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PATIENT & FAMILY ASSESSMENT Presented by: Michelle Harkins, MD.

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Presentation on theme: "PATIENT & FAMILY ASSESSMENT Presented by: Michelle Harkins, MD."— Presentation transcript:

1 PATIENT & FAMILY ASSESSMENT Presented by: Michelle Harkins, MD

2 Medical history Physical exam Objective measures This lesson will cover:

3 Determine that: Patient has a history or presence of episodic symptoms of airflow obstruction or hyper- reactivity (wheeze, chest tightness, shortness of breath or cough). Airflow obstruction is at least partially reversible. Alternative diagnoses are excluded. Initial Assessment & Diagnosis of Asthma NAEPP. EPR-3, page 40.

4 Methods for establishing diagnosis: Detailed medical history (airway hyper-reactivity, recurrence, reversibility) Physical exam Spirometry to demonstrate reversibility Additional studies as necessary to exclude alternative diagnoses Initial Assessment & Diagnosis of Asthma NAEPP. EPR-3, page 40.

5 Symptom history and Quality of Life Questionnaires: History of symptoms of airflow obstruction – Cough – Wheeze – Chest tightness/pain – Shortness of breath Episodic symptoms Response to treatment Medical History

6 Identify symptoms Pattern of symptoms Precipitating/aggravating factors Development of disease and treatment Family history –Atopy, asthma Medical History NAEPP. EPR-3, page 69.

7 Social history History of exacerbations Impact of asthma on patient/family Patient/family perception of the disease Medical History NAEPP. EPR-3, page 69

8 In the past 12 months, have you had: A sudden, severe episode or recurrent episodes of coughing, wheezing or shortness of breath? Colds that go to the chest or take more than 10 days to get over? Coughing, wheezing or shortness of breath (SOB) during a particular season or time of the year? Coughing, wheezing or SOB in certain places or when exposed to certain things, such as animals, tobacco smoke, perfumes? Interviewing the Individual with Asthma NAEPP. EPR-3, page 70

9 In the past 12 months, have you had: Do you have symptoms of heartburn or awaken with an acid taste in back of your throat? Do you have symptoms of post-nasal drip or sinus congestion? Has wheezing, cough, chest tightness, shortness of breath – Awakened you at night? In the early morning? After running, moderate exercise or other physical activity? Interviewing the Individual with Asthma NAEPP. EPR-3, page 70.

10 In the past 12 months, have you had: Have you used any medicine that has helped you breathe better? How often? Are your symptoms relieved when these medicines are used? Interviewing the Individual with Asthma NAEPP. EPR-3, page 70.

11 Early Asthma Signs & Symptoms Coughing Wheezing Shortness of breath Chest tightness and/or pain Peak-flow numbers usually 50% to 80% of personal best Symptoms that indicate an asthma episode is occurring

12 Itchy throat or chin Runny or stuffy nose Sneezing Headache Funny feeling in the chest Stomach ache/poor appetite Glassy eyes Feeling tired Other Early Warning Signs & Symptoms

13 Severe asthma symptoms are a life-threatening emergency. They indicate respiratory distress. Examples of severe asthma symptoms include: Patient experiences severe coughing, wheezing, shortness of breath or tightness in the chest Patient experiences difficulty talking or concentrating; mental deterioration may occur. Walking causes shortness of breath. Late or Severe Asthma Symptoms

14 Breathing may be shallow and fast, or slower than usual; paradoxical breathing in small children Shoulders may be hunched. Nasal flaring may be present. Accessory muscle use and retractions may be present. –Retractions: Neck area and between or below the ribs moves inward with breathing Severe Asthma Symptoms

15 Skin may be gray or bluish tint, beginning around the mouth or fingernail beds (cyanosis). Peak-flow numbers may be in the danger zone (usually below 50% of personal best). Wheezing may be moderate, loud or absent. –The absence of wheezing implies severely compromised airflow. Severe Asthma Symptoms

16 Pulses Paradoxus: There is normally a decrease in systolic pressure during inspiration, When that difference is greater than 10 mmHg, it is called pulsus paradoxus. A paradox is caused by a fall in cardiac output as a result of increased negative intrathoracic pressure. Severe Asthma Symptoms

17 Past history of sudden, severe exacerbations Prior intubation for asthma Prior ICU admission for asthma >2 asthma hospitalizations in past year >3 asthma ER visits/year. Hospitalized/ER asthma visit in past month High-Risk Asthma Patients NAEPP. EPR-3, page 377.

