ASTHMA MANAGEMENT Flashcards
ASTHMA MANAGEMENT
Recommendations
2.1 Initial Clinical Assessment
Check for symptoms like wheezing, breathlessness, and triggers. Physical examination should assess wheezing and rule out other respiratory conditions.
2.2 Objective Tests for Diagnosing Asthma
Adults & Children (5-16 years old): Tests include blood eosinophil count, FeNO (fractional exhaled nitric oxide), bronchodilator reversibility (BDR) with spirometry, peak expiratory flow (PEF), and bronchial challenge tests.
Children Under 5: Diagnosis is challenging due to difficulty performing objective tests; treatment trials with inhaled corticosteroids are recommended.
2.3 Diagnosing Occupational Asthma
Occupational exposure should be considered in adult-onset asthma cases. Symptoms should be monitored concerning work environment and holidays.
2.4 Monitoring Asthma Control
Regular monitoring at every review, including symptoms, medication use, and exacerbation history.
Symptom questionnaires and FeNO tests may be used for assessment.
ASTHMA MANAGEMENT
2.5 Principles of Pharmacological Treatment
Assess factors affecting asthma control before adjusting medication. Ensure correct inhaler technique and address non-adherence. Short-acting beta-agonists (SABAs) should not be prescribed without inhaled corticosteroids.
2.6 Pharmacological Management
People Aged 12 and Over:
Initial treatment includes low-dose inhaled corticosteroid/formoterol (ICS/Formoterol) as needed.
Maintenance and reliever therapy (MART) recommended for uncontrolled asthma. Stepwise approach based on control, involving leukotriene receptor antagonists (LTRAs) or long-acting muscarinic receptor antagonists (LAMAs) if necessary.
Children Aged 5-11:
Initial treatment with low-dose ICS and SABA as needed.
MART may be considered for children capable of managing it. LTRA may be added if MART is unsuitable.
Children Under 5:
Trial of ICS recommended if symptoms indicate asthma.
Step-up approach with moderate ICS or LTRA if symptoms persist.
2.7 Decreasing Maintenance Therapy
Step-down approach when asthma is well controlled for at least a year. Reduction should be gradual and monitored closely.
2.8 Adherence
Regular adherence checks using prescription records and inhaler technique assessments.
ASTHMA MANAGEMENT
2.9 Asthma in Pregnancy & Breastfeeding. Emphasis on maintaining asthma control during pregnancy.
Safe use of ICS, SABAs, and theophyllines. Monitoring and adjustments should be made based on asthma control.
2.10 Asthma in Adolescents
Discuss future career choices and occupational risks.
Address smoking and vaping.
Consider psychological and social factors affecting adherence.
2.11 Self-Management
Offer personalized asthma action plans.
Provide education on symptom control, environmental triggers, and medication use.
2.12 Risk-Stratified Care
Identify high-risk patients (e.g., frequent SABA use, multiple hospital visits).
Tailor management plans accordingly.
2.13 Organisation and Delivery of Care
Annual asthma reviews for all patients.
Consider telehealth for self-management support.
Use digital tools and decision-support systems.
- Research Recommendations
Areas requiring further research include diagnostic test accuracy, medication sequencing, self-management programs, and risk-stratified care.
- Implementation Considerations
Healthcare professionals should consider environmental sustainability when implementing asthma care strategies.
This guideline aims to standardize asthma diagnosis and treatment across different age groups, emphasizing evidence-based approaches and individualized care plans.
ASTHMA MANAGEMENT
Recommendations
2.1 Initial Clinical Assessment
Key Points:
Diagnosis should start with a structured clinical history including:
Symptoms: Wheeze, breathlessness, chest tightness, and cough.
Patterns: Symptoms worsening at night, with triggers (allergens, exercise, infections).
Family history: Asthma, atopic conditions (eczema, allergic rhinitis).
Differential diagnosis: Ruling out conditions such as chronic obstructive pulmonary disease (COPD), heart failure, or vocal cord dysfunction.
Physical Examination:
Look for (prolong) expiratory wheeze and rule out other causes.
A normal exam does not exclude asthma.
Initial Treatment and Testing:
If symptoms are severe, initiate bronchodilator therapy and assess response.
Perform objective lung function tests where possible.
