Notes: Asthma Review (Family Medicine/Primary Care)

Establish rapport

1. Hello my name is Dr.______. How can I help you today? 
1. New complaint*
2. I came to renew my medications
2. Demographics: How old are you? What do you work? Are you married? Do you have any children? Who do you live with?
3. E: So is there anything else I can help you with today/you expect me to help you with?
4. I: What are your ideas about [insert complaint]?
5. C: What are your concerns today/is there anything worrying you about todays visit?

*NOTE: Refer to Respiratory Complaints post.

How to proceed in interview: 
1. Take a detailed history of new complaint if having any and then do asthma review.
2. Start with asthma review if patient only came for medications or reviewing results of a test)

Asthma review

1. Assessing asthma control
1. During these past week, how many times did you have an asthma attack? During these past 4 weeks? (>2x/week) *
2. During this past week, how many times did you use your asthma medications? During these past 4 weeks? (>2x/week) *
3. During this past week how many times did you wake up at night because of coughing or shortness of breath? During these past 4 weeks. *
4. Has it affected your activity this week? *
5. Ever been to hospital for asthma problem? When was the last time?
2. Assessing medications and adherence
1. What are the medications you use for asthma? 
2. What are the doses and timings of these medications? 
3. Assessing atopy 
1. a. Do you have itchy/runny nose? Itchy eyes? Rash on body? Food allergies?
2. b. Do you notice something specific causing the attacks? Dust, exercise, laughing, perfume, incense?
4. Assessing uncontrolled asthma
1. Do you know how to use the inhaler? Can you show me how you use it?
2. Allergens (already been asked above)
3. Inform patient: 
1. We may need to go up with the treatment by increasing dose. 
2. OR you must lower exposure to allergen and come back in 3 months. If it still uncontrolled, we may need to add another drug.

Controlled	Partially controlled	Poorly controlled
No *	1-2 *	3-4 *

Management

1. Investigations: 
1. If patient comes with a complaint, then do the investigations based on that.
2. Education: 
1. Try to stay away from allergens or exacerbating factors (such as perfume, incense)
2. Use inhaler correctly (links to youtube videos of instructions for device use):
1. Spacer: take 4 breaths after 1 puff, wait 4 minutes and take another 4 puffs (4x4x4 rule) (max 4)
1. MDI: can take up to 4-6 puffs (standard 1-2 puffs)
2. Nebulizer: breathe normally
3. Educate about medication adherence
4. Take puff of inhaler before exercise if exercise-induced
3. Referral: if needed, patient may go to ER
4. Follow up: see as fit based on the complaint and control of asthma. According to Murtagh's General Practice:
1. After starting ttx: 1-3 months later
2.  Thereafter: 3-12mo
5. Step-wise management:

ICS = inhaled corticosteroid

OCS = oral corticosteroids

LABA = long-acting beta agonist

SABA = short-acting beta agonist

	Reliever	Controller	Add-on therapy
Step 1	SABA
Step 2	SABA	Low dose ICS
Step 3	SABA or ICS/formoterol	Low dose ICS + LABA	Theophylline
Step 4	SABA or ICS/formoterol	Medium/high dose ICS + LABA	Tiotropium/ Theophylline LTRA
Step 6	SABA or ICS/formoterol	Low-dose OCS (refer)	Theophylline/ omalizumab (anti-IgE)

Stepping up and down drugs:

1. Down: if controlled for 3 months by slowly reducing dose and then keep patient on low dose ICS (do not completely withdraw).
2. Up (if exacerbations persist for 2-3mo despite controller): 
1. Assess: compliance, inhaler technique, modifiable risk factors (smoking, incense)

Facts about medications doctors love to ask about:

• ICS side effects are not wide spread like OCS:
• Oral thrush, dysphonia
• Therefore advise patient to wash mouth with water after use of ICS.
• Beta-agonist side effects:
• Tremors, tachycardia, hypokalemia
• Corticosteroids given in an acute attack do not need to be tapered (like the usual usage) because it is a very short period of use.

Managing asthma attack in primary care/clinic setting:

1. O₂ & SABA + corticosteroid oral in ER room
2. Vitals check & IV access
3. Call for ambulance and transfer to hospital
4. Tell hospital to arrange follow up in clinic within 1 week for patient

References
GINA Pocket Guide for Asthma Management and Prevention 2015

*NOTE: Refer to the latest guidelines available for management at the time you are reading this. 

