Noninfectious Respiratory Problems

Asthma

Essentials of Diagnosis

Recurrent wheezing, shortness of breath, or cough.

Histories of allergies in children.
Increase in airway secretions.
Airway constriction, obstruction, or both.
Bronchospasm documented on spirometry.
Dyspnea.

General Considerations

Asthma is one of the most common illnesses in childhood. Risk factors for the development of
asthma include living in poverty and being in a nonwhite racial group. Part of the difference in
asthma rates noted among different races may be related to increased exposure to allergens and
other irritants such as air pollution, cigarette smoke, dust mites, and cockroaches in less affluent
families, but racial differences persist even after adjusting for socioeconomic status.

Allergy is an important factor in asthma development in children but does not appear to be as
significant a factor in adults. Although as many as 80% of children with asthma also are atopic,
70% of adults younger than 30 and fewer than half of all adults older than 30 have any evidence
of allergy. Therefore, although an allergic component should be sought in adults, it is less
commonly found than in children with asthma.

Clinical Findings

In most cases, asthma is diagnosed based on symptoms of recurrent wheezing, shortness of

breath, or cough. Children with recurrent cases of "bronchitis" who experience night cough or
have difficulty with exercise tolerance should be suspected of having asthma. An additional
history of allergies is useful, because 80% of childhood asthma is associated with atopy.

Formal spirometry testing can usually be accomplished in children as young as 5 years of age
and can confirm the diagnosis of asthma. Both the forced expiratory volume in 1 second (FEV1)
and FEV1 to forced vital capacity (FVC) ratio are useful in documenting obstruction to airway
flow. Further confirmation is provided by improvement of the FEV1 by 12% or more following
the use of a short-acting bronchodilator. For a valid test, though, children should avoid using a
long-acting -agonist in the previous 24 hours or a short-acting -agonist in the previous 6 hours.

In some patients with asthma, spirometry may be normal. When there is a high index of
suspicion that asthma may still be present, provocative testing with methacholine may be
necessary to make the diagnosis.
It is useful to stratify patients with asthma by the severity of their illness. The severity of asthma
is based on the frequency, intensity, and duration of baseline symptoms, level of airflow
obstruction, and the extent to which asthma interferes with daily activities. Stages of severity
range from severe persistent (step 4), in which symptoms are chronic and limit activity, to mild
intermittent (step 1), in which symptoms are present no more than twice a week and pulmonary
function studies are normal between exacerbations (Table 27-6). Patients are classified as to
severity based on their worst symptom and frequency, not upon having met all or the majority of
the criteria in any category.

Table 27-6. Classification of Asthma Severity.

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Treatment

The approach to managing asthma relies on acute management of exacerbations, treatment of

chronic airway inflammation, monitoring of respiratory function, and control of the factors that
precipitate wheezing episodes. For all of these, patient and family education is vital.

Treatment of persistent asthma requires daily medication to prevent long-term airway

remodeling. Mild, intermittent asthma may require therapy only during wheezing episodes.
Guidelines for the management of asthma are based on the child's age (6 years) and are
stratified by severity of illness. Guidelines for older children, adults, and younger children are
provided in Table 27-7.

Table 27-7. Asthma Drug Therapy Based on Severity.

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The treatment of exacerbations of asthma relies on fast-acting bronchodilators to produce rapid

changes in airway resistance along with management of the late-phase changes that occur several
hours after the initial symptoms are manifested. The failure to recognize the late-phase
component of an acute exacerbation may lead to a rebound of symptoms several hours after the
patient has left the office or emergency department. Corticosteroids are the mainstay for
preventing the late-phase response.

For patients with persistent symptoms (step 2 and higher), chronic therapy is required. The
management of persistent asthma may include long-acting bronchodilators to control intermittent
symptoms and nighttime cough, but also should provide chronic anti-inflammatory therapy to
prevent long-term remodeling. Both inhaled steroids and nonsteroidal anti-inflammatory
medications (ie, cromoglycates) can provide anti-inflammatory therapy. When symptoms are
recurrent or large doses of anti-inflammatory agents are required, treatment with a leukotriene
inhibitor can provide additional anti-inflammatory therapy and may allow a reduction in the dose
of other anti-inflammatory agents such as steroids.
When drugs are selected for the treatment of asthma, the potential side effects of each agent need
to be weighed against the potential benefits. For children, chronic use of inhaled steroids has
been associated with a small decrease in total height attained. Although the difference in height
attainment is small, it might be preferable to use nonsteroidal anti-inflammatory agents such as
cromolyn and nedocromil in children.

In addition to pharmacologic management, patients with asthma should avoid known and
possible airway irritants. These include cigarette smoke (including second-hand inhalation of
smoke), environmental pollutants, suspected or known allergens, and cold air. Children who
have difficulty participating in sports may benefit from the use of a short-acting -agonist such
as albuterol before participating in exertion to prevent wheezing or cough.

The monitoring of pulmonary function is an important component of asthma management for all
patients with persistent disease. Children and adults should be provided with a peak flow meter
and instructed on how to use the device reliably. The use of a peak flow meter can determine
subtle changes in respiratory function that may not cause symptoms for several days. To use a
peak flow meter, patients must establish a "personal best," which represents the best reading that
they can obtain when they are as asymptomatic as possible. Daily or periodic recordings of peak
flows are compared with this personal best to gauge the current pulmonary function. Readings
between 80% and 100% of the personal best indicate that the patient is doing well. Peak flows
between 50% and 80% of an individual's personal best are cause for concern even if symptoms
are mild. Patients should be instructed beforehand how to respond in these instances. If a repeat
of the peak flow later in the day after appropriate measures have been taken does not show
improvement, patients should seek further medical attention. Patients should be told that severe
decreases in peak flow to less than 50% are cause for immediate medical attention.

