Anastassios C. Koumbourlis

Evidence-based medicine holds considerable weight, but it is not without controversy. Many controversies surround the diagnosis and management of common conditions encountered in clinical practice.

Three such controversies in pediatrics, pulmonology, and neonatology will drive the discussion during Wednesday’s session with Anastassios C. Koumbourlis, MD, MPH, ATSF, at the helm. Dr. Koumbourlis is chief of the division of pulmonary and sleep medicine and director of the Cystic Fibrosis Center at Children’s National Medical Center and a professor of Pediatrics at George Washington University School of Medicine & Health Sciences in Washington, D.C.

Dr. Koumbourlis will lead a panel discussion on the relationship between obesity and asthma, two conditions that have reached almost epidemic proportions, especially among minority children; the method of delivery of inhaled medications that are the main therapies for conditions such as asthma and chronic lung disease; and the use of diuretics, which have become part of the standard therapies given to treat acute and chronic lung disease in premature infants. Yet, the efficacy and potential side effects of diuretics recently have been questioned by large epidemiologic studies.

“Controversies in clinical practice vary. Sometimes, the controversy is due to the fact that a medical intervention or treatment may be scientifically sound, but not necessarily the ‘best’ from a practical standpoint. This is the case of the controversy surrounding the issue of inhalers versus nebulizers for the administration of medications in asthma,” Dr. Koumbourlis said. “Other times, the controversy is due to the fact that there is ‘evidence’ of a relationship between two conditions, but it does not amount to a proof, so it becomes an issue of interpretation. This is the case about the relationship between obesity and asthma. Finally, controversies arise from the fact that epidemiologic associations do not always correspond with actual clinical experience, which is the case with the use of diuretics in prematurely born infants.”

Currently, debates rage over the strength of the association between obesity and asthma, Dr. Koumbourlis said. For example, while obesity may predispose people to the development of asthma or exacerbate its severity, some studies suggest it does not cause asthma. This belief differs among health care professionals.

Similarly, the debate over the effectiveness of diuretics in treating acute lung disease in premature infants continues. In fact, said Dr. Koumbourlis, “the jury is still out” on whether the drugs “substantially” improve the respiratory status of premature newborns, and depends on the physicians’ interpretation of the literature.

Finally, what about questions surrounding the medical and financial benefits of different methods of administration of inhaled medications?

It depends on who you ask and what exactly you ask, Dr. Koubourlis said. In general, compared with the nebulizers, inhalers are more efficient in that they deliver a higher proportion of the medication to the lungs in particle size, which allows them to travel farther into the small airways; they are portable; and much faster to administer. However, they also are more likely to be used incorrectly, in which case the patient does not get any medication.

“In medicine, there are very few, if any, absolute ‘rights’ or ‘wrongs.’ Therefore, physicians should develop and use critical thinking, both when they read the literature and when they consider adopting new methods or following new ‘guidelines,’” he said. “Physicians should exercise their judgment on what would be the most ‘appropriate’ intervention for a patient, which may be very different than what they prescribe for another patient.”