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Patient & Family Assessment. Presented by: Michelle Harkins, MD. This lesson will cover:. Medical history Physical exam Objective measures. Initial Assessment & Diagnosis of Asthma. Determine that: - PowerPoint PPT Presentation
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PATIENT & FAMILY
ASSESSMENTPresented by:
Michelle Harkins, MD
• Medical history• Physical exam• Objective measures
This lesson will cover:
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.
Initial Assessment & Diagnosis of Asthma
NAEPP. EPR-3, page 40.
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
Initial Assessment & Diagnosis of Asthma
NAEPP. EPR-3, page 40.
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
Medical History
• Identify symptoms• Pattern of symptoms• Precipitating/aggravating factors• Development of disease and
treatment• Family history
– Atopy, asthma
Medical History
NAEPP. EPR-3, page 69.
• Social history• History of exacerbations• Impact of asthma on patient/family• Patient/family perception of the disease
Medical History
NAEPP. EPR-3, page 69
In the past 12 months, have you had:
• A sudden, severe episode or recurrent episodes of coughing, wheezing or shortness of breath?
• Colds that go to the chest or take more than 10 days to get over?
• Coughing, wheezing or shortness of breath (SOB) during a particular season or time of the year?
• Coughing, wheezing or SOB in certain places or when exposed to certain things, such as animals, tobacco smoke, perfumes?
Interviewing the Individual with Asthma
NAEPP. EPR-3, page 70
In the past 12 months, have you had:
• Do you have symptoms of heartburn or awaken with an acid taste in back of your throat?
• Do you have symptoms of post-nasal drip or sinus congestion?
• Has wheezing, cough, chest tightness, shortness of breath – • Awakened you at night?• In the early morning?• After running, moderate exercise or other physical
activity?
Interviewing the Individual with Asthma
NAEPP. EPR-3, page 70.
In the past 12 months, have you had:
• Have you used any medicine that has helped you breathe better? How often?
• Are your symptoms relieved when these medicines are used?
Interviewing the Individual with Asthma
NAEPP. EPR-3, page 70.
Early Asthma Signs & Symptoms
•Coughing•Wheezing•Shortness of breath•Chest tightness and/or pain•Peak-flow numbers usually 50%
to 80% of personal best
Symptoms that indicate an
asthma episode is occurring
•Itchy throat or chin•Runny or stuffy nose•Sneezing•Headache•Funny feeling in the chest•Stomach ache/poor appetite•Glassy eyes•Feeling tired
Other Early Warning Signs & 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.
Late or 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
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.
Severe Asthma Symptoms
Pulses Paradoxus:• There is normally a decrease in systolic pressure
during inspiration, When that difference is greater than 10 mmHg, it is called pulsus paradoxus.
• A paradox is caused by a fall in cardiac output as a result of increased negative intrathoracic pressure.
Severe Asthma Symptoms
• 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
High-Risk Asthma Patients
NAEPP. EPR-3, page 377.
• >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
High-Risk Asthma Patients
NAEPP. EPR-3, page 377.
• The physical examination may be normal.
• Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma.
Physical Examination
NAEPP. EPR-3, page 377.
The upper respiratory tract, chest, and skin are the focus of the
physical exam for asthma.
Physical findings that increase the probability of asthma include:• Hyper-expansion of the thorax, especially in
children• Use of accessory muscles, appearance of
hunched shoulders, chest deformity
Physical Examination
NAEPP. EPR-3, page 42.
• 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
Physical Examination
NAEPP. EPR-3, page 43.
• What are some alternative diagnoses in adults that may present with similar symptoms?
What Is Your Differential Diagnosis?
Alternative Diagnoses in Adults
Chronic obstructive pulmonary disease – chronic bronchitis or
emphysema
Congestive heart failure
Mechanical obstruction of the airways – benign
and malignant tumors
Cough secondary to drugs (angiotensin-converting enzyme
[ACE] inhibitors)
Vocal cord dysfunction
NAEPP. EPR-3, page 46.
• 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.
Diagnosis of Asthma in Children
Alternative Diagnoses in Children
Allergic rhinitis Sinusitis Gastroesophageal reflux
Laryngotracheomalacia Bronchopulmonary dysplasia Cystic Fibrosis
NAEPP. EPR-3, page 46.
Alternative Diagnoses in Children
Bronchiolitis Foreign body aspiration
Vascular ring or laryngeal
web
Congenital heart disease
Vocal cord dysfunction
NAEPP. EPR-3, page 46.
