Clinical Management
- Slide 28: Clinical Management of Asthma
We are fortunate to have available standards related to asthma care. These are the Clinical Practice Guidelines developed by the National Asthma Education and Prevention Program's Expert Panel, under the National Heart, Lung and Blood Institute. Developed in 1991 and updated in 1997 and 2002, these guidelines offer specific advice in several key areas of asthma assessment and management. The guidelines provide a gold standard for asthma care and are recognized by federal public health agencies, health-care providers, universities, and nonprofit organizations. - Slide 29: Diagnosing Asthma: Medical
History
Asthma can be difficult to diagnose. Clinicians use a variety of means to try to determine whether episodic symptoms of airflow obstruction are present and whether this obstruction is at least partially reversible. A detailed medical history is a key element of this process.
The physician may ask questions about coughing, especially at night, and whether the patient's breathing problems are worse after physical activity or during a particular season. Other symptoms, such as chest tightness, wheezing, colds that last beyond 10 days, and relief after use of medication, should be discussed.
The physician will ask about the patient's family history of asthma, allergy, sinusitis, rhinitis or nasal polyps, and home environment. The physician also will try to quantify the severity of disease by asking about its impact on the patient and his or her family members - such as lost school or work days and limitation of activity. - Slide 30: Diagnosing Asthma: Patient
Checklist
A physician may ask questions such as these when examining someone with possible asthma:- Do you have a troublesome cough, particularly at night?
- Are you awakened by coughing or difficult breathing?
- Do you cough or wheeze after physical activity?
- Do you have breathing problems during a particular season?
- Do you cough, wheeze, or develop chest tightness after exposure to allergens?
- Do colds "go to your chest" or last more than 10 days?
- Do you use any medications? How often?
- Are your symptoms relieved after you take medication?
- Slide 31: Diagnosing Asthma: Physical
Examination
In the absence of specific symptoms, some physical findings still increase the possibility that a patient has asthma. These include:- A wheezing sound in the lungs
- Hyperexpansion of the chest area (expansion of the area between the neck and abdomen), especially in children
- Hunched shoulders
- Chest deformity
- Nasal swelling
- Increased secretions or polyps, and
- Indications of an allergic skin condition
The physician may suggest that the patient be tested for allergies to help isolate substances to which he or she has a strong allergic reaction.
- Slide 32: Diagnosing Asthma: Spirometry
Testing of lung function, or spirometry, is another means of diagnosing asthma. A spirometer is a piece of equipment that measures the maximum amount of air forcibly exhaled from the lungs after the patient has taken a very deep breath. Airflow can be measured before and after a patient uses a fast-acting bronchodilator to determine the medication’s affect on reversing airflow obstruction. - Slide 33: Medications to Treat Asthma
Because everyone's asthma is different, medications to treat it come in many forms: liquids, pills, powders, vapors, and injections. Treating asthma involves managing both the chronic inflammation and recurrent episodes of airflow limitation and bronchoconstriction. - Slide 34: Long-term Control
Long-term control medicines are taken daily over a long period of time. The most effective of these to reduce inflammation of the airways are corticosteroids, which are generally prescribed in inhaled form or in pills. Another important type of long-term control medicine is long-acting beta2-agonists. Usually inhaled, but also available orally, this medicine relaxes the smooth muscles of the airways for long-term prevention of symptoms, especially at night.
The last type of long-term control medication to treat asthma is leukotriene modifiers. Leukotriene modifiers may be considered as alternative therapy to low doses of inhaled corticosteriods for children with mild persistent asthma, but the position of leukotriene modifiers in therapy has not been fully established. Leukotriene modifiers improve symptoms and pulmonary function and reduce the need for quick-relief medications. - Slide 35: Quick-Relief
Quick-relief medications are used to help counter the effects of an acute asthma episode. These are generally short-acting beta2-agonist bronchodilators delivered through an inhaler. People with an inhaler need to know how to use it correctly for the drug to reach the lungs and have a full effect. - Slide 36: How to Use a Spray Inhaler
Inhalers also are called metered-dose inhalers, meaning that medications are measured by the inhaler apparatus. They are usually the press-and-breathe type.
Many people, especially young children, have a hard time coordinating the pressing and the breathing. This means they may not get the full dose of their medication. If an inhalant is not having much effect, it could mean the person is not using it properly or it is blocked or empty. A health-care provider should evaluate the technique of patients using inhalers at each visit.
If the health-care provider sees that someone is having difficulty using the inhaler, he or she can prescribe a spacer. Spacers come in a variety of shapes and sizes, but the concept is the same for all. The inhaler is attached at one end and a mouthpiece at the other end. When the inhaler is pressed, the drug is released into the spacer chamber and the person can slowly inhale it in two or three breaths. - Slide 37: Inhalers and Spacers
Spacers also can reduce potential side effects like mouth sores and mouth dryness common to some inhaled medications. Here are some examples of actual inhalers and spacers. - Slide 38: Nebulizers
A nebulizer is a device which allows people to inhale asthma medication in a mist or wet aerosol. It consists of a cup, a mouthpiece attached to a T-shaped port or a mask, and thin plastic tubing to connect to the compressed air machine. This equipment may be needed for small children or others who cannot coordinate the use of an inhaler. It is often used in emergency departments to deliver medicine quickly and effectively to a person having severe symptoms.
