or COX-2 inhibitors (if aspirin desensitization has not been performed);

•    optimized asthma treatment;

•    treatment of rhinosinusitis;

•    an LTRA (montelukast), which may be beneficial;

•    biologic therapy (anti-IL-5, omalizumab, dupilumab) if asthma is severe. (Strong recommendation)

6.1.9.1 We recommend that regular ICS-containing treatment be optimized as the cornerstone of managing exercise-induced bronchoconstriction (EIB), since breakthrough EIB usually signals poorly controlled asthma; an adequate warm-up before exercise further reduces the frequency and severity of EIB. (Strong recommendation)

6.1.10.1 We recommend considering ABPA in patients with asthma who have recurrent fleeting pulmonary opacities, bronchiectasis, expectoration of brownish mucus plugs or a markedly elevated total serum IgE, and confirming the diagnosis using composite criteria (immediate hypersensitivity to Aspergillus fumigatus, total serum IgE, specific IgG to A. fumigatus, radiological features and blood eosinophil count). (Strong recommendation)

6.1.10.2 We recommend regular chest physiotherapy and daily airway clearance in patients with ABPA and bronchiectasis, with referral for specialist investigation and care. (Strong recommendation)

6.2.1.1 We recommend counseling women with asthma who are planning pregnancy about:

•    the importance of asthma control during pregnancy;

•    the safety of asthma medications in pregnancy;

•    the potential for asthma to improve, worsen or remain stable during pregnancy;

•    the risk of gestational complications (preeclampsia, gestational diabetes) when asthma is poorly controlled. (Strong recommendation)

6.2.1.2 We recommend that pregnant women with asthma continue their asthma medications, as the benefits of asthma control far outweigh any risks from the medications. Recommended medications include ICS, β₂-agonists, montelukast and theophylline, which are not associated with an increased incidence of fetal abnormalities. (Strong recommendation)

6.2.1.3 We recommend optimizing asthma control during pregnancy using the same management approach as for non-pregnant patients, as uncontrolled asthma carries a greater risk to mother and fetus than asthma medications. (Strong recommendation)

6.2.1.4 We do not recommend bronchial provocation testing during pregnancy, as it may precipitate exacerbations. (Strong recommendation)

6.2.1.5 We advise against stepping down asthma medications during pregnancy, even if asthma appears well controlled, as the risk of exacerbations and poor fetal outcomes with uncontrolled asthma is greater than the risk from medications. (Conditional recommendation)

6.2.1.6 We recommend treating asthma exacerbations in pregnancy promptly and aggressively with:

•    a SABA;

•    early administration of systemic corticosteroids;

•    oxygen;

•    monitoring and appropriate management of respiratory infections, as inadequately treated exacerbations pose risks to mother and fetus. (Strong recommendation)

6.2.2.1 We recommend smoking cessation for all patients with asthma who smoke, as smoking:

•    reduces ICS responsiveness;

•    increases the risk of exacerbations;

•    impairs lung function recovery;

•    increases mortality risk. (Strong recommendation)

6.2.2.2 We recommend carefully evaluating patients with a smoking history and respiratory symptoms to distinguish between asthma alone, COPD alone and asthma–COPD overlap, as this distinction is important for treatment decisions. (Strong recommendation)

6.2.2.3 We recommend assessing for asthma–COPD overlap using:

•    a detailed history (symptom onset, smoking history, occupational exposures, childhood respiratory symptoms);

•    post-bronchodilator spirometry (FEV₁/FVC <0.7);

•    evidence of variable airflow (bronchodilator responsiveness, PEF variability);

•    DLCO testing, if available. (Strong recommendation)

6.2.2.4 We advise that patients with asthma–COPD overlap generally require ICS (for the asthma component) together with LABA/LAMA bronchodilators (for the COPD component), often as triple ICS-LABA-LAMA therapy; treatment should address both asthma and COPD features, recognizing that the prognosis is worse than for asthma or COPD alone. (Conditional recommendation)

6.2.3.1 We recommend confirming the diagnosis of asthma objectively in patients with obesity and respiratory symptoms, as respiratory symptoms can be mimicked by obesity-related factors; symptoms should not be assumed to be due solely to obesity. (Strong recommendation)

