Which of My Patients With Asthma Should See a Subspecialist?
While asthma remains the most common chronic disease of childhood and a condition that primary-care practitioners should be comfortable managing, there will be times when subspecialty evaluation is necessary or requested by a concerned family. The common situations for which subspecialty referrals for asthma are recommended are well-defined in asthma guidelines (Table 49-1). These recommendations are generally supported by outcomes studies demonstrating improvements in parameters, such as decreased emergency department visits or hospitalizations, as well as improvements in asthma-related symptoms and health-care costs. Subspecialty-guided care programs for pediatric asthma have been most successful when they have included ongoing follow-up, asthma education, and the provision of a clear action plan.
In general, the need for consultation with a subspecialist can be considered in alignment with the asthma guidelines themselves: Referral can occur due to excessive or persistent patient impairment. Referral may be needed due to the risk of an adverse asthma outcome. A patient may need further evaluation for asthma comorbidities or exacerbating environmental factors. An additional reason for referral may be the need for more intensive education than can be provided in a primary-care setting. Finally, the patient may require complex medical management that can be more readily facilitated by an asthma specialist.
Excessive asthma impairment and risk are closely linked and together represent poorly controlled asthma. Those children in whom symptoms are severe, persistent, or atypical are all candidates for subspecialty referral. Asthma guidelines specifically suggest that patients with frequent and/or severe exacerbations, including those with a history of hospitalization and frequent emergency department visits, those with a history of an intensive care unit admission or episode of respiratory failure, and children who have required more than 2 bursts of oral steroids in the past year, be evaluated by an asthma specialist. An additional recommendation involves those children with persistent asthma requiring more intensive and complex asthma therapy (Expert Panel Report 3 Steps 3 and 4 for older children and Expert Panel Report 3 Steps 2 and 3 for children aged 0 to 4 years).
Patients with asthma should undergo evaluation for comorbidities or exacerbating environmental factors, and this may require subspecialty testing or care coordination. This evaluation may even require the services of different types of specialists if a child has multiple comorbidities. While most patients with asthma require minimal and straightforward testing, some will require testing that necessitates subspecialty evaluation. Detailed allergy testing for environmental triggers or food allergy is the most obvious example and is most frequently performed by an asthma-allergy specialist. Occasionally, other specialized tests, such as flexible bronchoscopy, exercise testing with or without laryngoscopy, exercise or other pulmonary challenge testing, or even polysomnography, will require referral to a pediatric pulmonologist. Other specialized testing or clinical evaluation might require the input of a gastroenterologist (symptomatic gastroesophageal reflux or eosinophilic esophagitis), an otolaryngologist (severe sinus disease), or an immunologist.
Prioritizing the differential diagnosis and tailoring the consult question(s) to the needs of the patient is important. So is trying to avoid the need for multiple visits to multiple specialists, each of whom will have their own biases and points of emphasis. This can quickly result in confusion for the patient if the evaluation or recommendations become fragmented or even contradictory. Clearly, there needs to be a physician who serves as the main point of contact to provide guidance and synthesis of the plan for the patient and family. It is also critical to define which physician is responsible for ordering and following up on the necessary tests. An important result can be overlooked or a test not ordered if it is unclear who is responsible for ensuring test completion and communication of the results with the family.
Patients who require complex medical regimens or intensive education are also candidates for subspecialty referral. Subspecialty practices may have resources for patient education that are simply unavailable in primary care. For example, in our pediatric pulmonology practice, we have respiratory therapists in clinic who regularly perform spirometry or review asthma devices and medication delivery systems. We also have nurse practitioners who can review other important aspects of asthma care, such as which medications should be taken and their purposes, environmental control interventions, and the implementation of an individualized asthma action plan. Other practices may have certified asthma educators or even offer specific asthma classes for patients.
Similarly, subspecialty physicians can assist in the management of children who require multiple medications. While the specialist will not have a “silver bullet” or other cure-all, they can provide input to the plan and help with medication titration and adjustment. If a patient is a candidate for allergen immunotherapy or omalizumab injections, this can be facilitated by the involvement of a subspecialist, most often an asthma-allergy physician.
When implementing a plan for subspecialty referral, there are several scenarios to consider and clarify. One scenario involves the consultant becoming responsible for the ongoing management of the patient as the primary asthma physician. Another scenario involves a one-time visit to the asthma specialist for evaluation and implementation or continuation of a previously established management plan. In this case, the primary care physician will remain the primary asthma physician. The third scenario involves the co-management of a child with asthma between the primary-care and subspecialty physician. In this case, the visits rotate between the physicians so that ongoing follow-up is adequately spaced with both physicians partnering in the care of the patient.
My personal experience is that each of these scenarios can be implemented successfully as long as communication is clear and expectations are established at the outset. For example, I might take over the asthma management of certain asthma patients, such as those with severe disease or complex respiratory comorbidities, whereas at other times, I will provide a one-time consult with recommendations about any additional testing and changes in therapy for an individual patient that are then implemented by the primary-care physician. Most often, the model employed in our community is one of collaborative co-management. However, this will vary from community to community and with other factors, such as the severity and complexity of the individual patient, the level of availability of subspecialists, and the level of comfort of primary-care physicians in managing asthma. Whatever the case, it is important for consultants and referring physicians to work collaboratively and with clarity so that the patient knows who to call and when to call and is not confused by conflicting messages or frustrated by a lack of access.
The asthma guidelines are fairly clear on which pediatric patients are good candidates for referral to an asthma specialist, most often a pediatric pulmonologist or asthma-allergy physician. The specialist can assume a primary role in asthma management or complement the management provided by a general pediatrician or family practice physician. This collaboration between family, primary care, and subspecialty physician can be rewarding and can successfully improve asthma outcomes as long as the overarching goal is to work collaboratively in a patient-centered fashion to enhance access and quality of care for the patient and to ease the overall burden of asthma on the family.
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National Asthma Education and Prevention Program. Expert panel report 3 (EPR-3): guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. NIH publication no. 08-4051.
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