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- Methodology for the development of the Allergic Rhinitis and its Impact on Asthma (ARIA)-EAACI 2024–2025 Guidelines: From evidence-to-decision frameworks to digitalised shared decision-making algorithmsPublication . Bousquet, Jean; Amaral, Rita; Amaral, RitaThe Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines produced their first edition in 1999, with subsequent revisions in 2008, 2010, 2016 and 2019. A new iteration of ARIA—ARIA 2024–2025—in collaboration with EAACI is currently being developed, focusing on the management of allergic rhinitis. ARIA 2024–2025 follows the GRADE framework and is endorsed by the European Academy of Allergy and Clinical Immunology (EAACI). A set of approaches has been used to develop guideline questions, including surveying key opinion leaders and using artificial intelligence (AI)-based tools to analyse web searches on allergic rhinitis and to generate questions. Each prioritised guideline question is assessed through an Evidence-to-Decision (EtD) framework. EtDs support the systematic and transparent formulation of recommendations, comprising 12 criteria for which the best available evidence should be sought. In the context of ARIA-EAACI 2024–2025, such evidence is derived not only from randomised controlled trials but also—among others—from patient-generated data sources that better reflect the affected individuals' perspectives. Moreover, ARIA-EAACI 2024–2025 incorporates evidence on planetary health. Developed guideline recommendations will support the creation of digitalised decision algorithms and care pathways. This paper describes the methodology used to develop the person-centred, digitally enabled and AI-assisted ARIA-EAACI 2024–2025. Among others, it describes (i) the development and prioritisation of guideline questions, (ii) sources of evidence for EtDs and (iii) the development of digitalised decision algorithms and care pathways.
- Prevalence of asthma in Portuguese adults - the EPI-ASTHMA study, a nationwide population-based surveyPublication . Jácome, Cristina; Amaral, Rita; Amaral, RitaIn 2010, 6.8% of the Portuguese adults had asthma. Contemporary studies employing more accurate methods are needed. We aimed to assess asthma prevalence in Portugal and to identify associated-factors. A population-based nationwide study was conducted from May 2021 to March 2024. A multistage random sampling approach was applied to select adults from primary care. Stage 1 involved a telephone screening interview to collect sociodemographic and clinical data. Patients with an Adult Asthma Score (A2 Score) ≥1 were eligible for Stage 2, and 5% of those with an A2 Score = 0 were also invited to participate in Stage 2, which consisted of a diagnostic visit with a physical examination and diagnostic tests. We computed weighted asthma prevalence estimates and multivariable logistic regression models were used. Results: A total of 7,556 participants completed Stage 1 and 1,857 Stage 2. The prevalence of asthma was 7.1% (95%CI = 6.3–8.0%), with slight differences by sex, age, and region. Education, family history of asthma, inhaler prescription, nasal/ocular symptoms, food allergies, and previous allergy skin tests were associated with an increased risk of asthma (R2 = 33%). Asthma diagnosis could also be predicted by the A2 score, either on its own (R2 = 43%) or in combination with family history and previous allergy skin tests (R2 = 45%). Asthma affects 7.1% of Portuguese adults. Family history of asthma, nasal/ ocular symptoms, and comorbid food allergy are associated with increased risk of asthma.
