Transcript Medical History - American Lung Association

PATIENT &
FAMILY
ASSESSMENT
Presented by:
Michelle Harkins, MD
This lesson will cover:
• Medical history
• Physical exam
• Objective measures
Initial Assessment & Diagnosis of Asthma
Determine that:
• Patient has a history or presence of episodic
symptoms of airflow obstruction or hyperreactivity (wheeze, chest tightness, shortness of
breath or cough).
• Airflow obstruction is at least partially reversible.
• Alternative diagnoses are excluded.
NAEPP. EPR-3, page 40.
Initial Assessment & Diagnosis of Asthma
Methods for establishing diagnosis:
• Detailed medical history (airway hyper-reactivity,
recurrence, reversibility)
• Physical exam
• Spirometry to demonstrate reversibility
• Additional studies as necessary to exclude
alternative diagnoses
NAEPP. EPR-3, page 40.
Medical History
Symptom history and Quality of Life
Questionnaires:
• History of symptoms of airflow obstruction
– Cough
– Wheeze
– Chest tightness/pain
– Shortness of breath
• Episodic symptoms
• Response to treatment
Medical History
•
•
•
•
Identify symptoms
Pattern of symptoms
Precipitating/aggravating factors
Development of disease and
treatment
• Family history
– Atopy, asthma
NAEPP. EPR-3, page 69.
Medical History
•
•
•
•
Social history
History of exacerbations
Impact of asthma on patient/family
Patient/family perception of the disease
NAEPP. EPR-3, page 69
Interviewing the Individual with Asthma
In the past 12 months, have you had:
• A sudden, severe episode or recurrent episodes of
coughing, wheezing or shortness of breath?
• Colds that go to the chest or take more than 10 days to get
over?
• Coughing, wheezing or shortness of breath (SOB) during a
particular season or time of the year?
• Coughing, wheezing or SOB in certain places or when
exposed to certain things, such as animals, tobacco smoke,
perfumes?
NAEPP. EPR-3, page 70
Interviewing the Individual with Asthma
In the past 12 months, have you had:
• Do you have symptoms of heartburn or awaken with an
acid taste in back of your throat?
• Do you have symptoms of post-nasal drip or sinus
congestion?
• Has wheezing, cough, chest tightness, shortness of breath –
• Awakened you at night?
• In the early morning?
• After running, moderate exercise or other physical
activity?
NAEPP. EPR-3, page 70.
Interviewing the Individual with Asthma
In the past 12 months, have you had:
• Have you used any medicine that has helped you breathe
better? How often?
• Are your symptoms relieved when these medicines are
used?
NAEPP. EPR-3, page 70.
Early Asthma Signs & Symptoms
Symptoms that
indicate an
asthma episode
is occurring
•
•
•
•
•
Coughing
Wheezing
Shortness of breath
Chest tightness and/or pain
Peak-flow numbers usually 50%
to 80% of personal best
Other Early
Warning Signs
& Symptoms
• Itchy throat or chin
• Runny or stuffy nose
• Sneezing
• Headache
• Funny feeling in the chest
• Stomach ache/poor appetite
• Glassy eyes
• Feeling tired
Late or Severe Asthma Symptoms
Severe asthma symptoms are a life-threatening
emergency. They indicate respiratory distress.
Examples of severe asthma symptoms include:
• Patient experiences severe coughing, wheezing,
shortness of breath or tightness in the chest
• Patient experiences difficulty talking or
concentrating; mental deterioration may occur.
• Walking causes shortness of breath.
Severe Asthma Symptoms
• Breathing may be shallow and fast,
or slower than usual; paradoxical
breathing in small children
• Shoulders may be hunched.
• Nasal flaring may be present.
• Accessory muscle use and
retractions may be present.
– Retractions: Neck area and between
or below the ribs moves inward with
breathing
Severe Asthma Symptoms
• Skin may be gray or bluish tint, beginning
around the mouth or fingernail beds (cyanosis).
• Peak-flow numbers may be in the danger zone
(usually below 50% of personal best).
• Wheezing may be moderate, loud or absent.
– The absence of wheezing implies severely
compromised airflow.
