Transcript Clinical Slide Set. Asthma - Annals of Internal Medicine

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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (3): ITC3-1.
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© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (3): ITC3-1.
in the clinic
Asthma
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 160 (3): ITC3-1.
Does normal spirometry rule out a diagnosis
of asthma? What additional testing should
patients with normal spirometry have?
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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 hyperresponsiveness
 Sensitive + high negative predictive value for asthma Dx
 Highly reproducible + generally safe (but expensive)
 Requires sophisticated instrumentation + labor-intensive
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann Int Med. 160 (3): ITC3-1.
 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
 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
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann Int Med. 160 (3): ITC3-1.
© Copyright Annals of Internal Medicine, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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, 2014
Ann 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
© Copyright Annals of Internal Medicine, 2014
Ann Int Med. 160 (3): ITC3-1.