Shilpa J. Patel, MD, MPH: Pediatricians should lead asthma care

General pediatricians are well positioned to serve as the primary providers for most children with asthma, even when subspecialty care is pending, according to Shilpa J. Patel, MD, MPH, medical director of the Improving Pediatric Asthma Care DC Asthma Clinic and attending physician in the Division of Emergency Medicine at Children's National Hospital as well as associate professor of pediatrics and emergency medicine at George Washington University School of Medicine & Health Sciences.

Patel emphasized that clearly establishing the pediatrician as the central asthma provider helps build trust and continuity for families. “General pediatricians are 100% capable of taking care of most patients with asthma,” she said, noting that frequent follow-up—every 3 to 6 months early on—allows clinicians to assess whether therapy is working and to step treatment up or down as needed.

At IMPACT DC, an asthma care coordination clinic, Patel and colleagues conduct 90-minute education visits designed to address gaps that often contribute to poor control. The clinic sees both newly diagnosed children and those with ongoing, poorly controlled asthma who may require additional support, such as trigger mitigation or referral to pulmonology or severe asthma programs. A key starting point, Patel said, is understanding what families believe asthma is and where misconceptions exist.

Education focuses on the core physiology of asthma: airway inflammation, tightening of the muscles around the airways, and mucus buildup. Patel said breaking asthma down into these components helps families understand why different medications are prescribed. “Medication confusion is probably the No. 1 thing that I see,” she said, both in the clinic and in the emergency department.

Patel spends significant time clarifying the difference between rescue and controller medications. She explained that short-acting bronchodilators are muscle relaxants—not steroids—and can provide rapid relief of chest tightness. “Within 10 to 15 minutes, you should feel a little bit of a release in that tense chest tightness,” she said, a description that often resonates with adolescents.

She also stressed that focusing only on rescue therapy leaves asthma inadequately treated. Daily inhaled corticosteroids address swelling inside the airways and must be taken consistently to be effective. To reduce fear around steroids, Patel often compares inhaled corticosteroids to topical steroid creams used for eczema. “You can’t reach down into the airways with your hands,” she said, explaining that inhalers deliver medication directly to where inflammation is occurring.

Concerns about long-term medication use are common, particularly after a new diagnosis. Patel reassured families that asthma is a chronic but highly controllable condition and that treatment plans evolve over time. “Three months from now, we may take it off, and 6 months from now, we actually may put it up,” she said, emphasizing individualized care based on regular reassessment.

Patel also reframed concerns about steroid exposure by comparing daily inhaled therapy with repeated courses of oral steroids given during emergency visits. She tells families that a year of low-dose inhaled steroids results in less whole-body steroid exposure than a single emergency department steroid burst—an approach she said often helps families feel more comfortable with preventive treatment aimed at keeping children out of the hospital.