Assessing primary care physicians' beliefs and attitudes of asthma exacerbation treatment and follow-up.

DEAR EDITOR,

We congratulate Lincourt et al. on their article [1]. The relevance of the primary care physician in the treatment of asthma, and the use of controller medications in order to prevent asthma exacerbations cannot be emphasized enough.

However, we do not agree with their conclusion that healthcare providers may not share a common definition of asthma exacerbations, at least, not based on the described data.

In 2009, the American Thoracic Society/European Respiratory Society presented consensus definitions for asthma exacerbations to be used in research and clinical practice [2]. In this statement, compiled by a broad clinical expert group including primary care physicians in Europe and the US, exacerbations of asthma are distinguished by severity.

The definition of a severe asthma exacerbation should include at least one of the following:

Use of systemic corticosteroids (tablets, suspension, or injection), or an increase from a stable maintenance dose, for at least 3 days.

A hospitalization or ER visit because of asthma, requiring systemic corticosteroids.

A moderate exacerbation is defined as deterioration in symptoms, in lung function, and/or increased rescue bronchodilator use, not severe enough to warrant the use of systemic corticosteroid.

The definition of a mild asthma exacerbation was abandoned because the symptoms or changes in flow rates during these episodes will be only just outside the normal range of variation for the individual.

Especially in primary care this differentiation is relevant. In the author’s questionnaire no such difference in severity has been made. We are convinced that if an option to discriminate severity had been offered, a higher degree of agreement amongst the physician would have been obtained.

In our view the differentiation between moderate and severe exacerbation has clinical implications (whether or not prescribing systemic corticosteroids). Unfortunately, virtually all currently used definitions are retrospective: when the decision has been made to prescribe or withhold systemic corticosteroids, the event is thereby defined as a severe or moderate exacerbation, respectively. There is no consensus on which clinical criteria one should start systemic corticosteroids. A prospective definition based on objective clinical criteria is desirable.