Clinical Impact:
Ensures asthma is not misdiagnosed, reducing unnecessary treatment or delays in appropriate care.
Prevents over-reliance on clinical symptoms alone by incorporating objective measures.
ASTHMA MANAGEMENT
Objective Tests for Diagnosing Asthma
Adults & Children (5-16 years old)
Fractional exhaled nitric oxide (FeNO):
Indicates eosinophilic inflammation.
≥50 ppb in adults or ≥35 ppb in children supports an asthma diagnosis.
Spirometry with Bronchodilator Reversibility (BDR):
Forced expiratory volume (FEV₁) increase of ≥12% and 200mL after bronchodilator suggests asthma.
Peak Expiratory Flow (PEF) Monitoring:
Variability ≥20% over 2 weeks supports asthma diagnosis.
Bronchial Challenge Tests (Methacholine, Mannitol, Exercise-Induced):
Used in uncertain cases to assess airway hyper-responsiveness.
Children Under 5
Objective testing is unreliable; diagnosis relies on clinical history and treatment response.
Trial of inhaled corticosteroids (ICS):
Improvement suggests likely asthma.
Clinical Impact:
Increases diagnostic accuracy by using multiple tests instead of symptoms alone.
Avoids misdiagnosing asthma in conditions like vocal cord dysfunction or COPD.
2.3 Diagnosing Occupational Asthma
Occupational history:
Symptoms worsening at work and improving on days off.
Common triggers: Isocyanates (paint, plastics), flour dust, wood dust, latex.
Peak Flow Monitoring at Work:
PEF measured several times daily over 2 weeks.
Greater variability during workdays suggests occupational asthma.
Clinical Impact:
Helps prevent work-related disability.
Guides employer and employee decisions regarding workplace exposure modifications.
Avoids misdiagnosing asthma in conditions like vocal cord dysfunction or COPD.
Avoiding Asthma Misdiagnosis: Accurate Diagnosis, Red Flags & Enhancing Diagnostic Accuracy
Asthma is frequently overdiagnosed and misdiagnosed, often confused with vocal cord dysfunction (VCD), COPD, heart failure, GERD, or anxiety-induced dyspnea. Accurate diagnosis is critical to ensure proper treatment and avoid unnecessary use of inhaled corticosteroids (ICS) or bronchodilators.
📌 How to Reach an Accurate Asthma Diagnosis
Asthma is a chronic airway disorder characterized by:
✅ Reversible airway obstruction
✅ Airway hyperresponsiveness
✅ Chronic inflammation
The key to an accurate diagnosis is correlating symptoms, pulmonary function tests (PFTs), and clinical response to therapy.
🔹 Step 1: Clinical History & Red Flags for Alternative Diagnoses
A thorough history differentiates asthma from conditions like COPD, heart failure, vocal cord dysfunction (VCD), or anxiety-related dyspnea.
Symptom:
A. WHEEZING
Asthma: Expiratory wheeze
VCD: Inspiratory wheeze
COPD: Expiratory wheezing
Herat Failure: No wheezing, Crackles
B. Dyspnea
Asthma: Episodic, worse at night.
VCD: Sudden onset, often during stress/exercise
COPD: Progressive, exertional
Heart failure: Exertional dyspnea, orthopnea
C. Triggers
Asthma: Allergens, exercise, cold air
VCD: stress, exercise, irritants
COPD: Smoking, pollutants
Heart Failure: Fluid overload, hypertension
D. Cough
Asthma: Dry or Productive, Nocturnal
VCD: Throat Triggers, no cough
COPD: Chronic, Productive
Heart Failure: Dry, worse when supine
E. Response to Bronchodilators
Asthma: Improves with Albuterol
VCD: No improvement
COPD: Partial response
Heart failure: No improvement
F. Spirometry:
Asthma: Obstructive, reversible
VCD: Normal PFTs, abnormal flow volume loop
CODP: Obstructive, not fully reversible
Herat Failure: Restrictive or normal.
📌 Red Flags Suggesting Alternative Diagnoses:
🚨 No response to bronchodilators (Suggests COPD, VCD, or cardiac causes)
🚨 Inspiratory stridor instead of expiratory wheezing (Suggests VCD or upper airway obstruction)
🚨 Crackles on lung exam (Suggests heart failure instead of asthma)
🚨 Chronic productive cough (Suggests COPD, bronchiectasis, or GERD-related cough)
🔹 Step 2: Objective Testing (Pulmonary Function Tests & Challenge Tests)
Pulmonary Function Tests (PFTs) with Spirometry are essential for confirming asthma.