6.2.3.2 We recommend offering structured weight reduction programs (diet, exercise, behavior modification) to patients with asthma and obesity, as weight loss can significantly improve asthma control and reduce exacerbations. (Strong recommendation)

6.2.4.1 We recommend systematically asking all patients with newly diagnosed adult-onset asthma about occupational exposures, as occupational asthma accounts for approximately 5–20% of new adult asthma cases; the essential screening question is “Do your symptoms improve when you are away from work?” (Strong recommendation)

6.2.4.2 We recommend referring patients with suspected occupational asthma to a specialist for diagnosis. (Strong recommendation)

6.2.4.3 We recommend that the management of occupational asthma include:

•    reduction or elimination of workplace exposure (first priority);

•    early diagnosis to prevent permanent airway changes;

•    use of appropriate respiratory protective equipment if exposure cannot be eliminated;

•    continuation of ICS-based asthma treatment. (Strong recommendation)

6.2.5.1 We advise considering perimenstrual (catamenial) asthma in women whose asthma reliably worsens in the premenstrual phase; in addition to optimizing standard asthma treatment, oral contraceptives and/or a leukotriene receptor antagonist may be helpful. (Conditional recommendation)

6.2.6.1 We recommend that, before elective surgery, asthma control be optimized, with particular attention to patients with severe asthma, current symptoms, a recent exacerbation or persistent airflow limitation, and that ICS-containing therapy be continued throughout the peri-operative period. (Strong recommendation)

6.2.7.1 We advise that patients optimize asthma control before air travel and carry all asthma medications, the spacer (if used) and a copy of their written asthma action plan in the cabin for immediate access (including in case checked luggage is delayed or mislaid). (Conditional recommendation)

Section 7: Difficult-to-Treat and Severe Asthma in Adults and Adolescents

7.1 We recommend defining severe asthma as asthma that requires treatment with high-dose ICS and LABA (± LTRA or theophylline) ± systemic corticosteroids for ≥50% of the previous year to prevent it from becoming uncontrolled, or that remains uncontrolled despite this therapy, together with any one of the following:

•    poor symptom control: ACQ >1.5 or ACT <20;

•    frequent severe exacerbations: ≥2 bursts of systemic corticosteroids (>3 days each) in the previous year;

•    serious exacerbations: ≥1 hospitalization, ICU stay or mechanical ventilation in the previous year;

•    airflow limitation: FEV₁ <80% predicted after appropriate bronchodilator withholding, with FEV₁/FVC below the lower limit of normal;

•    controlled asthma that worsens on tapering of treatment (see Annex 5). (Strong recommendation)

7.2 We recommend distinguishing difficult-to-treat asthma (uncontrolled despite high-intensity treatment because of poor adherence, psychosocial factors, persistent exposure to environmental allergens, triggers and amplifiers, or untreated comorbidities) from severe asthma, which remains uncontrolled despite high-intensity treatment with good adherence, exclusion of differential diagnoses, optimally treated comorbidities and removal of aggravating factors (see Annex 6). (Strong recommendation)

7.3 We recommend assessing the panel of Type 2 biomarkers to fully characterize patients with Type 2 inflammation before selecting biologic therapy; clinically allergen-driven disease is defined by specific IgE or a positive skin prick test for relevant allergens (see Annex 7). (Strong recommendation)

7.4 We recommend that the biologic agents available for severe asthma in Egypt be prescribed according to their licensed age and indication: omalizumab (anti-IgE, ≥6 years, severe allergic asthma); benralizumab (anti-IL-5Rα, ≥12 years, severe eosinophilic/Type 2 asthma); and dupilumab (anti-IL-4Rα, ≥6 years, severe eosinophilic/Type 2 asthma or dependence on maintenance oral corticosteroids). Local eligibility criteria for specific biologic therapies must be checked (see Annex 8). (Strong recommendation)

7.5 We recommend selecting the biologic agent according to the blood eosinophil stratum and the presence of Type 2 comorbidities, noting that the response to biologic treatment improves with increasing blood eosinophil levels; in patients with blood eosinophils >1500 cells/µL, other hematological conditions must be ruled out first (see Annex 9). (Strong recommendation)

7.6 We recommend referring all candidates for biologic therapy to a severe asthma clinic, where the diagnosis is confirmed and treatment is prescribed for committee approval. (Strong recommendation)

