Patient & Family Assessment

1. Patient & Family Assessment • Presented by: • Michelle Harkins, MD

2. This lesson will cover: • Medical history • Physical exam • Objective measures

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. NAEPP. EPR-3, page 40.

4. 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.

5. 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

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

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

8. Interviewing the Individual with Asthma NAEPP. EPR-3, page 70

9. Interviewing the Individual with Asthma NAEPP. EPR-3, page 70.

10. Interviewing the Individual with Asthma NAEPP. EPR-3, page 70.

11. Early Asthma Signs & Symptoms

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 chest • Patient 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 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

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

17. 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.

18. 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 NAEPP. EPR-3, page 377.

19. Physical Examination • 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.

21. 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 NAEPP. 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 NAEPP. 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 NAEPP. EPR-3, page 46.

26. Alternative Diagnoses in Children NAEPP. EPR-3, page 46.

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

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

29. Determine Diagnosis & Severity of Asthma Based on: History and QOL questionnaire Physical exam Objective measures

30. Classifying Asthma Severity: 0 – 4 years Classifying severity in children who are not currently taking long-term control medication.

31. Classifying Asthma Severity: 5 – 11 years Classifying severity in children who are not currently taking long-term control medication.

32. Classifying Asthma Severity: 12 and older Classifying severity for patients who are not currently taking long-term control medication.

33. Spirometry 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 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.

35. 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

36. 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.

37. Calculating % Predicted FEV1 Predicted: 4.00L Patient’s FEV1: 3.00L What is the percent predicted for this patient? 3.00 = 3 = 75% 4.00 4

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.

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 Loop A 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

42. 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.

43. Normal Obstruction Normal vs. Obstructed

44. Restrictive Lung Disease • Both the FEV1 and FVC are reduced proportionately. • FEV1/FVC ratio is normal or even elevated.

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

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 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 1.50 5 Does 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)