Patient & Family Assessment

Patient & Family Assessment
Purpose: The purpose of this section is to describe the measures of asthma assessment and monitoring especially related to medical history, physical examination, pulmonary function testing (spirometry), and differential diagnosis of asthma. Suggested Activities: 1) role-play/interviewing the patient to obtain the history 2) case studies to practice spirometry 3) asthma severity determination 4) Demo of spirometry Presented by: Michelle Harkins, MD

This lesson will cover:
Medical history Physical exam Objective measures At the end of the lesson, participants will be able to: Explain the assessment & diagnosis of asthma Demonstrate how to collect a medical history by interviewing the individual with asthma Identify symptoms and risk Conduct a physical exam Recognize alternative diagnoses Explain the use of other objective measures, including radiology studies, spirometry, peak flow monitoring, ABG/oxygen saturation, and allergy testing Assess asthma control Recognize when to refer to a specialist

Initial Assessment & Diagnosis of Asthma
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. When conducting the initial assessment and diagnosis of asthma, you need to determine that: [read slide] NAEPP. EPR-3, page 40.

Initial Assessment & Diagnosis of Asthma
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 NAEPP. EPR-3, page 40.

Symptom history and Quality of Life Questionnaires:
Medical History 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 [*QOL questionnaires mentioned again in lesson six.]

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

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

Interviewing the Individual with Asthma
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? (Note: In children, shortness of breath greater than peers may not be seasonal to indicate asthma) Ask, “In the past 12 months have you had…..” NAEPP. EPR-3, page 70

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? [slide continues from previous] NAEPP. EPR-3, page 70.

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? NAEPP. EPR-3, page 70.

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

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

Late or Severe Asthma Symptoms
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.

Severe Asthma Symptoms
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 Retractions - Neck area and between or below the ribs moves inward with breathing

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.

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. The peak systolic pressure during expiration should first be identified and reconfirmed. The cuff is then deflated slowly to establish the pressure at which Korotkoff sounds become audible during both inspiration and expiration. When the differences between these two observed levels reaches or exceeds 10 mm Hg during quiet respiration, a paradoxical pulse is present. Paradoxical breathing is like a see-saw – it happens in infants

High-Risk Asthma Patients
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 NAEPP. EPR-3, page 377.

High-Risk Asthma Patients
>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 Comorbidites are discussed in lesson 4 NAEPP. EPR-3, page 377.

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

Physical Examination NAEPP. EPR-3, page 42.
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 NAEPP. EPR-3, page 42.

Increased nasal secretions, mucosal swelling, and/or nasal polyps
Physical Examination 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 Speaker – provide examples or demonstrate what the wheezing sounds like NAEPP. EPR-3, page 43.

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

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.

Diagnosis of Asthma in Children
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.

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

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

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

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

Determine Diagnosis & Severity of Asthma
Based on: History and QOL questionnaire Physical exam Objective measures What are some examples of objective measures? Spirometry Peak flow

Classifying Asthma Severity: 0 – 4 years
Components of Severity Intermittent Persistent Mild Moderate Severe 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) Several times per day Activity limits Minor Limitation Some 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 Asthma Severity in Children Aged 0 to 4 Years Key Point: This slide represents the approach to classifying asthma severity as a guide to initiating therapy in children aged 0 to 4 years who are not currently taking controller medication. It is meant to assist, not replace, the clinical decision making required to meet individual patient needs Level of severity (highlighted in blue) is determined by the new domains of current impairment (effects of asthma on quality of life and functional capacity) and future risk (potential for asthma-related adverse events) Specific measures for assessing impairment are in yellow and include symptoms (daytime and nighttime), use of short-acting β2-agonists (SABAs) for quick relief, and interference with activity—measures previously used in the EPR-2 for classifying severity Measures of risk are in purple. Exacerbations as a measure of risk are a new feature of the EPR-3 Exacerbation is defined as an acute episode of signs and symptoms requiring oral systemic corticosteroids Within the persistent classification, there are no data to correspond frequencies of exacerbations or wheezing episodes with different severity categories. In general, more frequent and intense exacerbations indicate greater underlying disease severity Exacerbations of any severity may occur in patients in any severity category The risk domain also includes infants and preschool-aged children with 4 or more episodes of wheezing in the past year that lasted more than 1 day and affected sleep and who have risk factors for developing asthma. Risk factors include One of the following: parental history of asthma, a diagnosis of atopic dermatitis by a physician, or evidence of sensitization to aeroallergens, or Two of the following: evidence of sensitization to foods, ≥4% peripheral blood eosinophilia, or wheezing apart from colds Also new to the EPR-3 is that “intermittent” has replaced “mild intermittent” as a category in the severity classification to emphasize that patients at any level of severity, including intermittent, can have severe exacerbations Severity should be assigned to the most severe category in which any feature occurs Daily long-term controller medication is recommended for all severities of persistent asthma Classifying severity in children who are not currently taking long-term control medication.

