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Introduction: Another episode of Radio Rounds, the podcast interview series presented by St. Louis Children's Hospital covering pediatric topics of interest to doctors and healthcare professionals. Here's Melanie Cole.

Melanie Cole: Welcome to Radio Rounds. The podcast series from Washington University Pediatric Specialists at St. Louis Children's Hospital. I'm Melanie Cole, and I invite you to listen in, as we discuss specialized care for severe asthma, the severe asthma clinic for kids at St. Louis Children's Hospital. Joining me is Lila Kertz. She's the clinical director of the severe asthma clinic for kids at St. Louis Children's Hospital. Lila, it's a pleasure to have you with us today, as we get going, please kind of give us a working definition of the difference for other providers between asthma and severe asthma and how prevalent it is.

Lila Kertz: So severe asthma is asthma that requires a maximum therapy, maximum maintenance therapy for asthma that is either controlled with that maximum amount of therapy or remains uncontrolled despite the use of the maximum therapy.

Host: So why is it severe? Why is it difficult to control for some kids?

Lila Kertz: That's a really good question. So approximately five to 10% of children with asthma have severe asthma. These kids typically have frequent exacerbation of asthma repeated hospitalization, emergency department room utilization, and frequent bursts of oral corticosteroids. Our clinic began in January of 2014. And what we have found over the years is that typically the majority of these children have uncontrolled asthma or severe uncontrolled asthma, not because of the medications that they're on, but because of barriers to care that are present in their lives, both economic and or social healthcare barriers.

Host: That's so interesting. So what would differentiate children with asthma, from the children with severe asthma? Tell us what symptoms a provider might notice that would send them to the clinic?

Lila Kertz: So, patients who are seen frequently for exacerbations who are coming in for acute episodes of cough, wheeze, shortness of breath, or who are needing recurrent courses of oral steroids for treatment of these acute exacerbation’s are patients that should be considered being referred to the severe asthma clinic. And certainly patients who, again, the maximal amount of inhaled steroid has been trialed and either failed where the child continues to have exacerbation of asthma, or even if their asthma seems to be well controlled. We worry about those patients that continue to need high doses of inhaled steroids, or again, recurrent courses of oral corticosteroids.

Host: So then tell us about the difference in care and what are you doing for children with severe asthma. And you mentioned that some of the reasons are socioeconomic. So how does that come into play in their care?

Lila Kertz: So, our clinic is unique in that we have a multidisciplinary team. We are one of the only if not the only severe asthma clinic for children in the region. Our team is comprised of myself. I'm a pediatric nurse practitioner. Who's also a certified asthma educator, two pediatric pulmonologist. We have a social worker, we have two asthma coaches that are there for our families as well. And then of course, we have a nurse that works with us. That's dedicated to these patients. And then also pulmonary function technicians that work with these patients when they come for their visits. So the visits are done in a way that's very systematic where we follow an algorithm that myself and one of the pulmonologists created before we started the clinic back in 2014, where we go over potential comorbid conditions, differential diagnosis, and again, pay attention to potential barriers to care that the families might have.

Host: Well, then tell us about some of those and some of the challenges in treating these patients.

Lila Kertz: What we have found is that over half, actually around 65% of the patients, we see report a barrier to care. So this can be either social or economic. So whether it's issues with transportation, to, and from the clinic, being able to afford medications, having the ability to pick up medications, whether there's social support at school, if there's a school nurse present or not present at the school, some of these families that the children have more than one home. So are medications available in both of the homes? So our social worker is extremely important to us, to the clinic and to the children, because she is the one who typically reviews these barriers and then helps the family address them. Our asthma coaches who are lay people, who've been trained about asthma are also there for the families. So if there are needs that arise in between visits, the family can contact our asthma coaches and let them know that they're having issues, getting medications or with transportation, or if their child is having recurrent issues with their asthma. Our asthma coaches are there to help guide them as to how to make decisions and also help to address these barriers as well.

Host: Well then tell us about some of the specialized therapies for severe asthma. What are you doing there at the clinic?

Lila Kertz: One of the things we do is evaluate of course, lung function for these patients, all of our patients receive lung function, testing age four and above, I should say, receive lung function testing, which is what we do in regular asthma clinic. But for these patients, we always look to see if these children have a bronchodilator response, because it's not uncommon for patients even with severe asthma children with severe asthma to have normal spirometry. So, we make a point to see if the children respond to bronchodilators. We also do exhaled nitric oxide testing at every visit, which is not typically done in routine at during routine asthma visits. And I think we're more apt look for biomarkers. So to draw blood on these patients, if they're as was not well controlled to consider the use of biologic therapy for treatment of asthma, which certainly can be done in a normal clinic.

