Pulmonology Book

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Asthma Evaluation

Aka: Asthma Evaluation
  1. See Also
    1. Asthma
    2. Intrinsic Asthma (Non-allergic asthma)
    3. Extrinsic Asthma (Allergic Asthma)
    4. Asthma Management
    5. Asthma Exacerbation
  2. Pathophysiology
    1. See Asthma
  3. History: Initial
    1. General: History is not always accurate
      1. Confirm with Pulmonary Function Tests every 3-6 month
      2. Patient may underplay symptoms
      3. Symptom accommodators (10% of patients)
        1. Do not recognize severe Symptoms of their Asthma
    2. Age of onset and Asthma diagnosis
    3. Past history of respiratory failure or Intubation
    4. Recognize cohorts at additional risk
      1. Elderly
      2. Pregnancy
    5. History of early life injury to airways
      1. Bronchopulmonary Dysplasia
      2. Parental smoking
    6. Disease progression
    7. Present management and response
    8. Frequency of Systemic Corticosteroid use
      1. History steroid-induced complications
    9. Comorbid conditions and potential triggers
      1. Exercise Induced Bronchospasm
      2. Aspirin and NSAID allergy
      3. Allergic Rhinitis
      4. Chronic Sinusitis
        1. Assess in all Asthma patients
        2. Consider empiric treatment if refractory Asthma
        3. Tsao (2003) Chest 123:757-64 [PubMed]
    10. Family History
      1. Asthma
      2. Allergic Rhinitis
      3. Sinusitis
      4. Nasal Polyps
    11. Social History
      1. Home characteristics
        1. Heating and cooling system
        2. Wood burning stove
        3. Humidifier
        4. Carpeting over concrete
      2. Smokers in home
      3. Daycare and school situation impacting compliance
      4. Level of education of patient and parents (if child)
    12. Effects of Asthma
      1. Episodes of unscheduled care (Emergency Department)
      2. Life threatening exacerbations
      3. Number of missed school days
      4. Limitation of activity
      5. History of nocturnal awakenings
      6. Impact of family routines and finances
  4. History: Follow-up Asthma control questions (last month)
    1. How often did Asthma interfere with activities?
    2. How often are you short of breath?
    3. How often are you awakened by your Asthma?
    4. How often do you use your rescue Inhaler?
  5. Symptoms: Episodic
    1. Recurrent Wheezing
    2. Dyspnea
    3. Productive or paroxysmal cough (especially at night)
    4. Chest tightness
    5. Provocative factors
      1. Exercise
      2. Viral infection
      3. Animals with fur or feathers
      4. House-Dust mites
      5. Mold
      6. Smoke (Tobacco, wood)
      7. Airborne irritants (Pollen, chemicals, dusts)
      8. Weather changes
      9. Emotional stress
      10. Menses
  6. Signs: General
    1. Expiratory Rhonchi
      1. High pitched sounds
      2. Air moving through constricted and inflamed airway
    2. Wheezing may or may not be heard
      1. Provocative measures
        1. Maximal expiration quickly
        2. Apply pressure anterior and superior
    3. Prolonged Inspiratory to Expiratory ratio
    4. Hyperexpansion of thorax and accessory muscle use
    5. Diminished chest excursion
      1. Place one hand on anterior chest
      2. Place the other hand posteriorly
    6. Nasal mucosal swelling or Nasal Polyps
    7. Atopic Dermatitis, Eczema, Urticaria
  7. Signs: Respiratory distress
    1. Tachypnea
    2. Dyspnea
    3. Anxiety
    4. Accessory Muscle Use
      1. Intercostal muscle use
      2. Sternocleidomastoid use
      3. Scalenes Muscle use
    5. Cyanosis in severe cases (lips)
    6. Tachycardia
    7. Pulsus Paradoxus
  8. Imaging: Chest XRay
    1. See Chest XRay in Asthma
  9. Diagnosis
    1. Age 5 years old or over
    2. Symptomatic episodes of airflow obstruction or hyperresponsiveness (see below)
      1. Dyspnea (breathlessness)
      2. Cough
      3. Chest tightness
      4. Wheezing
      5. Diminished air entry
      6. Intercostal retractions
    3. Alternatives on differential diagnosis excluded (see below)
    4. Partially reversible airflow obstruction
      1. Peak Expiratory Flow >20% variation over 2 weeks
      2. FEV1 and FEV1/FVC ratio reduced
      3. FEV1 improves >12% or 200 ml after Bronchodilator
  10. Differential Diagnosis
    1. General
      1. See Wheezing
      2. All that Wheezes is not Asthma (see Wheezing)!!
      3. However most recurrent cough with Wheezing is Asthma
    2. Children
      1. See Chronic Cough Causes in Children
      2. Upper airway disease
        1. Allergic Rhinitis
        2. Sinusitis
      3. Large airway obstruction
        1. Foreign body
        2. Vocal Cord Dysfunction
        3. Vascular Rings of laryngeal webs
        4. Laryngotracheomalacia
        5. Tracheobronchial-stenosis
        6. Enlarged lymph node or tumor
      4. Small Airway obstruction
        1. Viral Bronchiolitis
        2. Bronchiolitis Obliterans
        3. Cystic Fibrosis
        4. Bronchopulmonary Dysplasia
        5. Congenital Heart Disease
      5. Other Causes
        1. Psychogenic cough
        2. Gastroesophageal Reflux
        3. Malingering if Secondary Gain (e.g. missed school)
        4. Eosinophilic Granulomatosis with polyangiitis (Churg-Strauss)
    3. Adults
      1. See Chronic Cough Causes
      2. ACE Inhibitors
      3. Chronic Obstructive Pulmonary Disease (COPD)
      4. Congestive Heart Failure (CHF)
      5. Pulmonary Embolism
      6. Vocal Cord Dysfunction
  11. Labs
    1. Arterial Blood Gas (ABG)
      1. Hypoxemia
      2. Hypercarbia (or normal CO2) with decompensation
    2. Complete Blood Count
      1. Eosinophilia may be present
      2. Increased Levels of IgE may be present
    3. Sputum Sample
      1. May show casts of small airways
      2. Thick mucoid Sputum
      3. Curschmann's spirals
      4. Charcot-Leyden crystals
    4. Pulmonary Function Tests display Obstructive pattern
      1. See Diagnosis above
  12. Management
    1. See Asthma Management
    2. See Asthma Exacerbation
  13. References
    1. (1997) Practical Guide for Asthma, NIH 97-4053
    2. Serrano (2014) Crit Dec Emerg Med 28(6):2-10
    3. Wojtczak (1999) Guidelines for Pediatric Asthma Lecture
    4. Evans (1992) Chest 101(6 suppl):368S-71S [PubMed]
    5. Falk (2016) Am Fam Physician 94(6): 454-62 [PubMed]
    6. Kemp (2001) Am Fam Physician 63(7):1341-54 [PubMed]
    7. Moffitt (1994) Am Fam Physician 50(5): 1039-50 [PubMed]
    8. Shutari (1995) Am Fam Physician 52(8): 2225-35 [PubMed]
    9. (1996) MMWR Morb Mortal Wkly Rep 45:350-3 [PubMed]

