Evidence-Based Medicine: Asthma in 2012

Sandra K. Willsie, D.O., MA, FACOI, FACP, FCCP [email protected]

The case of MJ  A 26 yr old female presents with a chief complaint of

persistent dyspnea on exertion, cough and wheezing  Onset of symptoms: 2 years ago; worsening to date  Wakes up 2-3 times per week coughing and wheezing  Wheezing worsened with exercise, cold air

 Dyspnea is worse with exertion (2 blocks)  Cough nonproductive of clear mucous;

 Denies fever, hemoptysis, weight loss or night sweats

MJ  PMHX:  PSHX:  Allergies:  Medications:  SHX:

Pregnancy associated hypertension S/P appendectomy; Penicillin (hives) Hall’s eucalyptus cough drops; current nonsmoker; past 2 ppd for 10 years; no significant ETOH; no HIV risks. Hobbies: volleyball; running;

MJ  Remarkable Physical Examination:  Vitals: BP 110/65 P 80 RR 14 T 98.3  Occasional nonproductive cough  Chest: slight hyperresonant, symmetrical expansion,

midline trachea; no wheezing;  CV: no murmur; split S2;  Absence of clubbing

http://www.ginasthma.org/

Last updated: December, 2011

Diagnostic work-up? Chest X-Ray? Spirometry? Assessment of oxygenation?

Anything else?

MJ Chest roentgenogram: FVC FEV1

Actual 2.70 L 1.75 L

FEV1/FVC ratio

58%

Mild Hyperinflation % Predicted 88% 73%

Is the diagnosis clear? Any further evaluation needed?

MJ Bronchodilator challenge is indicated Postbronchodilator Results: FVC FEV1 FEV1/FVC

Actual

3.60 L 2.75 L 76%

% Predicted

99% 93%

% change

33% 57%

WHAT IF???

MJ Chest roentgenogram: FVC FEV1

FEV1/FVC ratio

Actual 3.60 L 2.75 L

Normal % Predicted 99% 93%

76%

Is the diagnosis clear? Any further evaluation needed? Does this patient have Asthma?? (Methacholine, Exercise or Histamine challenge)

RELIEVER Medications

I can’t breathe and I need help NOW!!!

QUICK ONSET: albuterol

CONTROLLER Medications

DAILY, whether you need it OR not medication

Examples: ICS; LM;

http://www.ginasthma.org/uploads/users/files/ GINA_PocketGuide_2011.pdf

Characteristics

Levels of Asthma Control Controlled Partly Uncontrolled controlled

Daytime symptoms NONE (twice or less per week)

Limitation of activities

NONE

Nocturnal Symptoms or awakenings

NONE

Need for reliever/ rescue inhaler

NONE

Lung Function (PEF or FEV1)

NORMAL

(twice or less per week)

MORE than twice per week THREE or MORE features of ANY PARTIALLY controlled ANY ASTHMA MORE than twice per (by definition, an exacerbation in any week week = uncontrolled week) 80%

60-80%