Asthma

Asthma Evaluation

search

Asthma Evaluation

  • Pathophysiology
  1. See Asthma
  • History
  • Initial
  1. General: History is not always accurate
    1. Confirm with Pulmonary Function Tests every 3-6 month
    2. Patient may underplay symptoms
    3. Symptom accommodators (10% of patients)
      1. Do not recognize severe Symptoms of their Asthma
  2. Age of onset and Asthma diagnosis
  3. Past history of Respiratory Failure or Intubation
  4. Recognize cohorts at additional risk
    1. Elderly
    2. Pregnancy
  5. History of early life injury to airways
    1. Bronchopulmonary Dysplasia
    2. Parental smoking
  6. Disease progression
  7. Present management and response
  8. Frequency of Systemic Corticosteroid use
    1. History steroid-induced complications
  9. Comorbid conditions and potential triggers
    1. Exercise Induced Bronchospasm
    2. Aspirin and NSAID allergy
    3. Allergic Rhinitis
    4. Chronic Sinusitis
      1. Assess in all Asthma patients
      2. Consider empiric treatment if refractory Asthma
      3. Tsao (2003) Chest 123:757-64 [PubMed]
  10. Family History
    1. Asthma
    2. Allergic Rhinitis
    3. Sinusitis
    4. Nasal Polyps
  11. Social History
    1. Home characteristics
      1. Heating and cooling system
      2. Wood burning stove
      3. Humidifier
      4. Carpeting over concrete
    2. Smokers in home
    3. Daycare and school situation impacting compliance
    4. Level of education of patient and parents (if child)
  12. Effects of Asthma
    1. Episodes of unscheduled care (Emergency Department)
    2. Life threatening exacerbations
    3. Number of missed school days
    4. Limitation of activity
    5. History of nocturnal awakenings
    6. Impact of family routines and finances
  • History
  • Follow-up Asthma control questions (last month)
  1. How often did Asthma interfere with activities?
  2. How often are you short of breath?
  3. How often are you awakened by your Asthma?
  4. How often do you use your rescue Inhaler?
  • Symptoms
  • Episodic
  1. Recurrent Wheezing
  2. Dyspnea
  3. Productive or Paroxysmal cough (especially at night)
  4. Chest tightness
  5. Provocative factors
    1. Exercise
    2. Viral infection
    3. Animals with fur or feathers
    4. House-Dust mites
    5. Mold
    6. Smoke (Tobacco, wood)
    7. Airborne irritants (Pollen, chemicals, dusts)
    8. Weather changes
    9. Emotional stress
    10. Menses
  1. Expiratory Rhonchi
    1. High pitched sounds
    2. Air moving through constricted and inflamed airway
  2. Wheezing may or may not be heard
    1. Provocative measures
      1. Maximal expiration quickly
      2. Apply pressure anterior and superior
  3. Prolonged Inspiratory to Expiratory ratio
  4. Hyperexpansion of thorax and accessory muscle use
  5. Diminished chest excursion
    1. Place one hand on anterior chest
    2. Place the other hand posteriorly
  6. Nasal mucosal swelling or Nasal Polyps
  7. Atopic Dermatitis, Eczema, Urticaria
  • Signs
  • Respiratory distress
  1. Tachypnea
  2. Dyspnea
  3. Anxiety
  4. Accessory Muscle Use
    1. Intercostal muscle use
    2. Sternocleidomastoid use
    3. Scalenes Muscle use
  5. Cyanosis in severe cases (lips)
  6. Tachycardia
  7. Pulsus Paradoxus
  • Diagnosis
  1. Age 5 years old or over
  2. Symptomatic episodes of airflow obstruction or hyperresponsiveness (see below)
    1. Dyspnea (breathlessness)
    2. Cough
    3. Chest tightness
    4. Wheezing
    5. Diminished air entry
    6. Intercostal retractions
  3. Alternatives on differential diagnosis excluded (see below)
  4. Partially reversible airflow obstruction
    1. Peak Expiratory Flow >20% variation over 2 weeks
    2. FEV1 and FEV1/FVC ratio reduced
    3. FEV1 improves >12% or 200 ml after Bronchodilator
  • Differential Diagnosis
  1. General
    1. See Wheezing
    2. All that Wheezes is not Asthma (see Wheezing)!!
    3. However most recurrent cough with Wheezing is Asthma
  2. Children
    1. See Chronic Cough Causes in Children
    2. Upper airway disease
      1. Allergic Rhinitis
      2. Sinusitis
    3. Large airway obstruction
      1. Foreign body
      2. Vocal Cord Dysfunction
      3. Vascular Rings of laryngeal webs
      4. Laryngotracheomalacia
      5. Tracheobronchial-stenosis
      6. Enlarged lymph node or tumor
    4. Small Airway obstruction
      1. Viral Bronchiolitis
      2. Bronchiolitis Obliterans
      3. Cystic Fibrosis
      4. Bronchopulmonary Dysplasia
      5. Congenital Heart Disease
    5. Other Causes
      1. Psychogenic cough
      2. Gastroesophageal Reflux
      3. Malingering if Secondary Gain (e.g. missed school)
      4. Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss)
  3. Adults
    1. See Chronic Cough Causes
    2. ACE Inhibitors
    3. Chronic Obstructive Pulmonary Disease (COPD)
    4. Congestive Heart Failure (CHF)
    5. Pulmonary Embolism
    6. Vocal Cord Dysfunction
  • Labs
  1. Arterial Blood Gas (ABG)
    1. Hypoxemia
    2. Hypercarbia (or normal CO2) with decompensation
  2. Complete Blood Count
    1. Eosinophilia may be present
    2. Increased Levels of IgE may be present
  3. Sputum Sample
    1. May show casts of small airways
    2. Thick mucoid Sputum
    3. Curschmann's spirals
    4. Charcot-Leyden crystals
  4. Pulmonary Function Tests display Obstructive pattern
    1. See Diagnosis above