ASTHMA

Beth A. Longenecker, DO, FACOEP, FACEP

Associate Dean, Clinical Sciences
William Carey University
College of Osteopathic Medicine
Learning Objectives
Define asthma

Perform or describe components of an appropriate history

for a patient presenting with asthma

Describe common examination findings in asthma

patients

Correlate examination findings with the severity of an

asthma exacerbation
Learning Objectives
Classify asthma patients by severity of their disease

Apply appropriate management based on asthma severity

using evidence based recommendations

Discuss the components of a self management regimen

for asthma
Why is this important?
20 million people in the US have asthma

1.9 million ED visits per year

> 4000 patients per year die due to asthma in the US

Asthma is the most common chronic disease of childhood

Low income, less insured patients have worse outcomes

> 3 times more hospitalizations
Which phrase best defines asthma?
1. Reversible, episodic, 20% 20% 20% 20% 20%
inflammatory obstructive lung
disease
2. Reversible, episodic
bronchospastic obstructive
lung disease
3. Reversible, episodic
inflammatory restrictive lung
disease
4. Reversible, episodic
bronchospastic restrictive lung
disease
5. Chronic, irreversible
obstructive lung diseaase
1 2 3 4 5
Risk Factors for Development
Exposure to household smoke

Family history of asthma or atopy

Family history of nasal polyps or ASA hypersensitivity

Bottle vs. breast feedingcontroversial

Paradoxical protective exposure to petscontroversial

Common Presentation
History
Complaints of: Ask about:
Dyspnea Severity of disease
Cough Admissions
Intubations
Chest tightness
Attack frequency
Wheezing
Day vs. night symptoms
Whistling
Family history
Wheezling
Possible triggers
Exercise intolerance
Smokers
Carpeting
Pets
Occupational/hobby
Physical Examination
Tachypnea

Dyspnea with speech

Describe by number of words between breaths

Signs of respiratory distress

Nasal flaring, grunting, retractions, use of accessory muscles,
cyanosis, AMS

Hyper-expansion of chest

Resonance to percussion
Auscultation
Prolonged expiratory phase

Wheeze with forced expiration

Wheeze on spontaneous expiration

Wheezes on inspiration and expiration

No wheezes/no air movement

Pulmonary Function Testing
Office Diagnosis of Asthma (PFTs)
FEV1/FVC(forced vital capacity) ratio of < 70%

Improvement of FEV1 by at least 12% and at least 200mL

After giving beta-agonists

Peak expiratory flow rates

Self management
Response to treatment
Other Evaluation
Chest XRAY
Not usually indicated
Hyperinflation
Flattened diaphragms
Look for complications
Pneumothorax
Pneumomediastinum
Other Evaluation
Pulse Oximetry
Normal until severe
Can be used to assess severity in children
Drops initially with treatment

ABGs
Initially mild CO2 retention, eventually hypoxia and severe acidosis
What PaO2 correlates with a pulse ox of
95%?
1. 100 20% 20% 20% 20% 20%
2. 90
3. 80
4. 70
5. 60

1 2 3 4 5
Staging of Asthma
Case # 1
A 23 year old WCU student presents to your office complaining
of shortness of breath and chest tightness. He notices the
symptoms most while playing soccer, but not every time he
plays. He notices this feeling about once or twice a week, always
on the soccer field. He manages to keep playing, but symptoms
get worse as he plays. His symptoms are relieved by rest, or at
times by drinking coffee. Occasionally this is accompanied by a
dry cough. He does not smoke. He has a negative past medical
history. His physical examination is normal. You attend a WCU
soccer game and your patient comes up to you during a time out
and says he feels short of breath. You note mild tachypnea, 3
word dyspnea and when you auscultate his chest he has a
prolonged expiratory phase and mild expiratory wheezes.
Treatment of Intermittent Asthma
Short acting beta-agonist agents
albuterol
Case # 2
A mother brings her 18 month old daughter to the emergency department. She has
been having a runny nose and cough for a few days. Last night, the mom noted
that she was breathing funny and making funny sounds when she breaths.

