Asthma
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1) Bronchial asthma is a chronic inflammatory airway disease characterized by intermittent airway obstruction and hyper-reactivity. 2) It affects approximately 300 million people worldwide with 250,000 annual deaths. In Saudi Arabia, the prevalence is estimated to be 4.05-11.3%. 3) Diagnosis is based on a history of characteristic symptoms, evidence of variable airflow limitation from pulmonary function tests, and reversibility with bronchodilators.
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Asthma
- 1. Bronchial Asthma 2020 Presented by : Hibah Al-Thuwaini
- 2. OBJECTIVES : Defination of asthma Pathophysiology Epidemilogy Diagnosis Classification of asthma severity Management ( step up approch ) Asthma axacerbation
- 3. Asthma is a chronic inflammatory airway disease characterized by intermittent airway obstruction and hyper-reactivity. Asthma
- 4. Epidemiology 2020 4 Worldwide : • Prevalence: 300 Million people Variable from country to country (may affect as many as 18% of population in some countries) • Mortality: 250,000 deaths/year worldwide Of Asthma
- 5. Epidemiology 2020 5 Of Asthma Saudi Arabia o In 2013 , a study done to estimate the prevalence of asthma in KSA, and was estimated to be 4.05 % . o In 2018, study done in Riyadh reported that the prevalence of physician-diagnosed asthma was 11.3%.
- 9. The Diagnosis Should Be Based On : A history of charctriatic symtoms patterns Evidence of variable airflow limitation, from PFT
- 11. I. History Wheezing Cough Shortness of Breath Chest Tightness
- 12. The following features are typical of asthma and, if present, INCREASE the probability that the patient has asthma: Respiratory symptoms of wheeze, shortness of breath, cough and/or chest tightness: Patterns Of Respiratory Symptoms That Are Characteristic Of Asthma : • Patients (especially adults) experience more than one of these types of symptoms • Symptoms are often worse at night or in the early morning • Symptoms vary over time and in intensity • Hx of triggers
- 13. The following features Decrease the probability that respiratory symptoms are due to asthma: • Isolated cough with no other respiratory symptoms • Chronic production of sputum • Shortness of breath associated with dizziness, light- headedness or peripheral tingling (paresthesia) • Chest pain • Exercise-induced dyspnea with noisy inspiration. Patterns Of Respiratory Symptoms That Are Characteristic Of Asthma :
- 14. I. History Common Triggers: Dust Mites Air pollution Cleaning chemicls Pollen and Mould Pets Smoke Exercise
- 15. I. History Risk Factors: Family Hx Allergies Occupational Exposure Obesity
- 16. I. History Associated conditions: GERD Rinosinusitis Atopic dermatitis Obsity Sleep disorders
- 17. I. History RED Flags : Hemopytesis Fever Chest pain Night sweating Wight loss
- 19. II. Physical Examination General Examination: Vital Signs: Chest Examination: Nasal polyps, congestion , conjunctivitis, Respiratory distress Wheezing on auscultation is the prominent finding
- 22. PULMONARY FUNCTION TEST • Spirometry ( Reliable & preferred ) • Peak Expiratory Flow Rate ( alternative )
- 23. SPIROMETRY OBSTRUCTIVE < 80 % RESTRICTIVE > 80%
- 24. SPIROMETRY The ratio of FEV1 to FVC is < 80%. Obstructive lung disease Is it asthma ? Reversibility test with bronchodilators A significant increase in the FEV1 > 12% Diagnosis confirmed
- 25. SPIROMETRY Asymptomatic patient Methacholine Challenge Test Decline in the FEV1 (20% decline is abnormal). Diagnosis confirmed Induce asthma symtoms
- 26. 3 Ways To Diagnose: 1. Reversible Airway Obstruction on Spirometry (Preferred) FEV1/FEV (vs. norms) and > 12% in FEV1 after SABA 2. Peak Expiratory Flow Variability (Alternative) > 20 % improvement in PEF with SABA 3. Positive Challenge Test (Alternative) positive methacholine challenge test
- 27. A 38-year-old female with a 6-month history of mild shortness of breath associated with some intermittent wheezing during upper respiratory infections presents for follow-up. You previously prescribed albuterol (Proventil, Ventolin) via metered-dose inhaler, which she says helps her symptoms. You suspect asthma. Pulmonary function testing reveals a normal FEV1/FVC ratio for her age. Which one of the following would be the most appropriate next step? A. Consider an alternative diagnosis B. Assess her bronchodilator response C. Perform a methacholine challenge D. Prescribe an inhaled corticosteroid E. E. Proceed with treatment for COPD
- 28. A 20-year-old woman with no significant past medical history presents with a 2-month history of episodic shortness of breath. She has fits of coughing and trouble catching her breath with exertion. She tried a friend’s albuterol inhaler and notice some improvement and wonders if she has asthma. On examination, she is breathing comfortably at 16 times per minute and her oxygen saturation is 96% on room air. Her lungs are clear to auscultation, and the remainder of her examination is unremarkable. You want to better categorize this patient’s disease. Which of the following tests is most appropriate to order now? A) Spirometry B) Chest x-ray C) Arterial blood gas (ABG) D) Methacholine challenge
- 30. The National Asthma Education and Prevention Program
- 31. GINA 2020
- 32. You are seeing a 13-year-old patient in the office for the first time. She has had recent episodic shortness of breath and her mother is concerned that she has developed asthma. As you explore this patient’s history, you learn that she has been having 2 to 3 months of daytime symptoms, including coughing, wheezing, and shortness of breath more than 2 days per week but not daily. She wakes up once weekly at night with coughing spells and the teacher at school just told her mother that the patient is often not participating in her normal recess activities because of her symptoms. She has never been to the emergency department (ED) or hospitalized for these symptoms and has not had any workup at this point.