Severe Asthma Symptoms
Pulses Paradoxus:
• There is normally a decrease in systolic pressure
during inspiration, When that difference is greater
than 10 mmHg, it is called pulsus paradoxus.
• A paradox is caused by a fall in cardiac output as a
result of increased negative intrathoracic pressure.
High-Risk Asthma Patients
•
•
•
•
•
•
Past history of sudden, severe exacerbations
Prior intubation for asthma
Prior ICU admission for asthma
>2 asthma hospitalizations in past year
>3 asthma ER visits/year.
Hospitalized/ER asthma visit in past month
NAEPP. EPR-3, page 377.
High-Risk Asthma Patients
•
•
•
•
•
•
•
>2 albuterol MDIs/month
Low SES or inner city residence
Poor perception of symptoms/severity
Comorbidities
Complex psychiatric/psychosocial problems
Illicit drug use
Sensitivity to Alternaria mold
NAEPP. EPR-3, page 377.
Physical Examination
• The physical examination may be normal.
• Absence of symptoms at the time of the
examination does not exclude the diagnosis of
asthma.
NAEPP. EPR-3, page 377.
Physical Examination
The upper respiratory tract, chest,
and skin are the focus of the
physical exam for asthma.
Physical findings that increase the
probability of asthma include:
• Hyper-expansion of the thorax, especially in
children
• Use of accessory muscles, appearance of
hunched shoulders, chest deformity
NAEPP. EPR-3, page 42.
Physical Examination
• Sounds of wheezing during normal
breathing or a prolonged phase of forced
exhalation (typical of airflow obstruction)
-- In intermittent asthma, or between exacerbations,
wheezing may be absent.
• Increased nasal secretions, mucosal
swelling, and/or nasal polyps
• Atopic dermatitis/eczema or any other
manifestation of an allergic skin condition
NAEPP. EPR-3, page 43.
What Is Your Differential Diagnosis?
• What are some alternative diagnoses in adults
that may present with similar symptoms?
Alternative Diagnoses in Adults
Chronic obstructive
pulmonary disease –
chronic bronchitis or
emphysema
Congestive heart
failure
Cough secondary to
drugs (angiotensinconverting enzyme
[ACE] inhibitors)
NAEPP. EPR-3, page 46.
Mechanical
obstruction of the
airways – benign
and malignant
tumors
Vocal cord
dysfunction
Diagnosis of Asthma in Children
• Signs and symptoms of asthma can
vary widely and may mimic other
common childhood illnesses. Diagnosis
may be difficult.
• Asthma is frequently under diagnosed.
Not all wheeze and cough are caused
by asthma.
• Coughing may be the only symptom
present.
• Recurrent episodes of cough suggest
asthma, but other causes must be ruled
out.
Alternative Diagnoses in Children
Allergic rhinitis
Sinusitis
Gastroesophageal
reflux
Laryngotracheomalacia
Bronchopulmonary
dysplasia
Cystic Fibrosis
NAEPP. EPR-3, page 46.
Alternative Diagnoses in Children
Bronchiolitis
Foreign body
aspiration
Congenital
heart disease
NAEPP. EPR-3, page 46.
Vascular ring
or laryngeal
web
Vocal cord
dysfunction
Objective Measures
In addition to the physical exam, other measures
include:
•
•
•
•
•
Radiology studies
Spirometry
Peak-flow monitoring
Arterial Blood Gas /oxygen saturation
Allergy testing
Interpret the Findings from:
•
•
•
•
Family, clinical and past medical history
Physical examination
Vital signs
Pulmonary function, radiology and laboratory
results
Determine Diagnosis & Severity of
Asthma
Based on:
• History and QOL questionnaire
• Physical exam
• Objective measures
Classifying Asthma Severity: 0 – 4 years
Components of
Severity
Persistent
Intermittent
Mild
Moderate
Severe
Symptoms
 2 days/week
>2
days/week
but not daily
Daily
Throughout
the day
Nighttime
awakenings
None
1-2x/
month
3-4x/month
>1x/ week
 2 days/week
>2
days/week
but not daily
Daily
Several times
per day
None
Minor
Limitation
Some
Limitation
Extremely
Limited
Impairment
B-agonist use
(not prevention of EIB)
Activity limits
Risk
Exacerbations
requiring OSC
0-1/yr
 2 exacerbations in 6 months requiring oral systemic
corticosteroids, or  4 wheezing episodes/ 1 year
lasting >1 day AND risk factors for persistent asthma
Classifying severity in children who are not currently taking longterm control medication.