Student Notes: Respiratory Complaints (Pediatrics)

History

1. My name is ____, I’m a medical student and my doctor wants me to ask you a few questions about your child, is that all right? 
2. What’s his name? How old is he? Does he go to school?
3. What have you come here for today?
1. Shortness of breath (can’t breathe, difficulty breathing, wheezing):
1. When did it start?
2. Is this the first time?
3. What was he doing when he got it?
4. What makes it worse? Playing? Eating?
5. Have you tried anything to make it go away? Sleep, medicines?
2. b. Cough:
1. When did it start?
2. Is there a specific time of day that it comes in? (Does it come at night or during the day or throughout?)
3. Do you feel it is dry cough?
4. Does blood come out?
5. Does he vomit after coughing?
6. Did you try something to make it better?
7. What makes it worse?
4. Associated symptoms:
1. Does he have a fever? How much is it? Did you measure it?
2. Is he tired most of the time? Or crying a lot?
3. Does he have muscle aches?
4. Does he have a runny nose?
5. Does he scratch his ear or bend his head to one side?
6. Does he snore or breathe out loud? Does he have strange sounds on breathing?
7. Does he have a rash?
8. Does he have chest pain?
9. Does he have vomiting?
10. Does he have tummy pain?
11. Does he have diarrhea? When was the last time he passed motion? (Constipation)
12. Does he cry when he urinates? What color is the urine?
13. Does he have joint swelling or pain?
5. PMH: 
1. Has he ever had a similar complaint before?
2. Has he been sick before?
3. Has he come to the hospital before?
4. Has he had any infections?
5. Does he take any medications?
6. What have you given him for this? Have you given him oxygen? Have you gone to a hospital/doctor for this time?
7. Does he have allergies? Asthma? (Yes: do asthma review[LINK POST]):
1. How many attacks in a week? Month? (How many times do you use the inhaler?)
2. Have you ever woken up at night due to asthma/coughing? How many times in a month?
3. Have you been to hospital due to asthma? What did they do for you?
4. What medications are you on for it?
5. How long have you had asthma? When were you diagnosed? How/why were you diagnosed?
6. What makes your asthma worse? Laughing? Crying? Smoke? Perfume? Playing?
7. What about school performance? Is it being affected?
6. PSH: has he done any surgeries? 
7. FH: 
1. In your family do you have similar problems? 
2. Is anyone sick currently? 
3. Does anyone have asthma? Allergies?
4. Does anyone have heart diseases?
8. SH: 
1. Has he been with a friend/family member with similar complaint recently?
2. Do you live in a house or apartment?
3. Do you live alone or with family?
4. Does he sleep in his own room or with someone?
5. Do you have any pets?
6. Does anyone smoke at home?
7. Do you do bukhoor?
8. Is he absent a lot from school? Does he participate in sports?
9. Birth:
1. Born by natural delivery or cesarean?
2. How many weeks pregnancy?
3. Any complications during birth?
4. Was the baby crying when he first came out?
5. Did they take him to an incubator? Did he have yellow skin color (jaundice) few days later? Fever?
10. Feeding:
1. How many meals a day does he have? What do they consist of?
2. How long was he breast fed for? Was it exclusive?
3. When did you wean him? What did you start giving him first?
4. When did you stop breastfeeding completely?
11. Vaccination?
12.  Growth:
1. How much did he weigh when he was born? Height?
2. How much does he weigh now? How tall is he?
13. Development:
1. Gross motor/fine motor/speech/social
14. Other:
1. Have you possibly seen him putting some toy or object in his mouth?

Differential diagnosis (make sure to state the differentials in order of most common/most likely diagnosis first, moving on to rarer causes in the end)

Cough & SOB:

• Respiratory:
• Infectious: pneumonia, croup, bronchiolitis
• Tracheomalacia 
• Asthma 
• Measles, TB
• Foreign object aspiration
• Cardiac:
• Heart failure
• Congenital heart diseases
• Other:
• GERD

Wheezing: a high pitched musical sound produced by oscillations of narrowed airways that happens mostly on expiration

• Allergy: Asthma, anaphylaxis
• Infection: Viral induced wheeze
• Mechanical obstruction: Foreign body aspiration, Tumor
• Anatomic abnormality: laryngomalacia, Tracheomalacia, vascular ring
• Aspiration: GERD
• Bronchopulmonary dysplasia
• Mucociliary disorders: CF, primary ciliary dyskinesia

Investigations:

• Imaging: CXR (to exclude pneumonia and anatomic lesions or collapse or localized lesions)
• Blood: CBC, CRP

Asthma

Definition: an obstructive partially reversible small airway disease (why partially? Because there is still chronic inflammation going on) with hyperresponsiveness and chronic inflammation.