18 >2 albuterol MDIs/month Low SES or inner city residence Poor perception of symptoms/severity Comorbidities Complex psychiatric/psychosocial problems Illicit drug use Sensitivity to Alternaria mold High-Risk Asthma Patients NAEPP. EPR-3, page 377.

19 The physical examination may be normal. Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma. Physical Examination NAEPP. EPR-3, page 377.

20 The upper respiratory tract, chest, and skin are the focus of the physical exam for asthma. Physical findings that increase the probability of asthma include: Hyper-expansion of the thorax, especially in children Use of accessory muscles, appearance of hunched shoulders, chest deformity Physical Examination NAEPP. EPR-3, page 42.

21 Sounds of wheezing during normal breathing or a prolonged phase of forced exhalation (typical of airflow obstruction) -- In intermittent asthma, or between exacerbations, wheezing may be absent. Increased nasal secretions, mucosal swelling, and/or nasal polyps Atopic dermatitis/eczema or any other manifestation of an allergic skin condition Physical Examination NAEPP. EPR-3, page 43.

22 What are some alternative diagnoses in adults that may present with similar symptoms? What Is Your Differential Diagnosis?

23 Alternative Diagnoses in Adults Chronic obstructive pulmonary disease – chronic bronchitis or emphysema Congestive heart failure Mechanical obstruction of the airways – benign and malignant tumors Cough secondary to drugs (angiotensin- converting enzyme [ACE] inhibitors) Vocal cord dysfunction NAEPP. EPR-3, page 46.

24 Signs and symptoms of asthma can vary widely and may mimic other common childhood illnesses. Diagnosis may be difficult. Asthma is frequently under diagnosed. Not all wheeze and cough are caused by asthma. Coughing may be the only symptom present. Recurrent episodes of cough suggest asthma, but other causes must be ruled out. Diagnosis of Asthma in Children

25 Alternative Diagnoses in Children Allergic rhinitisSinusitis Gastroesophageal reflux Laryngotracheomalacia Bronchopulmonary dysplasia Cystic Fibrosis NAEPP. EPR-3, page 46.

26 Alternative Diagnoses in Children Bronchiolitis Foreign body aspiration Vascular ring or laryngeal web Congenital heart disease Vocal cord dysfunction NAEPP. EPR-3, page 46.

27 In addition to the physical exam, other measures include: Radiology studies Spirometry Peak-flow monitoring Arterial Blood Gas /oxygen saturation Allergy testing Objective Measures

28 Interpret the Findings from: Family, clinical and past medical history Physical examination Vital signs Pulmonary function, radiology and laboratory results

29 Determine Diagnosis & Severity of Asthma Based on: History and QOL questionnaire Physical exam Objective measures

30 Components of Severity Intermittent Persistent MildModerateSevere Impairment Symptoms  2 days/week >2 days/week but not daily Daily Throughout the day Nighttime awakenings None 1-2x/ month 3-4x/month>1x/ week B-agonist use (not prevention of EIB)  2 days/week >2 days/week but not daily Daily Several times per day Activity limits None Minor Limitation Some Limitation Extremely Limited Risk Exacerbations requiring OSC 0-1/yr  2 exacerbations in 6 months requiring oral systemic corticosteroids, or  4 wheezing episodes/ 1 year lasting >1 day AND risk factors for persistent asthma Classifying Asthma Severity: 0 – 4 years Classifying severity in children who are not currently taking long- term control medication.

31 Components of Severity Intermittent Persistent MildModerateSevere Impairment Symptoms  2 days/wk >2 days/wk but not daily Daily Throughout the day Nighttime awakenings  2x/month 1-2x/month3-4x/month>1x/wk B-agonist use (not prevention of EIB)  2 days/wk >2 days/wk but not daily Daily Several times per day Activity limits None Minor limitation Some Limitation Extremely limited Lung Function FEV 1 FEV 1 /FVC >80% >85% 80% >80% 60 – 80% % <60% <75% Risk Exacerbations requiring OSC 0-1/yr  2/year Classifying Asthma Severity: 5 – 11 years Classifying severity in children who are not currently taking long- term control medication.

