ASTHMA   4A

A 25-year-old previously well woman presents to your office with complaints of episodic shortness of breath and chest tightness. She has had these symptoms on and off for about 2 years but states that they have worsened lately, occurring two or three times a month. She notes that the symptoms are worse during the spring months and since her new roommate moved in with his cat. She has no exercise-induced or nocturnal symptoms. The patient smokes occasionally when out with friends, drinks socially, and has no history of drug use. Examination is notable for mild end-expiratory wheezing.

What are the salient features of this patient’s problem? How do you think through her problem?

Salient features: Intermittent shortness of breath and chest tightness; environmental triggers; family history; wheezing on physical examination

How to think through: What are other possible causes of shortness of breath, and what makes asthma the most likely cause in this patient? What are common environmental triggers to explore? What associated atopic diseases would you ask about? What are non–allergy-mediated exacerbating factors to explore? How can you best establish the severity of her asthma symptoms and the potential for life-threatening exacerbations? (History of emergency department visits, hospital admissions, and intubations.) If she did not have audible wheezing on examination, what more subtle signs could you look for? (Increased expiratory time, cough induced by rapid expiration.) What would her pulmonary function tests (PFTs) likely show? When you begin treatment of her asthma, what should serve as your barometer for the degree of control? (Number of episodes per week, peak expiratory flow rate [PEFR].) At what point would you add a daily controller medication, and what would be your first choice? Beyond medication, what are other important interventions? (Allergen reduction, smoking cessation.)

ASTHMA   4B

What are the essentials of diagnosis and general considerations regarding asthma?

Essentials of Diagnosis

Episodic or chronic symptoms of airflow obstruction

Reversibility of airflow obstruction, either spontaneously or after bronchodilator therapy

Symptoms frequently worse at night or in the early morning

Prolonged expiration and diffuse wheezes on physical examination

Limitation of airflow on pulmonary function testing or positive bronchoprovocation challenge

General Considerations

Hospitalization and death rates highest among blacks

Affects 5% of the population; prevalence and severity has increased in the United States

ASTHMA   4C

What are the symptoms and signs of asthma?

Symptoms and Signs

Episodic wheezing and difficulty breathing, chest tightness, and cough

Excess sputum production

Symptoms are frequently worse at night

Common aeroallergens include dust mites, cockroaches, cats, and pollen

Nonspecific precipitants include exercise, respiratory tract infections, rhinitis and sinusitis, postnasal drip, aspiration, gastroesophageal reflux, changes in weather, and stress

Tobacco smoke increases symptoms and decreases lung function

Certain medications (including aspirin and nonsteroidal anti-inflammatory drugs) may be triggers

Nasal findings consistent with allergy and evidence of allergic skin disorders

Wheezing with normal breathing or a prolonged forced expiratory phase

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