Etiology: genetic predeisposition (polygenic) + environmental triggers + hygiene hypothesis

Diagnosis: clinical diagnosis where the following must be present: 

• If typical features of asthma, then clinical diagnosis:
• Minimum of 3 attacks of wheezing
• Attacks respond to bronchodilators
• Normal in between attacks
• Family history of atopy
• If <5 years old, trial of B2 agonists
• Spirometry if >5 years old.

Management:

Pharmacologic
Asthma management is quite different from different diseases in the sense that there is no first line and second line of drugs to give. There is a 'step up' and 'step down' of drugs. What that means is, you start by giving 1 drug, after a while with reassessment of the patient and monitoring their condition in a specific amount of time, if there is no improvement, you add on a second drug. This is called a 'step up'. It continues by adding a drug until you reach the highest step whereby you have no more drugs to add on in the severest forms of asthma. A 'step down' is of the same concept but you remove a drug once you find the patient is well-controlled after reassessing and monitoring for a specific period of time.
Here is the GINA guideline with 'step up' and 'step down' managements:

• GINA 2015: Pocket Guide for Asthma Management and Prevention for children 5 years and younger (page 14 has the management table)

NOTE: You may be handed different guidelines for management in class, so please refer to those for the exams.

Drugs:

• Short acting beta agonists (salbutamol): anxiety, tremors, cardiovascular toxicity with overuse, low systemic toxicity, hypokalemia is especially with IV form
• Anticholinergics (ipratropium): dry mouth, nausea, throat irritation, cough, GI (diarrhea and constipation)
• Theophylline (xanthine bronchodilator): hypokalemia (especially if combined with beta agonists). Aminophylline is combination of theophylline + ethylenediamine and is more soluble.
• Inhaled Corticosteroids: hoarseness, dysphonia, throat irritation and oral thrush.
• Oral corticosteroids: growth suppression, hair thinning/loss, glaucoma, skin thinning, cushingoid features, hyperglycemia, hypertension, immune suppression

Devices

• Metered dose inhalers ±:
• Spacer: few side effects from medications, easier to use as less coordination required, more medication is delivered to lung. The type of spacer used depends on personal preference, budget and medication type.
• Mask and spacer: for children under 5 to ensure that as much asthma medication is breathed in as possible.
• Nebulizer
• Dry powder inhalers: (require being able to breathe deeply)
• Accuhaler
• Turbuhalers
• Autohaler: breath actuated so needs no coordination

Nonpharmacologic:

• Breastfeeding
• Desensitization therapy
• No smoking/incense

Acute attack

1. Assess child (vitals and consciousness):
2. Pulse and respiratory rate and pulse oximetry
3. Consciousness
4. Respiratory distress signs
5. Wheezing 
6. ABG if needed
7. Administer relievers:
1. Oxygen if SpO2<92%
2. Oral/IV corticosteroids
3. First Line: SABA nebulized/MDI-spacer (spacer causes less tachycardia)

If it is not working, give 3 trials 20 minutes apart + ipratropium

1. Second Line: IV salbutamol bolus
2. Third Line: IV Aminophylline
3. Fourth Line: IV magnesium sulfate
4. Fifth Line: intubation
5. Reassess: improvement of respiratory distress and SpO2

Status asthmaticus: an acute attack that does not respond initially to therapeutic measures

Bronchiolitis

Etiology

• RSV
• Parainfluenza virus
• Adenovirus

Virus enters respiratory tract and causes inflammation of the bronchioles and mucus accumulates in bronchioles along with bronchiolar edema causes their obstruction. Some areas become atelectatic and others become emphysematous.