1️⃣ Spirometry with Bronchodilator Reversibility Test
✅ FEV1/FVC < 70% (Obstructive Pattern)
✅ FEV1 improvement of >12% and >200 mL after bronchodilator → CONFIRMS asthma
❌ If FEV1 does NOT improve significantly → Consider COPD or VCD instead
2️⃣ Methacholine or Exercise Challenge Test
📌 For patients with normal spirometry but persistent asthma-like symptoms
✅ FEV1 drop >20% with methacholine → Confirms airway hyperresponsiveness (Asthma)
❌ Negative test → Rules out asthma in most cases
3️⃣ Peak Expiratory Flow (PEF) Variability Monitoring
* Asthma: ≥20% variability in PEF over 2 weeks
* COPD: Minimal daily variability
🔹 Step 3: Distinguishing Asthma from Common Mimickers
🚨 Misdiagnosis is common in the following conditions:
1️⃣ Vocal Cord Dysfunction (VCD)
* Key Feature: Paradoxical vocal cord movement causing inspiratory stridor instead of expiratory wheezing
* Diagnostic Test: Laryngoscopy during an episode → Shows adduction of vocal cords
* Treatment: Speech therapy, breathing exercises (not inhalers!)
2️⃣ Chronic Obstructive Pulmonary Disease (COPD)
* Key Feature: Persistent airflow limitation, not reversible with bronchodilators
* Diagnostic Test: Post-bronchodilator spirometry (FEV1/FVC < 70% and non-reversible airflow obstruction)
* Treatment: Long-acting bronchodilators, smoking cessation
3️⃣ Gastroesophageal Reflux Disease (GERD)
* Key Feature: Nocturnal cough & wheezing without triggers
* Diagnostic Test: pH monitoring or trial of PPI
* Treatment: Proton pump inhibitors (PPIs), lifestyle modifications
4️⃣ Heart Failure (Cardiac Asthma)
* Key Feature: Dyspnea, crackles, orthopnea, edema
* Diagnostic Test: BNP, echocardiogram
* Treatment: Diuretics, ACE inhibitors, beta-blockers
🔹 Step 4: Enhancing Diagnostic Criteria & Accuracy
To avoid misdiagnosis, consider the following approach:
✔ Use spirometry in ALL suspected cases before diagnosing asthma.
✔ Challenge tests (methacholine, exercise-induced challenge) if spirometry is normal.
✔ Peak flow variability monitoring to differentiate asthma from COPD.
✔ Consider alternative diagnoses when symptoms don’t improve with asthma therapy.
✔ Red flag symptoms (e.g., inspiratory stridor, chronic productive cough, cardiac symptoms).
🔹 Summary: Steps to an Accurate Asthma Diagnosis
🔹 Step 1: Detailed History & Symptom Analysis
✅ Episodic symptoms, wheezing, nocturnal cough
✅ Triggers (allergens, exercise, cold air)
❌ Red Flags for alternative diagnoses
🔹 Step 2: Objective Testing with Spirometry
✅ Obstructive pattern with bronchodilator reversibility
❌ If non-reversible, consider COPD, VCD, or heart failure
🔹 Step 3: Challenge Testing if Spirometry is Normal
✅ Methacholine challenge if symptoms persist but normal PFTs
❌ Negative test strongly suggests non-asthma cause
🔹 Step 4: Consider Common Mimickers
✅ VCD: Inspiratory stridor, confirmed with laryngoscopy
✅ COPD: Persistent obstruction, non-reversible with bronchodilators
✅ GERD: Nocturnal wheeze/cough, improved with PPIs
✅ Heart Failure: Dyspnea, crackles, positive BNP
🔹 Key Takeaways for ANCC/AANP Exam
✅ Asthma is reversible! If FEV1 does not improve after bronchodilators, reconsider the diagnosis.
✅ Methacholine challenge test helps rule in asthma if spirometry is normal.
✅ Inspiratory stridor = Think Vocal Cord Dysfunction (VCD), NOT Asthma!
