Establishing a Collaborative Respiratory Transition Framework for Pediatric and Adult Patients
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By
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Sara Manti
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Paolo Ruggeri
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September 7, 2026
Clinical Scorecard: Establishing a Collaborative Respiratory Transition Framework for Pediatric and Adult Patients
At a Glance
| Category | Detail |
|---|
| Condition | Chronic Respiratory Diseases |
| Key Mechanisms | Structured transition pathways and collaboration between pediatric and adult care teams. |
| Target Population | Pediatric patients transitioning to adult respiratory services. |
| Care Setting | Respiratory medicine |
Key Highlights
- Transition from pediatric to adult care is a period of clinical vulnerability.
- Inadequate transition management is linked to poorer long-term health outcomes.
- Formalized transition protocols are uncommon in current practice.
- Monitoring lung function and psychosocial factors is critical during transition.
- A dedicated transition coordinator can enhance continuity of care.
Guideline-Based Recommendations
Diagnosis
- Utilize standardized data handover for diagnosis and therapeutic history.
Management
- Implement structured phases of identification, preparation, active transition, and follow-up.
Monitoring & Follow-up
- Monitor lung function trajectories and psychosocial variables throughout the transition.
Risks
- Patients are at risk of disengagement and loss to follow-up without structured protocols.
Patient & Prescribing Data
Patients with chronic respiratory diseases, including cystic fibrosis and severe asthma.
Therapeutic decisions should be planned early based on functional biomarkers.
Clinical Best Practices
- Establish clear timing and readiness criteria for transition initiation.
- Ensure collaboration between pediatric and adult pulmonology teams.
- Incorporate objective process and outcome indicators for quality improvement.
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