Asthma (C0004096)

Definition (MSH) A form of bronchial disorder with three distinct components: airway hyper-responsiveness (RESPIRATORY HYPERSENSITIVITY), airway INFLAMMATION, and intermittent AIRWAY OBSTRUCTION. It is characterized by spasmodic contraction of airway smooth muscle, WHEEZING, and dyspnea (DYSPNEA, PAROXYSMAL).
Definition (MEDLINEPLUS)

Asthma is a chronic disease that affects your airways. Your airways are tubes that carry air in and out of your lungs. If you have asthma, the inside walls of your airways become sore and swollen. That makes them very sensitive, and they may react strongly to things that you are allergic to or find irritating. When your airways react, they get narrower and your lungs get less air.

Symptoms of asthma include

  • Wheezing
  • Coughing, especially early in the morning or at night
  • Chest tightness
  • Shortness of breath

Not all people who have asthma have these symptoms. Having these symptoms doesn't always mean that you have asthma. Your doctor will diagnose asthma based on lung function tests, your medical history, and a physical exam. You may also have allergy tests.

When your asthma symptoms become worse than usual, it's called an asthma attack. Severe asthma attacks may require emergency care, and they can be fatal.

Asthma is treated with two kinds of medicines: quick-relief medicines to stop asthma symptoms and long-term control medicines to prevent symptoms.