Classifying Asthma Severity: 5 – 11 years
Components of Severity Intermittent Persistent Mild Moderate Severe Impairment Symptoms  2 days/wk >2 days/wk but not daily Daily Throughout the day Nighttime awakenings  2x/month 1-2x/month 3-4x/month >1x/wk B-agonist use (not prevention of EIB)  2 days/wk Several times per day Activity limits None Minor limitation Some Limitation Extremely limited Lung Function FEV1 FEV1/FVC >80% >85% 80% 60 – 80% % <60% <75% Risk Exacerbations requiring OSC 0-1/yr  2/year Asthma Severity in Children Aged 5 to 11 Years Key Point: Classifying asthma severity in children aged 5 to 11 years is similar to that in children aged 0 to 4 years, except that more frequent nighttime awakenings and exacerbations are allowed in every severity category. Major differences are highlighted in blue and include Measurements of lung function, including FEV1/FVC, as an additional measure of impairment This slide represents the approach to classifying asthma severity as a guide to initiating therapy in children aged 5 to 11 years who are not currently taking controller medication. It is meant to assist, not replace, the clinical decision making required to meet individual patient needs Classifying severity in children who are not currently taking long-term control medication.

Classifying Asthma Severity: 12 and older
Components of Severity Intermittent Persistent Mild Moderate Severe 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 Several times per day Activity limits None Minor limitation Some Limitation Extremely limited Lung Function FEV1 FEV1/FVC >80% normal 80% >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.

Spirometry is necessary for diagnosis, and
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 Peak flow monitoring should not be used to diagnose asthma. How often should spirometry be done? NAEPP. Epr-3, page 43.

Objective Measures: Spirometry
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. The next several slides discuss spirometry in more detail. The information provided is intended to reinforce prior training and is not enough to make you an expert in spirometry.

Spirometry Components
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 Results 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.

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

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. Abnormalities of lung function are categorized as restrictive and obstructive defects. A reduced ratio of FEV 1 /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. The severity of abnormality of spirometric measurements is evaluated by comparison of the patient's results with reference values based on age, height, sex, and race. (NIH references American Thoracic Society 1991)

Interpreting Spirometry
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.

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

Spirometry Results Showing Obstruction
Measured Predicted Percent (%) Predicted FVC 4.09 4.25 96 FEV1 1.95 2.88 68 FEV1/FVC 48 PEF 6.27 8.06 78 Reduced FEV1 and ratio indicate obstruction.

Obstruction 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.

Normal vs. Obstructed Obstruction Normal

Restrictive Lung Disease
Both the FEV1 and FVC are reduced proportionately. FEV1/FVC ratio is normal or even elevated. Measured Predicted Percent (%) Predicted FVC 0.96 2.75 35 FEV1 0.94 1.90 49 FEV1/FVC 98 69 PEF 2.98 5.40 55

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.

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 >200 mL for adults only.

Calculating Change in FEV1
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.

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?

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?

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) This does not meet ATS criteria for adults but may for a child.

Reliability of Spirometry
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.

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.

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

Unacceptable Efforts Variable Effort Cough

Preparing Patients for Spirometry
Painless procedure Noninvasive Outpatient When you send a patient for his or her initial spirometry test, you will want to let the patient know what to expect. You may want to assure the patient that spirometry is a painless procedure that is noninvasive, and that it may be performed on an outpatient basis.

Normal breathing prior to test Maximum forced exhalation during test
Spirometry Maneuvers Normal breathing prior to test Maximum forced exhalation during test Maneuver repeated until results are consistent When a patient undergoes spirometry, he or she will typically undertake several normal or tidal breaths before the spirometry begins. Then the patient will be instructed to exhale with maximal force into a cylinder attached to the spirometry device. Typically the patient is coached to blow “hard and fast,” and coached to keep breathing out until the maneuver is complete. The patient will then be asked to repeat the entire maneuver from tidal breathing to completion. Repeat maneuvers will continue until the spirometry device is able to document “consistent” or “reproducible” results.