In addition to the physical exam, other measures include:
• Radiology studies• Spirometry• Peak-flow monitoring• Arterial Blood Gas /oxygen saturation• Allergy testing
Objective Measures
Interpret the Findings from:
• Family, clinical and past medical history• Physical examination• Vital signs• Pulmonary function, radiology and laboratory
results
Determine Diagnosis & Severity of AsthmaBased on:• History and QOL questionnaire• Physical exam• Objective measures
Components of Severity Intermittent
Persistent
Mild Moderate Severe
Impairment
Symptoms 2 days/week>2
days/week but not daily
Daily Throughout the day
Nighttime awakenings None 1-2x/
month 3-4x/month >1x/ week
B-agonist use (not prevention of EIB)
2 days/week>2
days/week but not daily
Daily Several times per day
Activity limits None Minor Limitation
Some Limitation
Extremely Limited
Risk Exacerbations requiring OSC 0-1/yr
2 exacerbations in 6 months requiring oral systemic corticosteroids, or 4 wheezing episodes/ 1 year lasting >1 day AND risk factors for persistent
asthma
Classifying Asthma Severity: 0 – 4 years
Classifying severity in children who are not currently taking long-term control medication.
Components of Severity Intermittent
Persistent
Mild Moderate Severe
Impairment
Symptoms 2 days/wk
>2 days/wk but not daily Daily Throughout
the day
Nighttime awakenings 2x/month 1-2x/month 3-4x/month >1x/wk
B-agonist use (not prevention of EIB)
2 days/wk >2 days/wkbut not daily Daily Several times
per day
Activity limits None Minor limitation
Some Limitation
Extremely limited
Lung FunctionFEV1
FEV1/FVC>80%>85%
80%>80%
60 – 80%75 - 80%
<60%<75%
Risk Exacerbations requiring OSC 0-1/yr 2/year
Classifying Asthma Severity: 5 – 11 years
Classifying severity in children who are not currently taking long-term control medication.
Classifying Asthma Severity: 12 and older
Components of Severity Intermittent
Persistent
Mild Moderate Severe
Impairment
Normal FEV1/FVC:8-19yrs 85%20-39yrs 80%40-59yrs 75%60-80yrs 70%
Symptoms 2 days/wk >2 days/wkbut not daily Daily Throughout
the day
Nighttime awakenings 2x/month 3-4x/month >1x/wk but not
nightly Often 7x/week
B-agonist use (not prevention of EIB)
2 days/week >2 days/wk but not daily, and not more than 1x on any day
Daily Several times per day
Activity limits None Minor limitation
Some Limitation
Extremely limited
Lung FunctionFEV1
FEV1/FVC>80%
normal80%
normal>60 -80%
reduced 5%<60%
reduced >5%
Risk Exacerbations requiring OSC 0-1/yr 2/yr
Classifying severity for patients who are not currently taking long-term control medication.
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
Spirometry
NAEPP. Epr-3, page 43.
• 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.
Objective Measures: Spirometry
• 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
Spirometry Components
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.
Spirometry Results
FEV1 Predicted: 4.00LPatient’s FEV1: 3.00L
What is the percent predicted for this patient? 3.00 = 3 = 75% 4.00 4
Calculating % Predicted
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.
Objective Measures: 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.
Interpreting Spirometry
A normal flow volume loop has a rapid peak expiratory flow rate with a gradual decline in flow back to zero.
Flow Volume Loop
Spirometry Results Showing Obstruction
Measured Predicted Percent (%) Predicted
FVC 4.09 4.25 96
FEV1 1.95 2.88 68
FEV1/FVC 48 68
PEF 6.27 8.06 78
• 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.
Obstruction
Normal Obstruction
Normal vs. Obstructed
Both the FEV1 and FVC are reduced proportionately. FEV1/FVC ratio is normal or even elevated.
Measured Predicted Percent (%) Predicted
FVC 0.96 2.75 35
FEV1 0.94 1.90 49
FEV1/FVC 98 69
PEF 2.98 5.40 55
Restrictive Lung Disease
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.
Objective Measures: Spirometry
Is airflow obstruction present and is it at least partially reversible?
Use spirometry to establish airflow
obstruction
FEV1 < 80% predicted
FEV1/FVC below the lower limit of
normal, as compared to the individual’s own predicted value
Use spirometry to establish reversibility
FEV1 increases >12% and
> 200 mL after using a short-acting inhaled beta2-agonist
2- to 3-week trial of oral
corticosteroid therapy may be
required to demonstrate reversibility
Pre BD FEV 1 = 2.00 L Post BD FEV 1 = 2.40 LWhat 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.
Calculating Change in FEV1
Post BD FEV1 minus Pre BD FEV1Pre 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?