- Allergic Rhinitis and its Impact on Asthma (ARIA) Classes in MASK-air usersPublication . Bousquet, Jean; Amaral, Rita; Amaral, RitaThe Allergic Rhinitis and its Impact on Asthma (ARIA) guidelines classify rhinitis as "intermittent" or "persistent" and "mild" or "moderate-severe". To assess ARIA classes in a real-world study in terms of phenotypic differences and their association with asthma. We performed a cross-sectional real-world study based on users of the MASK-air® app who reported data for at least 3 different months. We assessed the frequency of users according to the ARIA classes and compared these classes in terms of rhinitis symptoms, use of comedication, frequency of comorbid asthma, and the association between comorbid asthma and rhinitis control. A total of 2273 users (180 796 days) were assessed. Most users had moderate-severe rhinitis (n=2003; 88.1%) and persistent rhinitis (n=1144; 50.3%). The frequency of patients with probable asthma was 35.7% (95%CI, 34.5%-37.0%) for intermittent rhinitis and 48.5% (95%CI, 47.1%-49.9%) for persistent rhinitis. The maximum values on the visual analog scale (VAS) for rhinitis symptoms and the combined symptom-medication score were lower in patients with mild rhinitis than in those with moderate-severe rhinitis (irrespective of whether they had persistent or intermittent rhinitis). In most ARIA classes, VAS nose and VAS eye and rhinitis comedication were more frequent in patients with rhinitis+asthma than in those with rhinitis alone. This study suggests that the presence of asthma is more closely related to persistence of rhinitis than to severity and that the presence of comorbid asthma may be associated with poorer control of rhinitis across the different ARIA classes.
- Assessment of the effectiveness of allergic rhinitis medications using a target trial emulation approach based on mobile health dataPublication . Amaral, Rita; Bousquet, Jean; Amaral, RitaRandomised controlled trials (RCTs) are the paradigm for questions on causal inference but often face challenges in generalisability due to strict eligibility criteria. In allergic rhinitis (AR), this limitation is particularly relevant, with RCTs on AR displaying an overrepresentation of patients with severe disease and not providing sufficiently detailed information on the impact of comorbidities on treatment effectiveness. Mobile health (mHealth) applications provide an opportunity to collect large-scale patient-reported data that can complement traditional trial evidence and broaden our understanding of treatment effectiveness in routine care. However, to adequately use mHealth data for that purpose, approaches to adequately deal with confounding must be applied.
- Comparison of allergic rhinitis treatments on patient satisfaction: A MASK-air and EAACI Methodological Committee ReportPublication . Bousquet, Jean; Amaral, RitaSatisfaction with treatments may affect medication adherence and use patterns, including the use of comedication. We aimed to compare different medications for allergic rhinitis (AR) on (i) patients' satisfaction and (ii) co-medication use frequency. We assessed data from the mHealth app MASK-air. We evaluated days on which users with self-reported AR had used—alone or in co-medication—intranasal corticosteroids (INCS), intranasal antihistamines (INAH), fixed combinations of INAH+INCS, or oral antihistamines (OAH). We built multivariable regression models to compare these different AR medication classes (as well as individual medications) on their (i) treatment satisfaction levels (measured using a specific daily visual analogue scale [‘VAS satisfaction’]) and (ii) odds of being used in co-medication. We assessed 28,177days reported by 1691 MASK-air users. For all medication classes, co-medication usage was associated with lower treatment satisfaction. When used in monotherapy, OAH were associated with lower VAS satisfaction than INCS (−1.7 points; 95% CI=–2.7; –0.7) or INAH+INCS (−2.1 points; 95% CI=–3.5; –0.7). INCS displayed higher odds of being used in co-medication than OAH (OR=1.3; 95% CI=1.0; 1.6) or INAH+INCS (OR=1.3; 95% CI=0.8; 1.8). When comparing individual intranasal medications, fluticasone furoate and fluticasone propionate tended to be more frequently used in co-medication. Among individual OAH, desloratadine and rupatadine were associated with higher satisfaction, while fexofenadine was more frequently used in co-medication. Using patient-reported data, we evaluated different medication classes and treatments in terms of satisfaction and co-medication frequency. These results provide key insights into the acceptability of AR treatments and will contribute to future treatment guidelines.
