2008 guidelines 2.4 diagnosis in adults (1) -based on the recognition of a characteristic pattern of...
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2008 Guidelines2.4 DIAGNOSIS IN ADULTS (1)
- based on the recognition of a characteristic pattern of symptoms and signs and the absence of an alternative explanation for them
- the key is to take a careful clinical history
- if asthma is a likely diagnosis, the history should explore possible causes, particularly occupational
- even in relatively clear-cut cases, to try to obtain objective support for the diagnosis
2008 Guidelines2.4 DIAGNOSIS IN ADULTS (2)
- whether or not this should happen before starting treatment depends on the certainty of the initial diagnosis and the severity of presenting symptoms
- repeated assessment and measurement may be necessary before confirmatory evidence is acquired.
2008 Guidelines2.4 DIAGNOSIS IN ADULTS (3)• Confirmation hinges on demonstration of airflow
obstruction varying over short periods of time
• Spirometry is preferable to measurement of peak expiratory flow because it allows clearer identification of airflow obstruction, and the results are less dependent on effort
2008 Guidelines2.4 DIAGNOSIS IN ADULTS (4)• Spirometry should be the preferred test where available
(training is required to obtain reliable recordings and to interpret the results)
• A normal spirogram (or PEF) obtained when the patient is not symptomatic does not exclude the diagnosis of
asthma.
2008 Guidelines
With airflow obstruction• COPD• Bronchiectasis*• Inhaled foreign body*• Obliterative bronchiolitis• Large airway stenosis• Lung cancer*• Sarcoidosis*• *may also be associated with
non-obstructive spirometry
Differential diagnosis of asthma in adults, according to the presence or absence of airflow obstruction (FEV1/FVC <0.7)
Without airflow obstruction• Chronic cough syndromes• Hyperventilation syndrome• Vocal cord dysfunction• Rhinitis• Gastro-oesophageal reflux• Cardiac failure• Pulmonary fibrosis
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ADULT with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability Low ProbabilityIntermediate Probability
Yes No
ObstructiveFEV/FVC <70%
Manage according to alternative diagnosis
Response?
Investigate and treat alternative diagnosis
Yes
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
NormalFEV/FVC >70%
Reconsider probable diagnosis
Further investigation
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High Probability
Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
1)Symptoms (cough, wheeze, SOB or chest tightness):• worse at night and in the morning• in response to exercise, allergen exposure and cold air• after taking aspirin or beta blockers
2) History of atopic disease
3) Family history of asthma or atopic disease
4) Widespread wheeze
5) Evidence of airway narrowing (NB Normal spirometry when free of symptoms does not exclude asthma)
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Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes
10
Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
11
Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
Low probability equals:1) Cough in the absence of wheeze or breathlessness2) Prominent dizziness, light headedness, peripheral tingling3) Repeatedly normal clinical examination even when
symptomatic4) No evidence of airway narrowing when symptomatic5) Voice disturbance6) Symptoms with colds only7) Chronic productive cough8) Significant smoking history (>20 pack years)9) Cardiac disease
Low Probability
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Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
Low Probability
Manage according to alternative diagnosis
Investigate and treat alternative diagnosis
Response?Yes
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Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
Low Probability
Manage according to alternative diagnosis
Response?
Investigate and treat alternative diagnosis
YesReconsider probable
diagnosisFurther investigation
No
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Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
Low Probability
Manage according to alternative diagnosis
Response?
Investigate and treat alternative diagnosis
YesReconsider probable
diagnosisFurther investigation
No
Intermediate Probability
ObstructiveFEV/FVC <70%
NormalFEV/FVC >70%
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Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability Low Probability
Manage according to alternative diagnosis
Response?
Investigate and treat alternative diagnosis
YesReconsider probable
diagnosisFurther investigation
No
Intermediate Probability
ObstructiveFEV/FVC <70%
NormalFEV/FVC >70%
Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
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Trial of Treatment
Response?
Asthma diagnosis confirmedContinue Rx
Yes No
Assess compliance and inhaler technique.
Reconsider the diagnosisConsider further tests
or referral
Patient with symptoms that may be due to asthma
Clinical History and examinationSpirometry (or PEF if spirometry not available)
High Probability Low Probability
Manage according to alternative diagnosis
Response?
Investigate and treat alternative diagnosis
YesNo
Intermediate Probability
ObstructiveFEV/FVC <70%
NormalFEV/FVC >70%
Reconsider probable diagnosis
Further investigation
© Imperial College LondonPage 17
Assessment: Royal College of Assessment: Royal College of Physicians of London three questionsPhysicians of London three questions
Outcomes and audit. Thorax 2003; 58 (Suppl I): i1-i92
• Applies to all patients with asthma aged 16 and over.• Only use after diagnosis has been established.
IN THE LAST WEEK / MONTH
YES NO“Have you had difficulty sleeping because of your asthma symptoms (including cough)?”
“Have you had your usual asthma symptoms during the day (cough, wheeze, chest tightness or breathlessness)?”
“Has your asthma interfered with your usual activities(e.g. housework, work, school, etc)?”
Date / / /
1.1. In the past 4 weeks, how much of the time did your asthma keep you from In the past 4 weeks, how much of the time did your asthma keep you from getting as much done at work, school or at home?getting as much done at work, school or at home?
2.2. During the past 4 weeks, how often have you had shortness During the past 4 weeks, how often have you had shortness of breath?of breath?
3.3. During the past 4 weeks, how often did your asthma symptoms During the past 4 weeks, how often did your asthma symptoms (wheezing, coughing, shortness of breath, chest tightness or pain) (wheezing, coughing, shortness of breath, chest tightness or pain)
wake you up at night, or earlier than usual in the morning?wake you up at night, or earlier than usual in the morning?
4.4. During the past 4 weeks, how often have you used your rescue During the past 4 weeks, how often have you used your rescue inhaler or nebulizer medication (such as salbutamol)?inhaler or nebulizer medication (such as salbutamol)?
5.5. How would you rate your asthma control during the past How would you rate your asthma control during the past 4 weeks?4 weeks?
ScoreScore
Patient Total ScorePatient Total ScoreCopyright 2002, QualityMetric Incorporated.Copyright 2002, QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.Asthma Control Test Is a Trademark of QualityMetric Incorporated.
Asthma Control Test™ (ACT)