The Management of Patients With Asthma
In this video, Albert Rizzo, MD, speaks with allergist and immunologist Juanita Mora, MD, pediatrician John Harrington, MD, and pulmonary and critical care physician, David Hill, MD, about the role of a multidisciplinary approach in the management of patients with asthma, including the importance of taking a careful history of the patient, the role of allergy testing in patients with asthma, and when to refer a patient to a specialist.
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Juanita Mora, MD, is an allergist and immunologist at Chicago Allergy Center and a national spokesperson for the American Lung Association (Chicago, IL).
John W. Harrington, MD, is the Vice President of Quality, Safety, and Clinical Integration, a General Academic Pediatric Practice Co-Director at Children’s Hospital of the King’s Daughters, and a professor of pediatrics at Eastern Virginia Medical School (Norfolk, VA).
David G. Hill, MD, is Chair of the Public Policy Committee for the American Lung Association, a Clinical Assistant Professor of Medicine at Yale University School of Medicine, and Frank Netter College of Medicine at Quinnipiac University, and a Pulmonary and Critical Care Physician and the Director of Clinical Research at Waterbury Pulmonary Associates (Waterbury, CT).
Albert A. Rizzo, MD, is the chief medical officer of the American Lung Association and a member of ChristianaCare Pulmonary Associates (Newark, DE).
TRANSCRIPTION:
Albert Rizzo, MD:
Hello everyone, and welcome to our multidisciplinary discussion on asthma. I'm Dr Albert Rizzo, the Chief Medical Officer of the American Lung Association and Clinical Assistant Professor of Medicine at Sidney Kimmel Medical College at Thomas Jefferson University in Philadelphia, and also a Pulmonologist practicing at ChristianaCare in Newark, Delaware. I'm really happy to be joined today by three esteemed guests. Dr Juanita Mora is an Allergist, an Immunologist at Chicago Allergy Center in Chicago, Illinois, and is a National Spokesperson for the American Lung Association. Dr John Harrington is the Vice President of Quality, Safety and Clinical Integration, a General academic and Pediatric Practice Co-Director at Children's Hospital of the King's Daughters, and a Professor of Pediatrics at Eastern Virginia Medical School in Norfolk, Virginia.
And we also have Dr David Hill, who's currently the Chair of the Public Policy Committee for the American Lung Association, is also a spokesperson for the Lung Association and a Clinical Assistant Professor of Medicine at Yale University School of Medicine and the Frank Netter College of Medicine at Quinnipiac University. He also is a Pulmonary and Clinical Care Physician and the Director of Clinical Research at Waterbury Pulmonary Associates in Waterbury, Connecticut. Thank you all for joining us today.
David Hill, MD:
Thank you.
John Harrington, MD:
Yep. Thanks for having us. Thanks for having us.
Juanita Mora, MD:
Thank you.
Albert Rizzo, MD:
We're going to start out with the first part of the discussion talking about the multidisciplinary approach to the diagnosis and treatment of asthma, and we do have multiple disciplines on the panel today. I'd like you to each one in turn, go down through what your role in your current practice is with regard to diagnosing and management of patients with asthma. Maybe start with Dr. Mora.
Juanita Mora, MD:
Sure. Well, I have a 60% pediatric practice and 40% of adults, related to the kids that I see. And so obviously allergies and asthma are going to be very much interrelated. So my role when it comes to asthma is one, managing from when they're very little and they present the first actual activity of reactive airway disease, when they start wheezing with that RSV or that cold, and following these kids all throughout as they become either mild persistent asthmatics, mild or persistent and severe persistence. Now for the adults that I see, it's about managing their asthma as well too, finding out their triggers, not only allergic triggers, but are they smoking, any chemical or irritants at work that might actually be contributing to their asthma. It's that further investigating and taking the asthma care to the next level, which is the biologic care as well too, because as specialists, that's what we offer. We offer the next level from the inhaled steroids, combined inhaled steroids to the Montelukast or singular, and then adding biologics to treat these patients and get them under the best control possible.