Calculating Change in FEV1
Post BD FEV 1 minus Pre BD FEV1 Pre BD FEV 1
Pre BD FEV 1 = 3.00LPost 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?
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)
Calculating Change in FEV1
• Spirometry is an effort-dependent maneuver that requires understanding, coordination and cooperation by the patient, who must be carefully instructed.
• Technicians must be trained and maintain a high level of proficiency to assure optimal results.
• Spirometry should be performed using equipment and techniques that meet standards developed by the American Thoracic Society.
Reliability of Spirometry
• Correct technique, calibration methods and maintenance of equipment are necessary to achieve consistently accurate test results.
• Maximal patient effort in performing the test is required to avoid important errors in diagnosis and management (reproducibility).
• Spirometry is generally valuable in children over age 4; however, some children cannot conduct the maneuver adequately until after age 7.
Reliability of Spirometry
Criteria for acceptability include: 1. Lack of artifact induced by coughing, glottic closure
or equipment problems (primarily leak); 2. Satisfactory start to the test without hesitation; and3. Satisfactory exhalation with six seconds of smooth
continuous exhalation, or a reasonable duration of exhalation with a plateau.
Reliability of Spirometry
Unacceptable Efforts
Cough Variable Effort
• Painless procedure• Noninvasive• Outpatient
Preparing Patients for Spirometry
• Normal breathing prior to test• Maximum forced exhalation during test• Maneuver repeated until results are consistent
Spirometry Maneuvers
• Connect spirometry results to the broader picture of the patient’s asthma.
• Explain that spirometry results can improve with effective asthma management.
• Stress that effective asthma management can lead to less severe disease.
Discussing Results with Patients
1. At the time of the initial assessment;2. After treatment is initiated and symptoms and
peak flow have stabilized to document attainment of (near) “normal” airway function;
3. During periods of loss of control;4. When assessing response to a change in
pharmacotherapy; and5. At least every 1 to 2 years to assess the
maintenance of airway function.
NAEPP Recommends Spirometry
NAEPP. EPR-3, pages 53, 59.
Depending on clinical severity, spirometry is also useful:• As a periodic check on the accuracy of the peak-flow
meter,• When more precision is desired in evaluating response
to therapy and• When peak flow results are unreliable.
Spirometry May Be Done More Frequently
NAEPP. EPR-3, page 59.
• Measured as the largest expiratory flow achieved with a maximally forced effort from a position of maximal inspiration, expressed in liters/minute.
• Spirometry documents PEFR in L/sec, so multiply this number by 60 to get L/min for noting personal best on the patient’s PFM.
Peak Flow*
Long-term daily peak flow monitoring is helpful in managing patients with moderate-to-severe persistent asthma to:• Detect early changes in disease status that
require treatment,• Evaluate responses to changes in therapy,• Provide assessment of severity for patients with
poor perception of airflow obstruction and• Afford a quantitative measure of impairment.
Peak-Flow Monitoring
NAEPP. EPR-3, page 120
• Not routine. • Usually normal yet
hyperinflation may be present• Identify complications
– Pneumonia– Pneumothorax– Pneumomediastinum– Tumor
Radiological (CXR) Results
Arterial blood gases are useful in assessing acutely ill patients.• Hypoxemia is generally not severe but does decline
with worsening airflow obstruction.• CO2 is low in mild exacerbations and rises with
severity of obstruction.• A normal CO2 in an acutely ill asthmatic can be a very
serious finding. If the exacerbation progresses unabated, respiratory failure may result.
• “Normal” 7.40/40/70
Arterial Blood Gas (ABG)
• Signs and symptoms• Pulmonary Function Test• QOL survey• History of exacerbations• Pharmacotherapy• Patient satisfaction
Periodic Assessments of Asthma Control
NAEPP. EPR-3, page 53.
