Historically asthma care was reactive, responding
to patient need as clinical demand rose. Subsequently, medical input
was focused on managing acute exacerbations and severe asthma in
secondary care. The following statistics over past 30 years have
changed the management: increased incidence(1,2), rising
mortality(3), substantial morbidity(4), under and delayed
diagnosis(5) and sub optimal treatment(6,7). This combined with
guidelines(8,9) and significant primary care based research in
developed countries like UK, USA, Europe has led us to consider
specific and focused primary care in general pediatrician’s clinic
for childhood bronchial asthma in our country.
There can be two types of care: primary care in
general pediatricians clinic (supported by practicing pediatricians
with interest in asthma, with or without trained nurses/ attendant)
and secondary care (pediatric chest physicians with a lung
laboratory). There should be good communication and referral between
the two and a concept of shared care between them is most
needed(10).
Before considering the effective delivery device
for asthma care in our setting it is wise to emphasize the problems
in routine diagnosis and management of child- hood bronchial asthma
in primary care settings.
Diagnostic Dilemmas: Primary Care Physician’s Point of View
First of all, the diagnosis of childhood
bronchial asthma is still not acceptable to many pediatricians. The
terms ‘wheezy bronchitis’, ‘asthmatic bronchitis’, ‘allergic
bronchitis, etc. are still used which mystify the diagnosis.
Some may fear loss of clients as the diagnosis of ‘asthma’ is still
a social taboo in most parts of our country. The blame should not go
to the general pediatricians as asthma is a complex disease with
variable presentations and has so many differential diagnoses to
exclude. The co- morbid states like posterior nasal drip, allergic
rhinitis, gastroesophageal reflux and atopic states often confuse
them in making a correct diagnosis. Little time is available in
primary care physicians outpatient clinics (OPC) to take elaborate
medical, social, familial, environmental and emotional history of
the patient and parents. Moreover, poor records in most of the cases
make the diagnosis very difficult. It may also reflect
dissatisfaction with the communication aspects of traditional health
care: ‘My doctor has not got the time/My child gets back the
symptoms again as soon as the medicine is stopped’ etc.(11).
Parents and relatives of the child also face
multiple communication problems, which hinders acceptance of the
diagnosis and delays treatment. Parents reluctance to accept an
asthma diagnosis to their children is common but variable and they
can be classified in the following groups:
(a) Acceptors: Simply accept this
with a hope that it will be cured soon ( mostly have asthma in
families).
(b) Pragmatists: Have difficulty
reconciling asthma with their beliefs, but agree at least
temporarily that their children have it and continue prophylactic
therapy (those with repeated acute attacks in their children).
(c) Deniers: Claim not to have
asthma and refuse medications (mostly with less acute attacks and
other doctor’s opinion against this diagnosis and ironically these
children may be taking recurrent oral steroids as rescue medicines
without grudge).
(d) Distancers: They find relief
treatment acceptable but not regular preventive treatment as this
symbolizes ‘proper asthma’.
(e) Choosers: Accept every thing
and ready to take medications but nothing by inhalation devices ,
as this is considered as social taboo(11).
The main obstacles in convincing the parents is
lack of time and a uniform guideline regarding diagnosis and
management of asthma available to the primary care physicians. A
well informed asthma clinic may help in giving time and correct
information to the parents and restrain them from shopping from one
clinic to the other.
Management Dilemmas: Doctor’s Point of View
(1) In the first visit parents need time and
not prescription. This can be better accomplished in an asthma
clinic. Informing the parent that the disease is variable,
unpredictable and reversible and there is no magic cure is most
important. But many a time, physicians are hesitant to state this
fact.
(2) It is very difficult to convince the
parents that inhaler devices are best and not expensive, the last
resort, habit forming or addictive. This needs sympathetic time
consuming attitude to the parents which can be best achieved in an
asthma clinic.
(3) There is considerable confusion regarding
knowledge, attitude and practice of the NIH (National Institute of
health) (1997) and GINA (Global Initiative against Asthma) (2002)
guidelines and strict adherence to them amongst the doctors.
(4) While dealing with poor asthma control, one
must consider medication related factors
(drug / device / delivery) and patient related factors carefully
with time. The best guideline is to request the parents to
demonstrate the devices in each visit, which can be better
executed in asthma clinic.
(5) A child may have severe disease with good
control by regular medications and trigger avoidance while another
may have mild disease with poor control resulting in regular
emergency visits. Hence one should remember that more acute
attacks do not always mean severe disease but could as well be due
to poor control or therapy(12).
(6) Many a times the parents self medicate
their children with bronchodilators, steroids, antibiotics as in
the last prescription in each relapse attack to save time and
money. It makes the job more difficult for the physicians.
(7) There is very scanty referral service
available as regards pediatric pulmonologists and pulmonary labs
(secondary care).
Management dilemmas: Parent’s Point of View
(1) First they are hesitant regarding inhaler
use considering it expensive, addictive and the final resort in
asthma therapy. Secondly, there is appreciable confusion regarding
skill of administration specially in infants and toddlers.