✅ Red Flags: Crackles (Heart Failure), Chronic Cough (COPD), No Response to Albuterol (Consider VCD or Cardiac Cause).
🚀 Would you like:
✅ Case-based questions for asthma differential diagnosis?
✅ Flashcards for spirometry interpretation?
✅ Flowcharts for asthma vs. COPD vs. VCD?
Let me know how I can further optimize your ANCC/AANP exam prep! 🚀
Avoids misdiagnosing COPD in conditions like Bronchiectasis and GarRD. Deep dive how to reach accurate diagnosis and avoid misdiagnosis, red flags to look for to enhance diagnostic criteria and accuracy
Avoiding COPD Misdiagnosis: Enhancing Diagnostic Accuracy & Identifying Red Flags
🔹 Why COPD is Misdiagnosed?
COPD is frequently misdiagnosed, either overdiagnosed in patients with asthma or underdiagnosed in patients with bronchiectasis, heart failure, or gastroesophageal reflux disease (GERD).
Accurate diagnosis is critical to ensure proper treatment, prevent inappropriate use of inhalers, corticosteroids, or antibiotics, and avoid delayed management of the true underlying condition.
📌 How to Reach an Accurate COPD Diagnosis?
COPD is a progressive, irreversible airway obstruction due to chronic bronchitis and/or emphysema. Key criteria for COPD diagnosis:
✅ Persistent respiratory symptoms (dyspnea, chronic cough, sputum production).
✅ Risk factors present (smoking, occupational exposure).
✅ Irreversible airflow obstruction on spirometry.
📌 Key to Accurate Diagnosis:
✔ Clinical symptoms + Risk Factors + Spirometry.
✔ Exclude mimicking conditions (Bronchiectasis, GERD, Heart Failure).
🔹 Step 1: Clinical History & Red Flags for Misdiagnosis
A thorough history differentiates COPD from other conditions like asthma, bronchiectasis, GERD, or heart failure.
COPD vs. Common Mimickers
Feature COPD Bronchiectasis Asthma GERD-Related Cough Heart Failure (Cardiac Asthma)
Cough Chronic, often productive Persistent, copious mucus, recurrent infections Episodic, dry or productive, nocturnal Nocturnal cough, triggered by reflux Dry, worse in supine position
Dyspnea Progressive, exertional Progressive, worse with infections Episodic, reversible with bronchodilators Postprandial, worse when lying down Orthopnea, PND
Sputum Production Scant, white sputum Large volumes, purulent Mild sputum Possible throat clearing Frothy, pink sputum
Trigger Factors Smoking, pollutants Recurrent infections Allergens, exercise, cold air Acid reflux, lying down Fluid overload, hypertension
Lung Exam Prolonged expiration, wheezing, distant breath sounds Crackles, wheezing, clubbing Wheezing, prolonged expiration Clear or mild wheezing Crackles, S3 heart sound
Response to Bronchodilators Partial response Partial or minimal response Marked improvement No effect No effect
Imaging Findings Hyperinflation, flattened diaphragm Bronchial wall thickening, mucus plugging Normal or mild changes Normal CXR Pulmonary edema, cardiomegaly
📌 Red Flags Suggesting Alternative Diagnoses:
🚨 Chronic large-volume mucus production + recurrent infections (Bronchiectasis).
🚨 Wheezing that resolves completely with bronchodilators (Asthma, not COPD).
🚨 Heart failure symptoms (edema, orthopnea, paroxysmal nocturnal dyspnea) with crackles.
🚨 No response to bronchodilators (Consider GERD, Bronchiectasis, or Heart Failure instead).
🔹 Step 2: Objective Testing (Pulmonary Function Tests & Imaging)
1️⃣ Spirometry – The Gold Standard for COPD Diagnosis
COPD = Persistent, irreversible obstruction on spirometry.
✅ FEV1/FVC < 70% (Obstructive Pattern)
✅ FEV1 does NOT fully improve after bronchodilator (IRREVERSIBLE airflow obstruction).
❌ If reversible, consider ASTHMA instead.
2️⃣ High-Resolution CT Scan (HRCT) – Differentiating COPD from Bronchiectasis
Indicated if:
✔ Frequent lung infections, chronic sputum, or clubbing → R/O Bronchiectasis.
