Presentation on theme: "Patient & Family Assessment"— Presentation transcript:
1 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 history2) case studies to practice spirometry3) asthma severity determination4) Demo of spirometryPresented by:Michelle Harkins, MD
2 This lesson will cover: Medical historyPhysical examObjective measuresAt the end of the lesson, participants will be able to:Explain the assessment & diagnosis of asthmaDemonstrate how to collect a medical history by interviewing the individual with asthmaIdentify symptoms and riskConduct a physical examRecognize alternative diagnosesExplain the use of other objective measures, including radiology studies, spirometry, peak flow monitoring, ABG/oxygen saturation, and allergy testingAssess asthma controlRecognize when to refer to a specialist
3 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.
4 Initial Assessment & Diagnosis of Asthma Methods for establishing diagnosis:Detailed medical history (airway hyper-reactivity, recurrence, reversibility)Physical examSpirometry to demonstrate reversibilityAdditional studies as necessary to exclude alternative diagnosesNAEPP. EPR-3, page 40.
5 Symptom history and Quality of Life Questionnaires: Medical HistorySymptom history and Quality of Life Questionnaires:History of symptoms of airflow obstruction– Cough– Wheeze– Chest tightness/pain– Shortness of breathEpisodic symptomsResponse to treatment[*QOL questionnaires mentioned again in lesson six.]
6 Precipitating/aggravating factors Development of disease and treatment Medical HistoryIdentify symptomsPattern of symptomsPrecipitating/aggravating factorsDevelopment of disease and treatmentFamily historyAtopy, asthmaNAEPP. EPR-3, page 69.
7 History of exacerbations Impact of asthma on patient/family Medical HistorySocial historyHistory of exacerbationsImpact of asthma on patient/familyPatient/family perception of the diseaseNAEPP. EPR-3, page 69
8 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
9 Interviewing the Individual with Asthma 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.
10 Interviewing the Individual with Asthma 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.
11 Early Asthma Signs & Symptoms Symptoms that indicate an asthma episode is occurringCoughingWheezingShortness of breathChest tightness and/or painPeak-flow numbers usually 50% to 80% of personal best
12 Other Early Warning Signs & Symptoms Itchy throat or chinRunny or stuffy noseSneezingHeadacheFunny feeling in the chestStomach ache/poor appetiteGlassy eyesFeeling tired
13 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 chestPatient experiences difficulty talking or concentrating; mental deterioration may occur.Walking causes shortness of breath.
14 Severe Asthma Symptoms Breathing may be shallow and fast, or slower than usual; paradoxical breathing in small childrenShoulders 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 breathingRetractions - Neck area and between or below the ribs moves inward with breathing
15 Severe Asthma Symptoms 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.
16 Severe Asthma Symptoms 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
17 High-Risk Asthma Patients Past history of sudden, severe exacerbationsPrior intubation for asthmaPrior ICU admission for asthma>2 asthma hospitalizations in past year>3 asthma ER visits/year.Hospitalized/ER asthma visit in past monthNAEPP. EPR-3, page 377.
18 High-Risk Asthma Patients >2 albuterol MDIs/monthLow SES or inner city residencePoor perception of symptoms/severityComorbiditiesComplex psychiatric/psychosocial problemsIllicit drug useSensitivity to Alternaria moldComorbidites are discussed in lesson 4NAEPP. 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.NAEPP. EPR-3, page 377.
20 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 childrenUse of accessory muscles, appearance of hunched shoulders, chest deformityNAEPP. EPR-3, page 42.
21 Increased nasal secretions, mucosal swelling, and/or nasal polyps Physical ExaminationSounds 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 polypsAtopic dermatitis/eczema or any other manifestation of an allergic skin conditionSpeaker – provide examples or demonstrate what the wheezing sounds likeNAEPP. EPR-3, page 43.
22 What Is Your Differential Diagnosis? What are some alternative diagnoses in adults that may present with similar symptoms?
23 Alternative Diagnoses in Adults Chronic obstructive pulmonary disease – chronic bronchitis or emphysemaCongestive heart failureMechanical obstruction of the airways – benign and malignant tumorsCough secondary to drugs (angiotensin-converting enzyme [ACE] inhibitors)Vocal cord dysfunctionNAEPP. EPR-3, page 46.
