A cross-sectional paper-based survey was conducted throughout March 2023. A paper-based survey was created resembling the structured consensus-building technique of Delphi methods with only a single round [3], and participants were invited to complete the form. Allergists and pulmonologists working in Kuwait were invited to participate in the survey.

To determine the sample size, Minitab 17.1.0.0 for Windows (Minitab Inc., 2013, Pennsylvania, USA) was used. The expected frequency of allergists and pulmonologists dealing with asthma cases was 30% of total allergists and pulmonologists in Kuwait [5], along with a 95% confidence interval and a precision limit of 5%. Therefore, the minimum sample size was calculated to be 20 participants.

The survey was divided into two sections. The first one covered employment-related information. The second section evaluated the sixteen consensus statements that derived from the GINA 2022 guidelines [4], which covered four main themes; familiarity with GINA 2022 guidelines, diagnosis confirmation, management optimization, and recommended follow-up and maintenance. The questionnaire offered respondents a 3-point scale to rate their agreement with each statement, ranging from “Disagree” to “Agree” responses to the consensus statements were calculated and further analyzed; the widely accepted threshold for consensus is 75% based on percent agreement. Consensus was defined as high if ≥ 75%, and very high if ≥ 90% of respondents agreed with a statement [3, 6].

The statistical analysis was performed by Minitab 17.1.0.0 for Windows (Minitab Inc., 2013, Pennsylvania, USA). The normality of data was examined using the Shapiro-Wilk test. Categorical data were presented as numbers and percentages (%), and continuous data as mean and standard deviation.

Twenty-six medical professionals participated in the study, with an average age of 42 years and a standard deviation of approximately 5 years. The inter-quartile range (IQR) spanned from 35 years to 48 years, and the gender distribution was equal among the participants. All of them had at least a master’s degree in pulmonary medicine or allergy and immunology. The minimum years of experience of all participants was 8 years in dealing with cases of bronchial asthma.

More than 80% of participant agreed that changes in GINA 2022 guidelines were practical with their asthmatic patients (88.5%) (Table 1 and Figure 1), and they were familiar with it (84.6%), which represents a higher degree of consensus [Aspect 1 (86.6%), as shown in Figure 2].

The participants had a high level of agreement (80.8%) regarding spirometry before and after bronchodilators for diagnosing asthma. However, only 57.7% of them considered requesting lung function tests before starting long-term treatment to be a practical investigation. Four out of 26 participants (15.4%) were neutral towards this statement (Table 1).

The participants showed a high level of agreement on the importance of treating modified risk factors (84.6%) and taking into account the symptoms of patients with mild asthma, which can become severe (76.9%). Overall, the consensus level for diagnosis was still high, with more than 75% agreement (Aspect 2 in Figure 2).

The majority of participants did not fully agree with the optimal management statement of GINA 2022 guidelines, with only 63.5% expressing their support (Aspect 3 in Figure 2).

Only 38.5% agreed with using a SABA inhaler as a rescue medication, while 76.9% favored using low-dose ICS and LABA as a reliever. Additionally, 69.2% preferred the ICS-formoterol regimen over using SABA as needed, noting that it reduces the risk of severe exacerbations by 60–64%. Furthermore, 61.5% believed using SABA as a reliever was not a priority. Half of the participants acknowledged that regular SABA use, even for 1–2 weeks, could lead to increased AHR, reduced bronchodilator effect, increased allergic response, and increased eosinophils. Most participants (53.8%) chose track 2 as their preferred option.

In exacerbations, the agreement was higher (76.9%) among participants for receiving at least a medium dose of ICS-LABA before considering add-on LAMA. Additionally, 80.8% agreed that LAMA should not be used as a monotherapy for asthma (i.e. without ICS), as it could increase the risk of severe exacerbations (Table 1 and Figure 1).

Regarding checking inhaler technique in every patient at every visit and those with suspected severe asthma should be seen within 12 weeks of referral to an appropriate specialist severe asthma service; even though 73.1% of the participants agreed with those two recommendations, this percentage of consensus did not reach the threshold value of higher agreement as with Delphi method (75%) (Aspect 4 in Figure 2).

The questionnaire utilized in this study had numerous strengths. Firstly, it was developed with the input of asthma experts who provided their insights and perspectives. This data ensured that the survey captured valuable information from professionals with extensive knowledge and experience in asthma management. Secondly, the questionnaire considered the latest updates and changes in the GINA 2022 guidelines, providing valuable insights into implementing these updates. These strengths helped provide a comprehensive and informed assessment of healthcare providers’ perspectives on asthma management.

Even though, the study has certain limitations that should be acknowledged. Firstly, employing a single round of modified Delphi methods, which was different from the traditional Delphi technique, even though it can still provide valuable insights, particularly in exploratory phases of research or when used as part of a larger mixed-methods approach. The second limitation was the selection of respondents, which may have introduced bias, as those most familiar with the GINA guidelines were likely included, potentially excluding primary care physicians with different perspectives. The third limitation, the total number of responses was small, and not all questions were answered, which could impact the generalizability of the findings. Finally, the absence of patient perspectives is a limitation, as their viewpoints may differ significantly from those of specialist physicians, and including their opinions could have provided a more comprehensive understanding of asthma management. These limitations underscore the need for future research to address these gaps and obtain a broader range of perspectives to enhance the findings’ validity and applicability.

Based on the updated GINA guidelines, this study assessed physician consensus on critical statements related to asthma management. The high consensus among respondents demonstrated a clear understanding of the guidelines. Objective lung function testing, comorbid conditions, and early use of ICS were emphasized. Some physicians still favored SABA inhalers, but there was agreement on the effectiveness of low-dose ICS-formoterol. LAMA monotherapy was not recommended, and checking inhaler technique and follow-up were highlighted. Limitations include single round modified Delphi survey, respondent bias, a small sample size, and the absence of patient perspectives. These findings highlight the perspective view of allergists and pulmonologists who deal with asthma cases in everyday practice, which could influence how asthma management is optimized.