Clinical picture

History:

• Upper respiratory infection
• Cough and feeding difficulty
• Vomiting
• Irritability
• Fever

Physical examination:

• Respiratory distress
• Tachypnea
• Resonance on percussion
• Diminished breath sounds, prolonged expiration
• Palpable spleen and liver due to depression of diaphragm as a result of hyperinflation

Investigations

• CXR: hyperinflation, increased bronchovascular markings with mild infiltrates
• Blood: CBC, CRP
• RSV, viral antibody titers

Treatment

• Admission to hospital if in respiratory distress
• Humidified oxygen if SpO2 is low
• Adequate hydration to prevent dehydration
• Ribavirin use is controversial
• Antibiotics are not useful because it is a viral infection unless there is bacterial superinfection
• Bronchodilators and steroids are not effective

Pneumonia

Etiology

Newborn:

• GBS
• E. coli
• Staph aureus
• Klebsiella & Pseudomonas

Infants and children:

• Strep pneumonia
• HiB
• Staph aureus (mostly causes pneumatoceles)
• Mycoplasma

Types

• Atypical: lung infiltrates, mostly caused by mycoplasma pneumonia
• Lobar: consolidation of an entire lobe, caused by Strep pneumonia mostly. 
• Bronchopneumonia: inflammation around the bronchioles, mostly caused by Staph aureus
• Interstitial: inflammation of the lung interstitium

Clinical features:

History:

• Cough
• Fever and chills
• Refuse feeding, drowsy

Physical examination

• Dull percussion
• Decreased breath sounds
• Crackles
• Increased tactile fremitus

Investigations

• Blood: CBC, CRP, U&E, blood culture, ASO titer, ABG (if respiratory distress)
• CXR: consolidation, infiltrates, pneumatocele

Management

• Atypical: macrolides (clarithromycin)
• Commonly: amoxicillin/augmentin
• If not working: 2^nd generation cephalosporins
• Duration: 10 days

Indications for hospital admission

• Respiratory distress
• Dehydration
• High fever
• Poor feeding
• Not responding to antipyretics
• Looks very sick/toxic
• Coexisting problems (gastroenteritis, heart problems)

Indications for hospital discharge

• No fever for 24 hours
• Improving, no signs of respiratory distress
• Tolerating orally
• Looking well and playful

Croup

Types

• Viral croup
• Spasmodic croup: allergic croup that happens with symptoms usually at night and is recurrent with no prior upper respiratory signs such as runny nose and no fever.

Definition

It is a laryngotracheobronchitis.

Etiology

• Parainfluenza virus
• RSV

Clinical features

• Runny nose
• Inspiratory stridor
• Barking cough
• Low grade fever
• Respiratory distress

Investigations 

• Clinical diagnosis
• CBC  WBCs = normal
• Parainfluenza virus and RSV tests (PCR)
• CXR = steeple sign indicating narrowing of the subglottic region

Treatment

• Mild to moderate croup is treated by dexamethasone (oral or IM) + humidified air + O2 if needed
• Moderate to severe croup is treated with dexamethasone and nebulized racemic epinephrine (causes vasoconstriction thereby decreasing airway edema) + humidified air + O2 

Criteria for hospital admission

Children with stridor at rest

Contraindications

Sedatives, expectorants, bronchodilators, anti-histamines

Complications

• Hypoxia with respiratory fatigue
• Secondary bacterial infection (bacterial tracheitis by Staph aureus)
• Viral pneumonia
• Secondary bacterial pneumonia

Differentials of Croup

• Laryngeal diphtheria:
• All ages
• No immunization
• Membrane on the pharynx
• Epiglottitis:
• Age 1-4 years
• Rapid deterioration
• Severely toxic
• Dysphagia and drooling
• Red and swollen epiglottis
• Spasmodic croup:
• 3 months - 3 years
• Family history +ve, history of previous attacks
• Attacks are sudden at night
• Foreign body:
• Age 6 months – 2 years
• Sudden onset
• Putting object in mouth

Respiratory distress

• Respiratory rate:
• 1 month = up to 60/min
• 1 year = up to 40/min
• 2 years = up to 35-40/min
• >2 years = up to 25-30
• What is respiratory distress?
• Tachypnea
• Recessions
• Nasal flaring
• Grunting
• Which recessions are more serious/dangerous? 
• Suprasternal because they reflect upper respiratory tract involvement.
• What is the first investigation to do in a respiratory distressed child? 
• Pulse oximetry

References

1. Year 4: Pediatrics Clerkship - Part 5
2. Clerkship Years: Helpful Online Resources for Students