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.