Conference Coverage

Asthma Guidelines Are Not Always Followed



ORLANDO – The 2007 National Asthma Education and Prevention Program guidelines are viewed as cumbersome and too time-consuming by some primary care physicians caring for children.

That finding, from a 23-question survey sent to 80 pediatricians, suggests that "there is room for improvement. I think the allergist can play a big role in helping co-manage severe asthmatic patients," Dr. Nabeel Farooqui of Ohio State University and Nationwide Children’s Hospital, Columbus, Ohio, said in an interview at the annual meeting of the American Academy of Allergy, Asthma, and Immunology.

The Expert Panel Report 3 (EPR3): Guidelines for the Diagnosis and Management of Asthma, published by the National Heart, Lung, and Blood Institute, recommend referral to an asthma subspecialist for patients with difficult-to-manage moderate to severe persistent asthma, when a diagnosis is in question, or for patients who need additional testing. Such a subspecialist could be either an allergist or a pulmonologist, but only the allergist can do an allergy assessment, Dr. Farooqui noted.

"Many children with asthma also have allergic rhinitis. These children should be skin-tested. Allergists can help diagnose and treat some of the allergic comorbidities associated with asthma such as allergic rhinitis, and thereby get better control of the asthma," he said.

Of the 28 pediatricians who responded to the anonymous survey, 13 (46%) said that they "always" follow the NAEPP EPR 3 guidelines. Another 8 (29%) said they follow the guidelines "most of the time." Among those who didn’t always follow the guidelines, the most common reason, given by 11 respondents (39% of the total), was that they are "too cumbersome."

Nearly two-thirds of the respondents (17) reported always initiating inhaled steroids for patients with persistent asthma, whereas the other 11 expressed at least some hesitation. "Concern about nonadherence" to inhaled steroids was listed most often as the reason.

Just 15 of the 28 respondents (54%) reported reviewing a written asthma action plan with their patients at every visit as recommended, whereas another 12 (43%) did so only when they made a change in the patient’s care. Lack of time was listed by eight respondents as the reason not to review the plan at every visit, while another six said they did not think that such plans improve management or outcomes.

While all of the respondents endorsed influenza immunization for all asthma patients, nine mistakenly believed that egg allergy is a contraindication to receipt of the vaccine. (The contraindication was lifted in June 2011.)

While all but one respondent said that they refer difficult-to-manage asthma patients to subspecialists, only half referred for additional testing and less than half for a questionable diagnosis. The majority (69%) refer to pulmonologists, while the other 31% referred patients to both a pulmonologist and an allergist/immunologist. "The only time referral to allergist is made is when the patient is sent to pulmonary as well," Dr. Farooqui commented.

"Lack of timely appointment" was the most common reason given for not referring to a subspecialist.

For patients with well-controlled asthma who are on a daily controller medication, half of the respondents endorsed the recommended evaluation at 3-6 months for consideration of step-down therapy. However, the other half reported waiting a year or never stepping down therapy.

"Allergists should continue to promote their role, both in the community and academic centers, as specialists in the evaluation and management of asthma," Dr. Farooqui advised his colleagues.

Dr. Farooqui said he had no relevant financial disclosures.

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