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Asthma

Katie Humphries, DO PGY 3+ Emory Family Medicine. Asthma. What is Asthma?. •Lacks a precise definition

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Asthma

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  1. Katie Humphries, DO PGY 3+ Emory Family Medicine Asthma

  2. What is Asthma? •Lacks a precise definition • Summary Definition: “a common chronic disorder of the airways that is complex and characterized by variable and recurring symptoms, airflow obstruction, bronchial hyperesponsiveness, and an underlying inflammation”

  3. What makes it different from COPD? • REVERSIBILITY • Asthma =REVERSIBLE COPD =IRREVERSIBLE, or incompletely reversible

  4. What about asthma is reversible? • Asthma & COPD are OBSTRUCTIVE lung diseases • This means that while air can flow in easily, it does not move out of the lungs well • In asthma, this OBSTRUCTION of airflow can be completely reversed with medications

  5. Clinical Features of Asthma BasiCS • Can develop at any age but new onset less common in adults than kids/teens • Diagnosed before age 7 in 75% of cases • Most teenagers experience remission of symptoms around puberty that may or may not return

  6. Clinical Features of Asthma History Description of symptoms Cough: usually worse at night. Can be dry or productive of clear/pale yellow sputum Wheeze: high-pitched, typically on exhalation Shortness of breath/trouble breathing: chest tightness, heavy weight on chest • Respiratory symptoms that are episodic and occur with triggers • Cough ,wheezing, shortness of breath or difficultly breathing • Symptoms reversed with meds and/or trigger avoidance

  7. Episodic Symptoms • Episodic Symptoms are typical • The symptoms come and go with a time frame of hours to days, resolving with trigger avoidance or meds • Patients can be asymptomatic for long periods of time • Nocturnal symptoms are common

  8. Triggers • Exercise (see, you always knew it was bad for you, right?) • Exercise-triggered symptoms typically develop 5-15 minutes into exercise and resolve after 30-60 minutes of rest • More common and more intense in cold air

  9. Triggers • Allergens: dust mites, mold, cockroaches, furry animals, pollen, etc! • Acute onset of symptoms (cough, wheeze, SOB) with exposure to furry animals is VERY characteristic of asthma • Symptoms with smoke, fumes, chemicals and dust are less specific

  10. Triggers • Viral infections are common triggers, but they trigger symptoms of other lung diseases as well • Onset of symptoms within 30-120 minutes of ingesting aspirin or other COX-1 inhibitors is UNIQUE to asthma, but occurs in very few patients

  11. Occupational Asthma • An estimated 10% of new cases of asthma are thought to be related to work-related exposures • Called “Occupational Asthma” • Suspect this with the right history: symptoms only during work hours, only in place of work, known exposure to irritants

  12. Family History • Strong family history of asthma & allergies OR a personal history of atopic conditions in a symptomatic patient favors asthma • Asthma appears to be passed down through families in complex patterns. Some components of the asthma phenotype are heritable, but the genes responsible for these inherited components have yet to be identified.

  13. Probably not asthma? • Irreversibility with meds: bronchodilators or oral CS • Onset of symptoms >50 yo • Concomitant symptoms like chest pain, dizziness, syncope, palpitations • History of longstanding tobacco abuse

  14. Physical Findings • Widespread, musical wheezes are characteristic • Wheezing usually involves high-pitched sounds starting and stopping at various points in the respiratory cycle and varying in tone and duration • But, not all wheezing is asthma and not all asthmatics wheeze all the time!

  15. Let’s Listen to the Difference… • Lung Sounds

  16. Evaluation • Pulmonary Function Testing (spirometry) • Maximal inhalation is followed by a rapid and forceful complete exhalation into a spirometer • Measurement of forced expiratory volume in one second (FEV1) and forced vital capacity (FVC). It’s all in the ratio!

  17. Spirometry Uses in Asthma Determine whether baseline obstruction is present (reduced FEV1/FVC ratio) • Assess the reversibility of the obstruction by repeating test after administration of a bronchodilator • Characterize the severity of airflow limitation (based on the FEV1 as a percentage of the normal predicted value)

  18. Obstructive Pattern on PFT • FEV1/FVC ≤ 0.70 for patients 65 and older (GOLD) or < LLN for adults < 65 yo • FEV1/FVC ≤ 0.85 predicted in ages 5-18 • Severity of obstruction categorized as borderline, mild, moderate and severe • This is based on FEV1 value

