Non-acute Asthma in Adults; Hx and exam Flashcards
About non-acute asthma in adults and young people
Māori and Pacific peoples aged 15 to 49 years are x3 more likely to be admitted with asthma, with 14% readmitted within 90 days.
The use of salbutamol without inhaled corticosteroid (ICS) is no longer recommended, as it results in poorer outcomes.
Anti-inflammatory reliever (AIR) therapy is the use of a combination ICS/formoterol inhaler that provides both maintenance and acute relief of asthma regardless of severity.
The rapid-onset long-acting beta agonist (LABA) provides both acute and long-lasting relief. A short-acting beta agonist (SABA) is not required.
The SMART protocol uses an anti-inflammatory reliever inhaler as both regular maintenance and reliever therapy to control moderate to severe asthma.
The only inhalers currently licensed for AIR therapy, either on an as-needed or SMART protocol basis, are dry powder inhalers (DPI) that contain budesonide and formoterol.
Features suggesting asthma
Intermittent, diurnal variation, seasonal variation
Triggers such as allergens, irritants, exercise, medications or supplements
Positive response to treatment
Family history of asthma
History of atopy, rhinosinusitis
Childhood symptoms of asthma
Take a history
Typical symptoms of wheeze, breathlessness, chest tightness and cough
All forms of smoking, including vaping and cannabis or other drugs
Occupational causes
Patient factors that affect access to care and health outcomes e.g., ethnicity, socio-economic situation, lack of a healthy home environment.
High‑risk work for occupational asthma includes:
baking or pastry-making
woodwork
spray painting
welding, soldering, metalwork
laboratory animal work
healthcare, dental care
food processing, chemical processing
textile, plastics, and rubber manufacture
farming and other jobs with exposure to dusts and fumes.
Recognition and control of exposure to the causative agent is the most important means of controlling the asthma.
Examine the patient:
Cardiorespiratory systems – Check for atypical or unexpected findings
Signs of atopy
Peak expiratory flow rate
Atypical or unexpected cardiorespiratory findings
Crackles, clubbing, or cyanosis
Persistent non-variable breathlessness
Monophonic wheeze or stridor
Systemic features such as weight loss, myalgia, fever
Signs of atopy
Swollen turbinates, reduced nasal airflow
Transverse nasal crease
Mouth breathing
Darkness and swelling under eyes caused by sinus congestion
Eczema
Assess the patient’s asthma control:
If they get symptoms or need their reliever inhaler more than twice a week, control can be improved.
The Asthma Control Test: Adult 12+ Years can be used for a detailed assessment. (https://www.asthmacontroltest.com/en-au/quiz/adult-quiz/)
Consider treatable conditions that may co-exist with, exacerbate, or mimic asthma:
1) Alternative diagnoses and co-morbidities
. Obesity or poor fitness
. COPD
. Bronchiectasis
. Upper airway abnormalities (including OSA and vocal cord dysfunction)
. Heart failure and other cardiac conditions
. Anxiety, depression
. Breathing pattern disorder or hyperventilation
. Medications e.g., ACEI‑induced cough
. GORD
. Allergic bronchopulmonary aspergillosis
. Diffuse lung disease
2) COPD and asthma-COPD overlap syndrome (ACOS) in older smokers
Consider arranging investigations:
Spirometry
Biomarkers
Chest X-ray – to help assess for alternative diagnoses or co-morbidities if there is an unclear diagnosis, poor control, or frequent exacerbations
Challenge tests
Spirometry
Spirometry is the gold standard for assessing airflow obstruction.
Perform spirometry if diagnosis is uncertain. If unavailable in your practice, request spirometry testing from another provider.
Interpret normal spirometry results carefully:
. Patients who were asymptomatic at the time of testing may still have asthma.
. Patients who were symptomatic at the time of testing most likely have an alternate diagnosis to asthma.
. See also spirometry interpretation.
Biomarkers
Arrange biomarker testing (e.g., eosinophil count, total IgE) as needed to assess complex or atypical cases with ongoing poor control.
Suspect allergic bronchopulmonary aspergillosis if:
. Blood eosinophil count > 1.0.
. Raised total IgE is > 1000.
. Raised aspergillus specific IgE – See Allergy Testing.
. Consider skin prick tests – See Allergy Testing.
Challenge tests
Consider arranging bronchial challenge tests for diagnosis and risk assessment if:
. the diagnosis is uncertain.
. the patient has specific employment circumstances, e.g. armed forces, fire service, police.
. required for scuba diving assessment.
. investigating exercise-induced bronchospasm.
Bronchial challenge tests
A number of different challenge tests are available, including saline, methacholine, exercise, and eucapnic voluntary hyperventilation.
If required, arrange via eReferral or Web Referral – Respiratory – COPD/Asthma – Pulmonary Function Testing.
Lung function testing is also available through private providers.
