Ann Allergy Asthma Immunol 111 (2013) 465e507 Contents lists available at ScienceDirect Practice Parameter Environmental assessment and exposure control of dust mites: a practice parameter Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD *; J. David Miller, PhD; Fares Zaitoun, MD; Wanda Phipatanakul, MD, MS; Kevin Kennedy, MPH; Charles Barnes, PhD; Carl Grimes, CIEC; Désirée Larenas-Linnemann, MD; James Sublett, MD; David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; and Dana Wallace, MD Chief Editors: Jay Portnoy, MD; Jeffrey D. Miller, MD; P. Brock Williams, PhD; Ginger L. Chew, ScD* Members of the Joint Taskforce on Practice Parameters: David Bernstein, MD; Joann Blessing-Moore, MD; David Khan, MD; David Lang, MD; Richard Nicklas, MD; John Oppenheimer, MD; Jay Portnoy, MD; Christopher Randolph, MD; Diane Schuller, MD; Sheldon Spector, MD; Stephen A. Tilles, MD; Dana Wallace, MD This parameter was developed by the Joint Task Force on Practice Parameters, representing the American Academy of Allergy, Asthma and Immunology, the American College of Allergy, Asthma and Immunology, and the Joint Council of Allergy, Asthma and Immunology. Disclaimer: The American Academy of Allergy, Asthma and Immunology (AAAAI) and the American College of Allergy, Asthma and Immunology (ACAAI) have jointly accepted responsibility for establishing “Environmental Assessment and Exposure Control of Dust Mites: A Practice Parameter.” This is a complete and comprehensive document at the current time. The medical environment is a changing environment, and not all recommendations will be appropriate for all patients. Because this document incorporated the efforts of many participants, no single individual, including those who served on the Joint Task force, is authorized to provide an official AAAAI or ACAAI interpretation of these practice parameters. Any request for information about or an interpretation of these practice parameters by the AAAAI or ACAAI should be directed to the Executive Offices of the AAAAI, the ACAAI, and the Joint Council of Allergy, Asthma, and Immunology. These parameters are not designed for use by pharmaceutical companies in drug promotion. *The findings and conclusions in this article are those of the authors and do not necessarily represent the official position of the Centers for Disease Control and Prevention. Reprints: Joint Council of Allergy, Asthma, and Immunology, 50 N Brockway Street, #3-3, Palatine, IL 60067. Disclosures: Dr Barnes received research grants from the National Institutes of Health and the Department of Housing and Urban Development. Dr Larenas-Linnemann received travel grants from UCB, MSD, Senosian, Almirall, and Hollister Stier and speaker’s fees from MSD, AstraZeneca, and GlaxoSmithKline; served on the advisory board of Almirall and Hollister Stier; received grants from Greer Laboratories and ALK Abbott; and led immunotherapy committees for the AAAI and CMICA. Dr Blessing- Moore served on committees of the AAAI, ATS, and ACCP and consulted for BJB Pharmaceuticals, Pfizer, and Stanford University Hospital. Dr Tilles consulted for Istra, Hycor, and Sunonon and received from grants from TEVA, Genetech, Aventis, Boehringer, the National Institutes of Health, Novartis, Amphistar, and Astellos. The Joint Task Force has made a concerted effort to acknowledge all contributors to this parameter. If any contributors have been excluded inadvertently, the Task Force will ensure that appropriate recognition of such contributions is made subsequently. Workgroup Co-Chairs: James Sublett, MD, Family Allergy and Asthma, Louisville, Kentucky; Kevin Kennedy, MPH, Center for Environmental Health, Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; Joint Taskforce Liaison: Jay M. Portnoy, MD, Section of Allergy, Asthma & Immunology, The Children’s Mercy Hospitals & Clinics, University of MissourieKansas City School of Medicine, Kansas City, Missouri; Joint Task Force Members: David I. Bernstein, MD, Division of Allergy/Immunology, University of Cincinnati College of Medicine, Cincinnati, Ohio; Joann Blessing-Moore, MD, Department of Immunology, Stanford University Medical Center, Palo Alto, California; David A. Khan, MD, University of Texas Southwestern Medical Center, Dallas, Texas; David M. Lang, MD (methodologist), Allergy/Immunology Section, Division of Medicine, Cleveland Clinic Foundation, Cleveland, Ohio; Richard A. Nicklas, MD, George Washington Medical Center, Washington, DC; John Oppenheimer, MD, Department of Internal Medicine, New Jersey Medical School, Pulmonary and Allergy Associates, Morristown, New Jersey; Jay M. Portnoy, MD, Section of Allergy, Asthma, and