- 34. LONG-TERM GOALS OF ASTHMA MANAGEMENT : o To achieve good control of symptoms and maintain normal activity levels . o To minimize the risk of asthma-related death, exacerbations, persistent airflow limitation and side-effects.
- 35. I. Non-pharmacological • Patient education • Avoid exposures to triggers • Cessation of smoking • Weight reduction • Avoid triggering medications (e.g. aspirin, beta-blocker). • Annual influenza vaccination
- 36. Controller medications Reliever (rescue) medications corticosteroids Long-acting B2-agonists (LABAs) include salmeterol and formoterol Leukotriene modifiers include zafirlukast and montelukast Tiotropium Short-acting B2- agonists(SABAs) Ipratropium II. pharmacological
- 37. PHARMACOLOGICAL ( controller ) Fluticasone ICS Beclomethasone ICS Fluticasone (ICS) + Salmeterol (LABA) Seretide
- 38. Types of Inhalers :
- 40. © Global Initiative for Asthma, www.ginasthma.org A reminder – the key change in GINA 2019
- 41. GINA 2020
- 42. © Global Initiative for Asthma, www.ginasthma.org ICS-formoterol is the preferred reliever for patients prescribed maintenance and reliever therapy. For other ICS-LABAs, the reliever is SABA GINA 2020, Box 3-5A
- 43. Presenting symptoms Preferred INITIAL treatment Infrequent asthma symptoms, e.g. less than twice a month and no risk factors for exacerbations (Box 2-2B, p.35) As-needed low dose ICS-formoterol (Evidence B) Other options include taking ICS whenever SABA is taken, in combination or separate inhalers (Evidence B) Asthma symptoms or need for reliever twice a month or more Low dose ICS with as-needed SABA (Evidence A), or As-needed low dose ICS- formoterol (Evidence A) Troublesome asthma symptoms most days; or waking due to asthma once a week or more, especially if any risk factors exist (Box 2-2B) Low dose ICS-LABA as maintenance and reliever therapy with ICS- formoterol (Evidence A) OR Maintenance-only ICS-LABA with as- needed SABA (Evidence A), OR Medium dose ICS with as-needed SABA (Evidence A) Initial asthma presentation is with severely uncontrolled asthma, or with an acute exacerbation Start regular controller treatment with high dose ICS (Evidence A), or medium dose ICS- LABA (Evidence D) A short course of oral corticosteroids may also be needed Box 3-4A. Initial asthma treatment - recommended options for adults and adolescents
- 44. Low, medium and high doses of different ICS This is NOT a table of equivalence. These are suggested total daily doses for the ‘low’, ‘medium’ and ‘high’ dose treatment options with different ICS.
- 51. Action plan Green Zone (80-100% of your personal best) : good control. Take your usual daily long-term-control medicines, if you take any. Yellow Zone (50-79% of your personal best) : (caution) your asthma is getting worse. Add quick-reliever medicine and increase asthma medications as directed by doctor. Red Zone (< 50% of your personal best) : (medical alert!). Add or increase quick-relief medicine and call your doctor now.
- 52. Follow up o It is recommended to have a follow-up at 1–3 month intervals o To review Asthma action plan ,medication adherence , inhaler technique ,patient’s behaviors, comorbidities and side effects. o If controlled, reassess at least every 3-6 months. o If not controlled every 2-6 weeks.
- 53. Follow up
- 54. 1. Assess asthma control = symptom control and future risk of adverse outcomes • Assess symptom control over the last 4weeks (Box2-2A) • Identify any other risk factors for exacerbations, persistent air flow limitation or side- effects (Box2-2B) • Measure lung function at diagnosis/start of treatment,3-6 months after starting controller treatment, then periodically, e.g. at least once every 1–2 years, but more often in at-risk patients and those with severe asthma 2. Assess treatment issues • Document the patient’s current treatment step (Box3-5,p.54) • Watch inhaler technique, assess adherence and side-effects • Check that the patient has a written asthma action plan • Ask about the patient’s attitudes and goals for their asthma and medications 3. Assess comorbidities Rhinitis, rhinosinusitis, gastroesophageal reflux, obesity, obstructive sleep apnea, depression and anxiety can contribute to symptoms and poor quality of life, and sometimes to poor asthma control Follow up
- 55. Follow up Asthma control assessment
- 56. Follow up Asthma control assessment B. Risk factors for poor asthma outcomes • Having uncontrolled asthma • Medications: high SABA use, inadequate ICS: not prescribed ICS; poor adherence; incorrect inhaler technique • Comorbidities • Exposures: • Context: • Lung function: lowFEV1, especially <60% predicted high BD reversibility • Other major independent risk factors for flare-ups (exacerbations) • Ever intubated or in intensive care unit for asthma • ≥ 1 severe exacerbation in last 12 months Having any of these risk factors increases the patient’s risk of exacerbations even if they have few asthma symptoms
- 57. Referral uncertainty regarding the diagnosis Difficulty achieving or maintaining control of asthma Immunotherapy or biologic is being considered acute asthma exacerbation requiring hospitalization If the patient required 2 or more oral corticosteroid in the past 12 m.