✔ HRCT Findings in Bronchiectasis:
* Bronchial dilation
* Mucus plugging
* “Tram-track sign”
* “Signet ring sign”
3️⃣ Chest X-ray (CXR)
* COPD: Hyperinflation, flattened diaphragm, barrel-shaped chest.
* Heart Failure: Cardiomegaly, pulmonary edema.
* Bronchiectasis: Thickened bronchial walls, mucus plugging.
📌 Key Takeaway:
✅ COPD must be confirmed with SPIROMETRY.
✅ If large-volume mucus production → Order HRCT to R/O Bronchiectasis.
✅ If heart failure suspected → BNP, echocardiogram.
🔹 Step 3: Distinguishing COPD from Common Mimickers
🚨 Misdiagnosis is common in the following conditions:
1️⃣ Bronchiectasis (Frequently Misdiagnosed as COPD)
* Key Features: Chronic large-volume mucus production, recurrent lung infections, clubbing.
* HRCT Findings: Dilated bronchi, mucus plugging, bronchial wall thickening.
* Treatment: Airway clearance therapy (chest physiotherapy, mucolytics), antibiotics for exacerbations.
📌 Red Flags for Bronchiectasis:
✅ Recurrent lung infections
✅ Chronic purulent sputum > 3 months
✅ HRCT findings: bronchial dilation, mucus plugging
2️⃣ Asthma (Misdiagnosed in Overlapping Cases)
* Key Features: Episodic reversible airflow obstruction, no progressive lung damage.
* Spirometry: FEV1 improves >12% post-bronchodilator → ASTHMA, not COPD.
* Treatment: Inhaled corticosteroids (ICS), bronchodilators.
📌 Red Flags for Asthma Instead of COPD:
✅ Young age (<40), strong allergic history
✅ Reversible airflow obstruction on spirometry
✅ Wheezing that resolves completely with bronchodilators
3️⃣ GERD-Related Chronic Cough
* Key Features: Nocturnal cough, postprandial symptoms, worsens with lying down.
* Diagnostic Test: pH monitoring, trial of proton pump inhibitors (PPIs).
* Treatment: Lifestyle modifications, PPIs.
📌 Red Flags for GERD:
✅ Cough worse at night/post-meal
✅ No response to bronchodilators
✅ Heartburn, throat clearing symptoms
4️⃣ Heart Failure (“Cardiac Asthma”)
* Key Features: Dyspnea, orthopnea, PND, crackles.
* Diagnostic Tests: BNP, echocardiogram.
* Treatment: Diuretics, ACE inhibitors, beta-blockers.
📌 Red Flags for Heart Failure:
✅ Orthopnea, PND, dependent edema
✅ Crackles (instead of wheezing) on lung exam
✅ Elevated BNP, echocardiogram abnormalities
🔹 Enhancing Diagnostic Criteria & Avoiding Misdiagnosis
✔ Use spirometry in ALL suspected COPD cases before diagnosing.
✔ If spirometry is normal, reconsider the diagnosis!
✔ Order HRCT if large mucus production suggests bronchiectasis.
✔ Check BNP and echocardiogram in heart failure-suspected cases.
✔ Consider GERD if cough persists despite COPD therapy.
🔹 Summary: Steps to an Accurate COPD Diagnosis
🔹 Step 1: Detailed History & Symptom Analysis
✅ Chronic symptoms, smoking history, progressive dyspnea.
❌ Red Flags for alternative diagnoses.
🔹 Step 2: Objective Testing
✅ Spirometry confirms COPD (FEV1/FVC <70%, irreversible).
✅ HRCT for bronchiectasis suspicion.
✅ BNP/Echo for heart failure suspicion.
🔹 Step 3: Consider Common Mimickers
✅ Bronchiectasis: Recurrent infections, purulent sputum.
✅ Asthma: Reversible airflow obstruction.
✅ GERD: Nocturnal cough, post-meal worsening.
✅ Heart Failure: Crackles, edema, orthopnea.
🚀 Would you like:
✅ Case-based questions for COPD differential diagnosis?
✅ Flashcards for spirometry interpretation?
✅ Flowcharts for COPD vs. Bronchiectasis vs. Asthma?
Let me know how I can further optimize your ANCC/AANP exam prep! 🚀
