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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
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© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
in the clinic
Asthma
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What symptoms or elements of clinical history are helpful in diagnosis?
Episodic wheezing
Dyspnea
Difficulty taking a deep breath
Chest tightness
Cough (especially if chronic and nocturnal, seasonal, or related to workplace or a specific activity)
History
Symptoms often intermittent, remit spontaneously
Symptoms may vary seasonally
Symptoms may be associated with specific triggers
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What physical exam findings are suggestive?
Wheezing during tidal respirations or forced expiration
Prolonged expiratory phase of breathing
Hyperexpansion of chest
Unless patient is having an active exacerbation, physical exam less helpful than a carefully elicited history
Sometimes most helpful in looking for evidence of alternative diagnoses
Inspiratory crackles may suggest ILD or CHF
Abnormal heart sounds might indicate CHF or other cardiac causes of dyspnea
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What are the indications for spirometry in a patient whose clinical presentation is consistent with asthma?
Indicated for all patients with possible asthma
Measure FEV1, FVC, FEV1–FVC ratio
Evaluate before and after bronchodilator use
Post-bronchodilator improvement ≥12% and 200mL of FEV1 or FVC indicates significant reversibility
Reversibility of airflow obstruction defines asthma
Some patients may have difficulty with the FVC maneuver
Surrogate: FEV6 (reduction in the FEV1–FEV6 ratio signifies obstruction)
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
Normal spirometry does not rule out asthma
If signs suggest asthma but spirometry is normal
Bronchoprovocation with methacholine or histamine
Helps establish Dx of seasonal / exercise-induced asthma
Marked diurnal variability
Helps establish asthma Dx
Record measurements ≥2 weeks in a peak flow diary
Does normal spirometry rule out a diagnosis of asthma? What additional testing should patients with normal spirometry have?
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
Other Studies for Asthma Bronchoprovocation
Positive results: diagnostic of airway hyperresponsiveness
Negative results essentially rule out asthma
Chest radiograph
Mostly useful in ruling out other diagnoses
Allergy testing
To evaluate the role of allergens in asthma management
CBC with differential
Mild eosinophilia common in asthma
Sputum evaluation
Not indicated for routine evaluation
IgE
Mild elevation is common with asthma
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
When should clinicians consider provocative pulmonary testing?
If symptoms suggest asthma but spirometry is normal
Use: methacholine hyper-responsiveness test
Low PC20 result: diagnostic for airway hyper-responsiveness
Sensitive + high negative predictive value for asthma Dx
Highly reproducible + generally safe (but expensive)
Requires sophisticated instrumentation + labor-intensive
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
How should clinicians classify asthma?
Disease severity
Intrinsic intensity of disease
Assess when patient isn’t yet on long-term medication, or
Estimate based on lowest level therapy needed for control
Disease control
Degree to which asthma manifestations are minimized and
Degree to which goals of long-term control therapy are met
Measure used to maintain & adjust treatment as necessary
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
To aid classification, obtain spirometry at intervals:
At the time of initial diagnosis and evaluation
After stabilization of symptoms with therapy
After any prolonged exacerbations or progressive, chronic worsening
Every 1–2 yrs for routine monitoring of the disease
Classify both severity and control by two domains:
Impairment Frequency of symptoms
Nocturnal symptoms
Rescue inhaler use
Interference with normal activity
Spirometric measurements
Risk Frequency of exacerbations
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What comorbid conditions and alternative diagnoses should clinicians consider in patients with suspected asthma?
COPD
Vocal cord dysfunction
Heart failure
Bronchiectasis
Allergic bronchopulmonary
Cystic fibrosis
Mechanical obstruction
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
When should primary care clinicians consider referring patients with suspected asthma to specialists for diagnosis? Before ordering provocative pulmonary function test
Testing is time- and labor-intensive
Testing requires skilled performance and interpretation
When patient presents with atypical symptoms
Abnormal chest radiographs
Pulmonary function tests suggest obstruction + restriction
Unusual manifestations of the disease
Suboptimal response to therapy
When asthma seems to have an allergic component
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
CLINICAL BOTTOM LINE: Diagnosis… Take a careful history that focuses on:
Nature and timing of symptoms
• Wheezing
• Dyspnea
• Cough
• Chest tightness
Potential triggers
Use spirometry to assess all patients with suspected asthma
Normal spirometry doesn’t rule out asthma
If spirometry is normal but symptoms suggest asthma, consider provocative pulmonary testing
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What advice about reducing allergen exposure should clinicians give patients?
Use air conditioning to maintain humidity <50%
Remove carpets
Limit fabric household items (e.g., drapes, soft toys)
Use impermeable covers for mattresses and pillows
Launder bedding weekly in water ≥130°F
Ensure adequate ventilation
Exterminate to reduce cockroaches
Remove cats from the home
Reduce dampness in the home
Avoid wood-burning / unvented gas fireplaces or stoves
Avoid tobacco smoke
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What evidence supports the use of indoor air-cleaning devices for patients with asthma?