- 59. Definition of asthma exacerbations Episodes characterized by a progressive increase in symptoms of shortness of breath, cough, wheezing or chest tightness and progressive decrease in lung function
- 60. What triggers asthma exacerbations? o Viral respiratory infections o Allergen exposure e.g. grass pollen, soy bean dust, fungal spores o Food allergy o Outdoor air pollution o Seasonal changes and/or returning to school in fall (autumn) o Poor adherence with ICS
- 61. 2020 67 Management Of Asthma Exacerbations in PRIMARY CARE
- 62. PRIMARY CARE Patient present with acute or sub-acute asthma exacerbation ASSESS the PATIENT Is it asthma ? Severity of exacerbation ? MILD – MODERATE - Talks in phrases - Prefers sitting - Not agitated - RR increased - Accessory muscle not used - Pulse 100-120 bpm - O2 sat 90- 95% - PEF >50% predicated or best SEVERE - Talks in WORDS - Sit HUNCHED forwarded - AGITATITED - RR > 30 - Accessory muscle USED - Pulse > 120 bpm - O2 sat < 90 % - PEF <50% predicated or best LIFE- THREATENING - Drowsy - Confused - Silent chest
- 63. MILD – MODERATE SEVERE LIFE-THREATENING START TREATMENT SABA: 4-10 puffs by pMDI + spacer ( reapet every 20 min for 1 hr ) Predinsolne : Adult 40-50 mg Cildern 1-2mg/Kg, max 40 mg Controlled oxygen ( if avaliable) : Targeted saturation: Adut: 93-95% Children: 94-98% WORSENING TRANSFER TO ACUTE CARE FACITITY While waiting: give SABA, ipratropium, O2, systemic corticostroid ASSESS RESPONSE AT 1 HOUR ( or earlier ) Continue treatment with SABA as needed WORSENING
- 64. AFTER TREATMENT ASSESS FOR DISCHARGE - Symptoms improved - Not needing SABA - PEF improving >60-80% - O2 sat > 94% at room air - Resources at home adequate ARRANGE at DISCHARGEYGTR - Reliver: continue as needed - Controller: start, or step up - Check inhaler technique, adherence - Prednisolone: continue, usually for 5-7 days ( 3-5 days for children) - Follow up: within 2-7 days ( 1-2 days for children ) FOLLOW UP - Review symptoms and signs - Reliver : reduce to as-needed - Controller : continue high dose for short term (1-2 weeks ) or longer - Risk factors : check and correct modifiable risk factors - Refer: if > 1-2 exacerbation in a year - Action plan : understood? Used appropriately ? Need modification ?
- 65. 8- A 19-year-old female presents to the ED with complaints of wheezing. She has a history of asthma. In general, she has mild asthma controlled with occasional albuterol and not requiring an inhaled steroid. However, over the past several months, things have accelerated, and she now uses her rescue inhaler daily. On examination, she is tachypneic, using accessory muscles of respiration with a respiratory rate of 30 and wheezing in all fields. Her oxygen saturation is 95% on room air. Pulse is 110 bpm with a normal BP. You decide to initiate therapy for this patient. Of the following options, the initial treatment of this patient is: A) Subcutaneous epinephrine B) Albuterol MDI (metered-dose inhaler) with spacer C) Nebulized ipratropium D) Oral steroids E) IV steroids
- 66. 2020 73 Management Of Asthma Exacerbations in ER
- 69. 2020 77 QUIZ
- 70. 1 2 -
- 71. 1- A 28-year-old male with a long history of severe asthma presents to the emergency room with shortness of breath. He has previously required admission to the hospital and was once intubated for asthma. Which of the following findings on physical examination would predict a benign course? Silent chest Hypercapnia Thoracoabdominal paradox (paradoxical respiration) Pulsus paradoxus of 5 mm Hg Pulsus paradoxus of 5 mm Hg
- 72. 2- Your patient’s office spirometry shows the following: Normal FVC FEV1 82% predicted FEV1/FVC 0.68 These findings are most consistent with which of the following? Normal spirometry Obstructive lung disease End-stage emphysema Interstitial fibrosis
- 73. 3- You are caring for a 22-year-old with moderate persistent asthma who has been wellcontrolled for several months. He developed an upper respiratory infection and his control worsened. He has not had a fever, but is coughing up sputum. In addition to stepping up his therapy, which of the following is true? begin a course of amoxicillin begin a course of amoxicillin/clavulanat e begin a course of azithromycin No antibiotics are necessary
- 74. 4- Which one of the following is TRUE concerning the use of short-acting inhaled beta agonists for asthma? They should be given before any inhaled corticosteroid to facilitate lung delivery They are ineffective in patients taking beta blockers They are less effective than oral beta agonists GINA strategy no longer recommends treatment of asthma in adults and adolescents with SABA alone
- 75. 5- a 19-year-old female who newly diagnosed with asthma. Patient reports symptoms less than 2 times in a month , her symptoms didn’t cause her to skip her usual exercise regimen and didn’t wake her at night. Based on the latest updated GINA strategy , what’s the best next step ? Reassurance Start her on Inhaled corticosteroids as needed Start her on ICS-formoterol as needed Start her on SABA as needed