NIH: National Heart, Lung, and Blood Institute

Definition (NCI) A chronic respiratory disease manifested as difficulty breathing due to the narrowing of bronchial passageways.
Definition (NCI_NCI-GLOSS) A chronic disease in which the bronchial airways in the lungs become narrowed and swollen, making it difficult to breathe. Symptoms include wheezing, coughing, tightness in the chest, shortness of breath, and rapid breathing. An attack may be brought on by pet hair, dust, smoke, pollen, mold, exercise, cold air, or stress.
Definition (CSP) form of bronchial disorder associated with airway obstruction, marked by recurrent attacks of paroxysmal dyspnea, with wheezing due to spasmodic contraction of the bronchi.
Concepts Disease or Syndrome (T047)
MSH D001249
ICD9 493, 493.9
ICD10 J45, J45.9, J45.909, J45.90
SnomedCT 21341004, 266365004, 187687003, 266398009, 155574008, 195979001, 155579003, 278517007, 195983001, 195967001
LNC MTHU020815, LA10564-5, LA16982-3
English Asthma, Bronchial, Asthmas, Bronchial Asthma, Asthma bronchial, Asthma NOS, Asthma unspecified, Asthma, unspecified, BRONCHIAL ASTHMA, asthma, asthma (diagnosis), Br. asthma, Bronchitic asthma, Unspecified asthma, Asthma [Disease/Finding], asthma disorders, asthmatic, br asthma, bronchial asthma, asthmatics, bronchitic asthma, Asthma unspecified (disorder), Asthma NOS (disorder), ASTHMA, -- Asthma, Airway hyperreactivity, Asthmatic, Bronchial asthma, Asthma (disorder), Asthma, NOS, Bronchial asthma, NOS, Asthma (disorder) [Ambiguous], Asthma
French ASTHME, Asthme, non précisé, Asthme br., Bronchite asthmatique, Asthme SAI, Asthmatique, Asthme bronchitique, Asthme, Asthme bronchique
Portuguese ASMA, Asma brônquica, Asma bronquítica, Asma NE, Asmático, Asma, Asma Brônquica
Spanish ASMA, Asma NEOM, Asma bronquial, Bronquitis asmática, Asma no especificada, Asmático, Asma bronquítico, asma no especificado (trastorno), asma no especificado, Asthma (disorder), asma no especificada (trastorno), asma no especificada, asma, SAI (trastorno), asma, SAI, asma (concepto no activo), asma (trastorno), asma bronquial, asma, Asma, Asma Bronquial
German ASTHMA, asthmatisch, Asthma unspezifisch, bronchitisches Asthma, Asthma NNB, Asthma bronchial, br.F3589 Asthma, Asthma bronchiale, nicht naeher bezeichnet, Asthma bronchiale, Asthma, Bronchial-Asthma
Dutch astmatische bronchitis, bronchiaal astma, niet-gespecificeerd astma, astma NAO, astmatisch, Astma, niet gespecificeerd, astma, Astma, Asthma bronchiale, Astma, bronchiaal, Bronchiaal astma
Italian Asmatico, Bronchite asmatica, Asma NAS, Asma, non specificata, Asma bronchiale, Asma
Japanese 喘息NOS, 喘息性, 気管支炎様喘息, 喘息、詳細不明, ゼンソクNOS, ゼンソクセイ, ゼンソクショウサイフメイ, ゼンソク, キカンシゼンソク, キカンシエンヨウゼンソク, 気管支喘息, 喘息, 急性可逆性気道閉塞, ぜん息, 喘息-気管支
Swedish Astma
Czech astma, Astma, Br. astma, Astmatická bronchitida, Bronchiální astma, Astma, blíže neurčené, Astmatický, Astma NOS, asthma bronchiale, průduškové astma, astma bronchiale
Finnish Astma
Russian BRONKHIAL'NAIA ASTMA, ASTMA BRONKHIAL'NAIA, АСТМА БРОНХИАЛЬНАЯ, БРОНХИАЛЬНАЯ АСТМА
Korean 천식, 상세불명의 천식
Croatian ASTMA
Polish Astma, Astma oskrzelowa, Dychawica oskrzelowa
Hungarian Asthma, Asthmatikus, Asthma k.m.n., Asthma, k.m.n., Bronchialis asthma, Asthma, bronchitises, Asthmaticus bronchitis
Norwegian Astma
Sources
Derived from the NIH UMLS (Unified Medical Language System)


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