Section 8: Worsening Asthma and Exacerbations

8.1 We recommend that every patient presenting with worsening asthma be assessed for three things: (1) whether it is an asthma exacerbation; (2) whether there are risk factors for asthma-related death; and (3) the severity of the exacerbation (see Annex 10). (Strong recommendation)

8.2 We recommend identifying risk factors for asthma-related death, which include: any history of near-fatal asthma requiring intubation and ventilation; hospitalization or emergency care for asthma in the last 12 months; not currently using ICS, or poor adherence with ICS; current or recent use of oral corticosteroids; over-use of SABAs, especially more than one canister per month; a history of psychiatric disease or psychosocial problems; poor adherence with asthma medications; lack of a written asthma action plan; and confirmed food allergy. (Strong recommendation)

8.3 We recommend classifying the severity of the exacerbation as mild or moderate, severe, or life-threatening, according to the stated characteristics; because some patients have features of more than one level of severity, the patient should, for safety, be classified at the higher level and managed accordingly (see Annex 11). (Strong recommendation)

8.4 We recommend immediate admission to an ICU with ventilation facilities for patients with a life-threatening exacerbation (drowsiness, confusion, silent chest, bradycardia), notifying senior staff and ventilating if required. (Strong recommendation)

8.5 We recommend controlled oxygen therapy immediately, targeting SpO₂ >92% in adults and adolescents and >95% in pregnancy or concomitant heart disease; lack of pulse oximetry should not prevent the use of oxygen. (Strong recommendation)

8.6 We recommend inhaled bronchodilator therapy immediately, and systemic corticosteroids within minutes, at the doses stated for each severity level in the exacerbation treatment table (Section 8 and Annex 12). (Strong recommendation)

8.7 We recommend intravenous magnesium sulfate 1–2 g over 20 minutes and high-dose nebulized corticosteroids within the first hour in severe exacerbations not responding to initial treatment, and in life-threatening exacerbations. (Strong recommendation)

8.8 We advise that intravenous aminophylline and subcutaneous epinephrine be used only after consultation with senior medical staff, and that the aminophylline loading dose be withheld if the patient has taken any aminophylline that day. (Conditional recommendation)

8.9 We do not recommend the routine prescription of antibiotics for patients with acute asthma; antibiotics are indicated only when there are signs of infection. (Strong recommendation)

Section 9: Primary Prevention of Asthma

9.1.1 We advise maintaining good indoor air quality to reduce the risk of asthma:

•    minimize damp and mold in the home;

•    reduce allergen exposure (house dust mite, pet allergens) if there is a family history of atopy;

•    avoid exposure to air pollution when possible;

•    avoid exposure to second-hand smoke. (Conditional recommendation)

9.1.2 We advise that decisions about pet exposure be individualized, because:

•    the evidence is mixed as to whether early pet exposure increases or decreases the risk of asthma;

•    for families with a strong history of atopy or asthma, avoiding high-allergen pets may be prudent, particularly if the child already shows atopic features;

•    family preference should guide the decision. (Conditional recommendation)

9.1.3 We recommend that pregnant women and families of children at risk of asthma avoid:

•    active maternal/parental smoking;

•    maternal smoking during pregnancy (associated with an increased risk of asthma in the offspring);

•    postnatal tobacco smoke exposure. (Strong recommendation)

9.1.4 We advise against maternal allergen avoidance during pregnancy as a primary prevention strategy for asthma, because:

•    the evidence for effectiveness is weak;

•    some studies suggest that early allergen exposure may be protective. (Conditional recommendation)

9.1.5 We recommend the following measures in populations at high risk of occupational asthma (exposed to workplace allergens or irritants):

•    use of appropriate respiratory protective equipment;

•    control or reduction of workplace exposure;

•    early detection and diagnosis of work-related respiratory symptoms;

•    smoking cessation (smoking increases the risk of occupational asthma);

•    pre-placement lung function testing to establish a baseline. (Strong recommendation)

9.1.6 We recommend that adults without asthma who smoke stop smoking to reduce their risk of asthma, as smoking is associated with an increased risk of developing asthma in adulthood. (Strong recommendation)

9.1.7 We recommend weight management (maintaining a healthy BMI) to reduce the risk of asthma in adults, as obesity is associated with an increased incidence of asthma. (Strong recommendation)