- 76. 6- Which of the following medications, when used alone as maintenance therapy in persistent asthma, is associated with an increased risk of asthma-related mortality? Inhaled fluticasone Inhaled salmeterol Oral zafirlukast Oral prednisone
- 77. 7- When initiating supplemental oxygen by nasal cannula for a patient with acute asthma exacerbation, you instruct the nurse to keep the patient’s oxygen saturation: Between 96% and 100% Between 90% and 95% Between 85% and 89% At whatever saturation he looks most comfortable
- 78. 8- A 19-year-old female presents to the ED with complaints of wheezing. She has a history of asthma. In general, she has mild asthma controlled with occasional albuterol and not requiring an inhaled steroid. However, over the past several months, things have accelerated, and she now uses her rescue inhaler daily. On examination, she is tachypneic, using accessory muscles of respiration with a respiratory rate of 30 and wheezing in all fields. Her oxygen saturation is 95% on room air. Pulse is 110 bpm with a normal BP. Her blood gas is as follows: pH 7.40, CO2 40 mm Hg, O2 80 mm Hg, and HCO3 24 mEq/L. A normal blood gas in this patient suggests that: This is a mild exacerbation that should respond well to therapy she has a respiratory acidosis She has a respiratory alkalosis This is a severe exacerbation that will require aggressive therapy
- 79. 9- Which of the following tests are indicated in routine evaluation of a patient with an asthma exacerbation? Chest x-ray CBC Arterial blood gas None of the above
- 80. 10- A 32-year-old woman complains of severe seasonal asthma . Every year from April through July she is complains of cough, chest tightness . and the rest of the year days she is symtoms free. At what step ( ASTHMA TREATMENT STEPS you should start her ? step 1 Step 2 Step 3 Step 4
- 82. Reference
Editor's Notes
- Physical exam. Wheezing on auscultation is the prominent finding, which is a high-pitched “musical” sound, most prominent with expiration, but may be absent in very severe bronchos- pasm, reflecting severely impaired airflow. There is hyperresonance on percussion. There may be tachypnea or tachycardia, depending on severity of exacerbation. A pulsus paradoxus (inspiratory decrease in systolic blood pressure of more than 10 mm Hg) indicates gross overinflation of the lung and wide swings in pleural pressure. This is present only in severe asthma exacerbations.
- Q1 : How to take a history of bronchial asthma ? Q2 : How to examin a patient with bronchial asthma ? History of Present Illness. Patients with asthma usually present at a young age, although some patients have onset of asthma in middle age. With an asthma exacerbation (attack), patients will experience dyspnea, cough (productive or nonproductive), and chest tightness. They may report audible wheezing. The symptoms are intermittent, may occur at night or in the early morning or may be seasonal. The symptoms occur in response to a variety of stim- uli: inhaled allergens (pollen, dust mites, animal dander), viral infection, irritants (tobacco or wood smoke), airborne chemicals (perfumes), exercise, changes in weather, strong emotion (laughing or crying hard), or stress. Patients presenting with persistent non-productive cough as the only respiratory symptom Diagnoses to be considered are chronic upper airway cough syndrome (often called ‘postnasal drip’), cough induced by angiotensin converting enzyme (ACE) inhibitors, gastroesophageal reflux, chronic sinusitis, and inducible laryngeal obstruction.35,36 Patients with so-called ‘cough-variant asthma’ have persistent cough as their principal or only symptom, associated with airway hyperresponsiveness. It is often more problematic at night. Lung function may be normal, and for these patients, documentation of variability in lung function (Box 1-2, p.23) is important.37 Cough-variant asthma must be distinguished from eosinophilic bronchitis in which patients have cough and sputum eosinophilia but normal spirometry and airway responsiveness.37
- Symptoms are triggered by viral infections (colds), exercise, allergen exposure, changes in weather, laughter, or irritants such as car exhaust fumes, smoke or strong smells.
- Symptoms are triggered by viral infections (colds), exercise, allergen exposure, changes in weather, laughter, or irritants such as car exhaust fumes, smoke or strong smells.
- Medication : Beta blocker , NSAID ASPIRIN,
- Past medical history may include other forms of atopy, like eczema, allergic rhinitis, or aller- gic conjunctivitis. Family history mayi nclude a family history of atopy or asthma. Social history can be significant for living conditions: mold, carpet, tobacco, pet exposure. The presence of atopy increases the probability that a patient with respiratory symptoms has allergic asthma, history and family history Commencement of respiratory symptoms in childhood, a history of allergic rhinitis or eczema, or a family history of asthma or allergy, increases the probability that the respiratory symptoms are due to asthma. However, these features are not specific for asthma and are not seen in all asthma phenotypes. Patients with allergic rhinitis or atopic dermatitis should be asked specifically about respiratory symptoms.
