Dr. Albert Rizzo:
Welcome to Lungcast, the monthly respiratory health podcast series from the American Lung Association and the medical news site HCP Live. I'm your host, Dr. Albert Rizzo, Chief Medical Officer of the American Lung Association.
Our guest today is Dr. Stephanie Lovinsky-Desir, Associate Professor of Pediatrics and Environmental Health Sciences, and Director of the Pediatric Pulmonary Division at Columbia University Irving Medical Center in New York City. Her research focuses on how environmental factors impact children with asthma, particularly in urban and minority communities.
Dr. Lovinsky-Desir is also a volunteer national spokesperson for the American Lung Association, and we thank her for her contributions. I couldn’t think of a more ideal guest for today’s Lungcast, since May is National Asthma and Allergy Awareness Month. Thank you for joining me today.
Dr. Stephanie Lovinsky-Desir:
Thank you so much for having me. I’m absolutely delighted to speak with you today.
Dr. Rizzo:
Before we get into specific aspects of care, let’s do a little level setting for our audience about some terms that classify asthma: endotypes, phenotypes, allergic, eosinophilic, and more recently, T2 and non-T2 asthma. Can you give us a brief overview of these terms and why they matter in management decisions?
Dr. Lovinsky-Desir:
Yes, of course. It’s funny—when you talk to pulmonologists about asthma, one of the things we acknowledge is how much is still unknown. These terms are really our way of unpacking different aspects of asthma management and care.
Phenotypes describe how the disease presents externally—what it looks like, the signs and symptoms we observe. Endotypes dig deeper into the underlying biological causes. So, for example, phenotypes might be exercise-induced asthma, allergic asthma, or obesity-associated asthma. Endotypes address root causes, such as eosinophilic inflammation or allergic pathways.
T2 asthma refers to allergic pathways where inflammatory cells like eosinophils are elevated. Non-T2 asthma, such as obesity-related asthma, doesn’t typically have those same biomarkers. The reason this classification matters is that it guides treatment—specifically, which pathways we target with medications.
Dr. Rizzo:
The first topic I’d like to discuss is SMART therapy, or single maintenance and reliever therapy. In 2020, guidelines recommended a combination inhaled corticosteroid–formoterol inhaler for both maintenance and quick relief. That was a paradigm shift. Can you help sort out SMART, AIR therapy, and other related strategies, and talk about barriers to implementing them?
Dr. Lovinsky-Desir:
I agree—it’s a paradigm shift. When I was in training, we had a rigid mantra: inhaled steroids were only for daily control, and short-acting beta agonists were only for rescue. SMART therapy changed that thinking.
The rationale is that when someone has an asthma exacerbation, they often end up needing systemic steroids, which carry more side effects. By adding inhaled steroids into the reliever medication, you can reduce the need for systemic steroids.
So, SMART uses an inhaled corticosteroid plus formoterol, a long-acting beta agonist with rapid onset, for both control and quick relief. This prevents exacerbations and reduces oral steroid use.
Implementation has challenges. First, patients and families are used to the old mantra. Some say, “But my albuterol works—why switch?” Second, there are dose limits—children under 12 shouldn’t exceed 8 inhalations in 24 hours; those over 12 shouldn’t exceed 12. That can be hard for families to track. Third, insurance coverage is an issue. Patients using one inhaler for both maintenance and rescue may run out before the month is over, and insurance doesn’t always accommodate that.
And yes, physicians’ habits are another barrier. Some are adopting the paradigm shift, while others are slower to move.
Dr. Rizzo:
Let’s move to biologics. We now have omalizumab, anti-IL-5 agents, dupilumab, and others. What guidance can you offer on who is the right candidate, how to select among them, and how long to wait before switching?
Dr. Lovinsky-Desir:
It’s exciting—we’ve seen a flourishing of biologics during my career. Most target the T2 pathway, so they’re best for allergic asthma, which is the majority in pediatrics.
We consider biologics when a patient’s asthma remains uncontrolled despite inhaled corticosteroids and long-acting beta agonists. Blood tests help guide selection: elevated eosinophils suggest anti-IL-5 agents, while high IgE suggests omalizumab. Age approval matters too—some are approved for children 6 and up, others only for 12 or 18 and older.
I usually give a biologic at least 3–4 months, sometimes up to 6, before deciding if it’s effective. The good news is that if one doesn’t work, we can often switch to another.
Dr. Rizzo:
Some wonder if biologics could be used earlier, even preventively, to interrupt the allergic march. What are your thoughts?
Dr. Lovinsky-Desir:
It’s an intriguing idea, and trials are underway, like the PARK trial with omalizumab in very young children. But it’s challenging—recruiting young children who don’t yet have severe asthma is difficult. Conceptually, prevention is appealing, but practically it’s harder. We’ll need more evidence.
Dr. Rizzo:
You published on COVID-19 and asthma in 2020. Early on, we feared asthma would worsen COVID outcomes. What did you find?
Dr. Lovinsky-Desir:
We thought asthma would increase risk, given how viruses often trigger exacerbations. But in New York City, we didn’t see worse outcomes for asthma patients hospitalized with COVID compared to those without asthma. The reasons aren’t fully understood.
The pandemic did teach us valuable lessons: handwashing, masks, telehealth, and attention to indoor air quality likely reduced asthma exacerbations. These are strategies we can continue.
Dr. Rizzo:
You’ve also studied air pollution and asthma. Can you share insights from your recent work?
Dr. Lovinsky-Desir:
Yes, in the CAUSE Network, we found that high air pollution exposure can trigger asthma exacerbations even without viral infections. The study looked at the molecular pathways involved, giving us more insight into mechanisms. The hope is that understanding these pathways will lead to new therapies.
Dr. Rizzo:
You’ve done important work on inequities in asthma care. Can you explain the importance of community-based participatory research?
Dr. Lovinsky-Desir:
Yes. Historically, there’s mistrust in marginalized communities, often linked to abuses like Tuskegee. People sometimes assume these communities don’t want to participate in research, but that’s not true. The issue is trust and relevance.
Community-based participatory research means the community is involved from the beginning—in designing the study, choosing questions, and identifying participants. It ensures the research addresses what matters to them. The challenge is that it takes time and funding, and traditional grant mechanisms don’t always support that. We need more investment in this type of work if we want to reduce health disparities.
Dr. Rizzo:
Before we close, I want your thoughts on HFA-containing inhalers and climate change. HFAs replaced CFCs, which harmed the ozone, but HFAs are greenhouse gases. Companies are preparing alternatives. Do you foresee any downsides?
Dr. Lovinsky-Desir:
I feel caught in the middle. On one hand, reducing our healthcare carbon footprint is critical, and switching to lower-impact inhalers is a relatively simple change. On the other hand, some patients—young children, those with neuromuscular disease, severe COPD—cannot use dry powder inhalers effectively.
We need to balance environmental responsibility with patient needs. Most patients can switch, but we must preserve options for those who can’t. Insurance companies also need to make these transitions easier, not harder.
Dr. Rizzo:
Thank you for your perspectives today, and for your ongoing work with the American Lung Association.
Dr. Lovinsky-Desir:
Thank you. This was a great conversation.
Dr. Rizzo:
For our listeners, we have a rich archive of asthma discussions in past episodes. Be sure to subscribe and visit lung.org and HCPLive.com for more resources. Until next time, I’m Dr. Albert Rizzo, reminding you: if you can’t breathe, nothing else matters.