For patients with allergic symptoms, the use of immunotherapy should be considered. However,
although immunotherapy usually results in improvements in symptoms of allergic rhinitis, it
often does not improve asthma symptoms.

CURRENT Diagnosis & Treatment in Family Medicine, 3e > Chapter 27.

Respiratory Problems
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Table 27-6. Classification of Asthma Severity.

Nighttime
Step Symptoms Lung Function
Symptoms

Continual symptoms Forced expiratory volume in 1 s

Step 4
(FEV1) or peak expiratory flow
Limited physical activity Frequent (PEF) & leq; 60% predicted
Severe
persistent
Frequent exacerbations PEF variability >30%
 Nighttime
Step Symptoms Lung Function
Symptoms

Daily symptoms

Daily use of inhaled short-

Step 3
acting 2-agonist
>1 time a FEV1 or PEF >60%-<80% predicted
Exacerbations affect week
Moderate PEF variability >30%
activity
persistent
Exacerbations 2 times a
week; may last days
Symptoms >2 times a week
Step 2
but <1 time a day >2 times a FEV1 or PEF 80% predicted
Mild month
Exacerbations may affect PEF variability 20%-30%
persistent
activity
Symptoms <2 times a week
Step 1
Asymptomatic and normal 2 times a FEV1 or PEF 80% predicted
PEF between exacerbations month
Mild
PEF variability <20%
intermittent
Exacerbations are brief;
variable intensity

CURRENT Diagnosis & Treatment in Family Medicine, 3e > Chapter 27.

Respiratory Problems
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Table 27-7. Asthma Drug Therapy Based on Severity.

Ages 6 Years
Through
Adulthood

Step Daily Medications Quick Relief

Short-acting bronchodilator
Step 4 Choose all needed
Daily or increasing use of short-acting
Severe High-dose inhaled corticosteroid
inhaled 2-agonist indicates need for
persistent
additional long-term control therapy
 Ages 6 Years
Through
Adulthood

Step Daily Medications Quick Relief

Long-acting bronchodilator

A leukotriene modifier

Oral corticosteroid
Usually need two
Step 3 Short-acting bronchodilator
Either low- or medium-dose inhaled
Daily or increasing use of short-acting
corticosteroid
Moderate inhaled 2-agonist indicates need for
persistent additional long-term control therapy
Long-acting bronchodilator
Choose one

Low-dose inhaled corticosteroid Short-acting bronchodilator

Step 2
cromolyn
Daily or increasing use of short-acting
Mild
Sustained-release theophylline (to inhaled 2-agonist indicates need for
persistent
serum concentration of 5-15 g/mL) additional long-term control therapy

A leukotriene modifier
Short-acting bronchodilator
Step 1
No daily medication needed Use of short-acting inhaled 2-agonist
>2 times per week indicates need for
Intermittent
additional long-term control therapy
Step Down Step Up

If control is not maintained, consider step

up; first, review patient medication
Review treatment every 1-6 mo; a gradual
technique, adherence, and environ mental
stepwise reduction in treatment may be
control (avoidance of allergens and/or
possible
other factors that contribute to asthma
severity)

Step Daily Anti-inflammatory Medications Quick Relief

Step 4 High-dose inhaled corticosteroid with Short-acting bronchodilator as needed

spacer/holding chamber and facemask for symptoms
Severe
and, if needed, add systemic
persistent
 Ages 6 Years
Through
Adulthood

Step Daily Medications Quick Relief

corticosteroids 2 mg/kg/d and reduce to By nebulizer or metered dose inhaler

lowest daily or alternate-day dose that (MDI) with spacer/holding chamber and
stabilizes symptoms facemask or oral 2-agonist

Daily or increasing use of short-acting

Either medium-dose inhaled corticosteroid
Step 3
with spacer/ holding chamber and
facemask or low- to medium-dose inhaled spacer/holding chamber and facemask
corticosteroid and long-acting
Moderate
persistent bronchodilator (theophylline)
Young children usually begin with a trial of
Step 2 cromolyn or low-dose inhaled
corticosteroid with spacer/holding
Mild chamber and facemask
inhaled 2-agonist indicates need for
additional long-term control therapy
Short-acting bronchodilator as needed
for symptoms
By nebulizer or MDI with
or oral 2-agonist
Daily or increasing use of short-acting
inhaled 2-agonist indicates need for
additional long-term control therapy
Short-acting bronchodilator as needed
for symptoms
By nebulizer or MDI with
spacer/holding chamber and facemask
or oral 2-agonist
Daily or increasing use of short-acting
inhaled 2-agonist indicates need for
additional long-term control therapy
Short-acting bronchodilator as needed
for symptoms <2 times a week

By nebulizer or MDI with

Step 1
spacer/holding chamber and facemask
No daily medication or oral 2-agonist
Intermittent
Two times weekly or increasing use of
short-acting inhaled 2-agonist indicates
need for additional long-term control
therapy
Step Down Step Up
 Ages 6 Years
Through
Adulthood

Step Daily Medications Quick Relief

If control is not maintained, consider step

up; first, review patient medication
Review treatment every 1-6 mo; a gradual
technique, adherence, and environmental
stepwise reduction in treatment may be
control (avoidance of allergens and/or
possible
other factors that contribute to asthma
severity)

Namazy JA, Schatz JM: Current guidelines for the management of asthma during pregnancy.
Immunol Allergy Clin North Am 2006;26:93. [PubMed: 16443415]
Siwik JP et al: The evaluation and management of acute, severe asthma. Med Clin North Am
2002;86:1049. [PubMed: 12428545]