Discussing Results with Patients
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. If the spirometry results will lead to any changes in how the patient needs to manage his or her asthma, explain this connection to the patient. You may say, for example, “these results do indicate how important it is for you to get dust covers for your mattress and pillows.” If you will be making any changes in the patient’s medication regimen because of the spirometry results, explain these changes to the patient. The patient and family members need to know that spirometry results are not like dental records; they are not permanent. Therefore, while a patient may have moderate persistent or severe persistent disease today, with effective asthma management, the patient could have less severe disease over time, and that this would be demonstrated, in part, by improved spirometry results.

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

Spirometry May Be Done More Frequently
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. NAEPP. EPR-3, page 59.

Peak Flow* 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 is mentioned in lessons 6, 7 and 9

Detect early changes in disease status that require treatment,
Peak-Flow Monitoring 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 is mentioned in lessons 6, 7 and 9. EPR-3 does not include PFM for intermittent or mild persistent patients. NAEPP. EPR-3, page 120

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

Arterial Blood Gas (ABG)
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 Consider monitoring oxygen saturations.

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

Assessing Control: 0 – 4 years
Components of Control Classification of Asthma Control Well Controlled Not Well Controlled Very Poorly Impairment Symptoms  2 days/wk >2 days/wk Throughout the day Nighttime awakenings  1x/month >1x/month >1x/week Activity limits None Some limitation Extremely limited B-agonist use (not prevention of EIB)  2 days/week >2 days/week Several times per day Risk Exacerbations requiring OSC 0-1/year 2-3/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 Assessing Asthma Control in Children Aged 0 to 4 Years Key Point: This slide represents the approach to assessing asthma control in children aged 0 to 4 years who are currently taking controller medication. It is meant to assist, not replace, the clinical decision making required to meet individual patient needs Level of control (well controlled, not well controlled, or very poorly controlled) is determined by the degree to which both impairment and risk are minimized by therapeutic intervention Specific measures for assessing impairment include symptoms (daytime and nighttime), interference with normal activity, and use of SABAs for quick relief. Similar to that used in classifying severity, the risk domain is new and includes exacerbations and treatment-related adverse effects The level of control is based on the most severe impairment or risk category Treatment decisions are based on the level of control that has been achieved Using these criteria, Emily’s asthma would be assessed as “not well controlled” based on her SABA use, nighttime symptoms, and activity limitation

Asthma Control: 5 – 11 years
Components of Control Classification of Asthma Control Well Controlled Not Well Very Poorly 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 limits None Some limitation Extremely limited B-agonist use (not prevention of EIB) 2 days/wk >2 days/wk Several times per day Lung function FEV1 or PF FEV1/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. Asthma Control in Children Aged 5 to 11 Years Key Point: Assessing asthma control in children aged 5 to 11 years is similar to that in children aged 0 to 4 years, except that more frequent nighttime awakenings are allowed in every category of control. Major differences are highlighted in blue and include Measurements of lung function over time as an additional measure of impairment Reduction in lung growth, measured by serial spirometry as prolonged failure to attain predicted lung values for age, as an additional (theoretical) measure of risk This slide represents the approach to assessing asthma control in children aged 5 to 11 years who are currently taking controller medication. It is meant to assist, not replace, the clinical decision making required to meet individual patient needs

Asthma Control: 12 and older
Components of Control Classification of Asthma Control Well Controlled Not Well Very Poorly Impairment Symptoms  2 days/week >2 days/week Throughout the day Nighttime awakenings  2x/month 1-3x/week >4x/week Activity limits None Some limitation Extremely limited B-agonist use (not prevention of EIB) Several times per day Lung function FEV1 or PF >80% FEV1 or PF = % FEV1 or PF <60% QOL indicator ACT ≥20 ACT =16-19 ACT ≤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. Figure 4-7, pg 345

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

Classifying Severity of Asthma
Symptoms and Signs Initial 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 Classifying Severity of Asthma Exacerbations in the Urgent or Emergency Care Setting

Referral to Specialist When:
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. Additional testing: allergy testing, complete PFTs, bronchoscopy, rhinoscopy, etc.

Referral to Specialist When:
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. NAEPP. EPR-3, page 68.

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

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

Patient & Family Assessment

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