24 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.
25 Alternative Diagnoses in Children Allergic rhinitisSinusitisGastroesophageal refluxLaryngotracheomalaciaBronchopulmonary dysplasiaCystic FibrosisNAEPP. EPR-3, page 46.
26 Alternative Diagnoses in Children BronchiolitisForeign body aspirationVascular ring or laryngeal webCongenital heart diseaseVocal cord dysfunctionNAEPP. EPR-3, page 46.
27 In addition to the physical exam, other measures include: Objective MeasuresIn addition to the physical exam, other measures include:Radiology studiesSpirometryPeak-flow monitoringArterial Blood Gas /oxygen saturationAllergy testing[peak flow image from
28 Interpret the Findings from: Family, clinical and past medical historyPhysical examinationVital signsPulmonary function, radiology and laboratory results
29 Determine Diagnosis & Severity of Asthma Based on:History and QOL questionnairePhysical examObjective measuresWhat are some examples of objective measures?SpirometryPeak flow
30 Classifying Asthma Severity: 0 – 4 years Components of SeverityIntermittentPersistentMildModerateSevereImpairmentSymptoms 2 days/week>2days/weekbut not dailyDailyThroughoutthe dayNighttime awakeningsNone1-2x/month3-4x/month>1x/ weekB-agonist use (not prevention of EIB)Several timesper dayActivity limitsMinorLimitationSomeExtremelyLimitedRiskExacerbations requiring OSC0-1/yr 2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/ 1 year lasting >1 day AND risk factors for persistent asthmaAsthma Severity in Children Aged 0 to 4 YearsKey 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 needsLevel 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 severityMeasures of risk are in purple. Exacerbations as a measure of risk are a new feature of the EPR-3Exacerbation is defined as an acute episode of signs and symptoms requiring oral systemic corticosteroidsWithin 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 severityExacerbations of any severity may occur in patients in any severity categoryThe 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 includeOne of the following: parental history of asthma, a diagnosis of atopic dermatitis by a physician, or evidence of sensitization to aeroallergens, orTwo of the following: evidence of sensitization to foods, ≥4% peripheral blood eosinophilia, or wheezing apart from coldsAlso 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 exacerbationsSeverity should be assigned to the most severe category in which any feature occursDaily long-term controller medication is recommended for all severities of persistent asthmaClassifying severity in children who are not currently taking long-term control medication.
31 Classifying Asthma Severity: 5 – 11 years Components of SeverityIntermittentPersistentMildModerateSevereImpairmentSymptoms 2days/wk>2 days/wkbut not dailyDailyThroughoutthe dayNighttime awakenings 2x/month1-2x/month3-4x/month>1x/wkB-agonist use (not prevention of EIB) 2 days/wkSeveral timesper dayActivity limitsNoneMinorlimitationSomeLimitationExtremelylimitedLung FunctionFEV1FEV1/FVC>80%>85%80%60 – 80%%<60%<75%RiskExacerbations requiring OSC0-1/yr 2/yearAsthma Severity in Children Aged 5 to 11 YearsKey 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 includeMeasurements of lung function, including FEV1/FVC, as an additional measure of impairmentThis 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 needsClassifying severity in children who are not currently taking long-term control medication.
32 Classifying Asthma Severity: 12 and older Components of SeverityIntermittentPersistentMildModerateSevereImpairmentNormal FEV1/FVC:8-19yrs 85%20-39yrs 80%40-59yrs 75%60-80yrs 70%Symptoms 2 days/wk>2 days/wkbut not dailyDailyThroughoutthe dayNighttime awakenings 2x/month3-4x/month>1x/wk but not nightlyOften 7x/weekB-agonist use (not prevention of EIB) 2 days/week>2 days/wk but not daily, and not more than 1x on any daySeveral times per dayActivity limitsNoneMinorlimitationSomeLimitationExtremelylimitedLung FunctionFEV1FEV1/FVC>80%normal80%>60 -80%reduced 5%<60%reduced >5%RiskExacerbations requiring OSC0-1/yr 2/yrClassifying severity for patients who are not currently taking long-term control medication.
33 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, andPeak-flow is used for monitoring control onlyPeak flow monitoring should not be used to diagnose asthma.How often should spirometry be done?NAEPP. Epr-3, page 43.
