Asthma

Asthma is a chronic inflammatory airway disorder characterized by variable and recurring symptoms. It is characterized by reversible airflow obstruction and bronchospasm. In patients of all ages with respiratory symptoms it is important to include asthma in the differential diagnosis. Asthma's etiology is unclear. It is a combination of both genetic and environmental factors.

History

 * Shortness of breath
 * Chest tightness
 * Wheezing (worse at night or early morning)
 * Cough
 * Sputum production
 * Triggers: URTI, irritants, exercise, allergens
 * PMHx: previous episodes of wheeze, ICU admissions, prior intubations, pre-term
 * Family Hx: atopy (asthma, eczema, seasonal allergies)

Physical

 * Vitals, ABCs
 * Assess for work of breathing: respiratory rate, intercostal in-drawing, tracheal tug, nasal flaring, scalene retractions
 * CV: tachy
 * Resp: Air entry, adventitious sounds (wheeze)

PRAM score

 * Score that is used in the emergency department to grade the severity of the asthma exacerbationScreen_Shot_2016-02-02_at_6.23.47_PM.png



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Investigations

 * In order to diagnose asthma history and confirmion by lung function testing is required. This cannot be completed until 6 years of age
 * Test of choice = spirometry

Differential in pediatrics population

 * R/O croup, foreign body, bronchiolitis (see cough)

Management





 * Short acting beta-agonists: Ventolin 100mcg 2 puffs q 4h PRN
 * Inhaled corticosteroids:
 * Flovent (fluticasone) 50, 125, 250mcg 1 puff BID
 * Pulmicort (Budesonide) 100, 200, 400mcg 1 puff BID
 * Combined LABA (long acting beta-agonist)/ICS (inhaled corticosteroid)
 * Salmeterol + fluticasone (Advair) 100/50, 250/50, 500/50 1 puff BID
 * Formoterol + budesonide (Symbicort) 100/6, 200/6 2 puffs BID
 * Leukotriene receptor antagonist
 * Singulaire (montelelukast) 4mg granules/ chewable, 5mg chewable, 10 mg tablet 1 tab PO qPM


 * C In a known asthmatic, presenting either because of an acute exacerbation or for ongoing care, objectively determine the severity of the condition (e.g., with history, including the pattern of medication use), physical examination, spirometry). Do not underestimate severity. Clinical Reasoning Diagnosis 4 In a known asthmatic with an acute exacerbation: a) Treat the acute episode (e.g., use beta-agonists repeatedly and early steroids, and avoid under-treatment). Clinical Reasoning Selectivity Treatment b) Rule out co-morbid disease (e.g., complications, congestive heart failure, chronic obstructive pulmonary disease). Selectivity Clinical Reasoning Hypothesis generation Diagnosis c) Determine the need for hospitalization or discharge (basing the decision on the risk of recurrence or complications, and on the patient’s expectations and resources). Selectivity Clinical Reasoning Treatment 5 For the ongoing (chronic) treatment of an asthmatic, propose a stepwise management plan including: - self-monitoring. - self-adjustment of medication. - when to consult back. Clinical Reasoning Patient Centered Treatment 6 For a known asthmatic patient, who has ongoing or recurrent symptoms: a) Assess severity and compliance with medication regimens. Clinical Reasoning Patient Centered History Diagnosis b) Recommend lifestyle adjustments (e.g., avoiding irritants, triggers) that may result in less recurrence and better control.

Resources
http://www.respiratoryguidelines.ca/sites/all/files/2012_CTS_Asthma_%20Executive_%20Summary.pdf