- Past medical history may include other forms of atopy, like eczema, allergic rhinitis, or aller- gic conjunctivitis. Family history mayi nclude a family history of atopy or asthma. Social history can be significant for living conditions: mold, carpet, tobacco, pet exposure.
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- Physical exam. Wheezing on auscultation is the prominent finding, which is a high-pitched “musical” sound, most prominent with expiration, but may be absent in very severe bronchos- pasm, reflecting severely impaired airflow. There is hyperresonance on percussion. There may be tachypnea or tachycardia, depending on severity of exacerbation. A pulsus paradoxus (inspiratory decrease in systolic blood pressure of more than 10 mm Hg) indicates gross overinflation of the lung and wide swings in pleural pressure. This is present only in severe asthma exacerbations.
- Physical exam. Wheezing on auscultation is the prominent finding, which is a high-pitched “musical” sound, most prominent with expiration, but may be absent in very severe bronchos- pasm, reflecting severely impaired airflow. There is hyperresonance on percussion. There may be tachypnea or tachycardia, depending on severity of exacerbation. A pulsus paradoxus (inspiratory decrease in systolic blood pressure of more than 10 mm Hg) indicates gross overinflation of the lung and wide swings in pleural pressure. This is present only in severe asthma exacerbations. Physical examination in people with asthma is often normal. The most frequent abnormality is expiratory wheezing (rhonchi) on auscultation, but this may be absent or only heard on forced expiration. Wheezing may also be absent during severe asthma exacerbations, due to severely reduced airflow (so called ‘silent chest’), but at such times, other physical signs of respiratory failure are usually present. Wheezing may also be heard with inducible laryngeal obstruction, chronic obstructive pulmonary disease (COPD), respiratory infections, tracheomalacia, or inhaled foreign body. Crackles (crepitations) and inspiratory wheezing are not features of asthma. Examination of the nose may reveal signs of allergic rhinitis or nasal polyposis.
- The diagnosis of asthma is made predominantly by history, physical, and pulmonary function testing. Spirometry profides a wealth of information about lung voulmes and function Spirometery reports can be confusing . However, by looking at four indices , most of the important pattenrs of lung disease cab be distingushed Forced expiratory volume in 1 second (FEV1) from spirometry is more reliable than peak expiratory flow (PEF). If PEF is used, the same meter should be used each time, as measurements may differ from meter to meter by up to 20%.14 . Pulmonary function tests are typically normal when thepatient is not having an exacerbation of asthma. Now, because asthma is an obstructive lung disease, the FEV1 is decreased to a greater degree than the FVC1, so the ratio of FEV1 to FVC is usually less than 80%. Also, because asthma is episodic in nature, the PFTs are only abnormal when the patient is having symptoms. During attacks the FEV1 and FVC are reduced; the FEV1/FVC ratio is reduced but usually improves after inhalation of a bronchodilator, reflecting reversibility (the FEV1 should improve by 12% or more with bronchodilators—albuterol—to be considered reversible). RV, TLC, and lung compliance usually are increased, and the DLCO frequently is normal or MAYBE INCREASED In the absence of a reduced FEV1/FVC ratio but a suspicion for asthma, the methacholine challenge test may be performed to test for increased bronchial hyperresponsiveness and. if abnormal, is consistent with a diagnosis of asthma. It is performed by administering metha- choline (a cholinergic agonist) at increasing doses and monitoring for a decline in the FEV1 (20% decline is abnormal). Forced expiratory volume in 1 second (FEV1) from spirometry is more reliable than peak expiratory flow (PEF). If PEF is used, the same meter should be used each time, as measurements may differ from meter to meter by up to 20%.14 once an obstructive defect has been confirmed, variation in airflow limitation is generally assessed from variation in FEV1 or PEF. ‘Variability’ refers to improvement and/or deterioration in symptoms and lung function. Bronchial provocation tests Challenge agents include inhaled methacholine, histamine, exercise,19 eucapnic voluntary hyperventilation or inhaled mannitol. These tests are moderately sensitive for a diagnosis of asthma but have limited specificity; In the absence of a reduced FEV1/FVC ratio but a suspicion for asthma, the methacholine challenge test may be performed to test for increased bronchial hyperresponsiveness and. if abnormal, is consistent with a diagnosis of asthma. It is performed by administering metha- choline (a cholinergic agonist) at increasing doses and monitoring for a decline in the FEV1 (20% decline is abnormal).
- Now, if you do PFTs on asymptomatic patients, they would be normal, since asthma is an episodic disease. So, in this case we try to induce asthma symptoms by performing the “methacholine challenge test”. Methacholine is like acetylcholine, so it binds to muscarinic receptors on bronchial smooth muscle, causing mild bronchoconstriction.