Albert Rizzo, MD:
Thank you, Dr Mora. I'm sure we'll return to more about the allergy and immunotherapy aspect of the discussion. Let's turn to Dr. Harrington.
John Harrington, MD:
Hey, yeah, I agree with Dr Mora. I mean, a lot of the things are just teasing out the history in many ways and I do pediatrics, but some of my kids get bigger and turn into adults and stuff, but I think it's that early time that becomes difficult because a lot of the kids don't necessarily just come to me, they go to an ER, they go to an urgent care, they get told they have asthma or they get told that they have wheezing and stuff like that. And so they may be wheezing with their first cold or their first viral illness. They may never have had any of the atopic triad yet or anything like that. And they get told they have asthma and so they get sent home with an albuterol. And so that to me is always the hard part about trying to dissect that out when they're three, four, five, and then are they doing this consistently and persistently, and then do we go ahead and do the spirometry?
Do we do the other testing on them and stuff like that? And I think that is the hard part I have is trying to tease those out in terms of just the diagnosis, so are they doing this on a regular basis? And then sometimes you're dealing with a parent that may only have them on the weekend or only have them on the day or the grandparent or something, so whoever brought them in that day and stuff. So it does become a difficult and challenging thing to get that first diagnosis and am I going to give you this for life? Is this going to be a life sentence for you that you're going to have asthma and stuff, or is this just something that you had your first few years of life, your first viruses and stuff? So I think that's a critical thing.
Management-wise, once we finally figure out if they do have asthma, then we can start thinking about the management. And that unfortunately for me has changed a lot since I first started and stuff after the GINA guidelines came out and started doing some different things. But that's become a little bit more complex and I think has forced me to be a little more collaborative in my kids that don't do as well with my colleagues in allergy and pulmonary and stuff like that. And I think that's why this is a multidisciplinary meeting because as those kids get older and they need more therapies and they're showing up in the ED, even despite our best efforts and stuff, we need to have a consolidated effort and a collaborative effort towards that. So I'm happy to be here and learn more.
Albert Rizzo, MD:
Thank you. And Dr. Hil, from the standpoint of a busy pulmonary practice, your thoughts on this?
David Hill, MD:
So I get to come at this from the opposite perspective. My practice is, when it comes to asthma, is probably 80% adults and 20% kids. We do see kids six and up, and I'm primarily referral based, so they've already seen their pediatrician or their adult primary care provider when they come to me. There's a percentage of patients who self-refer. So I see some mild asthmatics. I see some people who may or may not have asthma, they've got symptoms, but come in and have normal spirometry and a normal physical exam. And you're trying to tease out are their complaints asthma? I see a big group of people who have well-defined asthma but have not been successful in controlling it with their primary care provider. So they're referred to me. And then I see a small number of patients who've been referred to me for asthma, and it turns out that not everything that wheezes is asthma.
So sometimes getting to the specialist, we're taking things back a step and saying maybe this isn't asthma and we need to do further workup and determine what's really causing your symptoms. So it keeps my life interesting. And I think that's where the multidisciplinary approach is really important. We've got primary care and allergy and pulmonary here, and you could even add more specialties depending on what you're looking at. So there are patients who have reflux who may need GI involved. In the adult population, there are patients who have cardiac disease and they're wheezing because they have heart failure and it's not truly asthma and they may need a cardiologist.
Albert Rizzo, MD:
Excellent point. You all three commented on this a bit. I just wanted to get more specific. If you could just narrow down one or two things that are specific about the history taking when you see these patients. Is it family history, where they live, what they've been exposed to? Just in a couple of words, what's the importance of the history in this situation? Again, we'll start with Dr. Mora with this.