Immunology, The Children’s Mercy Hospitals and Clinics, University of MissourieKansas City School of Medicine, Kansas City, Missouri; Christopher C. Randolph, MD, Yale Affiliated Hospitals, Center for Allergy, Asthma, and Immunology, Waterbury, Connecticut; Diane E. Schuller, MD, Pennsylvania State University Milton S. Hershey Medical College, Hershey, Pennsylvania; Sheldon L. Spector, MD, University of CaliforniaeLos Angeles School of Medicine, Los Angeles, California; Stephen A. Tilles, MD, University of Washington School of Medicine, Redmond, Washington; Dana Wallace MD, Nova Southeastern University College of Osteopathic Medicine, Davie, Florida; Parameter Workgroup Members: Charles Barnes, PhD (laboratory research), Center for Environmental Health, The Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; Ginger L. Chew, ScD (public health, epide- miology), Centers for Disease Control and Prevention, National Center for Environmental Health, Air Pollution and Respiratory Health Branch, Atlanta, Georgia; Carl Grimes, CIEC (past president, IAQA), Healthy Habitats LLC, Denver, Colorado; Désirée Larenas-Linnemann, MD (allergist), Faculty Allergy, Hospital Medica Sur, Mexico City, Mexico; Jeffrey D. Miller, MD (environment control), New York Medical College, Valhalla, New York; J. David Miller, PhD (housing & health, building science), NSERC Industrial Research Chair, Carleton, University, Ottawa, Ontario, Canada; Wanda Phipatanakul, MD, MS (clinical investigator), Division of Allergy and Immunology, Harvard Medical School, Children’s Hospital, Boston, Massachusetts; P. Brock Williams, PhD (molecular allergy), Allergy/Immunology Adjunct Faculty, University of MissourieKansas City School of Medicine and The Children’s Mercy Hospitals and Clinics, Kansas City, Missouri; Fares Zaitoun, MD (allergist), Allergy/Immunology Clinical Faculty, American University Hospital Medical Center, Beirut, Lebanon; Invited Reviewers: Janna Tuck, MD, Cape Girardeau, Missouri; Rosa Codina, PhD, Lenoir, North Carolina; Sachin Baxi, MD, Boston, Massachusetts. The authors also recognize the valuable review performed by Tom Platts-Mills, MD, Charlottesville, Virginia. 1081-1206/13/$36.00 - see front matter Ó 2013 American College of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.anai.2013.09.018 466 J. Portnoy et al. / Ann Allergy Asthma Immunol 111 (2013) 465e507 Practice Parameter Workgroup: James Sublett, MD, co-chair; Kevin Kennedy, MPH, co-chair; Charles Barnes, PhD; Ginger Chew, ScD*; Carl Grimes, CIEC; Désirée Larenas-Linnemann, MD; Jeffrey D. Miller, MD; J. David Miller, PhD; Wanda Phipatanakul, MD, MS; P. Brock Williams, PhD; Fares Zaitoun, MD Classification of recommendations and evidence There may be a separation between the strength of recommendation and the quality of evidence. Recommendation rating scale Statement Definition Implication Strong A strong recommendation means the benefits of the recommended Clinicians should follow a strong recommendation recommendation approach clearly exceed the harms (or that the harms clearly exceed unless a clear and compelling rationale for an the benefits in the case of a strong negative recommendation) and that alternative approach is present. the quality of the supporting evidence is excellent (grade A or B). In some clearly identified circumstances, strong recommendations may be made based on lesser evidence when high-quality evidence is impossible to obtain and the anticipated benefits strongly outweigh the harms. Moderate A moderate recommendation means the benefits exceed the harms (or that the Clinicians also should generally follow a moderate recommendation harms clearly exceed the benefits in the case of a negative recommendation), recommendation but should remain alert to new but the quality of evidence is not as strong (grade B or C). In some clearly identified information and sensitive to patient values and circumstances, recommendations may be made based on lesser evidence when preferences. high-quality evidence is impossible to obtain and the anticipated benefits outweigh the harms. Weak A weak recommendation means that the quality of evidence that exists is suspect Clinicians should be flexible in their decision recommendation (grade D) or that well-done studies (grade A, B, or C) show little clear advantage making regarding appropriate practice, although to one approach vs another. they may set bounds on alternatives; patient values and preferences should have a substantial influencing role. No recommendation No recommendation means there is a lack of pertinent evidence (grade D) and an Clinicians should feel little constraint in their decision unclear