32 Classifying Asthma Severity: 12 and older Components of Severity Intermittent Persistent MildModerateSevere Impairment Normal FEV1/FVC: 8-19yrs 85% 20-39yrs 80% 40-59yrs 75% 60-80yrs 70% Symptoms  2 days/wk >2 days/wk but not daily Daily Throughout the day Nighttime awakenings  2x/month 3-4x/month >1x/wk but not nightly Often 7x/week B-agonist use (not prevention of EIB)  2 days/week >2 days/wk but not daily, and not more than 1x on any day Daily Several times per day Activity limits None Minor limitation Some Limitation Extremely limited Lung Function FEV 1 FEV 1 /FVC >80% normal 80% normal >60 -80% reduced 5% <60% reduced >5% Risk Exacerbations requiring OSC 0-1/yr  2/yr Classifying severity for patients who are not currently taking long- term control medication.

33 Objective assessments of pulmonary function are necessary for the diagnosis of asthma because: History and physical exam alone are not reliable for excluding other diagnoses or characterizing the status of lung impairment in the clinician’s office, Spirometry is necessary for diagnosis, and Peak-flow is used for monitoring control only Spirometry NAEPP. Epr-3, page 43.

34 Spirometry measures how much and how quickly air can be expelled following a deep breath. The patient breathes out forcefully into a device called a spirometer. Pre- and post-bronchodilator spirometry should be done when a diagnosis of asthma is being considered. Objective Measures: Spirometry

35 Forced Vital Capacity (FVC) The maximal volume of air forcibly exhaled from the point of maximal inhalation Forced Expiratory Volume in 1 second (FEV 1) The volume of air exhaled during the first second of the FVC Ratio of FEV1 to FVC (FEV1/FVC) Expressed as a percentage Peak Expiratory Flow (PEF) Maximum air flow (rate) during forced exhalation Spirometry Components

36 Airflow obstruction is indicated by reduced FEV1 and FEV1 /FVC values relative to reference or predicted values The predicted values depend on the individual’s age, gender, height and race. The numbers are presented as percentages of the average expected in someone of the same age, height, sex and race. This is called percent predicted. Spirometry Results

37 FEV1 Predicted:4.00L Patient’s FEV1:3.00L What is the percent predicted for this patient? 3.00 = 3 = 75% Calculating % Predicted

38 Abnormalities of lung function are categorized as restrictive and obstructive defects. A reduced ratio of FEV1 / FVC, as compared to the predicted value, indicates obstruction to the flow of air from the lungs. A reduced FVC with a normal FEV 1 /FVC ratio suggests a restrictive pattern. Objective Measures: Spirometry

39 Normal values for FEV1 and FVC are expressed in both absolute numbers and percent predicted of normal. Values for FVC and FEV1 that are above 80% of predicted are defined as within the normal range. (The FEV1/FVC ratio is at least 80% of patient’s vital capacity in one second.) FEV1/FVC ratio declines as a normal part of aging. Interpreting Spirometry

40 A normal flow volume loop has a rapid peak expiratory flow rate with a gradual decline in flow back to zero. Flow Volume Loop

41 Spirometry Results Showing Obstruction MeasuredPredicted Percent (%) Predicted FVC FEV FEV 1 /FVC4868 PEF

42 Obstructive lung disease changes the appearance of the flow volume curve. As with a normal curve, there is a rapid peak expiratory flow, but the curve descends more quickly than normal and takes on a concave shape. Obstruction

43 Normal Obstruction Normal vs. Obstructed

44  Both the FEV 1 and FVC are reduced proportionately.  FEV 1 /FVC ratio is normal or even elevated. MeasuredPredicted Percent (%) Predicted FVC FEV FEV 1 /FVC9869 PEF Restrictive Lung Disease

45 Restrictive Flow Volume Loop The shape of the flow volume loop is relatively unaffected in restrictive disease, but the overall size of the curve will appear smaller when compared to normals on the same scale.

46 Objective Measures: Spirometry Is airflow obstruction present and is it at least partially reversible? Use spirometry to establish airflow obstruction FEV1 < 80% predicted FEV1/FVC below the lower limit of normal, as compared to the individual’s own predicted value Use spirometry to establish reversibility FEV1 increases >12% and > 200 mL after using a short- acting inhaled beta2-agonist 2- to 3-week trial of oral corticosteroid therapy may be required to demonstrate reversibility

47 Pre BD FEV 1 = 2.00 L Post BD FEV 1 = 2.40 L What is the % improvement in FEV1? Example 1: 2.40 L – 2.00 L=.40 = 20% improvement 2.00L 2.00 Does this meet the NAEPP criteria? There is > 12% improvement. Calculating Change in FEV1

48 Post BD FEV1 minus Pre BD FEV1 Pre BD FEV 1 Pre BD FEV1 = 1.50L Post BD FEV1 = 1.80L What is the % improvement in FEV1? Example 2: 1.80L – 1.50L=.30 = 1 = 20% improvement 1.50L Does this meet the NAEPP criteria? Calculating Change in FEV1