Juanita Mora, MD:
Well, I go back to the birth history when I see the babies first, especially when we're talking about were they born full-term or were they preemies? Because preemies are going to be more apt to be wheezers and have a higher risk for asthma. I also ask about the family history. If there's a strong family history for asthma, they're going to be, again, higher risk for asthma. And as an allergist, I have to ask about the atopic march. So have they had that runny nose, around cats or dogs, any history of food allergy, like exploding in hives after they taste their first cake at their first birthday party with the first time they taste egg. And then the third one is obviously the eczema that they have ever since they're babies. And then the wheezing that comes along as well too as the atopic march considers. So those are important factors that I look for. And then I go into when do they wheeze? Do they wheeze in the spring or the fall, around their cats or their dogs, trying to find those environmental or pet triggers that might be exacerbating their asthma.
Albert Rizzo, MD:
Thank you. Dr. Harrington, is that a similar approach or do you have something else to add?
John Harrington, MD:
It's always wonderful to have someone who's so comprehensive, right. Thanks a lot Dr Mora. No, I'm just kidding. So it is very interesting, all the things that Dr Mora said. And it's funny because I think people bring stuff into the room. So the one thing that I always, if I smell any type of smoke, I always say is they're a smoker. And it's funny because they'll say if you say that thing, do you smoke around the child, "Oh, I never smoke around the child. Nobody smokes around the child, nobody smokes around the child." But I go like, "Does anybody smoke that lives with a child or is near the child?" And I do a very comprehensive smoking cessation thing with my patients. So that's something that the AAP taught me. So it's one of these things where I can say, I can help you quit if you want to try and quit.
Most people do want to try and quit. So, I think that's one of the aspects that I take into it. Dr Mora was talking about the chronicity and the persistence. And those are all the questions that we ask in terms of trying to find out how much of this is a problem and are you actually going to do anything about it if I give you all these different things to do. Because a lot of times the child is not the one that's going to have to take the medicine. It's going to be the parent that has to give it to the child. So you have to understand what's the ability for them to do that. And so that becomes part of my history taking, because I want to know, should I functionally put a lot of effort into this if they're not going to be doing these things and stuff? So that becomes a difficult part about practicing medicine. It's like what will they be doing and how can I communicate that to them?
Albert Rizzo, MD:
And Dr. Hill, what else would you say is important here?
David Hill, MD:
So you guys have covered triggers, and to some degree I'll defer to Juanita, the allergist, in covering the allergy triggers and smoking's a big one as well. So the other things I look at in history are adherence to medication and proper use, which is a major issue either because people just don't take their medicine or they can't afford their medicine and severity. So are they ending up on steroids? Have they had to go to the ER or urgent care for their asthma symptoms because that really gives me a measure of where their disease is at. We talked about smoking and my history about smoking has changed over the years. So I used to ask patients, "Do you smoke?" And now I have this litany of, "Do you smoke? Do you vape? Do you use e-cigarettes? Do you smoke marijuana? Do you use hookah? And I have to go through each one because I've found patients who have told me for years, they don't smoke who were smoking a lot of marijuana every day.
And since marijuana has become legal, the number of patients coming in who don't smell like tobacco smoke, but smell like marijuana smoke has skyrocketed. And then in my practice, I love seeing the kids because a long time ago I wanted to be a pediatrician and then I became an adult pulmonologist. So your journeys are interesting, but for me, having the kids own their illness, and when I'm talking about history with them, I'm talking about what is your asthma stopping you from doing? And my initial visits are always about, we're going to have you control the asthma and the asthma is not going to control you and what the older kids making it, this is your medical problem, it's not your parents' issue. You have to take ownership of it. It used to be really challenging and now I find it fun.
Albert Rizzo, MD:
Very good. You may have all touched on this a little bit and implied it, but I'd like to ask specifically, since coming from the standpoint of the American Lung Association, where in your histories has it become important now to look at where the patients are living with regard to air quality, climate change that's occurring, inner city versus suburb? Is that something you're more aware of now when talking to patients about what may be some triggers?