- ANSWER: C Spirometry is central to confirming the diagnosis of asthma, which is characterized by a reversible obstructive pattern of pulmonary function. In this case the patient’s FEV1/FVC ratio is normal, which neither confirms nor rules out asthma. A methacholine challenge is recommended in this scenario to assess for the airway hyperresponsiveness that is the hallmark of asthma. Methacholine is a cholinergic agonist. Bronchoconstriction (defined as a reduction in FEV1 20%) observed at low levels of methacholine administration (<4 mg/mL) is consistent with asthma. If the FEV1/FVC ratio is reduced on initial spirometry, a bronchodilator response should be tested. A fixed or partially reversible obstructive pattern suggests an alternative diagnosis such as COPD, and full reversal after bronchodilator use is consistent with asthma. Inhaled corticosteroids are not appropriate for intermittent asthma.
- Answer 3.3.1 The correct answer is “A.” Since this patient has symptoms of bronchospasm, spirometry will be essential in determining if there is objective evidence of obstructive lung disease. However, spirometry results are often normal in mild cases of asthma, especially when the patient is asymptomatic. Bronchoprovocation testing, with methacholine or histamine, may be useful in such cases, but should follow basic spirometry. Although chest radiography (x-ray or CT) may reveal an occult process, it is not indicated in otherwise healthy patients with symptoms of bronchospasm. Bacterial pneumonia is a potential precipitant of bronchospasm that may be diagnosed on chest x-ray, but this patient has no constitutional symptoms (like fever) associated with serious bacterial infection. Obtaining an ABG (or better yet a venous blood gas) may be helpful when a patient pres- ents with respiratory distress but certainly not in the office setting.
- HELPFUL TIP: Remember the “rule of twos”: any patient who has >2 asthma exacerbations per week requiring rescue medi- cation or who wakes with nocturnal symptoms >2 times per month should be on an anti-inflammatory drug, preferably an inhaled corticosteroid. Asthma classifica- tion and treatment has gotten ridiculously complex. You
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- factors (Indoor\ Outdoor allergens )
- LABAs should not be used without cotherapy with corti- costeroids, as use of LABAs alone in asthma may increase mortality.
- Reddel HK, Ampon RD, Sawyer SM, Peters MJ. Risks associated with managing asthma without a preventer: urgent healthcare, poor asthma control and over-the-counter reliever use in a cross-sectional population survey. BMJ open 2017;7:e016688. Hancox RJ, Cowan JO, Flannery EM, Herbison GP, McLachlan CR, Taylor DR. Bronchodilator tolerance and rebound bronchoconstriction during regular inhaled beta-agonist treatment. Respir Med 2000;94:767-71. Aldridge RE, Hancox RJ, Robin Taylor D, Cowan JO, Winn MC, Frampton CM, Town GI. Effects of terbutaline and budesonide on sputum cells and bronchial hyperresponsiveness in asthma. Am J Respir Crit Care Med 2000;161:1459-64. Stanford RH, Shah MB, D’Souza AO, Dhamane AD, Schatz M. Short-acting β-agonist use and its ability to predict future asthma-related outcomes. Annals of Allergy, Asthma & Immunology 2012;109:403-7. Suissa S, Ernst P, Boivin JF, Horwitz RI, Habbick B, Cockroft D, Blais L, et al. A cohort analysis of excess mortality in asthma and the use of inhaled beta-agonists. Am J Respir Crit Care Med 1994;149:604-10.
- From product information, the maximum recommended total in one day is 72 mcg formoterol (12 inhalations of budesonide-formoterol Turbuhaler 200/6 mcg)
- Regular or over-use of SABAs: this causes beta-receptor down-regulation and reduction in response,
- https://www.sfda.gov.sa/en/drugs-list
- https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1920547/
- An integral part of asthma management is the development of a written asthma action plan by the person with asthma and/or their carer together with their doctor. An asthma action plan helps the person with asthma and/or their carer recognise worsening asthma and gives clear instructions on what to do in response. https://www.nationalasthma.org.au/health-professionals/asthma-action-plans/asthma-action-plan-library The asthma action plan may be based on symptoms and/or peak expiratory flow (PEF) measurements and is individualised according to the pattern of the person’s asthma. In children, symptom-based plans are preferred. Once completed, the asthma action plan is given to the person with asthma and/or their carer to keep. Parents should give a copy of their child’s asthma action plan to the school, pre-school and/or childcare facility. Regular review of the asthma action plan is important as a person’s level of asthma severity or control may change over time. c29d66c9cd7bc1f38bcdb6088cd11bf2.jpg
- Usage of PEF in self management plan !
