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How Referral to an Allergy/Immunology Physician can Help in the Diagnosis and Management of Asthma
1. Allergy/Immunology Physicians Can Help to Diagnose Asthma:
- Because asthma is a disorder characterized by intermittent blockage of the airways, a person may be bothered by asthma symptoms, but have normal lung functions while in the doctor’s office. The Allergy/Immunology Physician can perform specialized tests, such as methacholine or exercise challenge, to confirm a diagnosis of asthma
- Sometimes people with asthma have exercise-induced shortness of breath that does not respond as expected to pre-treatment with asthma medications. When this is the case, it is important to confirm that the shortness of breath is due to asthma, as opposed to other medical conditions. An Allergy/Immunology Physician can perform specialized tests, such as exercise challenge tests, to confirm the diagnosis.
- People with asthma may be at risk of damaging their lungs while scuba diving. Thus, a person with a history of asthma should ensure that their asthma is not currently active before scuba diving. An Allergy/Immunology Physician can perform specialized testing, such as an exercise challenge, to assess current risk.
2. Allergy/Immunology Physicians Can Identify and Manage Environmental Asthma Triggers
- Allergens, whether indoor or outdoor, are a common trigger for asthma, especially for persons who experience seasonal flares in their asthma symptoms. An Allergy/Immunology Physician can perform testing to identify allergen triggers. Once identified, the Allergy/Immunology Physician is specially trained to teach the allergic individual practical ways to avoid exposure to the identified allergens. Allergen avoidance has been demonstrated to reduce asthma severity and improve asthma control.
- The introduction of a new pet into the home is sometimes accompanied by the emergence, or worsening, of asthma symptoms. The Allergy/Immunology Physician can perform diagnostic testing to confirm whether or not the asthmatic individual is allergic to the new pet. Avoidance of pets to which one is allergic can reduce asthma symptoms.
3. Allergy/Immunology Physicians Can Treat the Allergic Asthmatic with Allergy Immunotherapy
- When there is a clear relationship between asthma symptoms and exposure to one’s diagnosed allergens (pollen, animals, mold, dust mite), allergy immunotherapy (allergy shots) can improve asthma symptoms by markedly reducing the degree to which the individual is sensitive to his/her allergens. An Allergy/Immunology Physician is specially trained in prescribing and administering allergy immunotherapy. Allergy immunotheapy is appropriate for allergic asthmatics who:
- Have had an inadequate response to asthma medications
- Have had an inadequate response to allergen avoidance
- Are experiencing unacceptable side effects from medications
- Wish to avoid the need for long term medications
- Children with allergic rhinitis (nasal allergies) are at risk of developing asthma. Allergy immunotherapy can reduce the risk of developing asthma, and can also reduce the risk of developing allergies to new allergens. An Allergy/Immunology Physician is specially trained in prescribing and administering allergy immunotherapy under these circumstances.
4. Allergy/Immunology Physicians Can Help Prevent Unpleasant Consequences (Morbidity) of Asthma
- For persons who have previously required emergency room care or hospitalizations for their asthma, care by an Allergy/Immunology Physician has been shown to reduce both subsequent hospitalizations and subsequent emergency room visits.
- People with uncontrolled asthma have frequent symptoms that interfere with sleep and/or daily activities, and use excessive amounts of short acting reliever medications, such as albuterol. Treatment by an Allergy/Immunology Physician has been shown to reduce asthma symptoms, reduce the use of short acting reliever medications, improve the ability of the asthmatic to function physically, and improve asthma-related quality of life.
- People with persistent asthma (symptoms more than twice a week when untreated) need controller medications to treat the inflammation associated with persistent asthma. Treatment by an Allergy/Immunology Physician is more likely to include controller medications, some of which (e.g., anti IgE) are not available to be used in the Primary Care Physician’s office.
- Asthma symptoms and severity vary depending upon the degree of exposure to asthma triggers. Thus the ability of the asthmatic individual to participate in the management of his/her asthma (self-management) is an important factor in keeping asthma under control. Care by an Allergy/Immunology Physician is more likely to lead to education in self-management, including use of written asthma management plans and the use of peak flow meters to self-monitor asthma severity. Self-management and written asthma action plans have been shown to improve asthma outcomes in both children and adults. Care by an Allergy/Immunology Physician is associated with more effective self-management education and knowledge.