Juanita Mora, MD:
So, I would definitely say that working with the American Lung Association has made me much, much more aware and asking where people live. So I practice in the inner city, so I see a lot of inner-city kids and adults as well too. And asking them, do they ride the bus? Do they open the windows when they're on the bus, is there a lot of black smoke coming? Do they live, for example, in a little village where the plant was demolished and there was all this actual pollution here in Chicago. It also makes me ask when they go outside and obviously, or they're in a car, do they get sick or etc., on certain days. It definitely makes me aware and as a doctor also allows me to teach parents and adults as well too, as well as kids, what are red days, like bad days for breathing obviously, and then what are good days as well too, and what activities might be hindered by the air that they are breathing.
Albert Rizzo, MD:
Very good. Let's go back a little bit now to the evaluation of the patient. And I know we're going to talk about some treatments specifically about biologics in a few minutes, but there are now more biomarkers that we're using to define what would be called phenotypes or endotypes of asthma, but as specialists in allergy and pulmonary, Dr Hill and Dr Mora, could you talk a little bit about the biomarkers that you use in patients to decide maybe some therapy options?
David Hill, MD:
Sure. So, I'll jump in first on this. So certainly in almost every asthmatic I'm seeing, I'm looking at a CBC with differential to look primarily at eosinophils. And then depending on where they're coming from, some form of allergy testing. So frequently somebody comes to me, they've already seen allergy or ENT and had skin testing and I know what they're allergic to. If they haven't, in my practice we don't do skin-prick testing. So typically I'll send them for IgE levels and rest testing for specific allergens. Quest will do a panel that's northeast-specific, so I get all the stuff that's in the air around here and the parental-home allergies. And then sometimes I may order some other specific ones depending on what the patient is complaining of or what unique pets they have at home.
And when it gets really challenging, I certainly send them to my allergy colleagues, particularly when I start hearing food allergies or anaphylaxis. There's a reason we have people who have more expertise than me in that area. So that's the big marker approach. And then FeNO testing, which also indirectly looks at allergies in eosinophilia can also be helpful as a biomarker test.
Albert Rizzo, MD:
Before we move on to Dr. Mora, the FeNO exhaled nitric oxide, do most practices find that readily available? I know I've heard variant reports about how readily that's used and how easily it is to obtain a FeNO.
David Hill, MD:
I don't get them.
Albert Rizzo, MD:
As a pulmonologist, we don't either because it's not easy to get at our institution, for some reason.
David Hill, MD:
And I'm in the same boat. I've been fighting because the American Thoracic Society says that it's standard of care. Unfortunately, it's a standard of care that loses the healthcare provider money. And that's a hard sell for a lot of institutions.
Juanita Mora, MD:
I have it in my office and I really love it. I love using FeNO and it's so easy to administer from ages four and above and it's so easy. And so I wish more institutions would have it because it really is a valuable piece of information that you can use as well. If a FeNO remains elevated in a child or in an adult then you can send to insurances to fight for biologics for these kids because it shows that they have uncontrolled asthma.
Albert Rizzo, MD:
Right. Well, Dr Mora, let's stick with you and maybe you can tell us a little bit more about the specific role of allergy testing. How you do it when you do it, things of that nature.
Juanita Mora, MD:
Sure. Well, allergy testing, we're in prime season. It's spring now and so what we're seeing is a lot of kids and a lot of adults coming in with runny noses, itchy eyes, that cough that's phlegmy, sometimes becomes dry as well, too. Tons of allergic asthma because when we're talking allergy and asthma, they have an 80% correlation in kids and about a 60% correlation in adults as well. Two, it's a huge trigger, especially this spring and fall season when the trees are in bloom. And so how we do it is we do it on the backs of children, so ages two and above for actual allergy testing, the environmental, the trees, the grasses for kids, and it goes on their back because we want them to at least have lived through two springs or two falls to be sensitized on the skin test. And then in adults, it goes on their arms and it takes, again, 15 minutes for us to have an answer.