34 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.
35 Spirometry Components Forced Vital Capacity (FVC)The maximal volume of air forcibly exhaled from the point of maximal inhalationForced Expiratory Volume in 1 second (FEV 1)The volume of air exhaled during the first second of the FVCRatio of FEV1 to FVC (FEV1/FVC)Expressed as a percentagePeak Expiratory Flow (PEF)Maximum air flow (rate) during forced exhalation
36 Spirometry ResultsAirflow obstruction is indicated by reduced FEV1 and FEV1 /FVC values relative to reference or predicted valuesThe 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.
37 Calculating % Predicted FEV1 Predicted: 4.00L Patient’s FEV1: 3.00L What is the percent predicted for this patient? 3.00 = 3 = 75%
38 Objective Measures: Spirometry 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)
39 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.
40 Flow Volume LoopA normal flow volume loop has a rapid peak expiratory flow rate with a gradual decline in flow back to zero.
41 Spirometry Results Showing Obstruction MeasuredPredictedPercent (%) PredictedFVC4.094.2596FEV11.952.8868FEV1/FVC48PEF6.278.0678Reduced FEV1 and ratio indicate obstruction.
42 ObstructionObstructive 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.
44 Restrictive Lung Disease Both the FEV1 and FVC are reduced proportionately.FEV1/FVC ratio is normal or even elevated.MeasuredPredictedPercent (%) PredictedFVC0.962.7535FEV10.941.9049FEV1/FVC9869PEF2.985.4055
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 obstructionFEV1 < 80% predictedFEV1/FVC below the lower limit of normal, as compared to the individual’s own predicted valueUse spirometry to establish reversibilityFEV1 increases >12% and> 200 mL after using a short-acting inhaled beta2-agonist2- to 3-week trial of oral corticosteroid therapy may be required to demonstrate reversibility>200 mL for adults only.
47 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.
48 Calculating Change in FEV1 Post BD FEV1 minus Pre BD FEV1Pre BD FEV 1Pre BD FEV1 = 1.50L Post BD FEV1 = 1.80LWhat is the % improvement in FEV1?Example 2: 1.80L – 1.50L= .30 = 1 = 20% improvement1.50LDoes this meet the NAEPP criteria?
49 Calculating Change in FEV1 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?
50 Calculating Change in FEV1 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.
51 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.
52 Reliability of Spirometry 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.
53 Reliability of Spirometry Criteria for acceptability include:Lack of artifact induced by coughing, glottic closure or equipment problems (primarily leak);Satisfactory start to the test without hesitation; andSatisfactory 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.
55 Preparing Patients for Spirometry Painless procedureNoninvasiveOutpatientWhen 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.
56 Normal breathing prior to test Maximum forced exhalation during test Spirometry ManeuversNormal breathing prior to testMaximum forced exhalation during testManeuver repeated until results are consistentWhen 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.
57 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.
58 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; andAt 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.
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 andWhen peak flow results are unreliable.NAEPP. EPR-3, page 59.
60 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
61 Detect early changes in disease status that require treatment, Peak-Flow MonitoringLong-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 andAfford 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
62 Radiological (CXR) Results Not routine.Usually normal yet hyperinflation may be presentIdentify complicationsPneumoniaPneumothoraxPneumomediastinumTumor
63 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” 7.40/40/70Consider monitoring oxygen saturations.
64 Periodic Assessments of Asthma Control Signs and symptomsPulmonary Function TestQOL surveyHistory of exacerbationsPharmacotherapyPatient satisfactionNAEPP. EPR-3, page 53.
