1. Asthma in a Nutshell Holger Link, MD

2. The Complexity of Asthma Immune System Environment Injury and Repair Genes

3. Major Criteria: - Parental asthma - Eczema Minor Criteria: - Allergic rhinitis - Wheezing apart from colds - Eosinophilia >4% Predicting asthma in young frequent “wheezers” Children less than 3 years of age with >3 episodes of wheezing per year and at least 1 major or 2 minor criteria: Am J Respir Crit Care Med Vol. 2000; 162: 1403-1406

4. Initial asthma visit Establish DiagnosisDetermine Severity Identify triggers Start Medication Educate: Treatment goals Inhaler technique Elimination of triggers Asthma action plan Explore parent's and patient's perspective Review and implement short and long term follow up schedule Adapted with modification from the National Asthma Education and Prevention Program. Asthma Care Quick Reference Guide: Diagnosing and Managing Asthma, 2012. NIH Publication No. 12-5075. Bethesda, MD: National Heart, Lung, and Blood Institute.

5. Follow up asthma visit Assess Asthma Control Identify asthma triggers and plan for elimination Review asthma action plan, treatment goals, proper inhaler use and parent/patient concerns Adjust medication if needed according to six step model Schedule follow up visit Parents and patient monitor asthma symptoms Adapted with modification from the National Asthma Education and Prevention Program. Asthma Care Quick Reference Guide: Diagnosing and Managing Asthma, 2012. NIH Publication No. 12-5075. Bethesda, MD: National Heart, Lung, and Blood Institute.

6. Goals of asthma therapy Impairment: − Good quality of life − Good symptom control − Rare use of  2 -agonist − No exercise or activity limitation Risk: ̶ Decrease emergency department visits or hospital admissions ̶ Decrease number and severity of exacerbations ̶ Reduce medication side effects

7. Troubleshooting poorly controlled asthma Confirm that patient takes medication Review correct inhaler technique Try different medication combinations Identify and removed all triggers Consider alternative diagnosis

8. Alternative diagnoses Red FlagPossible Diagnosis Sudden onset of symptomsForeign body Coughing and choking when eating or drinkingOropharyngeal dysphagia with aspiration Poor growth and low body mass indexCystic fibrosis, immune deficiency Family history of sterile malesCystic fibrosis, immotile cilia syndrome Chronic rhinorrhea and recurrent sinus infectionsCystic Fibrosis, immotile cilia syndrome Acute onset without prior history of asthma in teenagerVocal cord dysfunction Chronic wet productive coughBronchiectasis More than two episodes of pneumoniaImmune deficiency

9. Red flags for vocal cord dysfunction Not responding to standard asthma therapy Very acute onset and resolution of Sx Onset of symptoms in teenage years Never symptomatic during sleep Negative family history Negative allergic history

10. Normal and abnormal flow-volume loop Normal flow-volume loop Inspiratory flow-volume loop limitation as seen in vocal cord dysfunction