If they're allergic to it, they actually become a little hive or itchy, and if not, they're completely flat. So people love seeing their skin test and what they react to and also correlating with their symptoms. "Well, I knew it was my girlfriend's dog, I knew it was my boyfriend's new pet rat or the spring season", et cetera. But it allowed me as an allergist to be able to do a lot of counseling when it comes to their environment and what they can do to improve like not having the dog sleep in their bedroom, cutting their hair frequently, eta., having someone else shampoo the dog, eta., or in springtime medications to help them or even allergy shots.
Albert Rizzo, MD:
And what would be your trigger for deciding that somebody should be on immunotherapy?
Juanita Mora, MD:
So definitely when they're little and they have maybe asthma that has been uncontrolled and they have a lot of allergic triggers. One of the big reasons I actually give allergy shots because allergy shots have been proven in literature to help to improve asthma outcomes. And it also helps to improve allergy outcomes as well too, two that patient that doesn't want to take pills all the time as well too. They say, "I'm tired of taking medications, Dr Mora. I really want another option." And three, those people that even through medications continue to have symptoms and they're like, "I am ready for a new life. I'm ready to feel better." And they start allergy shots. And immunotherapy has an 85% success rate when it comes to treating allergies. You're desensitizing people, so it's amazing. It's just having that little five-year-old buy into those needles in their little arms, which lollipops help.
Albert Rizzo, MD:
And can you just briefly touch on the Sub-Q injections versus sublingual therapy for immunotherapy?
Juanita Mora, MD:
Of course. So subcutaneous injections go right into the fat of the arm and they basically help to desensitize kids and adults. They're a big compromise. They're once a week for a year or twice a week for six months, and then they go every two weeks for six months and then once a month for three to five years. So it's a big buy-in, it's a big commitment, but they work really great. The oral sublingual immunotherapy are drops and they're for individual allergens, so we don't have them for every single allergen that's out there. So, it's only for some, and for those who are maybe needle-phobic, they're a good option. But for those who have multiple allergens, they're going to have to take multiple drops. Biggest side effect when it comes to that is itchy throat or itchy mouth, because you are administering them orally. They also have about a 75 to 80% success rate. So, they both work well.
Albert Rizzo, MD:
Very good. Thank you. So let's move away from the specialists here. Dr. Harrington, we know that pediatricians and primary care physicians really are at the front line of patients who may be coming in with asthma, undiagnosed or suspected asthma. And you have to go through the triaging you said earlier, but when in your practice do you decide to start sending these patients off to individuals like Dr Hill and Dr Mora?
John Harrington, MD:
Yeah, I think that's a really good question because I think it's a bit variable and it takes in all the things that they've said, basically trying to make sure are they actually taking their medicine? Do they actually know how to use a spacer? And a lot of it is like, and now with our EMR, I can see you haven't even filled anything. Nothing's been filled. We started you on an inhaled corticosteroid, and that's the only prescription I see here for the last six months. And you must have either been very judicious about using it or you didn't use it at all. So there is a bit of sort of clarity and getting that realization that you got to take the medicine in order for it to work. And sometimes it's really hard to send them to a specialist if they never took the medicine.
So you're like, "Let's try it again and see how you do. You didn't wind up in the ER, which is good. So that means you're probably not a persistent or someone who's going to need to see a specialist. We just need to get you so that you're not having symptoms every two or three times a month or three or four times a month or whatever." And so getting them back on the track and stuff. So it is a bit of, I feel like as a pediatrician, you're always selling things. It's like immunizations. They're great for you, you really should take them, but you don't want them today. Fine, great. The same thing with asthma, you really don't want them coughing and having asthma attacks, you really should take the medicine. It will work, it helps. And so those are the things that we have to work through in the primary care office and stuff.