- Control of allergic rhinitis and asthma test for children (CARATkids): A systematic review and meta-analysis of its measurement propertiesPublication . Didi, Hadla Sami El; Pereira, Ana Margarida; Jácome, Cristina; Amaral, Rita; Wandalsen, Gustavo F.; Emons, Joyce; Grutta, Stefania La; Cilluffo, Giovanna; Batmaz, Sehra Birgül; Linhares, Daniela; Sole, Dirceu; Pinto, Bernardo Sousa; Fonseca, João Almeida; Vieira, Rafael José; Amaral, RitaControl of Allergic Rhinitis and Asthma Test for Children (CARATkids) is the first patient-reported outcome measure (PROM) designed to assess both allergic rhinitis and asthma simultaneously in children aged 6 to 12 years. CARATkids has been validated in several languages and countries, highlighting the need for a review of its psychometric properties. This study aims to evaluate the measurement properties of CARATkids. This systematic review follows PRISMA and COSMIN guidelines. A systematic search was performed across three databases (Ovid/MEDLINE, Web of Science, and Scopus in October 2023, updated in June 2025). We included studies focused on the development, cultural adaptation, or validation of CARATkids, as well as studies comparing CARATkids with other PROMs. We evaluated the quality of CARATkids development, the methodological quality of primary studies, the overall rating, and the certainty of evidence for each CARATkids measurement property and performed a meta-analysis of its measurement properties. Our search retrieved 193 results. We included nine studies. CARATkids displayed sufficient content validity. Regarding internal consistency, we found a meta-analytical Cronbach alpha of 0.81 (95% CI = 0.79; 0.83). CARATkids displayed sufficient reliability (meta-analytical intraclass correlation coefficient 0.86 [95% CI = 0.61; 0.96]). The minimal clinically important difference was 2.76. Construct validity had sufficient evidence for most correlations, with absolute meta-analytical Spearman coefficients from 0.37 to 0.71. Responsiveness showed strong correlations between CARATkids and most outcome measurement instruments. These findings support CARATkids as a suitable tool for assessing asthma and allergic rhinitis in children aged 6 to 12 years who present both conditions simultaneously.
- ERS International Congress 2023: highlights from the Allied Respiratory Professionals AssemblyPublication . Jacinto, Tiago; Smith, Elizabeth; Diciolla, Nicola S.; Herck, Maarten van; Silva, Liliana; Santiago, Maria Granados; Volpato, Eleonora; Verkleij, Marieke; Peters, Jeannette B.; Sylvester, Karl; Inal-Ince, Deniz; Padilha, José Miguel; Langer, Daniel; Demeyer, Heleen; Grønhaug, Louise Muxoll; Cruz, JoanaThis article summarises some of the outstanding sessions that were (co)organised by the Allied Respiratory Professionals Assembly during the 2023 European Respiratory Society International Congress. Two sessions from each Assembly group are outlined, covering the following topics: Group 9.01 focuses on respiratory physiology techniques, specifically on predicted values and reference equations, device development and novel applications of cardiopulmonary exercise tests; Group 9.02 presents an overview of the talks given at the mini-symposium on exercise training, physical activity and self-management at home and outlines some of the best abstracts in respiratory physiotherapy; Group 9.03 highlights the nursing role in global respiratory health and presents nursing interventions and outcomes; and Group 9.04 provides an overview of the best abstracts and recent advances in behavioural science and health psychology. This Highlights article provides valuable insight into the latest scientific data and emerging areas affecting the clinical practice of Allied Respiratory Professionals.
