Chronic Asthma - Diagnosis/Assessments Flashcards
Chronic Asthma Guidelines
- GINA 2019 - Global Initiative for Asthma
- EPR-3 - Diagnostic/Management of Asthma
Asthma Defintions
- Heterogeneous disease
- Chronic airway inflammation
- History of symptoms that vary over time and in severity
- Variable expiratory airflow limitation
Asthma Presentations
- Episodes of dyspnea
- Episodes of wheezing
- Tightness in chest
- Chronic daily OR intermittent symptoms
- Intervals between symptoms - weeks, months, year
- Characterized by recurrent exacerbations/remissions
Asthma Clinical Phenotypes
- Allergic asthma
- Non-allergic asthma
- Adult-onset asthma
- Asthma with persistent airflow limitation
- Asthma with obesity
Asthma Diagnosis - Need to determine…
- History of variable respiratory symptoms
- Confirm expiratory airflow limitation
- Make sure alternative diagnoses are excluded
Asthma Diagnosis Methods
- Detailed medical history
- Physical exam
- Spirometry
Asthma - Medical History questions
- Types of symptoms
- Pattern of symptoms
- Precipitating/aggravating factors
- Development of disease/treatment
- Family history
- Social history
- Profile of typical exacerbation
- Impact of asthma on patient/family
- Assessment of patient/family perceptions
Asthma Triggers
- Respiratory infections - viral
- Environment factors - smoke, bakers, farmers
- Psychological factors - stress, depression
- Obesity - may increase prevalence and decrease control
- Rhinitis/sinusitis
- Gastroesophageal reflux - noctural symptoms associated with reflux
- Female hormones - increase symptoms during periods and premenstrual times
- Preservatives - benzalkonium chloride, sulfite sensitivity
- Medications
Asthma Physical Exam Findings
The following increases the probability of asthma…
- Hyperexpansion of thorax
- Wheezing
- Atopic dermatitis/eczema
- Can also be noctural
Pulmonary Function Tests
- Used to establish diagnosis of asthma
- Spirometry to establish reversibility
- FEV1 increases by more than 12% after using a SABA
- Perform initial visit, then retest 3-6 months afterwards
- Then perform test every 1-2 years once treatment is established
<5 y.o. Diagnosis - Asthma
- Challenging
- Recurrence of wheezing is common in large portion of kids due to viral URI
- Certain factors that increase or decrease asthma probability
< 5 y.o. Increased Asthma Factors
- Wheezing/coughing occurs with exercise, laughing, or crying with no infection
- History of other allergic diseases (eczema, allergic rhinitis)
- Asthma in primary relatives
- Clinical improvement over 2-3 months of controller treatment and worsening after cessation
< 5 y.o. Decreased Asthma Factors
- Isolated cough with no other respiratory symptoms
- Chronic production of sputum
- SOB with dizziness, light headed, peripheral tingling
- Chest pain
- Exercise-induced dyspnea with noisy inspiration (stridor)
2 Domains to Control with Asthma
Symptom Control
- Burden to patients
- Increases risk of exacerbations if they aren’t controlled
Future Risk of Adverse Asthma Outcomes
- Exacerbations/Flare-ups
- Loss of lung function
- Medication SE
Severe Risk Factors - Exacerbations
- Uncontrolled asthma symptoms
- Inadequate ICS: not prescribed, adherent, or incorrect technique
- > = 1 exacerbation in past year
- Higher bronchodilation reversibility
- Major psychological or socioeconomic problems
- Comorbidities: chronic sinusitis, obesity, confirmed food allergy
- Sputum or blood eosinophilia
- Pregnancy
- Increased fractional concentration of exhaled NO (FNEO)
- Exposures: smoking, allergens, pollution
- Low FEV1 (<60% of predicted)
- High SABA use
- Ever intubated or ICU for asthma
Risk Factors: Decreased Lung Function
- Preterm birth
- Lack of ICS treatment
- Exposures: tobacco smoke, noxious chemicals, occupational exposure
Risk Factors: Medication SE
- Systemic rises from frequent oral CS use
- Long term, high dose ICS can also cause it
- Taking P450 inhibitors increases the risk for systemic SE as well
- Local SE rise from high dose ICS and poor inhaler technique
Asthma Goals of Therapy
- Avoid daytime and noctural symptoms
