Asthma is a common, long-term condition characterized by inflammation and narrowing of the airways, leading to recurring symptoms like wheezing, coughing, and shortness of breath. While there is no cure, effective ongoing care helps most people achieve good control and a high quality of life. Management typically begins with a general physician, but a specialized respiratory doctor, known as a pulmonologist, may be necessary if the condition progresses or becomes more complex. Knowing when to transition to a specialist is an important step in maintaining optimal respiratory health.
Asthma Management by a Primary Care Provider
The Primary Care Provider (PCP) manages most patients with mild to moderate asthma. PCPs handle the initial assessment, which often involves a physical exam and basic lung function tests like spirometry. Spirometry measures how much air a person can breathe out in one forced breath and is a foundational tool for diagnosis and monitoring.
A PCP develops a personalized Asthma Action Plan, a written guide detailing daily medication use and instructions for handling worsening symptoms or flare-ups. This plan typically includes prescribing long-term control medications, such as inhaled corticosteroids, which reduce airway inflammation over time. They also provide short-acting rescue inhalers, like albuterol, for sudden symptoms or before exercise.
Routine follow-up focuses on monitoring symptom frequency, tracking peak flow measurements at home, and ensuring the correct use of inhaler devices. The goal is to prevent exacerbations, reduce the need for rescue medication, and maintain near-normal lung function. If a patient’s asthma remains well-controlled on a low-to-moderate dose of inhaled corticosteroids, continued care under the PCP is appropriate.
When to Seek a Referral to a Pulmonologist
A referral to a pulmonologist becomes necessary when asthma symptoms are no longer adequately controlled by standard PCP treatment. A significant trigger for referral is difficult-to-control or severe asthma, which affects an estimated 5% to 10% of all asthma patients. This is defined as asthma that remains uncontrolled despite the use of high-dose inhaled corticosteroids combined with other controller medications.
Frequent need for oral corticosteroids, such as prednisone, is another indicator, especially if a patient requires more than two courses in a single year. Frequent visits to the emergency room or hospitalizations due to asthma exacerbations also signal poor control and the need for specialized intervention. These events indicate a high risk of future, potentially life-threatening attacks.
Referral is also recommended when the diagnosis is uncertain or complicated by other conditions. A pulmonologist can investigate symptoms that may be due to overlapping issues like Chronic Obstructive Pulmonary Disease (COPD), vocal cord dysfunction, or gastroesophageal reflux disease (GERD). They can also confirm a suspicion of occupational asthma, which is triggered by workplace exposures and requires specific diagnostic procedures.
Specialized Care and Advanced Treatment Options
A pulmonologist offers access to advanced diagnostic procedures and specialized treatment options. Diagnostic tools such as fractional exhaled nitric oxide (FeNO) testing measure airway inflammation by detecting nitric oxide levels in the breath. This test provides a specific assessment of the type of inflammation present, which guides treatment selection.
Pulmonologists also perform specialized lung function tests, including bronchial provocation testing. In this test, a patient inhales a substance like methacholine to determine the degree of airway hyper-responsiveness. This helps confirm the asthma diagnosis, particularly when baseline spirometry results appear normal, helping the specialist understand the underlying mechanism driving severe symptoms.
For patients whose asthma remains uncontrolled despite maximum standard therapy, a pulmonologist can initiate advanced treatment options, particularly biologic therapies. These treatments involve injectable medications, such as monoclonal antibodies, that target specific inflammatory pathways (e.g., those mediated by IgE or eosinophils). Biologics are tailored to a patient’s specific asthma type, often identified through blood tests for biomarkers like eosinophil counts. In select adult patients, bronchial thermoplasty may be considered, which uses controlled heat to reduce smooth muscle in the airways, limiting their ability to constrict.