- Prospective validation and usability evaluation of a mobile diagnostic App for Obstructive Sleep ApneaPublication . Amorim, Pedro; Santos, Daniela Ferreira; Drummond, Marta; Rodrigues, Pedro PereiraObstructive sleep apnea (OSA) classification relies on polysomnography (PSG) results. Current guidelines recommend the development of clinical prediction algorithms in screening prior to PSG. A recent intuitive and user-friendly tool (OSABayes), based on a Bayesian network model using six clinical variables, has been proposed to quantify the probability of OSA. Our aims are (1) to validate OSABayes prospectively, (2) to build a smartphone app based on the proposed model, and (3) to evaluate app usability. We prospectively included adult patients suspected of OSA, without suspicion of other sleep disorders, who underwent level I or III diagnostic PSG. Apnea–hypopnea index (AHI) and OSABayes probabilities were obtained and compared using the area under the ROC curve (AUC [95%CI]) for OSA diagnosis (AHI ≥ 5/h) and higher severity levels (AHI ≥ 15/h) prediction. We built the OSABayes app on ‘App Inventor 2’, and the usability was assessed with a cognitive walkthrough method and a general evaluation. 216 subjects were included in the validation cohort, performing PSG levels I (34%) and III (66%). OSABayes presented an AUC of 83.6% [77.3–90.0%] for OSA diagnosis and 76.3% [69.9–82.7%] for moderate/severe OSA prediction, showing good response for both types of PSG. The OSABayes smartphone application allows one to calculate the probability of having OSA and consult information about OSA and the tool. In the usability evaluation, 96% of the proposed tasks were carried out. These results show the good discrimination power of OSABayes and validate its applicability in identifying patients with a high pre-test probability of OSA. The tool is available as an online form and as a smartphone app, allowing a quick and accessible calculation of OSA probability
- Impact of the 2022 ATS/ERS update criteria on the bronchodilator responsiveness test resultPublication . Martins, B.; Marinho, A.; Amorim, PedroBronchodilator response (BDR) is a measurement of the degree of volume and airflow improvement in response to an inhaled short-acting bronchodilator. It is widely used in clinical practice to diagnose respiratory diseases such as chronic obstructive pulmonary disease (COPD) or asthma, to assess asthma control, and predict the response to inhaled treatment.
- mINSPIRERS – Estudo da exequibilidade de uma aplicação móvel para medição e melhoria da adesão à medicação inalada de controlo em adolescentes e adultos com asma persistente. Protocolo de um estudo observacional multicêntricoPublication . Jácome, Cristina; Guedes, Rui; Almeida, Rute; Teixeira, João Fonseca; Pinho, Bernardo; Vieira -Marques, Pedro; Vilaça, Rita; Fernandes, José; Ferreira, Ana; Couto, Mariana; Jacinto, Tiago; Pereira, Altamiro da Costa; Fonseca, João AlmeidaA má adesão à medicação inalada é um dos principais fatores que limita a melhoria clínica nos doentes com asma. Desta forma, é fundamental o desenvolvimento de ferramentas de monitorização de adesão à medicação objetivas e de fácil disseminação e a promoção de estratégias de adesão à medicação facilmente integráveis no dia a dia dos doentes. Os smartphones e jogos em comunidade virtual podem ter um papel relevante para a adoção de comportamentos promotores da saúde. Com bases nestes pressupostos foi desenvolvida a aplicação móvel InspirerMundi, com as suas componentes de monitorização, jogo e suporte por pares, para monitorizar e melhorar a adesão à medicação inalada de controlo em adolescentes e adultos com asma. O objetivo do estudo mINSPIRERS é avaliar a exequibilidade desta aplicação móvel. Estudo observacional prospetivo, multicêntrico composto por uma visita inicial e por três entrevistas telefónicas (após 1 semana, 1 mês e 4 meses) em cerca de 25 centros (Imunoalergologia, Pediatria, Pneumologia) de cuidados secundários em Portugal. Serão incluídos um mínimo de 20 adolescentes e 20 adultos com asma persistente. As principais dimensões avaliadas serão: adesão à medicação, crenças sobre a medicação, satisfação com o inalador, controlo da asma, exequibilidade técnica e padrões de utilização da aplicação, e a satisfação com a aplicação. A aplicação InspirerMundi pretende transformar a adesão à medicação inalada numa experiência positiva através de elementos de gamificação e suporte social, permitindo simultaneamente a monitorização verificada da adesão ao tratamento. É expectável que os resultados deste estudo contribuam não só para o aperfeiçoamento da aplicação InspirerMundi, mas também para informar o desenvolvimento de soluções mHealth e intervenções de melhoria da adesão à medicação em doentes com asma.