Classifying Asthma Severity: 5 – 11 years
Components of
Severity
Impairment
Risk
Persistent
Intermittent
Mild
Moderate
Severe
Symptoms
2
days/wk
>2 days/wk
but not daily
Daily
Throughout
the day
Nighttime
awakenings
 2x/month
1-2x/month
3-4x/month
>1x/wk
B-agonist use
 2 days/wk
>2 days/wk
but not daily
Daily
Several times
per day
Activity limits
None
Minor
limitation
Some
Limitation
Extremely
limited
Lung Function
FEV1
FEV1/FVC
>80%
80%
60 – 80%
<60%
>85%
>80%
75 - 80%
<75%
Exacerbations
requiring OSC
0-1/yr
(not prevention of EIB)
Classifying severity in children who are not currently taking longterm control medication.
 2/year
Classifying Asthma Severity: 12 and older
Components of
Severity
Impairment
Normal
FEV1/FVC:
8-19yrs 85%
20-39yrs 80%
40-59yrs 75%
60-80yrs 70%
Risk
Persistent
Intermittent
Mild
Moderate
Severe
Symptoms
 2 days/wk
>2 days/wk
but not daily
Daily
Throughout
the day
Nighttime
awakenings
 2x/month
3-4x/month
>1x/wk but not
nightly
Often 7x/week
>2 days/wk but
not daily, and
not more than
1x on any day
Daily
Several times
per day
B-agonist use
(not prevention of EIB)
 2 days/week
Activity limits
None
Minor
limitation
Some
Limitation
Extremely
limited
Lung Function
FEV1
FEV1/FVC
>80%
80%
>60 -80%
<60%
normal
normal
reduced 5%
reduced >5%
Exacerbations
requiring OSC
0-1/yr
Classifying severity for patients who are not currently taking longterm control medication.
 2/yr
Spirometry
Objective assessments of pulmonary function are
necessary for the diagnosis of asthma because:
• History and physical exam alone are not reliable
for excluding other diagnoses or characterizing
the status of lung impairment in the clinician’s
office,
• Spirometry is necessary for diagnosis, and
• Peak-flow is used for monitoring control only
NAEPP. Epr-3, page 43.
Objective Measures: Spirometry
• Spirometry measures how much and how
quickly air can be expelled following a deep
breath.
• The patient breathes out forcefully into a device
called a spirometer.
• Pre- and post-bronchodilator spirometry should
be done when a diagnosis of asthma is being
considered.
Spirometry Components
• Forced Vital Capacity (FVC)
The maximal volume of air forcibly exhaled from the
point of maximal inhalation
• Forced Expiratory Volume in 1 second (FEV 1)
The volume of air exhaled during the first second of
the FVC
• Ratio of FEV1 to FVC (FEV1/FVC)
Expressed as a percentage
• Peak Expiratory Flow (PEF)
Maximum air flow (rate) during forced exhalation
Spirometry Results
Airflow obstruction is indicated by reduced FEV1 and
FEV1 /FVC values relative to reference or predicted
values
• The predicted values depend on the individual’s
age, gender, height and race.
• The numbers are presented as percentages of the
average expected in someone of the same age,
height, sex and race. This is called percent
predicted.
Calculating % Predicted
FEV1 Predicted: 4.00L
Patient’s FEV1: 3.00L
What is the percent predicted for this patient?
3.00 = 3 = 75%
4.00
4
Objective Measures: Spirometry
Abnormalities of lung function are categorized as
restrictive and obstructive defects.
• A reduced ratio of FEV1 / FVC, as compared to
the predicted value, indicates obstruction to the
flow of air from the lungs.
• A reduced FVC with a normal FEV 1 /FVC ratio
suggests a restrictive pattern.
Interpreting Spirometry
• Normal values for FEV1 and FVC are expressed
in both absolute numbers and percent predicted of
normal.
• Values for FVC and FEV1 that are above 80% of
predicted are defined as within the normal range.
