Asthma

Diagnosis/Definition:

Asthma is a chronic inflammatory disorder of the airways. This inflammation results in bronchial hyperactivity, airway inflammation, and airways narrowing. Asthma is characterized by wheezing, breathlessness, chest tightness, and coughing. Multiple factors may elicit or exacerbate symptoms including allergies, infections, irritant exposures, exercise, gastroesophageal reflux, and certain medications.

Initial Diagnosis and Management

• A reliable history of recurrent dyspnea, wheezing, chest tightness, or nocturnal cough. See National Heart, Lung, and Blood Institute Report II (NHLBI Guidelines) for more details.
• A thorough history and physical exam, and chest x-ray should rule out other common reasons for symptoms such as cardiac disease or other pulmonary diseases.
• Worsening of symptoms in association with specific allergens, exercise or viral upper respiratory tract infection.
• Obstructive lung disease with reversibility demonstrated on spirometry.
• Classify asthma according to severity: mild intermittent, mild, moderate, or severe persistent.
• A methacholine or other bronchoprovocation challenge test may be useful in establishing the diagnosis of asthma in patients who present with a chronic cough or in those wishing to join the military.
• Management of asthma should be per the NHLBI guidelines and the MAMC Asthma Clinical Pathways. Inhaled steroids are the mainstay of treatment for patients with moderate or severe persistent asthma.
• Skin prick testing for allergens should be considered in patients with persistent asthma symptoms.
• All patients with asthma should receive asthma education as well as a written asthma management plan.

Ongoing Management and Objectives

• Patients should have good exercise tolerance, infrequent episodes of wheezing, and near normal pulmonary function tests and/or peak flows. Pulmonary function testing should be done at least annually.
• An established asthma management plan which results in good control of the patient’s symptoms.

Indications for Specialty Care Referral

Any patient who has severe persistent asthma and/or one of the following risk factors:

History of respiratory failure requiring an ICU admission (especially if mechanical ventilation was required).

Chronic or frequent use of oral corticosteroid bursts (>2/yr).

Has had more than two emergency department visits per year to treat acute asthma.

Any patient in whom skin prick testing for allergies is deemed necessary.

Patients with moderate persistent asthma who are not well controlled on >=1600 mcg/day (16 puffs) of Azmacort or >880 mcg/day of Fluticasone (Flovent).

Patients may be referred to either the Allergy or Pulmonary Service. Patients with a suspected strong allergy component should be preferentially referred to the Allergy Service.

Criteria for Return to Primary Care

Upon completion of allergy evaluation and immunotherapy, if this has been prescribed.

The patient is no longer considered to be a “high-risk” asthmatic.

The patient is no longer considered to have severe persistent asthma.

The patient’s asthma is in good control, and there is an established management plan.