Assessing Control: 0 – 4 years
Components of Control
Classification of Asthma Control
WellControlled
Not Well Controlled
Very PoorlyControlled
Impairment
Symptoms 2 days/wk >2 days/wk Throughout the day
Nighttime awakenings 1x/month >1x/month >1x/week
Activity limits None Some limitation Extremely limited
B-agonist use(not prevention of EIB)
2 days/week >2 days/week Several times per day
Risk Exacerbations requiring OSC 0-1/year 2-3/year >3/year
Recommended Action for Treatment
• Maintain current treatment
• Regular F/U every 1 – 6 mos
• Consider step down if well controlled for at least 3 mos
• Step up (1step) and• Reevaluate in 2 -6
wks• If no benefit in 6
wks, consider alternative diagnoses
• Consider short course of OSC
• Step up (1 – 2 steps) and
• Reevaluate in 2 wks
Asthma Control: 5 – 11 years
Components of Control
Classification of Asthma Control
WellControlled
Not Well Controlled
Very PoorlyControlled
Impairment
Symptoms 2 days/wk but
not more than once on each day
>2 days/wk or multiple times 2 days/wk Throughout the day
Nighttime awakenings 1x/month ≥2x/month ≥2x/week
Activity limits None Some limitation Extremely limited
B-agonist use (not prevention of EIB)
2 days/wk >2 days/wk Several times per day
Lung function• FEV1 or PF• FEV1/FVC
80% >80%
60 – 80% 75-80%
<60% <75%
Risk
Exacerbations requiring OSC 0-1/year ≥2/year
Reduction inlung growth Evaluation requires long-term follow-up
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
Asthma Control: 12 and older
Components of Control
Classification of Asthma Control
WellControlled
Not WellControlled
Very PoorlyControlled
Impairment
Symptoms 2 days/week >2 days/week Throughout the day
Nighttime awakenings 2x/month 1-3x/week >4x/week
Activity limits None Some limitation Extremely limited
B-agonist use (not prevention of EIB)
2 days/week >2 days/week Several times per day
Lung function FEV1 or PF >80% FEV1 or PF = 60 -80% FEV1 or PF <60%
QOL indicator ACT ≥20 ACT =16-19 ACT ≤15
Risk
Exacerbations requiring OSC 0-1/year > 2/ year
Reduction in lung growth Evaluation requires long-term follow-up
Treatment-related adverse effects
Medication side effects can vary in intensity from none to very troublesome and worrisome. The level of intensity does not correlate to specific levels of control but should be considered in the overall assessment of risk.
• Potential for workplace-related symptoms• Patterns of symptoms in relation to exposure• Documentation of work-relatedness of airflow
limitation
Occupational Asthma
NAEPP. EPR-3, page 189.
Classifying Severity of Asthma Symptoms and Signs Initial PEF (or FEV1) Clinical Course
MildDyspnea only with activity (assess tachyphena in young children)
PEF ≥ 70 % predicted or personal best
• Usually cared for at home• Prompt relief with inhaled SABA• Possible short course of OSC
ModerateDyspnea interferes with or limits usual activity
PEF 40-69 % predicted or personal best
• Usually requires office or ED visit• Relief from frequent inhaled SABA• OSC; some symptoms last for 1-2 days after treatment is begun
SevereDyspnea at rest; interferes with conversation
PEF < 40 % predicted or personal best
• Usually requires ED visit and likely hospitalization• Partial relief from frequent inhaled SABA• OSC; some symptoms last for >3 days after treatment is begun•Adjunctive therapies are helpful
Subset: Life Threatening
Too dyspneic to speak; perspiring
PEF <25 % predicted or personal best
•Requires ED/hospitalization; possible ICU• Minimal or no relief from frequent inhaled SABA• Intravenous cortosteroids•Adjunctive therapies are helpful
• A life-threatening asthma exacerbation exists,• Patient is not meeting goals of asthma therapy
after 3-6 months of treatment,• Signs and symptoms are atypical or there are
problems in differential diagnosis,• Comorbid conditions complicate asthma or its
diagnosis and• Additional diagnostic testing is needed.
Referral to Specialist When:
• Additional education needed (about complications of therapy, adherence, allergen avoidance);
• Patient is considered for immunotherapy;• Adult patient requires Step 4 or higher care –
consider referral if patient requires Step 3; and• Pediatric patient requires Step 3 or higher care –
consider referral if child 0-4 yrs requires Step 2 care.
Referral to Specialist When:
NAEPP. EPR-3, page 68.
Review the pulmonary function results, then select the correct basic interpretation.
Choose from the following answers:1. Normal2. Mild to moderate obstruction3. Severe obstruction4. Severe obstructive ventilatory defect, cannot exclude a
concomitant restrictive defect5. Restrictive ventilatory defect, large volumes necessary for
confirmation6. Cannot be interpreted; does not meet acceptability criteria.
Case Reviews
Acknowledgements
• Sally W. Southard, PNP, BC, AE-CPediatric Nurse Practitioner, Carilion Pediatric Pulmonology Clinic
We will breathe easier when the air in everyAmerican community is clean and healthy.
We will breathe easier when people are free from the addictivegrip of cigarettes and the debilitating effects of lung disease.
We will breathe easier when the air in our public spaces andworkplaces is clear of secondhand smoke.
We will breathe easier when children no longerbattle airborne poisons or fear an asthma attack.
Until then, we are fighting for air.