A new paradigm for asthma management

What does Dr. Weinberger mean by needing a new paradigm for managing asthma?  A paradigm is essentially a way of thinking about a problem and a method for doing something about that problem.  And we do have a problem with asthma, especially for children with asthma.  Despite general agreement that most emergency care and hospitalization for asthma is potentially preventable with currently available medications, asthma continues to be the leading illness causing hospitalization for children, even at many of the best Children’s Hospitals in the U.S..

Fig. 1. Emergency care and hospitalizations at 40 of the largest U.S. children’s hospitals

The illustration shown in Figure 1 shows the frequency of emergency department (ED) visits and hospital admissions at the 40 largest children’s hospitals (all members of the Child Health Corporation of America {CHCA}).  The  illustration in Figure 2 shows that the youngest children, the ages where asthma most commonly begins, have the highest rate of hospitalization, and there is no impressive decrease in hospitalization over a 10 year period.

Recognizing the problem of asthma care, a program was developed within the National Heart, Lung, and Blood Institute of the National Institutes of Health to address the high level of emergency care and hospitalization from asthma.  An Expert Panel was formed. They developed guidelines, first in 1991 and then updated those guidelines in 1997, 2002, and 2007.  The goal was to provide practicing physicians with the best recommendations for asthma care.  But asthma is a variable and complex disorder. It takes more time than many general physicians have to evaluate and provide the necessary education for a patient or family to provide appropriate care that can avoid emergency care and hospitalization.

Fig. 2. Hospitalizations for U.S. children of different ages.

A printed extensive guideline (the latest is over 400 pages) does not substitute for knowledge and experience that specialists in asthma care, generally allergists and pediatric pulmonologists, have acquired in their 3 years of subspecialty training beyond their 3 years of general pediatric education.  While primary care physicians are encouraged to follow the guidelines for children with asthma in their practice, many have not had the clinical experience in their training to develop the skills necessary to prevent emergency care and hospitalization for children with asthma.  Since there is excellent evidence that programs staffed by physicians and other health care personnel experienced in managing asthma decrease the frequency of those treatment failures for both adults and children.  Dr. Weinberger proposed that such asthma care programs be developed at all Children’s Hospitals that don’t currently have them with telemedicine available for outlying areas not directly accessible to those centers.  Moreover, he recommended that general pediatricians and other physicians who will be providing primary care for children with asthma receive supervised experience during their training in a specialized asthma care program.  That would enable them to see what can be done for asthma. They then would be more capable in providing the basic asthma care for many patients and know when to refer to a specialist.

Miles Weinberger MD
Professor Emeritus of Pediatrics
Director of the Pediatric Allergy and Pulmonary Division of the University of Iowa Hospital for 40 years
Iowa City, IA, USA



Time for a New Paradigm for Asthma Management.
Weinberger M
Mayo Clin Proc. 2016 Apr


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