ASTHMA-INITIAL EVALUATION

I. Hx of disease if not new in onset

  1. Age at onset and dx
  2. Progress of disease
  3. Characteristics of typical exacerbation and what has been effective as tx
  4. Present management of exacerbations
  5. ER visits, hospitalizations, intubations
  6. Limitation of activity
  1. Missed days from school/work due to asthma

II. In young infants, with lower airways dysfunction, differential includes:

  1. Bronchiolitis
  2. Pertussis (esp. in preemies)-us. no wheezing, though
  3. Chlamydia (50% also have conjunctivitis; 50% will have peripheral eosinophilia); us. no wheezing, though
  4. Bacterial pneumonia-us. no wheezing, though
  5. GERD/aspiration
  6. Bronchopulmonary Dysplasia due to prematurity or mechanical ventilation

III. Temporal pattern of sx (cough, wz, chest tightness, dyspnea)

  1. Continual, episodic, or both
  1. If episodic, frequency & duration
  1. Perennial, seasonal, or both
  2. Diurnal variation? (if so, look for corresponding precipitants)

IV. Precipitants (all of the following shown to be sig. in at least some pts)

  1. Inhalant allergens
  1. Exploration of this issue is indicated in any patients with persistent asthma requiring daily Rx
  2. For seasonal allergens, hx usually sufficient
  1. Early spring: trees
  2. Late spring: grass
  3. Summer-autumn: weeds
  1. For persistent asthma with suspected perennial indoor allergens, confirmation with skin testing or serology (IgE) is indicated. Here are some ?'s to ask:
  1. Do you have indoor pets (inc. Birds)?
  2. Is there visible dust in your home?
  3. Are there visible molds in your home?
  4. Are there damp rooms in house? (dust mites, molds)
  5. Do you have thick carpets in your home? (dust)
  6. Are there cockroaches in your home?
  7. Wood-burning stove in house?
  8. Unvented (gas, oil, or kerosene) stoves in house?
  9. Fume exposure (perfume, cleaning chemicals)?
  10. Sx worse inside vs. outside (or vice-versa)
  11. Are you exposed to pollution from traffic/industry?
  12. Tobacco smoking or secondhand exposure?
  13. Sx better on weekends? (work exposure)
  14. Airborne items at work?
  15. Sulfite containing foods exacerbate sx? (wine, beer, dried fruit, shrimp)
  1. Inhaled irritants (tobacco smoke, occupational irritants)
  2. Air pollution, esp. particulates, ozone, SO2, NO2
  3. Rhinitis and sinusitis
  1. For pts with persistent asthma and chronic rhinitis, intranasal steroids are indicated; may lower airways responsiveness
  1. GERD
  1. For infants, will lead to resp. sx worse after vomiting or regurgitation or with feeding
  2. 62 adults with GERD & asthma randomized to ranitidine 150mg TID vs. PRN antacids vs. Nissen fundoplication x at least 2y; over > 2y f/u, nocturnal asthma sx were sig. more improved in surgical group than either of the other two groups; no sig. diff. in overall mortality. (Am. J. Gastroent. 98:987, 2003--abst)
  1. Viral respiratory infections
  2. Cold air
  3. Exercise (us. will see at 15% decrease in PEF or PEV with exercise)
  4. Emotional stress
  5. Medications, e.g. beta-blockers (including eyedrops), ASA, and other NSAIDS
  1. Ask all pts if ASA ever precipitated sx; if pt has nasal polyps, avoid ASA even if pt hasn't noticed a connection
  1. Menses
  2. "Food allergens are not a common cause of asthma symptoms"
V. History of early life airways injury (BPD, pneumonia, bronchiolitis, parental smoking)

VI. Family hx of asthma or allergic disease

VII. Characteristics of work environment

VIII. Social/psych factors that may affect adherence

IX. Perceptions and expectations of disease course and effects of tx