(The FEV1/FVC ratio is at least 80% of patient’s
vital capacity in one second.)
• FEV1/FVC ratio declines as a normal part of
aging.
Flow Volume Loop
A normal flow volume
loop has a rapid peak
expiratory flow rate
with a gradual decline
in flow back to zero.
Spirometry Results Showing Obstruction
Measured Predicted
Percent (%)
Predicted
FVC
4.09
4.25
96
FEV1
1.95
2.88
68
FEV1/FVC
48
68
PEF
6.27
8.06
78
Obstruction
• Obstructive lung
disease changes the
appearance of the flow
volume curve.
• As with a normal curve,
there is a rapid peak
expiratory flow, but the
curve descends more
quickly than normal and
takes on a concave
shape.
Normal vs. Obstructed
Normal
Obstruction
Restrictive Lung Disease
 Both the FEV1 and FVC are reduced proportionately.
 FEV1/FVC ratio is normal or even elevated.
Measured
Predicted Percent (%)
Predicted
FVC
0.96
2.75
35
FEV1
0.94
1.90
49
FEV1/FVC
98
69
PEF
2.98
5.40
55
Restrictive Flow Volume Loop
The shape of the flow
volume loop is relatively
unaffected in restrictive
disease, but the overall
size of the curve will
appear smaller when
compared to normals on
the same scale.
Objective Measures: Spirometry
Is airflow obstruction present and is
it at least partially reversible?
Use spirometry to
establish airflow
obstruction
FEV1 < 80%
predicted
FEV1/FVC below
the lower limit of
normal, as
compared to the
individual’s own
predicted value
Use spirometry to establish
reversibility
FEV1 increases
>12% and
> 200 mL after
using a shortacting inhaled
beta2-agonist
2- to 3-week trial
of oral
corticosteroid
therapy may be
required to
demonstrate
reversibility
Calculating Change in FEV1
Pre BD FEV 1 = 2.00 L Post BD FEV 1 = 2.40 L
What is the % improvement in FEV1?
Example 1: 2.40 L – 2.00 L= .40 = 20% improvement
2.00L
2.00
Does this meet the NAEPP criteria?
There is > 12% improvement.
Calculating Change in FEV1
Post BD FEV1 minus Pre BD FEV1
Pre BD FEV 1
Pre BD FEV1 = 1.50L
Post BD FEV1 = 1.80L
What is the % improvement in FEV1?
Example 2: 1.80L – 1.50L= .30 = 1 = 20% improvement
1.50L
1.50 5
Does this meet the NAEPP criteria?
Calculating Change in FEV1
Post BD FEV 1 minus Pre BD FEV1
Pre BD FEV 1
Pre BD FEV 1 = 3.00L
Post BD FEV1 = 4.00L
What is the % improvement in FEV1?
Example 3: 4.00L – 3.00L= 1.00 = 33% improvement
3.00L
3.00
Does this meet the NAEPP criteria?
Calculating Change in FEV1
Second requirement is >200ml increase
1.15 L minus 1.00 L is improvement of 0.15 L or
150 ml
Does this meet the NAEAPP requirement?
(Post BD minus Pre BD = >200ml)
Reliability of Spirometry
• Spirometry is an effort-dependent maneuver that
requires understanding, coordination and
cooperation by the patient, who must be carefully
instructed.
• Technicians must be trained and maintain a high
level of proficiency to assure optimal results.
• Spirometry should be performed using equipment
and techniques that meet standards developed by
the American Thoracic Society.
Reliability of Spirometry
• Correct technique, calibration methods and
maintenance of equipment are necessary to
achieve consistently accurate test results.
• Maximal patient effort in performing the test is
required to avoid important errors in diagnosis and
management (reproducibility).
• Spirometry is generally valuable in children over
age 4; however, some children cannot conduct the
maneuver adequately until after age 7.
Reliability of Spirometry
Criteria for acceptability include:
1. Lack of artifact induced by coughing, glottic closure
or equipment problems (primarily leak);
2. Satisfactory start to the test without hesitation; and
3. Satisfactory exhalation with six seconds of smooth
continuous exhalation, or a reasonable duration of
exhalation with a plateau.