  19. Spirometry • Can also identify obstructive pattern of PFT by looking at shape of expiratory flow-volume curve • A scooped, concave appearance to the expiratory portion of the flow-volume curve signifies airflow obstruction, typical of asthma and many other obstructive lung diseases

  20. Bronchodilator Challenge • Acute reversibility of airflow obstruction is tested by administering 2 to 4 puffs of a quick-acting bronchodilator with a spacer and repeating spirometry 10 to 15 minutes later • An increase in FEV1 of ≥12% AND an absolute increase in FEV1 of at least 200 mL=responsiveness in adults. In kids 5-18, ≥12%

  21. Bronchoprovocation Testing • Done if no obstruction seen on PFT but symptoms are still suggestive of asthma (or obstructive lung disease) • Diagnostic test • A provocative stimulus (methacholine, exercise, or hyperventilation of cold, dry air) is used to stimulate bronchoconstriction. People with asthma are hyperresponsive to such stimuli

  22. Peak Expiratory Flow • Not a useful diagnostic test. More useful for maintenance • Measured during a brief, forceful exhalation, using a simple and inexpensive device  • Peak flow measurements lack graphic display to ensure maximal patient effort and appropriate technique and the meters cannot be calibrated

  23. PEF-Technique • Take a maximally large breath in, put the peak flow meter quickly to the mouth, seal the lips around the mouthpiece, and blow out as hard and fast as possible into the meter • Effort does not need to be sustained beyond one to two seconds • Perform 3 times and measure highest of 3

  24. Patient Education • How to perform Peak Expiratory Flow

  25. PEF-Interpretation • Average normal values for men and women are based upon height and age (calculator) • Average normal values for adolescents are based upon height (see next slide) • A single peak flow measurement made at the time that a patient is experiencing respiratory symptoms, if reduced from the normal predicted value, is suggestive of asthma. However, it is not diagnostic because a reduced peak flow is not specific for airflow obstruction and can be seen with other pulmonary processes

  26. Diagnosis: Putting it All Together • h/o intermittent symptoms plus physical examination with characteristic wheezing strongly points to a diagnosis of asthma • Confirmation of the diagnosis of asthma is based on: ●The demonstration of variable expiratory airflow limitation, preferably by spirometry ●Exclusion of alternative diagnoses

  27. Asthma Classification NAEPP Guidelines, based on 2009 update

  28. How Do I Assess Impairment? • Know what to ask-follow the classification chart • Validated questionnaires: ATAQ, ACQ, ACT • Use Peak Flow Meter at home and in office • PFTs • Schedule follow-ups and recheck status at each visit using some form of testing: patient history, questionnaire, PFM

  29. Treatment Medications: When and How to Use Them

  30. Patient Education • How To Use an MDI

  31. Asthma Action Plan • How to Make and Use an Asthma Action Plan • Everyone should have one! • Review this at EACH office visit for asthma • Be sure the school has one

  32. When Should I Refer Patients? • When you are unsure of diagnosis • When you’ve maximized treatment and the patient is still not well-controlled • When you suspect allergic/environmental component that would best be evaluated/treated by a specialist (ALCAT testing, allergy drops, shots, etc)

  33. Integrative Medicine Approach • Acute attacks: use indian tobacco (lobelia) + capsicum. Mix three parts tincture of lobelia with one part tincture of capsicum (red pepper, cayenne). Take twenty drops of the mixture in water at the start of an asthmatic attack. Repeat every thirty minutes for a total of three or four doses.

  34. Integrative Techniques • For Long Term Control: Anti-inflammatory diet • Protein < 10% daily caloric intake. Replace animal protein with plant proteins • Limit or eliminate dairy • EVOO as main source of fat • Eliminate polyunsaturated fats • Increase omega-3 intake • Adequate hydration

  35. Integrative Techniques • Use ginger and turmeric daily (either in supplements or in food) • Experiment with eliminating (one at a time) wheat, corn, soy and sugar for six to eight weeks to see if the condition improves. • OSTEOPATHIC MANIPULATION!

  36. OMT • Osteopathic manipulative techniques have been shown to increase vital capacity and rib cage mobility, improve diaphragmatic function, enhance the clearing of airway secretions, and possibly enhance autoimmune function.In patients with asthma, OM techniques that focus on thoracic structure and function can be employed to maximize the effectiveness of the respiratory cycle.

  37. OMT • Rib Raising • Muscle energy for ribs • Myofascial release (J Am Osteopath AssocJanuary 1, 2005 vol. 105 no. 1 7-12)

  38. Thank You Lucy George

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