But again, I think we are more apt to think through these and we have more time to spend with the patients. The initial evaluation is around two hours in length, follow up visits tend to be about an hour. So we're given plenty of time to spend with the families, really take a good history and also look to see if there are other things that could be affecting asthma. So we screen for depression. We look to see aside from barriers or barriers to care, the parents understanding of asthma. So health literacy from the parents. We also look to see how the parent's quality of life is in respect to the child's asthma. We also do medication refill histories at every visit. So we're looking to see if the families are able to get the medications that are prescribed, and if there are any issues with that, of course that's addressed as well.

Host: In these unprecedented times, Lila are kids with severe asthma, more at risk for significant issues with COVID-19?

Lila Kertz: That's a really good question. And what we've been telling families is that according to the CDC, patients with moderate to severe asthma are considered possibly to be at higher risk for worse infection with COVID if they were to catch COVID. So having severe asthma is not currently on the list of diagnoses underlying diagnoses. That definitely makes you at risk, but it is something that we are discussing with all of our families. And just with any other asthmatic we're encouraging mask wearing, hand-washing and appropriate social distancing.

Host: Well, then tell us a little bit more about the clinic. Tell us about your team and how did it even come about?

Lila Kertz: So, prior to 2014, probably the year or two priors, I started seeing more and more patients with severe asthma. They seem to be coming my way as being referred by the allergist and the pulmonologist within our group here at Washington University in St. Louis Children's Hospital. And over time, I realized that we probably needed to be doing more for these children. There had to be a better way to evaluate, a more thorough way to evaluate these kids, instead of just really looking and focusing on the medications, what are the other things that could be potentially affecting their asthma control? So from there, I approached our medical director and I asked him if creating such a clinic was a possibility. And he said, absolutely. If I had help from one of the physicians here within our group. So Dr. Katherine Rivera was more than willing to participate in creating this clinic. And so together we did, as we created it, we talked to many other specialties here at Children's Hospital.

In case we found patients with co-morbid conditions that could be affecting their asthma control. We wanted to be sure that we had a way for quick and thorough evaluation by our colleagues and other specialties. And then we also came up with the screening tools that I previously mentioned that we'd use during each visit. And also the algorithm that we created looking to help make decisions in a systematic way, not just during the visit, but before the families come with their children. A week prior to the clinic, our team meets the entire team meets to discuss the patients that will be seen in the upcoming clinic to go over their past medical history. What's been done the different interventions that have been tried, what kind of testing hasn't been done in the past. And then we also review patients that have been seen in recent months, or if anything, new or different has come up with any of them. That information is shared amongst our group during that meeting as well.

Host: Is there anything exciting in severe asthma you think is coming on the horizon or that you'd like to share with other providers and when do you want them to refer to the clinic?

Lila Kertz: So, one of the most exciting things in recent years for the treatment of asthma and severe asthma, is the use of biologic medications. So 16 or 17 years ago, the first asthma biologic therapy was brought to market. And so we've been using that for many years, but then in the last four to five years, we've had four additional biologics made available for us to use and choose from for our patients. And there are many more biologics being studied as we speak so potential for more treatment options that is truly considered personalized medicine based on each particular patient and their phenotype. We should have more options as the years go by to better treat these patients. As far as referring, we're happy to see any patient that a physician within the community or even outside of the community feels that they need additional help in managing these patients. The asthma guidelines tell us that, or suggest that referral have difficult to control asthma is appropriate to a specialist. So patients that have had recurrent hospitalization, recurrent courses of oral corticosteroid emergency room visits, patients who are on max therapy and still continue to have problems or on max therapy, even without issue, but could use further evaluation to see if again, comorbid conditions exist, or if a differential diagnosis is actually more of the issue than the underlying asthma. We're happy to see any of those patients and certainly welcome referrals.

Host: Thank you so much, Lila, what great work you're doing at the Severe Asthma Clinic for Kids at St. Louis children's hospital. Thank you so much for joining us today. And community physicians can refer a patient to the Severe Asthma Clinic for Kids by calling the children's direct physician access line at 1-800-678-help. That concludes this episode of Radio Rounds with St. Louis Children's Hospital, please visit StLouischildren's.org for more information, and to get connected with one of our providers. Please also remember to subscribe, rate, and review this podcast and all the other St. Louis Children's Hospital podcasts until next time Melanie Cole.