PATIENT & FAMILY ASSESSMENT Presented by: Michelle Harkins, MD

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


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


• 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



• 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?




• Have you used any medicine that has helped you breathe better? How often?

• Are your symptoms relieved when these medicines are used?



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.


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.


• 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


• >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


• The physical examination may be normal.

• Absence of symptoms at the time of the examination does not exclude the diagnosis of asthma.

Physical Examination


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



• 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



• 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


• 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

LaryngotracheomalaciaBronchopulmonary

dysplasia Cystic Fibrosis


Alternative Diagnoses in Children

Bronchiolitis Foreign body aspiration

Vascular ring or laryngeal

web

Congenital heart disease

Vocal cord dysfunction


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.


Persistent


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


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


Persistent


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


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: 4.00L

Patient’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.


• 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.


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 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.

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


Example 2: 1.80L – 1.50L= .30 = 1 = 20% improvement

1.50L 1.50 5



Post BD FEV 1 minus Pre BD FEV1 Pre BD FEV 1

Pre BD FEV 1 = 3.00LPost BD FEV1 = 4.00L


Example 3: 4.00L – 3.00L= 1.00 = 33% improvement 3.00L 3.00



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)


• 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.


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; and

3. Satisfactory exhalation with six seconds of smooth continuous exhalation, or a reasonable duration of exhalation with a plateau.


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; and

5. 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


• 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


• 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


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



WellControlled

Not Well Controlled


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



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



WellControlled

Not WellControlled


Impairment

Symptoms 2 days/week >2 days/week Throughout the day

Nighttime awakenings 2x/month 1-3x/week >4x/week



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


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:


Review the pulmonary function results, then select the correct basic interpretation.

Choose from the following answers:

1. Normal

2. Mild to moderate obstruction

3. Severe obstruction

4. Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive defect

5. Restrictive ventilatory defect, large volumes necessary for confirmation

6. Cannot be interpreted; does not meet acceptability criteria.

Case Reviews

Acknowledgements

• Sally W. Southard, PNP, BC, AE-C

Pediatric 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.

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PATIENT & FAMILY ASSESSMENT Presented by: Michelle Harkins, MD