VS: Temp 99.4 F rectal; HR-110; RR 18; Pulse Ox: 98% on room air

Physical examination:
General: smiling, playful and nontoxic appearing infant

HEENT: copious clear rhinorrhea, Tms benign, minimal erythema of pharynx

Heart: RRR, no murmur

Lungs: mild retractions, expiratory wheezing with a prolonged respiratory phase

Skin: warm, dry, no rashes, good capillary refill

Diagnosis
URI with reactive airway disease

Treatment:
Inhaled bronchodilators
Consider steroids

Asthma should not be diagnosed in infants

< 30% will develop asthma
Age to diagnose asthma varies from 2-5 years
Case 3
A 20 year old medical student presents to the clinic with
increasing episodes of shortness of breath and feeling
tight. These episodes frequently wake her from sleep and
are occurring at least 3 nights a month for the past 3 or 4
months. At times, she has similar episodes during the day.
These episodes are severe enough she is afraid to sleep
and when they occur during the day, she needs to stop, sit
down in a cool environment and hope it will go away
soon. When she feels these sensations, she hears a
funny high pitched squeaking when she breaths.
Currently her physical examination is unremarkable.
Case 3-Diagnosis and Management
Send her home with a Peak flow to monitor a AM and if
she feels SOB

Treat with short acting beta agonists (SABA)

Albuterol

Treat with a low dose inhaled corticosteroid

Fluticasone
Case 4
A 62 year old male presents to the ED with acute onset of
shortness of breath that woke him from sleep at 4AM. The
shortness of breath is accompanied by chest pressure. He has
never had these symptoms before. He has a dry cough, and
feels extremely short of breath if he tries to lie down.
VS: Temp: 98.4 F; HR: 120 Resp. Rate: 22 BP:
170/85 Pulse ox: 93% room air
Physical examination:
Patient is anxious appearing, tachypneic and markedly
diaphoretic
HEENT: normal with exception of JVD
Heart: tachycardic, regular, no murmur
Lungs: wheezes throughout, a few crackles at the bases
Abd: benign
Extremities: +1 pitting edema
Case 4
All that wheeze is not asthma!

DDX of asthma
CHF
Acute bronchitis
Airway obstruction
Aspiration of FB
COPD
Croup
Case 4-Eval/Management
Evaluation: Treatment
ECG Nitroglycerin
CBC, Chemistry drip
BNP Furosemide
Cardiac Consider BiPAP
Enzymes
Management of Asthma Exacerbation
Oxygen Corticosteriods
IV (methylprednisilone)
PO (prednisone)
Inhaled
bronchodilators
Beta-agonists Hydration
Albuterol
Others
Magnesium
Ipratroprium
Can reduce admissions Controversial

Nebulizer vs. MDI Use if not responding

Treatment of Chronic Asthma
Dependent on staging of Asthma

The critical decision is intermittent vs persistent

All use short acting beta agonists (rescue inhalers)

This is all if intermittent
Treatment of Persistent Asthma
Inhaled corticosteroids
Progress form low to medium to high dose

Long acting beta-agonist

Salmeterol
Do NOT use aloneblack boxincreased risk of death!

Oral steroids
Watch for adrenal suppression
Other Therapeutic Agents
Omaluzimab
For documented allergies

Leukotriene antagonists
(Montelukast; Singulair)

Mast cell stabilizers

Cromolyn
Do not use in acute exacerbation!!

Theophylline
Narrow therapeutic index
Management Chronic Asthma
Self-Management is Key!!!!
Personal Care Plan (MAP)
Management: what patient does daily
Ex: LABA, ICS
Action: what to do for a flare
Increased rescue inhaler use
PO prednisone
Prevention: what to avoid
Cigarette smoke!!!!!
Allergens
Take Home Points
Asthma is REVERSIBLE

Inflammation is key, bronchospasm is secondary

Examination progresses from:

Prolonged expiration
Expiratory wheezes
Inspiratory and expiratory wheezes
Silent chest
Take Home Points
Asthma is intermittent or persistent
Management of intermittent is solely with rescue beta-agonist MDI

All that wheezes is NOT asthma

Patients need to assist in managing this disease

Monitor peak flows
Personal care plans