Thirdly, they may argue the rationale to use steroid inhalers
continuously for months together when there are infrequent
symptoms. Finally, they may be diverted to the homeopathic /
alternative / magic cure advertisements for a trial
not-withstanding the long term therapy they were supposed to be
adhered to.
(2) A sizable portion of the parents believe
that asthma is a form of allergy and specific allergy testing,
avoidance and immunosensitization (desensitization with injectable
allergens) can cure asthma. They also try to adhere their wards to
strict food, exercise and climatic restrictions in fear of asthma
attacks.
All these queries can be better addressed to in
an asthma clinic by a team of doctors, nurses and attendants
(including medical service representatives) in repeated visits in a
sympathetic manner.
Functions of Asthma Clinic
Give time and sympathy to the parents first. The
doctors and his team should ensure that a correct diagnosis is made.
This will need a good history (listening and under-standing the
parent’s concern, the present, past, familial, environmental, social
problems of their child), detailed and meticulous scrutinizing the
past prescriptions (use of bronchodilators, steroids, antibiotics,
their frequency, duration of use and seasonal records of symptoms
etc.). Teaching the parents the importance of keeping every
single record is the most important advice. Clinical examination of
both upper and lower respiratory system (e.g.,
allergic rhinitis, atopy, sinusitis, ear infections other than
routine examinations) and of other relevant systems
(gastro-esophageal reflux, cardio-vascular anomalies, blood
pressure, etc.) are next important steps. Routine
investigations e.g., complete blood count, radiology
(chest/sinuses etc.), mantoux test and other relevant
investigations may be done only to exclude other diseases. Serum
specific immunoglobulin E allergy test spirometry are rarely needed
and only in difficult cases. Use of peak flowmetry, if needed, may
be demonstrated to the parents in a friendly manner.
Staging and grading their child’s asthma with due
explanation is the next step. One should actually demonstrate the
inhaler devices with the child and the parents in every visit.
Educating that one visit and prescription will not do magic cure
should be the principal communication. The need for regular follow
up is emphasized to search out the loopholes in non-responders and
attempt to convince the deniers. Home management plans are handed
out only after a few and reliable visits (in routine and emergency)
.
Explaining the details of environmental control,
promoting the exercises advocated, demystifying the acute care
guidelines should also be considered. Meticulous care must be taken
to identify failure of therapy, i.e., triggering factors,
wrong drug, dose or frequency, faulty delivery technique,
manipulating abnormal peak expiratory flow meter readings.
Keeping register for audit, research, review and
ready references is a must in these clinics. Provision of related
literatures, handouts, skills for using devices with photographs,
facts showing asthmatic sportsmen and celebrities who have reached
heights (enthusing the spirit in the children) and above all
depicting, analyzing and scientifically exposing the false claims
published in print media showing miraculous cure in asthma should be
the responsibility of these clinics.
Absorbing such information can be overwhelming in
a 15-minute appointment, but other health care team members can help
reinforce the educational message. Education is an ongoing process,
and information needs to be adjusted appropriately for the child as
he or she ages and for the family as they become more educated(13).
Hence, it is easy to understand why a specialized ASTHMA CLINIC is
more useful than routine clinic in primary care management.
Should Asthma Clinic be run by a Doctor or a
Nurse ?
Answer to this question is probably both. Nurse
run asthma clinic in general practice was first described by Great
Barnes in 1985. 90% of the general practice in UK offered
supervision of asthma under asthma clinic(14). In a pediatric study
by Madge, et al.(15) the outcome of a specialized nurse led
asthma clinic fared better than a hospital based specialized care in
admitted children. But this is still a dream to be fulfilled in our
country.
Parents like health professionals who are warm
and sympathetic, easy to talk to and appear self confident, listen
patiently and respond logistically, ask easy open ended questions
and above all do not repeat themselves(14). Nurses or assistants in
close collaboration with doctors are able to use their skills
comprehensively, effectively and efficiently(15). It is not who
delivers the care that is important, it is the quality of care that
counts(14). At this juncture the role of medical service
representatives who can demonstrate the devices correctly should be
kept in mind. The role of a video/ video CD demonstration can be
marvelous.
How to set up a Childhood Asthma Clinic in
Primary Care Setting?
It needs only the office clinic, preferably a
computer (for record keeping, video show of device usage, utilizing
an office spirometry, if available and information storage from the
net), a peak flow meter and the most important of all, available
time (minimum 15-30 min during the first visit and 10-15 min in the
successive ones) and dedication. The first experience may not be
that soothing, as people may try to avoid the clinic on suspicion of
over-diagnosis, but one will establish the relevance of such a
clinic with perseverance and dedication at the end. This setup is
not that expensive and may return rich dividends in goodwill and
revenue at the end.
Funding: None.
Competing interests: None.
Gautam Ghosh,
Consultant Pediatrician,
South Point Asthma Clinic,
Howrah, West Bengal,
India.
