Multidisciplinary Recommendations for the Use of Chest CT and Bronchial Biopsy in Severe Asthma: An Expert Consensus Based on Real-World Experience.

BACKGROUND

Chest computed tomography (CT) and bronchial biopsy can refine severe asthma phenotyping beyond systemic biomarkers, yet real-world implementation re mains heterogeneous and reporting is often non-standardized. Multidisciplinary integration is therefore needed to maximize clinical utility and comparability across centres.

METHODS

This manuscript reports a multidisciplinary expert consensus developed during the AGHORA workshop held in Santander, Spain (21-22 November 2025). Experts in severe asthma care, bronchoscopy, thoracic imaging, and pulmonary pathology from 13 predominantly tertiary hospitals participated. Recommendations were generated through structured plenary and discipline-focused sessions followed by cross-disciplinary discussion. Draft statements were refined in real time and submitted to show-of-hands voting; agreement was categorized qualitatively as high, moderate, or low.

RESULTS

The panel identified key decision points where CT is most likely to change management, particularly prior to biologic initiation and in cases of inadequate response to biologic therapy. When tracheobronchomalacia/central airway collapse was clinically suspected, expiratory imaging was considered essential. A minimum dataset for CT acquisition and structured reporting was proposed, emphasizing systematic assessment (and, where feasible, quantification) of mucus plugging, bronchial wall thickening/bronchiectasis distribution and extent, and air trapping/small-airway disease patterns, complemented by an actionable impression for multidisciplinary decision-making. For bronchial biopsy, experts agreed on scenarios where tissue assessment adds value (eg, suspected T2 low asthma, discordant biomarkers, and biologic non-response) and proposed minimum technical and reporting standards. Standardized histopathology reporting was anchored to the validated 11-item pathological score (PS score), enabling structured item-level reporting and benchmarking across inflammatory and remodelling domains.

CONCLUSION

This expert statement provides pragmatic, multidisciplinary recommendations and minimum reporting standards for CT and bronchial biopsy in severe asthma. Implementation may reduce inter-centre variability, improve personalized clinical decision-making, and facilitate multicentre research and prospective validation.