- What does the term ‘asthma control’ mean to patients? Many studies describe discordance between the patient’s and health provider’s assessment of the patient’s level of asthma control. This does not necessarily mean that patients ‘over-estimate’ their level of control or ‘under-estimate’ its severity, but that patients understand and use the word ‘control’ differently from health professionals, e.g. based on how quickly their symptoms resolve when they take reliever medication.59,60 If the term ‘asthma control’ is used with patients, the meaning should always be explained. Simple screening tools: these can be used in primary care to quickly identify patients who need more detailed assessment. Examples include the consensus-based GINA symptom control tool (Part A, Box 2-2A). This classification correlates with assessments made using numerical asthma control scores.64,65 It can be used, together with a risk assessmen Asthma symptoms such as wheeze, chest tightness, shortness of breath and cough typically vary in frequency and intensity, and contribute to the burden of asthma for the patient. Poor symptom control is also strongly associated with an increased risk of asthma exacerbations.61-63 Asthma symptom control should be assessed at every opportunity, including during routine prescribing or dispensing. Directed questioning is important, as the frequency or severity of symptoms that patients regard as unacceptable or bothersome may vary from current recommendations about the goals of asthma treatment, and differs from patient to patient. For example, despite having low lung function, a person with a sedentary lifestyle may not experience bothersome symptoms and so may appear to have good symptom control. Patients with asthma should be reviewed regularly to monitor their symptom control, risk factors and occurrence of exacerbations, as well as to document the response to any treatment changes. For most controller medications, improvement begins within days of initiating treatment, but the full benefit may only be evident after 3–4 months. Ideally, patients should be seen 1–3 months after starting treatment and every 3–12 months thereafter. After an exacerbation, a review visit within 1 week should be scheduled268 (Evidence D). Asthma symptom control should be assessed at every opportunity, including during routine prescribing or dispensing. Directed questioning is important, as the frequency or severity of symptoms that patients regard as unacceptable or bothersome may vary from current recommendations about the goals of asthma treatment, and differs from patient to patient. For example, despite having low lung function, a person with a sedentary lifestyle may not experience bothersome symptoms and so may appear to have good symptom control.
- Having uncontrolled asthma symptoms is an important risk factor for exacerbations. B. Risk factors for poor asthma outcomes Assess risk factors at diagnosis and periodically, particularly for patients experiencing exacerbations. Measure FEV1 at start of treatment, after 3–6 months of controller treatment to record the patient’s personal best lung function, then periodically for ongoing risk assessment.
- , i.e. they represent a change from the patient’s usual status that is sufficient to require a change in treatment. Exacerbations may occur in patients with a pre-existing diagnosis of asthma or, occasionally, as the first presentation of asthma.
- Exacerbations usually occur in response to exposure to an external agent (e.g. viral upper respiratory tract infection, pollen or pollution) and/or poor adherence with controller medication; however, a subset of patients present more acutely and without exposure to known risk factors.513,514 Severe exacerbations can occur in patients with mild or well- controlled asthma symptoms.11,188 Box 2-2B (p.35) lists factors that increase a patient’s risk of exacerbations, independent of their level of symptom control. Treatment options for written asthma action plans A written asthma action plan helps patients to recognize and respond appropriately to worsening asthma. It should include specific instructions for the patient about changes to reliever and controller medications, how to use oral corticosteroids (OCS) if needed (Box 4-2) and when and how to access medical care. The criteria for initiating an increase in controller medication will vary from patient to patient. For patients taking maintenance-only ICS-containing treatment, this should generally be increased when there is a clinically important change from the patient’s usual level of asthma control, for example, if asthma symptoms are interfering with normal activities, or PEF has fallen by >20% for more than 2 days.404
- History The history should include: Timing of onset and cause (if known) of the present exacerbation Severity of asthma symptoms, including any limiting exercise or disturbing sleep Any symptoms of anaphylaxis Any risk factors for asthma-related death (Box 4-1, p.113) All current reliever and controller medications, including doses and devices prescribed, adherence pattern, any recent dose changes, and response to current therapy. Physical examination The physical examination should assess: Signs of exacerbation severity (Box 4-3, p.119) and vital signs (e.g. level of consciousness, temperature, pulse rate, respiratory rate, blood pressure, ability to complete sentences, use of accessory muscles, wheeze). Complicating factors (e.g. anaphylaxis, pneumonia, pneumothorax) Signs of alternative conditions that could explain acute breathlessness (e.g. cardiac failure, inducible laryngeal obstruction, inhaled foreign body or pulmonary embolism). Objective measurements Pulse oximetry. Saturation levels <90% in children or adults signal the need for aggressive therapy. PEF in patients older than 5 years (Box 4-3, p.119) The main initial therapies include repetitive administration of short-acting inhaled bronchodilators, early introduction of systemic corticosteroids, and controlled flow oxygen supplementation.526 The aim is to rapidly relieve airflow obstruction and hypoxemia, address the underlying inflammatory pathophysiology, and prevent relapse. Delivery of SABA via a pMDI and spacer or a DPI leads to a similar improvement in lung function as delivery via nebulizer
- For mild to moderate exacerbations, repeated administration of inhaled SABA (up to 4–10 puffs every 20 minutes for the first hour) is an effective and efficient way to achieve rapid reversal of airflow limitation Controller medication Patients already prescribed controller medication should be provided with advice about increasing the dose for the next 2–4 weeks, Patients who present with signs of a severe or life-threatening exacerbation (Box 4-3, p.119), who fail to respond to treatment, or who continue to deteriorate should be transferred immediately to an acute care facility. Patients with little or slow response to SABA treatment should be closely monitored.
