1. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. * For Best Viewing: Open in Slide Show Mode Click on icon or From the View menu, select the Slide Show option * To help you as you prepare a talk, we have included the relevant text from ITC in the notes pages of each slide

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3. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. in the clinic Asthma

4. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What symptoms or elements of clinical history are helpful in diagnosis? Episodic wheezing Dyspnea Difficulty taking a deep breath Chest tightness Cough ( especially if chronic and nocturnal, seasonal, or related to workplace or a specific activity ) History Symptoms often intermittent, remit spontaneously Symptoms may vary seasonally Symptoms may be associated with specific triggers

5. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What physical exam findings are suggestive? Wheezing during tidal respirations or forced expiration Prolonged expiratory phase of breathing Hyperexpansion of chest Unless patient is having an active exacerbation, physical exam less helpful than a carefully elicited history Sometimes most helpful in looking for evidence of alternative diagnoses Inspiratory crackles may suggest ILD or CHF Abnormal heart sounds might indicate CHF or other cardiac causes of dyspnea

6. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What are the indications for spirometry in a patient whose clinical presentation is consistent with asthma? Indicated for all patients with possible asthma Measure FEV1, FVC, FEV1–FVC ratio Evaluate before and after bronchodilator use Post-bronchodilator improvement 12% and 200mL of FEV1 or FVC indicates significant reversibility Reversibility of airflow obstruction defines asthma Some patients may have difficulty with the FVC maneuver Surrogate: FEV6 (reduction in the FEV1–FEV6 ratio signifies obstruction)

7. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. Normal spirometry does not rule out asthma If signs suggest asthma but spirometry is normal Bronchoprovocation with methacholine or histamine Helps establish Dx of seasonal / exercise-induced asthma Marked diurnal variability Helps establish asthma Dx Record measurements 2 weeks in a peak flow diary Does normal spirometry rule out a diagnosis of asthma? What additional testing should patients with normal spirometry have?

8. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. Other Studies for Asthma Bronchoprovocation Positive results: diagnostic of airway hyperresponsiveness Negative results essentially rule out asthma Chest radiograph Mostly useful in ruling out other diagnoses Allergy testing To evaluate the role of allergens in asthma management CBC with differential Mild eosinophilia common in asthma Sputum evaluation Not indicated for routine evaluation IgE Mild elevation is common with asthma

9. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. When should clinicians consider provocative pulmonary testing? If symptoms suggest asthma but spirometry is normal Use: methacholine hyper-responsiveness test Low PC20 result: diagnostic for airway hyper- responsiveness Sensitive + high negative predictive value for asthma Dx Highly reproducible + generally safe (but expensive) Requires sophisticated instrumentation + labor-intensive

10. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. How should clinicians classify asthma? Disease severity Intrinsic intensity of disease Assess when patient isnt yet on long-term medication, or Estimate based on lowest level therapy needed for control Disease control Degree to which asthma manifestations are minimized and Degree to which goals of long-term control therapy are met Measure used to maintain & adjust treatment as necessary

11. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. To aid classification, obtain spirometry at intervals: At the time of initial diagnosis and evaluation After stabilization of symptoms with therapy After any prolonged exacerbations or progressive, chronic worsening Every 1–2 yrs for routine monitoring of the disease Classify both severity and control by two domains: Impairment Frequency of symptoms Nocturnal symptoms Rescue inhaler use Interference with normal activity Spirometric measurements Risk Frequency of exacerbations

12. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What comorbid conditions and alternative diagnoses should clinicians consider in patients with suspected asthma? COPD Vocal cord dysfunction Heart failure Bronchiectasis Allergic bronchopulmonary Cystic fibrosis Mechanical obstruction

13. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. When should primary care clinicians consider referring patients with suspected asthma to specialists for diagnosis? Before ordering provocative pulmonary function test Testing is time- and labor-intensive Testing requires skilled performance and interpretation When patient presents with atypical symptoms Abnormal chest radiographs Pulmonary function tests suggest obstruction + restriction Unusual manifestations of the disease Suboptimal response to therapy When asthma seems to have an allergic component

14. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. CLINICAL BOTTOM LINE: Diagnosis… Take a careful history that focuses on: Nature and timing of symptoms Wheezing Dyspnea Cough Chest tightness Potential triggers Use spirometry to assess all patients with suspected asthma Normal spirometry doesnt rule out asthma If spirometry is normal but symptoms suggest asthma, consider provocative pulmonary testing

15. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What advice about reducing allergen exposure should clinicians give patients? Use air conditioning to maintain humidity <50% Remove carpets Limit fabric household items (e.g., drapes, soft toys) Use impermeable covers for mattresses and pillows Launder bedding weekly in water 130°F Ensure adequate ventilation Exterminate to reduce cockroaches Remove cats from the home Reduce dampness in the home Avoid wood-burning / unvented gas fireplaces or stoves Avoid tobacco smoke

16. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What evidence supports the use of indoor air-cleaning devices for patients with asthma? Inadequate evidence to recommend these devices Little evidence supports HEPA filters or air duct cleaning However particle air cleaning may reduce symptoms Avoid humidifiers, which may increase allergen levels Keep humidity <50% with dehumidifiers or air conditioners Reduces dust mites and mold

17. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. How should clinicians select from among available drug therapy for asthma? Rescue therapy Short-acting β-agonists (SABAs): acute relief of symptoms Critical for all patients regardless of asthma severity Long-term controller therapy Step-wise Rx for long-term control of persistent symptoms Choose step 1-5 based on symptoms (mild to severe) If symptoms well-controlled 3 months, step down to less intensive therapy If not well-controlled, step up to more intense therapy Review therapy 2-6 wks at first, then every 1-6 months

18. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. To achieve asthma control : Reduce impairment through reduction of chronic and troublesome symptoms Minimize rescue bronchodilator use Maintain normal (or near normal) spirometry Minimize interference with activities Meet patients satisfaction with care Reduce risk by preventing exacerbations and loss of lung function and providing optimal pharmacotherapy with minimal adverse effects

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20. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What is the role of nonpharmacologic therapy? Many patients are interested in nonpharmacologic therapy for asthma But evidence is inadequate on the role of most complementary therapies in asthma management Experts recommend against acupuncture Alert patients to possible risks of herbal medications

21. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What therapeutic options are effective for exercise-induced bronchospasm? For patients who have normal pulmonary function but experience exercise-induced symptoms 15-30 minutes before exercise: use albuterol, cromolyn sodium, or nedocromil If exercise-induced symptoms persist: consider adding leukotriene antagonists (long-acting bronchodilators should not be used without inhaled steroid as increased adverse events) If pulmonary function tests are abnormal at baseline Its not just exercise-induced bronchospasm Treat according to stepwise regimen

22. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. When should primary care clinicians refer patients with asthma to a specialist? History of life-threatening exacerbations Atypical signs and symptoms Severe persistent asthma Need for continuous oral corticosteroids or high-dose inhaled steroids or >2 courses oral steroids in 1-y period Comorbid conditions complicate diagnosis or treatment Need for provocative testing or immunotherapy Problems with adherence or allergen avoidance Unusual occupational or other exposures

23. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. When should oral corticosteroids be used for outpatient treatment? Patients have an acute increase in asthma symptoms If symptoms incompletely controlled after 2 doses w/in 20mins of 2-6 puffs SABAs: use oral corticosteroids Also: continue using SABAs every 4h Seek immediate medical attention If symptoms persist or worsen If SABAs are required more than every 4h

24. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. How should the patient be educated to respond when symptoms increase? Physicians + patients should agree on written action plan: Daily management of asthma How to recognize signs and symptoms of worsening How to adjust medications and doses in response to acute symptoms How to adjust medications and doses in response to changes in peak expiratory flow rate When to seek medical attention

25. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. When is hospitalization indicated? When patient has a moderate exacerbation FEV1 40%–69% predicted or PEFR 40%–69% of personal best or Symptoms and physical exam findings are moderate When patient has a severe exacerbation FEV1–PEFR ratio <40% or Symptoms are severe or Physical exam findings include signs of severe respiratory distress When patient has an incomplete response to therapy Post-treatment PEFR remains <40% of predicted value ICU admission may be warranted

26. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. What factors identify patients with asthma at high risk for fatal or near-fatal events during an exacerbation? Prior intubation Multiple asthma-related exacerbations Emergency room visits for asthma in the previous year Nonuse or low adherence to inhaled corticosteroids History of depression, substance abuse, personality disorder, unemployment, or recent bereavement

27. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. How often should clinicians see patients with asthma for routine follow-up? Patients with newly diagnosed asthma 2–4 visits during the first 6 months after diagnosis Establish + reinforce patient knowledge, mgmt skills Patients with maximum improvement in pulmonary function and minimal to no related symptoms Follow-up every 1–6 months Patients discharged from the hospital Follow-up within 7 days Patients treated as outpatients for an exacerbation Follow-up within 10 days

28. © Copyright Annals of Internal Medicine, 2014 Ann Int Med. 160 (3): ITC3-1. CLINICAL BOTTOM LINE: Treatment… Avoid asthma triggers Use SABAs to relieve acute symptoms Use long-term controller medications for persistent asthma Closely monitor symptoms Step up or down as needed to maintain disease control Serial measures of asthma control guide treatment changes Educate patients on how to recognize and respond to early signs of clinical deterioration Evaluate and monitor patients with acute increase in symptoms