49 Post BD FEV 1 minus Pre BD FEV1 Pre BD FEV 1 Pre BD FEV 1 = 3.00L Post BD FEV1 = 4.00L What is the % improvement in FEV1? Example 3: 4.00L – 3.00L= 1.00 = 33% improvement 3.00L 3.00 Does this meet the NAEPP criteria? Calculating Change in FEV1

50 Second requirement is >200ml increase 1.15 L minus 1.00 L is improvement of 0.15 L or 150 ml Does this meet the NAEAPP requirement? (Post BD minus Pre BD = >200ml) Calculating Change in FEV1

51 Spirometry is an effort-dependent maneuver that requires understanding, coordination and cooperation by the patient, who must be carefully instructed. Technicians must be trained and maintain a high level of proficiency to assure optimal results. Spirometry should be performed using equipment and techniques that meet standards developed by the American Thoracic Society. Reliability of Spirometry

52 Correct technique, calibration methods and maintenance of equipment are necessary to achieve consistently accurate test results. Maximal patient effort in performing the test is required to avoid important errors in diagnosis and management (reproducibility). Spirometry is generally valuable in children over age 4; however, some children cannot conduct the maneuver adequately until after age 7. Reliability of Spirometry

53 Criteria for acceptability include: 1.Lack of artifact induced by coughing, glottic closure or equipment problems (primarily leak); 2.Satisfactory start to the test without hesitation; and 3.Satisfactory exhalation with six seconds of smooth continuous exhalation, or a reasonable duration of exhalation with a plateau. Reliability of Spirometry

54 Unacceptable Efforts Cough Variable Effort

55 Painless procedure Noninvasive Outpatient Preparing Patients for Spirometry

56 Normal breathing prior to test Maximum forced exhalation during test Maneuver repeated until results are consistent Spirometry Maneuvers

57 Connect spirometry results to the broader picture of the patient’s asthma. Explain that spirometry results can improve with effective asthma management. Stress that effective asthma management can lead to less severe disease. Discussing Results with Patients

58 1.At the time of the initial assessment; 2.After treatment is initiated and symptoms and peak flow have stabilized to document attainment of (near) “normal” airway function; 3.During periods of loss of control; 4.When assessing response to a change in pharmacotherapy; and 5.At least every 1 to 2 years to assess the maintenance of airway function. NAEPP Recommends Spirometry NAEPP. EPR-3, pages 53, 59.

59 Depending on clinical severity, spirometry is also useful: As a periodic check on the accuracy of the peak-flow meter, When more precision is desired in evaluating response to therapy and When peak flow results are unreliable. Spirometry May Be Done More Frequently NAEPP. EPR-3, page 59.

60 Measured as the largest expiratory flow achieved with a maximally forced effort from a position of maximal inspiration, expressed in liters/minute. Spirometry documents PEFR in L/sec, so multiply this number by 60 to get L/min for noting personal best on the patient’s PFM. Peak Flow*

61 Long-term daily peak flow monitoring is helpful in managing patients with moderate-to-severe persistent asthma to: Detect early changes in disease status that require treatment, Evaluate responses to changes in therapy, Provide assessment of severity for patients with poor perception of airflow obstruction and Afford a quantitative measure of impairment. Peak-Flow Monitoring NAEPP. EPR-3, page 120

62 Not routine. Usually normal yet hyperinflation may be present Identify complications –Pneumonia –Pneumothorax –Pneumomediastinum –Tumor Radiological (CXR) Results

63 Arterial blood gases are useful in assessing acutely ill patients. Hypoxemia is generally not severe but does decline with worsening airflow obstruction. CO2 is low in mild exacerbations and rises with severity of obstruction. A normal CO2 in an acutely ill asthmatic can be a very serious finding. If the exacerbation progresses unabated, respiratory failure may result. “Normal” 7.40/40/70 Arterial Blood Gas (ABG)

64 Signs and symptoms Pulmonary Function Test QOL survey History of exacerbations Pharmacotherapy Patient satisfaction Periodic Assessments of Asthma Control NAEPP. EPR-3, page 53.