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- Answer1.14.3Thecorrectansweris“B.”Theinitialtreatment for this patient—and any patient presenting with an asthma exac- erbation—is a bronchodilator. A beta-agonist is preferred, in this case albuterol. It makes little difference whether this is via nebu- lizer or MDI, as long as one uses adequate doses. One albuterol nebulization is equal to about 8 to 10 puffs of an albuterol MDI with a spacer. “A” is incorrect because subcutaneous epinephrine is second or third line in the treatment of asthma. “C” is incor- rect. While ipratropium is effective in asthma, it may be given with albuterol (Duoneb) and should not be given alone. “D” and “E” are incorrect. Steroids are indicated, but bronchodilator therapy is the primary treatment in acute asthma exacerbations.
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- 104. The answer is d. (Fauci pp 1596-1607.) It is important to accurately determine the severity of an exacerbation of asthma, since the major cause of death from asthma is the underestimation of the severity of a particular episode by either the patient or the physician. Silent chest is a particularly ominous finding, because the airway constriction is so great that airflow is insufficient to generate wheezing. Hypercapnia and thoracoabdominal paradox are almost always indicative of exhaustion and respiratory muscle failure or fatigue and generally need to be aggressively treated with mechanical ventilation. Altered mental status suggests severe hypoxia or hypercapnia, and ventilatory support is usually required. An increased pulsus paradoxus may also be a sign of severe asthma, as it increases with greater respiratory effort and generation of negative intrathoracic pressures during inspiration. However, pulsus paradoxus up to 8 to 10 mm Hg is considered normal; thus, a value of 5 mm Hg would not sug- gest a severe episode of asthma.
- Answer 3.3.3 The correct answer is “B.” Always go first to the FEV1/FVC ratio. In this case, it is <0.70, which is suggestive of airway obstruction. The information provided here lacks data regarding DLCO which should be decreased in emphysema, so you could not really differentiate between chronic obstruc- tive pulmonary disease (COPD) and asthma. But this is clearly not end-stage emphysema, so “C” is incorrect. “D” is incorrect. Interstitial fibrosis is generally marked by a restrictive pattern on spirometry and decreased TLC. Both flow rate (e.g., FEV1) and FVC are decreased in interstitial lung diseases but in proportion to each other. Thus, the FEV1/FVC is often normal or elevated. See Table 3-1 for more on interpreting spirometry results.
- The answer is D. Multiple studies have shown that infections with viruses and bacteria predispose to acute asthma exacerbations. However, the use of empiric antibiotics is not recommended. There is no consistent evidence to support improved clinical outcomes. Antibiotics should be considered in cases where there is a high likelihood of acute bacterialrespiratory infection, as in the case of high fever, purulent sputum production, or radiographic evidence of lower respiratory or sinus infection.
- D
- C
- Answer 3.3.9 The correct answer is “B.” Inhaled salmeterol, when used alone as a controller agent for asthma, has been asso- ciated with a two- to fourfold increase in the risk of death related to asthma or other respiratory conditions. Thus, the Food and Drug Administration (FDA) has mandated a “black box” warn- ing be applied to salmeterol-containing products. It is not known whether inhaled steroid therapy is protective, but NHLBI/ NAEPP guidelines recommend adding long-acting inhaled beta-agonists only after inhaled steroids are already in use.
- Answer 3.4.2 The correct answer is “B.” The primary goal of supplemental oxygen is to reduce the risk of tissue hypoxia. Maintaining oxygen saturations above 90% (or PaO2 60–65 mm) will ensure tissue oxygenation. Higher oxygen saturations may result in CO2 retention and hypercapnia, as noted earlier. Also, aiming at 100% with excessive levels of O2 supplemen- tation takes away an important patient assessment parameter because now you cannot tell easily whether his O2 needs are going up or down. “D” is of special note. Patients with COPD who look comfortable may be developing hypercapnia and CO2 narcosis. Thus, while comfort is a goal, it may not be the best judge of clinical status in patients with COPD exacerbations. To assess CO2 levels, you will need an ABG or VBG.
- Answer 1.14.1 The correct answer is “D.” A pH of 7.4 with a CO2 of 40 mm Hg in a patient who is asthmatic and tachypneic is a bad sign. The CO2 should be low in a tachypneic patient because they will be blowing off CO2. Thus, a normal CO2 and normal pH indicate that the patient is retaining CO2. This is just another case where looking at the patient is more impor- tant than looking at the labs. Even though the blood gas itself is technically within normal limits, this patient clinically appears sick. “B” and “C” are both incorrect since the blood gas indicates neither an acidosis nor alkalosis.
- Answer 1.14.2 The correct answer is “D.” None of the above tests are indicated in the routine evaluation of an asthma exacer- bation. A chest x-ray (“A”) should be reserved for those patients in whom pneumonia or other pulmonary process is suspected. A CBC (“B”) is not going to change your therapy in the routine asthma exacerbation and is not indicated. Likewise, an ABG (“C”) is unnecessary in most asthma exacerbations. It can be used to assist in your clinical evaluation to determine whether or not the patient is retaining CO2; however, even in the “crash- ing patient,” an ABG is not necessary because intubation is a clinical decision and should not be based on the blood gas.
- B For patients with purely seasonal allergic asthma, e.g. with birch pollen, with no interval asthma symptoms, regular daily ICS or as-needed ICS-formoterol should be started immediately symptoms commence, and be continued for four weeks after the relevant pollen season ends (Evidence D).