Unacceptable Efforts
Cough
Variable Effort
Preparing Patients for Spirometry
• Painless procedure
• Noninvasive
• Outpatient
Spirometry Maneuvers
• Normal breathing prior to test
• Maximum forced exhalation during test
• Maneuver repeated until results are consistent
Discussing Results with Patients
• Connect spirometry results to the broader
picture of the patient’s asthma.
• Explain that spirometry results can improve with
effective asthma management.
• Stress that effective asthma management can
lead to less severe disease.
NAEPP Recommends Spirometry
1. At the time of the initial assessment;
2. After treatment is initiated and symptoms and
peak flow have stabilized to document
attainment of (near) “normal” airway function;
3. During periods of loss of control;
4. When assessing response to a change in
pharmacotherapy; and
5. At least every 1 to 2 years to assess the
maintenance of airway function.
NAEPP. EPR-3, pages 53, 59.
Spirometry May Be Done More Frequently
Depending on clinical severity, spirometry is also
useful:
• As a periodic check on the accuracy of the peak-flow
meter,
• When more precision is desired in evaluating response
to therapy and
• When peak flow results are unreliable.
NAEPP. EPR-3, page 59.
Peak Flow*
• Measured as the largest expiratory flow
achieved with a maximally forced effort from a
position of maximal inspiration, expressed in
liters/minute.
• Spirometry documents PEFR in L/sec, so
multiply this number by 60 to get L/min for noting
personal best on the patient’s PFM.
Peak-Flow Monitoring
Long-term daily peak flow monitoring is helpful in
managing patients with moderate-to-severe
persistent asthma to:
• Detect early changes in disease status that
require treatment,
• Evaluate responses to changes in therapy,
• Provide assessment of severity for patients with
poor perception of airflow obstruction and
• Afford a quantitative measure of impairment.
NAEPP. EPR-3, page 120
Radiological (CXR) Results
• Not routine.
• Usually normal yet
hyperinflation may be present
• Identify complications
–
–
–
–
Pneumonia
Pneumothorax
Pneumomediastinum
Tumor
Arterial Blood Gas (ABG)
Arterial blood gases are useful in assessing
acutely ill patients.
• Hypoxemia is generally not severe but does decline
with worsening airflow obstruction.
• CO2 is low in mild exacerbations and rises with
severity of obstruction.
• A normal CO2 in an acutely ill asthmatic can be a
very serious finding. If the exacerbation progresses
unabated, respiratory failure may result.
• “Normal” 7.40/40/70
Periodic Assessments of Asthma Control
•
•
•
•
•
•
Signs and symptoms
Pulmonary Function Test
QOL survey
History of exacerbations
Pharmacotherapy
Patient satisfaction
NAEPP. EPR-3, page 53.
Assessing Control: 0 – 4 years
Components of
Control
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Symptoms
 2 days/wk
>2 days/wk
Throughout the day
Nighttime
awakenings
 1x/month
>1x/month
>1x/week
Activity limits
None
Some limitation
Extremely limited
B-agonist use
 2 days/week
>2 days/week
Several times per day
0-1/year
2-3/year
>3/year
• Maintain current
treatment
• Regular F/U every
1 – 6 mos
• Consider step
down if well
controlled for at
least 3 mos
• Step up (1step) and
• Reevaluate in 2 -6
wks
• If no benefit in 6
wks, consider
alternative
diagnoses
• Consider short
course of OSC
• Step up (1 – 2 steps)
and
• Reevaluate in 2 wks
(not prevention of EIB)
Risk
Classification of Asthma Control
Exacerbations
requiring OSC
Recommended Action for
Treatment
Asthma Control: 5 – 11 years
Components of
Control
Symptoms
Nighttime
awakenings
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
 2 days/wk but not
>2 days/wk or multiple
more than once on
times  2 days/wk
each day
Throughout the day
1x/month
≥2x/month
≥2x/week
Activity limits
None
Some limitation
Extremely limited
B-agonist use
2 days/wk
>2 days/wk
Several times per day
(not prevention of EIB)
Lung function
• FEV1 or PF
• FEV1/FVC
Exacerbations
requiring OSC
Risk
Classification of Asthma Control
Reduction in
lung growth
Treatment-related
adverse effects
80%
>80%
60 – 80%
75-80%
0-1/year
<60%
<75%
≥2/year
Evaluation requires long-term follow-up
Medication side effects can vary in intensity from none to very troublesome
and worrisome. The level of intensity does not correlate to specific levels of
control but should be considered in the overall assessment of risk.
