© Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. * For Best Viewing:...

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in the clinic

Asthma


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


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


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)


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?


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


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


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


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


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


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


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


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


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


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


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



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


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


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


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


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


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


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


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


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

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