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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:

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patient family assessment
Patient & Family Assessment
  • Presented by:
  • Michelle Harkins, MD
this lesson will cover
This lesson will cover:
  • Medical history
  • Physical exam
  • Objective measures
initial assessment diagnosis of asthma
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.

initial assessment diagnosis of asthma1
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.

medical history
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
medical history1
Medical History
  • Identify symptoms
  • Pattern of symptoms
  • Precipitating/aggravating factors
  • Development of disease and treatment
  • Family history
    • Atopy, asthma

NAEPP. EPR-3, page 69.

medical history2
Medical History
  • Social history
  • History of exacerbations
  • Impact of asthma on patient/family
  • Patient/family perception of the disease

NAEPP. EPR-3, page 69

late or severe asthma symptoms
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.
severe asthma symptoms
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 symptoms1
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.
high risk asthma patients
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.

high risk asthma patients1
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.

physical examination
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.

physical examination1
Physical Examination

NAEPP. EPR-3, page 42.

physical examination2
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.

what is your differential diagnosis
What Is Your Differential Diagnosis?
  • What are some alternative diagnoses in adults that may present with similar symptoms?
alternative diagnoses in adults
Alternative Diagnoses in Adults

NAEPP. EPR-3, page 46.

diagnosis of asthma in children
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.
alternative diagnoses in children
Alternative Diagnoses in Children

NAEPP. EPR-3, page 46.

alternative diagnoses in children1
Alternative Diagnoses in Children

NAEPP. EPR-3, page 46.

objective measures
Objective Measures

In addition to the physical exam, other measures include:

  • Radiology studies
  • Spirometry
  • Peak-flow monitoring
  • Arterial Blood Gas /oxygen saturation
  • Allergy testing
interpret the findings from
Interpret the Findings from:

Family, clinical and past medical history

Physical examination

Vital signs

Pulmonary function, radiology and laboratory results

determine diagnosis severity of asthma
Determine Diagnosis & Severity of Asthma

Based on:

History and QOL questionnaire

Physical exam

Objective measures

classifying asthma severity 0 4 years
Classifying Asthma Severity: 0 – 4 years

Classifying severity in children who are not currently taking long-term control medication.

classifying asthma severity 5 11 years
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
Classifying Asthma Severity: 12 and older

Classifying severity for patients who are not currently taking long-term control medication.

spirometry
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.

objective measures spirometry
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.
spirometry components
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

spirometry results
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.
calculating predicted
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

objective measures spirometry1
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.
interpreting spirometry
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.
flow volume loop
Flow Volume Loop

A normal flow volume loop has a rapid peak expiratory flow rate with a gradual decline in flow back to zero.

obstruction
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.
restrictive lung disease
Restrictive Lung Disease
  • Both the FEV1 and FVC are reduced proportionately.
  • FEV1/FVC ratio is normal or even elevated.
restrictive flow volume loop
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.

calculating change in fev1
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.

calculating change in fev11
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?

calculating change in fev12
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?

calculating change in fev13
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)

reliability of spirometry
Reliability of Spirometry
  • 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 spirometry1
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 spirometry2
Reliability of Spirometry

Criteria for acceptability include:

  • Lack of artifact induced by coughing, glottic closure or equipment problems (primarily leak);
  • Satisfactory start to the test without hesitation; and
  • Satisfactory exhalation with six seconds of smooth continuous exhalation, or a reasonable duration of exhalation with a plateau.
unacceptable efforts
Unacceptable Efforts

Variable Effort

Cough

preparing patients for spirometry
Preparing Patients for Spirometry
  • Painless procedure
  • Noninvasive
  • Outpatient
spirometry maneuvers
Spirometry Maneuvers
  • Normal breathing prior to test
  • Maximum forced exhalation during test
  • Maneuver repeated until results are consistent
discussing results with patients
Discussing Results with Patients
  • 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.
naepp recommends spirometry
NAEPP Recommends Spirometry
  • At the time of the initial assessment;
  • After treatment is initiated and symptoms and peak flow have stabilized to document attainment of (near) “normal” airway function;
  • During periods of loss of control;
  • When assessing response to a change in pharmacotherapy; and
  • At least every 1 to 2 years to assess the maintenance of airway function.

NAEPP. EPR-3, pages 53, 59.

spirometry may be done more frequently
Spirometry May Be Done More Frequently

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.

NAEPP. EPR-3, page 59.

peak flow
Peak Flow*
  • 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 monitoring
Peak-Flow Monitoring

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.

NAEPP. EPR-3, page 120

radiological cxr results
Radiological (CXR) Results
  • Not routine.
  • Usually normal yet hyperinflation may be present
  • Identify complications
    • Pneumonia
    • Pneumothorax
    • Pneumomediastinum
    • Tumor
arterial blood gas abg
Arterial Blood Gas (ABG)

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
periodic assessments of asthma control
Periodic Assessments of Asthma Control
  • Signs and symptoms
  • Pulmonary Function Test
  • QOL survey
  • History of exacerbations
  • Pharmacotherapy
  • Patient satisfaction

NAEPP. EPR-3, page 53.

occupational asthma
Occupational Asthma
  • Potential for workplace-related symptoms
  • Patterns of symptoms in relation to exposure
  • Documentation of work-relatedness of airflow limitation

NAEPP. EPR-3, page 189.

referral to specialist when
Referral to Specialist When:
  • 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 when1
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.

NAEPP. EPR-3, page 68.

case reviews
Case Reviews

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

Choose from the following answers:

  • Normal
  • Mild to moderate obstruction
  • Severe obstruction
  • Severe obstructive ventilatory defect, cannot exclude a concomitant restrictive defect
  • Restrictive ventilatory defect, large volumes necessary for confirmation
  • Cannot be interpreted; does not meet acceptability criteria.
acknowledgements
Acknowledgements

Sally W. Southard, PNP, BC, AE-C

Pediatric Nurse Practitioner, Carilion Pediatric Pulmonology Clinic