65 Assessing Control: 0 – 4 years Components of Control Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled Impairment Symptoms  2 days/wk >2 days/wkThroughout the day Nighttime awakenings  1x/month >1x/month>1x/week Activity limits NoneSome limitationExtremely limited B-agonist use (not prevention of EIB)  2 days/week >2 days/weekSeveral times per day Risk Exacerbations requiring OSC 0-1/year2-3/year>3/year Recommended Action for Treatment Maintain current treatment Regular F/U every 1 – 6 mos Consider step down if well controlled for at least 3 mos Step up (1step) and Reevaluate in 2 -6 wks If no benefit in 6 wks, consider alternative diagnoses Consider short course of OSC Step up (1 – 2 steps) and Reevaluate in 2 wks

66 Asthma Control: 5 – 11 years Components of Control Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled Impairment Symptoms  2 days/wk but not more than once on each day >2 days/wk or multiple times  2 days/wk Throughout the day Nighttime awakenings  1x/month ≥2x/month≥2x/week Activity limitsNoneSome limitationExtremely limited B-agonist use (not prevention of EIB)  2 days/wk >2 days/wkSeveral times per day Lung function FEV 1 or PF FEV 1 /FVC 80% >80% 60 – 80% 75-80% <60% <75% Risk Exacerbations requiring OSC 0-1/year ≥2/year Reduction in lung growth Evaluation requires long-term follow-up Treatment-related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

67 Asthma Control: 12 and older Components of Control Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Controlled Impairment Symptoms  2 days/week >2 days/weekThroughout the day Nighttime awakenings  2x/month 1-3x/week>4x/week Activity limits NoneSome limitationExtremely limited B-agonist use (not prevention of EIB)  2 days/week >2 days/weekSeveral times per day Lung function FEV 1 or PF >80%FEV 1 or PF = %FEV 1 or PF <60% QOL indicator ACT ≥20ACT =16-19ACT ≤15 Risk Exacerbations requiring OSC 0-1/year > 2/ year Reduction in lung growth Evaluation requires long-term follow-up Treatment- related adverse effects Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.

68 Potential for workplace-related symptoms Patterns of symptoms in relation to exposure Documentation of work-relatedness of airflow limitation Occupational Asthma NAEPP. EPR-3, page 189.

69 Classifying Severity of Asthma Symptoms and SignsInitial PEF (or FEV1)Clinical Course Mild Dyspnea only with activity (assess tachyphena in young children) PEF ≥ 70 % predicted or personal best Usually cared for at home Prompt relief with inhaled SABA Possible short course of OSC Moderate Dyspnea interferes with or limits usual activity PEF % predicted or personal best Usually requires office or ED visit Relief from frequent inhaled SABA OSC; some symptoms last for 1-2 days after treatment is begun Severe Dyspnea at rest; interferes with conversation PEF < 40 % predicted or personal best Usually requires ED visit and likely hospitalization Partial relief from frequent inhaled SABA OSC; some symptoms last for >3 days after treatment is begun Adjunctive therapies are helpful Subset: Life Threatening Too dyspneic to speak; perspiring PEF <25 % predicted or personal best Requires ED/hospitalization; possible ICU Minimal or no relief from frequent inhaled SABA Intravenous cortosteroids Adjunctive therapies are helpful

70 A life-threatening asthma exacerbation exists, Patient is not meeting goals of asthma therapy after 3-6 months of treatment, Signs and symptoms are atypical or there are problems in differential diagnosis, Comorbid conditions complicate asthma or its diagnosis and Additional diagnostic testing is needed. Referral to Specialist When:

71 Additional education needed (about complications of therapy, adherence, allergen avoidance); Patient is considered for immunotherapy; Adult patient requires Step 4 or higher care – consider referral if patient requires Step 3; and Pediatric patient requires Step 3 or higher care – consider referral if child 0-4 yrs requires Step 2 care. Referral to Specialist When: NAEPP. EPR-3, page 68.

72 Review the pulmonary function results, then select the correct basic interpretation. Choose from the following answers: 1.Normal 2.Mild to moderate obstruction 3.Severe obstruction 4.Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive defect 5.Restrictive ventilatory defect, large volumes necessary for confirmation 6.Cannot be interpreted; does not meet acceptability criteria. Case Reviews

73 Acknowledgements Sally W. Southard, PNP, BC, AE-C Pediatric Nurse Practitioner, Carilion Pediatric Pulmonology Clinic

74 We will breathe easier when the air in every American community is clean and healthy. We will breathe easier when people are free from the addictive grip of cigarettes and the debilitating effects of lung disease. We will breathe easier when the air in our public spaces and workplaces is clear of secondhand smoke. We will breathe easier when children no longer battle airborne poisons or fear an asthma attack. Until then, we are fighting for air.


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