Referral to an asthma specialist is advised under two general circumstances: the “tricky” diagnosis, and the need for expert evaluation or treatment.
When to Consult an Asthma Specialist
To establish the diagnosis
If your “asthma” symptoms and signs are not typical of asthma, you should obtain a referral to an asthma specialist.
If you require specialized diagnostic testing, you should obtain a referral to an expert.
Examples of specialized diagnostic tests are allergy skin testing, rhinoscopy, complete pulmonary function studies, bronchoprovocation (Methacholine) challenge lung testing, and bronchoscopy.
If it is suspected that an occupational or environmental inhalant is provoking or contributing to asthma (suspected occupational asthma or work-related asthma), you
should obtain a referral to an asthma specialist.
To optimize treatment
If you have experienced a serious, life-threatening asthma exacerbation, you should obtain a referral to an asthma specialist.
If treatment of your asthma has required more than two bursts of oral corticosteroids in the past year or if you have experienced an exacerbation requiring hospitalization, you should obtain a referral to an asthma specialist.
If you are not meeting the goals of asthma therapy after 3–6 months of treatment, you should obtain a referral to an asthma specialist.
If your asthma remains poorly controlled with frequent exacerbations despite your adherence to appropriate asthma treatment, you should obtain a referral to an asthma specialist.
If you have been diagnosed with other medical conditions that are known to poten-tially complicate the diagnosis and treatment of asthma, you should obtain a referral to an asthma specialist. Examples of such diagnoses include (but are not limited to)
COPD, GERD, nasal polyps, severe allergic rhinitis, sinusitis, and VCD.
If you require additional education about asthma and its treatment, guidance regard-ing possible complications of therapy, strategies on how to improve your adherence to treatments, including medications, monitoring, and allergen avoidance, you should obtain a referral to an asthma specialist.
If you are being considered for immunotherapy (“allergy shots”), you should obtain a referral to an allergy and asthma specialist.
If you require daily use of medium (or higher) dosing of ICS and a LABA (step 4 care or higher) to control your asthma, you should obtain a referral to an asthma spe-cialist.
Referral may be considered if you are on a low dose of ICS (step 3 care). Chil-dren younger than 4 years of age should be referred when treatment mandates a medium dosage of ICS (step 3 care) and referral may be considered for children on a low dosage of ICS (step 2 care).
In the first circumstance, asthma might be a suspected yet unproven diagnosis, either because of atypical symptoms or because of a superimposed illness, and referral leads to resolution of a diagnostic puzzle. In the second circumstance, referral leads to improved asthma control. Studies suggest that about 5% of adults with asthma are resistant to therapy as their asthma remains poorly con-trolled with frequent exacerbations despite appropriate treatment.
It is not understood why this minority of adult patients do not fully respond to asthma therapy, although it has been observed as a group; they tend to have a higher rate of superimposed illnesses, such as GERD, severe allergic rhinitis, and psychiatric conditions. So-called difficult-to-control asthma can reflect a myriad of factors, from adverse socioeconomic circumstances to a rare form of corticosteroid-resistant asthma. In the United States, the majority of individuals with asthma receive their care from physicians who are generalist doctors, such as family practitioners, internists, and pediatricians. The decision to seek care from an asthma specialist can be a matter of patient preference but is more frequently a consequence of severity of dis-ease. Consultation from an asthma specialist is indicated and appropriate when a person’s asthma is not well controlled.
An example is someone who has daily symptoms, frequent absences from work or school, or who requires hospitalization for asthma despite good adherence to a treatment plan. Similarly, persons with asthma classified as having moderate or severe persistent asthma should receive their care from an asthma specialist. The most recent update of the NAEPP’s Expert Panel Report (2007) addresses the question of when referral to an asthma specialist is mandatory and when it should be considered. Any person with asthma who has experienced a life-threatening exacerbation must be referred for consultation to an asthma specialist.
The same is true if a person with asthma has required more than two bursts of oral corticosteroid treatments (pills) in the prior 12 months or has been hospitalized overnight with exacerbated asthma. Any adult with severe persistent asthma, or any patient who requires step 4 or higher asthma treatment, should be under the care of a physician with an expertise in clinical asthma management. Similarly, referral to an asthma specialist may be considered for adults with moderate persistent asthma requiring step 3 treatment. If immunotherapy treatment (allergy shots) is contemplated, then consultation with an allergist is mandatory.