And actually just showing them how to do it is really important. And we've developed lots of videos on it and QR codes and things like that that they can do it at home. And we actually have a little sticker that we put on their spacer that they can just click on that and show how to use it again and if they forgot. And so the kids like that because as they get older, they go, "Oh, I'm supposed to hold my breath for that amount of time?" So, a lot of it is interesting because they seem to get bits and pieces of it. You know how we always talk about the patient only hears about 20% of what you tell them. So, if they can hear it six or seven times at home, they'll get to that 80% or 90% and actually do what you're supposed to do.
A lot of the stuff is really doing that. And then the other thing is smoking and stuff like that. Well, every time we come here he's coughing and having trouble. "Well, who comes with you?" "Well, grandma comes with you and she smokes in the car." It's like, "Well, smoking in the car." So if they're not going to quit smoking, at least don't smoke in the car. It's like the triple hand smoke, they got a second hand and then it's embedded in the car and blah, blah, blah. So those types of things I try to eliminate those things first as much as I can before I say, "Listen, we've done a lot of stuff. I've had you on some heavy hitters already, the inhaled corticosteroids and I've increased those and I'm thinking of putting you on something like a LABA or something like that. Then you probably need to see a specialist now because I'm not feeling comfortable with giving all these different types of meds without doing some testing and some other stuff with you.
We do spirometry, but it's not as much as I'd like to do and stuff because it takes a little extra time and sometimes they never show up for the appointment and it's just", anyway. So I usually say, "Why don't you go to the specialist and they'll take care of that, and then I won't be giving you oral steroids all the time", or "You won't be showing up in the ED all the time." So that's how we vet it.
Albert Rizzo, MD:
Before we move on to actually talking about some of the guidelines, I just want to throw out another question to all of you with regard to the role of an asthma action plan in your practices, the workflow of it, is it something that you try to do routinely and the utility of it?
John Harrington, MD:
I can start with it because I really should be coming from the primary care person and stuff. So we have it built into our system to get an asthma action plan. We have a clinically integrated network that basically keeps that as a tracker for us. And our goal is to have 90% of them all have an asthma action plan.
Albert Rizzo, MD:
Great.
John Harrington, MD:
We were at 78% and we got up to 85%, and we're still trying to get to that 90% because sometimes they just don't show up for a whole year and you don't get that person in. But we try very hard to make sure that there's an asthma action plan at home and at school. And so those are our two places that we want it to be there. Our pulmonology people and allergy people also provide those asthmatics plans too, if they are seeing them as well, so.
David Hill, MD:
Yeah, I think it's incredibly important, particularly in the kids. Some of my adults are well-controlled asthmatics who don't use their rescue inhaler ever and that population having an action plan is almost overkill. The Waterbury school district, which is the big city here, it's mandatory. So if a kid is going to have an inhaler in school, the school district requires you to hand them a asthma action plan and have it on file with the school nurse as well, which is great because it drives people to provide it even if they don't think it's beneficial. But I think all the data shows it works. And the number of times where I'm reviewing it with the patient who's seen doctors multiple times and they're looking at me going, "Wait, I'm supposed to use this medicine for rescue and that one as my controlling medicine?" It's that 20% thing. Patients need to be educated every time they see the doctor.
Albert Rizzo, MD:
Absolutely.
Juanita Mora, MD:
I couldn't agree more. I love giving asthma action plans to all the patients, and my rule is they always have one copy on the refrigerator, so that way if they ever get in trouble, it's always there so they can take a look at it as well. So that's one of the tips that I give mommies to always have it on the refrigerator. And then I always also review again, their rescue inhaler versus their everyday inhaler so that both the kids and the adults know. And then I quiz them a little bit in the office so that way they show me, "What would you do if you had a cold? What would you do if you start coughing during gym class, et cetera?" So I think it's incredibly important that every doctor uses asthma action plans in their asthmatic children and adults.