- Need little or no reliever medication
- Maintain normal activity levels
- Normal or near normal lung function
- Avoid serious asthma flare-ups
- Patient specific goals
- Minimize adverse effects
3 Asthma Medication Categories
- Controlled - ICS, LABA
- Reliever (Rescue) - SABA, SA anticholinergics, SCS
- Add-on (Severe asthma)
Controller Medications
- Regular maintenance treatment
- Decreased inflammation
- Controls symptoms
- Decreases future risk of exacerbations and decreased lung function
Reliever Medications
- All patients with asthma should have one
- Relieve breakthrough symptoms
- Prevention of exercise-induced bronchoconstriction
Add-On Medications
-Severe Asthma
-For those with persistent symptoms/exacerbations with high dose controller meds
EX: leukotriene modifiers, long-acting mus. antagonists, OCS, methylxanthones, cromolyn, biologics
Presenting Symptom: Infrequent Symptoms
Initial Treatment: PRN low dose ICD - formoterol
Controversial
Presenting Symptom: Asthma symptoms/reliever needed 2 times+/month
Initial Treatment: Low dose ICD or LTRA (less effective, theophylline)
Presenting Symptom: Troublesome asthma symptoms most days or waking asthma 1 times+/week
Initial Treatment: Medium dose ICS or Low dose ICD + LABA
Presenting Symptom: Severely uncontrolled asthma or acute exacerbations
Initial Treatment: Short course OCS AND high dose ICS
OR
Medium dose ICS + LABA
How severe is the asthma?
- Assessed retrospectively from level of treatment required to control symptoms and exacerbations
- Assessed once controller treatment for severe months and, if appropriate, after step down therapy has been attempted
Step 1 Therapy
- Preferred Controller: None, PRN ICS + Formoterol
- Other Controller Options: Low dose ICS
- Reliver: PRN SABA
- Mild asthma
Step 2 Therapy
- Preferred Controller: Low dose ICS
- Other Controller Options: LTRA
- Reliever: PRN SABA
- Mild asthma
Step 3
- Preferred Controller: Low dose ICS + LABA OR Medium dose ICS (preferred for 6-11 y.o.)
- Other Controller Options: Medium dose ICS, low dose ICS + LABA
- Reliver: PRN SABA
- Moderate asthma
Step 4
- Preferred Controller: Medium dose ICS + LABA and a specialist
- Other controller options: Add-on tiotropium, high dose ICS, add-on LTRA
- Reliever: PRN SABA
- Severe asthma
Step 5
- Preferred Controller: High dose ICS + LABA and a specialist
- Other controller options: Low dose OCS, tiotropium, LTRA, biologics
- Reliever: PRN SABA
- Severe asthma
Step Down Therapy
- Considered after 3 months of control and lung function hits a plateau
- Few data on optimal timing, sequence, or magnitude
- Decrease ICS dose by 25-30% at 3 months intervals is safe for MOST
- Step-down approach based on patient’s current medications and doses
Step Down Option: High dose ICS/LABA + OCS
OR High dose ICS/LABA + other add-on
- Continue high dose ICS/LABA, reduce OCS
- Alternate-day OCS
- Refer for expert advice
Step Down Option: Medium-high dose ICS/LABA
OR High dose ICS + second controller
- Continue combination; reduce ICS by 50%
- Discontinuing LABA may lead to deterioration
- Reduce ICS by 50% and continue second controller
Step Down Option: Low dose ICS/LABA
OR Moderate or high dose ICS
- Reduce ICS/LABA to once daily
- Discontinuing LABA may lead to deterioration
- Reduce ICS dose by 50%
Step Down Option: Low Dose ICS
- Once daily dosing
- Adding LTRA may allow ICS step down
Non-Pharm for Asthma
- Smoking cessation and environmental tobacco smoke avoidance
- Avoid occupational exposures
- Avoid medications that worsen asthma
- Avoid indoor/outdoor allergnes
- Weight loss
- Dealing with emotional stress
Check Following before Increasing Meds
- Inhaler technique
- Adherence to prescribed medications
- Environment changes
- Consider alternative diagnosis
Basic Asthma Educations
- Provide to ALL asthmatics
- Contrast normal and asthmatic airways
- What happens during an attack
Role of Medication Education
- Provide to ALL asthmatics
- Controller v.s. relievers
Skills Asthma Education
- Provide to ALL asthmatics
- Inhaler technique/device use
- Avoid environmental exposures
- Self-monitoring
- How to use written action plan
