pediatric asthma; a real challenge in management

Asthma is the most common chronic disease of childhood. Continuing on a theme we started yesterday, talking about children with chronic disease, I was very interested to read an  article by Kevin Dubrowski and colleagues from this month's edition of Pediatrics about one way to follow children with this disease, called spirometry.

I have asked my colleague, Dr. Andre Muelenaer, head of the Carilion Clinic Children's Hospital section of pediatric pulmonology and allergy, to comment on this article. Here is what he has to say:

In reference to Spirometry Use Among Pediatric Primary Care Physicians, Kevin J. Dombkowski, Fauziya Hassan, Elizabeth A. Wasilevich and Sarah J. Clark, Pediatrics 2010;126;682-687 In this large study, only 35% of pediatricians and 75% of family practitioners were utilizing spirometry as a standard tool in the management of childhood asthma.  This is despite recommendations by the National Asthma Education and Prevention Program Expert Panel (NAEPP) that spirometry should be performed as part of the initial diagnostic evaluation of children with asthma symptoms, and at a minimum of yearly thereafter. The NAEPP also recommends a written asthma action plan to include instructions for use of a short-acting bronchodilator medication to relieve/rescue the child from symptoms such as coughing, wheezing, or shortness of breath.  The NAEPP Expert Panel states that inhaled corticosteroids are the most effective medications for the long-term control of asthma, and should be administered on a daily basis for any child with persistent asthma.

Spirometry is to asthma as blood glucose is to diabetes. 

There can be significant changes in lung function long before symptoms, just as seen with glucose levels in diabetes.  Treating diabetes without monitoring glucose levels is unthinkable, yet management of asthma is commonly performed without lung function testing.  Spirometry establishes a baseline from which a treatment strategy for care of a child with asthma can be created.  As noted in the article in Pediatrics, spirometry can be performed in primary care offices, but this does require special equipment, personnel trained in its use, and providers competent in the interpretation of spirometry data.  Only 50% of family practitioners, and 25% of pediatricians indicated comfort with interpretation of spirometric values in this study.An alternative to spirometry in the primary care office is referral to a facility skilled in testing of pediatric patients.  At the CCCH Pediatric Pulmonology & Allergy Clinic, spirometry is routinely performed with children as young as cooperative 3 year olds.  The respiratory care practitioners have special training in the performance of pediatric pulmonary functions, and have many years of experience in working with children.  They have special equipment that is oriented to children, with visual feedback such as blowing out birthday candles, or seeing the bricks fly as they blow down the third pig’s house!  The medical providers, including two pediatric pulmonologists and an allergist, review and interpret the results of spirometry performed in children, and generate a report that is readily available in the EMR, EPIC, or can be faxed to the primary care office.  In order to improve quality of care, the CCCH Pediatric Pulmonology & Allergy section has been working with the EPIC team to create reminders known as Best Practice Alerts.  These Best Practice Alerts will pop up on the computer monitor if a child does not have a rescue inhaler or inhaled corticosteroid in his/her medication list.  The next Best Practice Alert will be to remind providers about recommendations for spirometry.  Additional alerts are contemplated for flu shots, written asthma action plans, and criteria for referral to specialists in pulmonology or allergy.     

Many thanks to Dr. Muelenaer for helping us understand the importance of testing the lung function in these children, or arranging for that testing to be done.

If you are a parent of a child with asthma, please consider discussing these recommendations with your physician, making certain your child has their lung function tested at least once a year, and that, if appropriate, your child is being treated with an inhaled steroid medication even in the absence of symptoms. Also, if you are a smoker, do everything you can to stop smoking now, and get a flu shot for yourself and your child. This will help your child and yourself.

As always, I welcome comments from parents, patients, health care providers, and any one else who cares about children's (and adolescnts) health.

About Dr. Ackerman

Alice Ackerman, MD, MBA, FAAP, FCCM is the Chair of the Department of Pediatrics at Carilion Clinic and Professor and Founding Chair of Pediatrics at the Virginia Tech Carilion School of Medicine. Dr. Ackerman is recognized nationally as an expert in pediatric critical care.

She has been at Carilion Clinic since June of 2007. Her primary goals are to enhance the health care of children in the Roanoke Valley and Southwest Virginia, and is actively working to do this both as physician in chief of the children's hospital, as well as through involvement with many state-wide initiatives.

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