- Severe asthmatics require costly medical care, including hospitalizations and emergency room treatment. Severe asthmatics also require numerous expensive medications to treat their asthma. Treatment by an Allergy/Immunology Physician reduces the financial cost of asthma care.
5. Allergy/Immunology Physicians Can Help Reduce Asthma-Related Deaths
- Persons with prior severe, life-threatening asthma episodes, including episodes requiring intubation, are at risk of dying from their asthma. Treatment by an Allergy/Immunology Physician can the reduce the risk of asthma death because:
- Regular treatment with inhaled corticosteroids and use of oral corticosteroids for the treatment of asthma attacks have both been associated with a reduction in the risk for fatal and near-fatal asthma exacerbations. Not only do Allergy/Immunology Physicians prescribe inhaled corticosteroids more often than do primary care physicians, but their patients are more likely to be using inhaled corticosteroids regularly. Patients managed by Allergy/Immunology Physicians are also more likely to receive appropriate treatment with oral corticosteroids.
- Allergen exposure may trigger fatal asthma attacks. The Allergy/Immunology Physician is specially trained in diagnosing allergy triggers, education of allergy avoidance techniques, and treatment of appropriate patients with allergy immunotherapy. Allergy immunotherapy has been shown to provide significant benefits, including immunotherapy for the mold alternaria, which has been associated with life-threatening asthma.
- People who have difficulty perceiving asthma symptoms are at higher risk of asthma-related death. Allergy/Immunology Physicians obtain objective measurement of lung functions more frequently than other physicians, thus reducing risk in “poor perceivers.”
- Asthma action plans provide at-home instructions for adjusting medications in the event of an asthma attack, and may reduce asthma mortality. Asthma specialists, such as Allergy/Immunology Physicians, are more likely to provide asthma action plans to their patients.
6. Allergy/Immunology Physicians Can Help Improve Patient Adherence to the Asthma Treatment Plan
- Asthmatics who are not adherent to their asthma management plan may be limiting themselves from achieving optimal control of their asthma. The Allergy/Immunology Physician can improve adherence.
- Misunderstanding of what controller medications are supposed to do can lead to the expectation of immediate symptom relief from controller medications and, when that doesn’t occur, subsequent discontinuation by the patient of appropriately prescribed controller medications. Such misunderstanding of controller medications is more likely to be seen in patients not treated by asthma specialists, such as Allergy/Immunology Physicians.
- Patients being treated by an Allergy/Immunology Physician are more likely to have been dispensed the “optimal” number of inhaled corticosteroid canisters for the year, suggesting good patient adherence to the asthma management plan.
- Further evidence that patients treated by an Allergy/Immunology Physician are more adherent to their asthma management plan include data that specialty care (including that provided by Allergy/Immunology Physicians) is associated with more refills of anti-inflammatory medications (such as inhaled corticosteroids), and data demonstrating that compliance with national asthma treatment guidelines was higher in patients treated by asthma specialists, such as Allergy/Immunology Physicians.
7. Allergy/Immunology Physicians Can Help Diagnose Occupational (Work-Related) Asthma
- People with asthma symptoms that are markedly increased or occur exclusively while at work should be referred to an Allergy/Immunology Physician for evaluation. The Allergy/Immunology Physician can evaluate whether the asthma is being caused by or triggered by agents at the workplace, and initiate appropriate avoidance therapy.
- A normal history and physical examination is insufficient to diagnose occupational asthma, and inaccurate conclusions can easily be drawn. The Allergy/Immunology Physician can perform and interpret specialized tests, such as serial tests of pulmonary function performed during work periods vs. off work periods.
- The Allergy/Immunology Physician can design a program of investigation into potential work-related asthma using specialized tests such as challenges with methacholine, cold air, and exercise. Such tests require expert interpretation, (which the Allergy/Immunology Physician can provide) since the results can vary depending on the timing and degree of relevant occupational exposures.
- The Allergy/Immunology Physician can review Material Safety Data Sheets for potential exposures, observe for potential exposure during an onsite work evaluation, or assist in obtaining professional testing of the workplace. The Allergy/Immunology Physician can arrange and interpret diagnostic “challenges” performed at the workplace and can assist in referral to highly specialized centers for specific challenges when indicated.
- It is important to identify specific workplace agents responsible for causing/exacerbating asthma because continued exposure can lead to worsening asthma and possibly persistent asthma even after exposure to the offending agent is discontinued. Thus, early diagnosis and removal of the individual from further exposure offers the best prognosis for individuals with occupational lung disease.
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