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Fall, 2010

GIP in Focus

Severity + History = A Roadmap to Treatment

During the winter of 1994, James W. Stout, MD, MPH, FAAP, was working at the Odessa Brown Children's Clinic in Seattle's lower-income Central District when he was struck by something.

"It seemed like the nebulizer [a machine that changes medication from a liquid to a mist so that it can be more easily inhaled into the lungs] was never turned off," said Dr. Stout. "It was kept on because of the large number of children with asthma who were coming into the clinic ill."

He also noted the great number of times he spoke with a child who told him that s/he had no problems breathing, but then a spirometry reading revealed that the child was "walking around obstructed without knowing it."

These experiences spurred Dr. Stout’s interest in investigating whether measuring lung function—through spirometry—alongside the usual review of a patient’s clinical history would substantially change where that patient ranked in terms of severity.

Girl using nebulizer
Girl uses nebulizer to inhale medication.

According to the findings of two different study groups of inner-city children with asthma , conducted by Stout and several co-authors, the answer is yes.

Approximately one out of every three study participants was reclassified into a higher National Asthma Education and Prevention Program (NAEPP) asthma-severity category when lung function was added.

As you may know, assessing asthma severity is one of six actions that the NAEPP Guidelines Implementation Panel (GIP)—of which Dr. Stout is a member—has identified as critical to the improvement of asthma control and care. The remaining five key GIP messages to healthcare providers are: 

  • Use inhaled corticosteroidsas indicated by the guidelines.
  • Use written asthma action plans to guide patient self-management.
  • Assess and monitor asthma control and adjust treatment if needed.
  • Schedule follow-up visits at periodic intervals.
  • Control environmental exposures that worsen the patient’s asthma.

Dr. Stout believes that spirometry is not only the key to assessing severity, it's a good catalyst for the other five GIP actions.

“It facilitates a planned-visit system,” said Dr. Stout. “A golden rule of spirometry is that you don't do it during an asthma attack; it requires scheduling a patient, putting together an action plan, and thus can serve as a catalytic point.”

Spirometer, a device used to assess asthma severitySpirometer, a device used to assess asthma severity.

Dr. Stout says the challenge is getting more practices to adopt spirometry as a way to measure severity. Data reveal that while 40 percent of practices own a spirometer, only about one-third are actively using it. And, out of those actively using it, less than half are using it correctly.

“A lot of people buy the spirometer with good intentions, but it's easy to use improperly without some training and feedback,” said Dr. Stout. “Think of learning a sport or musical instrument. You first have to see it done properly; then you need to practice; and then you need someone to tell you whether you’re doing it right.”

Those three steps—seeing, doing, and receiving feedback—are the focus of the University of Washington’s Better Asthma Care through Online Spirometry Training and Feedback: Targeting Safety Net Practices project, which is one of 10 National Asthma Control Initiative Strategic Partners.

Dr. Stout is the leader of the UW project, and the guiding force behind the development and testing of tools to help train physicians, and to support staff who might not have much formal medical training.

Those tools include a spirometry fundamentals CD-ROM; four 90-minute, case-based, educational webinars; and curve-tracking software that allows practices to upload data and receive feedback, all through the project’s Spirometry 360 program.

“It's exciting to work on this: to know that it is very scalable through collaboration with local experts and asthma champions. Our training resources could contribute to making a big difference by supporting primary care providers nationwide in more accurately diagnosing and treating their asthma patients,” said Stout. “The quality of their patients' lives should then improve through better care.”

Last Updated February 2011

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