65 Assessing Control: 0 – 4 years Components of ControlClassification of Asthma ControlWellControlledNot Well ControlledVery PoorlyImpairmentSymptoms 2 days/wk>2 days/wkThroughout the dayNighttime awakenings 1x/month>1x/month>1x/weekActivity limitsNoneSome limitationExtremely limitedB-agonist use(not prevention of EIB) 2 days/week>2 days/weekSeveral times per dayRiskExacerbations requiring OSC0-1/year2-3/year>3/yearRecommended Action for TreatmentMaintain current treatmentRegular F/U every 1 – 6 mosConsider step down if well controlled for at least 3 mosStep up (1step) andReevaluate in 2 -6 wksIf no benefit in 6 wks, consider alternative diagnosesConsider short course of OSCStep up (1 – 2 steps) andReevaluate in 2 wksAssessing Asthma Control in Children Aged 0 to 4 YearsKey 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 needsLevel 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 interventionSpecific 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 effectsThe level of control is based on the most severe impairment or risk categoryTreatment decisions are based on the level of control that has been achievedUsing these criteria, Emily’s asthma would be assessed as “not well controlled” based on her SABA use, nighttime symptoms, and activity limitation
66 Asthma Control: 5 – 11 years Components of ControlClassification of Asthma ControlWellControlledNot WellVery PoorlyImpairmentSymptoms 2 days/wk but not more than once on each day>2 days/wk or multiple times 2 days/wkThroughout the dayNighttime awakenings1x/month≥2x/month≥2x/weekActivity limitsNoneSome limitationExtremely limitedB-agonist use(not prevention of EIB)2 days/wk>2 days/wkSeveral times per dayLung functionFEV1 or PFFEV1/FVC80%>80%60 – 80%75-80%<60%<75%RiskExacerbations requiring OSC0-1/year≥2/yearReduction inlung growthEvaluation requires long-term follow-upTreatment-related adverse effectsMedication 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 YearsKey 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 includeMeasurements of lung function over time as an additional measure of impairmentReduction in lung growth, measured by serial spirometry as prolonged failure to attain predicted lung values for age, as an additional (theoretical) measure of riskThis 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
67 Asthma Control: 12 and older Components ofControlClassification of Asthma ControlWellControlledNot WellVery PoorlyImpairmentSymptoms 2 days/week>2 days/weekThroughout the dayNighttime awakenings 2x/month1-3x/week>4x/weekActivity limitsNoneSome limitationExtremely limitedB-agonist use (not prevention of EIB)Several times per dayLung functionFEV1 or PF >80%FEV1 or PF = %FEV1 or PF <60%QOL indicatorACT ≥20ACT =16-19ACT ≤15RiskExacerbations requiring OSC0-1/year> 2/ yearReduction in lung growthEvaluation requires long-term follow-upTreatment-related adverse effectsMedication 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
68 Potential for workplace-related symptoms Occupational AsthmaPotential for workplace-related symptomsPatterns of symptoms in relation to exposureDocumentation of work-relatedness of airflow limitationNAEPP. EPR-3, page 189.
69 Classifying Severity of Asthma Symptoms and SignsInitial PEF (or FEV1)Clinical CourseMildDyspnea only with activity (assess tachyphena in young children)PEF ≥ 70 % predicted or personal bestUsually cared for at homePrompt relief with inhaled SABAPossible short course of OSCModerateDyspnea interferes with or limits usual activityPEF % predicted or personal bestUsually requires office or ED visitRelief from frequent inhaled SABAOSC; some symptoms last for 1-2 days after treatment is begunSevereDyspnea at rest; interferes with conversationPEF < 40 % predictedor personal bestUsually requires ED visit and likely hospitalizationPartial relief from frequent inhaled SABAOSC; some symptoms last for >3 days after treatment is begunAdjunctive therapies are helpfulSubset: Life ThreateningToo dyspneic to speak; perspiringPEF <25 % predicted or personal bestRequires ED/hospitalization; possible ICUMinimal or no relief from frequent inhaled SABAIntravenous cortosteroidsClassifying Severity of Asthma Exacerbations in the Urgent or Emergency Care Setting
70 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 andAdditional diagnostic testing is needed.Additional testing: allergy testing, complete PFTs, bronchoscopy, rhinoscopy, etc.
71 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; andPediatric patient requires Step 3 or higher care – consider referral if child 0-4 yrs requires Step 2 care.NAEPP. EPR-3, page 68.
72 Choose from the following answers: Normal Mild to moderate obstruction Case ReviewsReview the pulmonary function results, then select the correct basic interpretation.Choose from the following answers:NormalMild to moderate obstructionSevere obstructionSevere obstructive ventilatory defect, cannot exclude a concomitant restrictive defectRestrictive ventilatory defect, large volumes necessary for confirmationCannot be interpreted; does not meet acceptability criteria.