When should a pediatrician refer an asthma patient to a pulmonologist? Primary care providers can help manage treatment for a child’s mild asthma, but when the patient’s symptoms exceed routine care or simple maintenance, it’s time to make a referral.

“If a patient is taking their medications and avoiding triggers, and their asthma still is not under control, then a referral is necessary,” said Scott G. Bickel, M.D., pediatric pulmonologist with Norton Children’s Pulmonology, affiliated with the UofL School of Medicine. “Severe asthma requires additional testing to determine the cause of the patient’s inflammation.”

Diagnosing the severity of asthma

When it comes to determining the severity of a child’s asthma, there are four general categories:

• Mild intermittent: Mild asthma symptoms occur less than two days per week and no more than two nights per month.
• Mild persistent: Symptoms occur more than twice per week, but less than daily.
• Moderate persistent: Symptoms occur once a day and/or more than one night per week.
• Severe persistent: Symptoms occur regularly throughout the day and/or frequently at night.

Objective measures of lung function using spirometry are also critical to accurately diagnosing and following children with asthma in children who are able to do spirometry (typically 6 years old and up). Failure to incorporate lung function into classification and control has been shown in research to under-classify a patient’s asthma, potentially leading to undertreatment and increasing their risk for asthma morbidty.

If you are unable to perform spirometry in your office, it can be ordered as an outpatient test through the pulmonary function testing laboratories at either the Novak Center or Norton Children’s Hospital by calling (502) 629-6200, option 2. Test results with intpretation by a pediatric pulmonologist will be provided.

When to make a referral

Providers should make a referral to Norton Children’s Pulmonology for any of the following:

• Difficulty controlling asthma, despite appropriate medications and good adherence
• Hospitalization or frequent emergency department visits due to asthma exacerbation
• Moderate or severe persistent asthma (see above criteria)
• Used more than two systemic corticosteroids for asthma attacks per year
• Additional testing

A patient may require additional testing for severe asthma or to rule out other comorbidities and diagnoses. The child may be a good candidate for combination medications or biologics.

Biologics are administered in the Norton Children’s Severe Asthma Clinic, a multidisciplinary clinic involving the teams from Norton Children’s Pulmonology and Norton Children’s Allergy & Immunology, affiliated with the UofL School of Medicine. The clinic specializes in caring for children with the most difficult-to-treat and severe cases of asthma.