Asthma Control: 12 and older
Components of
Control
Impairment
Well
Controlled
Not Well
Controlled
Very Poorly
Controlled
Symptoms
 2 days/week
>2 days/week
Throughout the day
Nighttime
awakenings
 2x/month
1-3x/week
>4x/week
Activity limits
None
Some limitation
Extremely limited
B-agonist use
 2 days/week
>2 days/week
Several times per day
(not prevention of EIB)
Risk
Classification of Asthma Control
Lung function
FEV1 or PF >80%
QOL indicator
ACT ≥20
Exacerbations
requiring OSC
0-1/year
FEV1 or PF = 60 -80%
FEV1 or PF <60%
ACT =16-19
ACT ≤15
> 2/ year
Reduction in lung
Evaluation requires long-term follow-up
growth
Treatmentrelated adverse
effects
Medication side effects can vary in intensity from none to very
troublesome and worrisome. The level of intensity does not correlate to
specific levels of control but should be considered in the overall
assessment of risk.
Occupational Asthma
• Potential for workplace-related symptoms
• Patterns of symptoms in relation to exposure
• Documentation of work-relatedness of airflow
limitation
NAEPP. EPR-3, page 189.
Classifying Severity of Asthma
Mild
Moderate
Severe
Subset: Life
Threatening
Symptoms and Signs
Initial PEF (or FEV1)
Dyspnea only with
activity (assess
tachyphena in young
children)
PEF ≥ 70 % predicted
• Prompt relief with inhaled SABA
or personal best
Dyspnea interferes
with or limits usual
activity
PEF 40-69 %
• Relief from frequent inhaled SABA
predicted or personal
• OSC; some symptoms last for 1-2
best
days after treatment is begun
Dyspnea at rest;
interferes with
conversation
Too dyspneic to speak;
perspiring
Clinical Course
• Usually cared for at home
• Possible short course of OSC
• Usually requires office or ED visit
PEF < 40 % predicted
or personal best
• Usually requires ED visit and likely
hospitalization
• Partial relief from frequent
inhaled SABA
• OSC; some symptoms last for >3
days after treatment is begun
•Adjunctive therapies are helpful
PEF <25 % predicted
or personal best
•Requires ED/hospitalization;
possible ICU
• Minimal or no relief from
frequent inhaled SABA
• Intravenous cortosteroids
•Adjunctive therapies are helpful
Referral to Specialist When:
• A life-threatening asthma exacerbation exists,
• Patient is not meeting goals of asthma therapy
after 3-6 months of treatment,
• Signs and symptoms are atypical or there are
problems in differential diagnosis,
• Comorbid conditions complicate asthma or its
diagnosis and
• Additional diagnostic testing is needed.
Referral to Specialist When:
• Additional education needed (about complications
of therapy, adherence, allergen avoidance);
• Patient is considered for immunotherapy;
• Adult patient requires Step 4 or higher care –
consider referral if patient requires Step 3; and
• Pediatric patient requires Step 3 or higher care –
consider referral if child 0-4 yrs requires Step 2
care.
NAEPP. EPR-3, page 68.
Case Reviews
Review the pulmonary function results, then select the
correct basic interpretation.
Choose from the following answers:
1. Normal
2. Mild to moderate obstruction
3. Severe obstruction
4. Severe obstructive ventilatory defect, cannot exclude
a concomitant restrictive defect
5. Restrictive ventilatory defect, large volumes necessary
for confirmation
6. Cannot be interpreted; does not meet acceptability
criteria.
Acknowledgements
• Sally W. Southard, PNP, BC, AE-C
Pediatric Nurse Practitioner, Carilion Pediatric
Pulmonology Clinic
We will breathe easier when the air in every
American community is clean and healthy.
We will breathe easier when people are free from the addictive
grip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces and
workplaces is clear of secondhand smoke.
We will breathe easier when children no longer
battle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.