Inadequate evidence to recommend these devices
Little evidence supports HEPA filters or air duct cleaning
However particle air cleaning may reduce symptoms
Avoid humidifiers, which may increase allergen levels
Keep humidity <50% with dehumidifiers or air conditioners
Reduces dust mites and mold
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
How should clinicians select from among available drug therapy for asthma?
Rescue therapy Short-acting β-agonists (SABAs): acute relief of symptoms
Critical for all patients regardless of asthma severity
Long-term controller therapy
Step-wise Rx for long-term control of persistent symptoms
Choose step 1-5 based on symptoms (mild to severe)
If symptoms well-controlled ≥3 months, step down to less intensive therapy
If not well-controlled, step up to more intense therapy
Review therapy 2-6 wks at first, then every 1-6 months
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
To achieve asthma control :
Reduce impairment through reduction of chronic and troublesome symptoms
Minimize rescue bronchodilator use
Maintain normal (or near normal) spirometry
Minimize interference with activities
Meet patient’s satisfaction with care
Reduce risk by preventing exacerbations and loss of lung function and providing optimal pharmacotherapy with minimal adverse effects
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What is the role of nonpharmacologic therapy?
Many patients are interested in nonpharmacologic therapy for asthma
But evidence is inadequate on the role of most complementary therapies in asthma management
Experts recommend against acupuncture
Alert patients to possible risks of herbal medications
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What therapeutic options are effective for exercise-induced bronchospasm?
For patients who have normal pulmonary function but experience exercise-induced symptoms
15-30 minutes before exercise: use albuterol, cromolyn sodium, or nedocromil
If exercise-induced symptoms persist: consider adding leukotriene antagonists (long-acting bronchodilators should not be used without inhaled steroid as increased adverse events)
If pulmonary function tests are abnormal at baseline
It’s not just exercise-induced bronchospasm
Treat according to stepwise regimen
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
When should primary care clinicians refer patients with asthma to a specialist?
History of life-threatening exacerbations
Atypical signs and symptoms
Severe persistent asthma
Need for continuous oral corticosteroids or high-dose inhaled steroids or >2 courses oral steroids in 1-y period
Comorbid conditions complicate diagnosis or treatment
Need for provocative testing or immunotherapy
Problems with adherence or allergen avoidance
Unusual occupational or other exposures
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
When should oral corticosteroids be used for outpatient treatment?
Patients have an acute increase in asthma symptoms
If symptoms incompletely controlled after 2 doses w/in 20mins of 2-6 puffs SABAs: use oral corticosteroids
Also: continue using SABAs every 4h
Seek immediate medical attention
If symptoms persist or worsen
If SABAs are required more than every 4h
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
How should the patient be educated to respond when symptoms increase?
Physicians + patients should agree on written action plan:
Daily management of asthma
How to recognize signs and symptoms of worsening
How to adjust medications and doses in response to acute symptoms
How to adjust medications and doses in response to changes in peak expiratory flow rate
When to seek medical attention
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
When is hospitalization indicated?
When patient has a moderate exacerbation
FEV1 40%–69% predicted or
PEFR 40%–69% of personal best or
Symptoms and physical exam findings are moderate
When patient has a severe exacerbation
FEV1–PEFR ratio <40% or
Symptoms are severe or
Physical exam findings include signs of severe respiratory distress
When patient has an incomplete response to therapy
Post-treatment PEFR remains <40% of predicted value
ICU admission may be warranted
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
What factors identify patients with asthma at high risk for fatal or near-fatal events during an exacerbation?
Prior intubation
Multiple asthma-related exacerbations
Emergency room visits for asthma in the previous year
Nonuse or low adherence to inhaled corticosteroids
History of depression, substance abuse, personality disorder, unemployment, or recent bereavement
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
How often should clinicians see patients with asthma for routine follow-up?
Patients with newly diagnosed asthma
2–4 visits during the first 6 months after diagnosis
Establish + reinforce patient knowledge, mgmt skills
Patients with maximum improvement in pulmonary function and minimal to no related symptoms Follow-up every 1–6 months
Patients discharged from the hospital
Follow-up within 7 days
Patients treated as outpatients for an exacerbation
Follow-up within 10 days
© Copyright Annals of Internal Medicine, 2014Ann Int Med. 160 (3): ITC3-1.
CLINICAL BOTTOM LINE: Treatment…
Avoid asthma triggers
Use SABAs to relieve acute symptoms
Use long-term controller medications for persistent asthma Closely monitor symptoms Step up or down as needed to maintain disease control Serial measures of asthma control guide treatment changes
Educate patients on how to recognize and respond to early signs of clinical deterioration
Evaluate and monitor patients with acute increase in symptoms