Asthma - Ongoing Assessment

Vital Signs

RR | HR | BP (medications may cause elevation), pulsus paradoxus if asthma symptoms present

Growth Parameters

height and weight (current and patterns of gain), for evidence of other chronic underlying disease (e.g., cystic fibrosis), effect of medications, obesity (which might complicate asthma)

Skin

evidence of atopy/eczema

Chest

evidence of accessory muscle use (tracheal tugging, intercostal retractions, nostril flaring, increased abdominal movement), sounds of expiratory wheezing with normal breathing or with forced expiration, prolonged expiratory phase, hyperexpansion of the thorax, hunched shoulders

HEENT

evidence of allergy (periorbital swelling, conjunctival injection or edema, nasal discharge, nasal polyps, pale or swollen nasal turbinates, Denny's lines, mouth breathing), sinusitis, otitis media or effusion

Extremities

cyanosis, clubbing (suggests other diagnoses, particularly cystic fibrosis)

Other Testing

Spirometry - (See Services) used in children 5 and older to assess airflow obstruction and reversibility with treatment. In children younger than 5, see Asthma in young children (< 5 years). In children with asthma, airflow obstruction should be present and it should be reversible within 15-20 min. after inhalation of a short acting bronchodilator. Airflow obstruction is measured by comparing the forced expiratory volume in 1 second (FEV1) and the FEV1 to Functional Vital Capacity (FVC) ratio to normal values for age. Reversibility is shown by an increase in FEV1 by 12% or a 200 ml increase. For more information see Asthma spirometry basics (getasthmahelp.org) ( 219 KB) . Spirometry should then be repeated periodically, including after treatment is initiated and symptoms and PEF have stabilized to document attainment of (near) normal airway function, or if asthma is not well controlled, and at a minimum of every 1 to 2 years. Spirometry measures should be followed chronically to detect any decline in pulmonary function over time [National: 2007].

Peak flow measurements - After initial diagnosis, peak flow measurements can be used to monitor response to treatment over time. It is quick, easy, and inexpensive, and with practice can be sufficiently reliable to guide daily therapy or as an in-office assessment tool (see Peak flow sample chart (Asthma and Allergy Information and Research) and Peak flow meter information (American Lung Association)). Although there is less emphasis on peak flow measurements in the most recent guidelines, these measurements are still in widespread use, and can be very helpful in certain patients as long as providers/families understand the pitfalls of peak flow use:

• They are extremely effort dependent.
• Personal best should be used as the 100% value, as opposed to predicted values.
• Many children cannot perform an adequate peak flow maneuver, making the value invalid.
• Personal best increases with height (as do predicted values).
• They are not as sensitive in children as FEV1 or FEF 25-75 for assessing airflow obstruction.

Pulmonary Function Testing (see Services below for relevant providers)

Spirometry and additional testing such as challenge testing are available in the laboratory when appropriate. Education regarding symptoms, how to use a peak flow meter and inhaler, etc. is also offered in many PFT laboratories.

Pediatric Pulmonology (see Services below for relevant providers)

A referral to an asthma specialist might be helpful if symptoms are atypical or if additional testing, such as a challenge, are needed for diagnosis. Also consider referral for specialty consultation and/or management when: two or more bursts of oral steroids are needed within 6 months, an exacerbation requires hospitalization, care is at the step 4 level or higher (see Treatment & Management), immuno-therapy is being considered, or additional testing is needed.

Pediatric Allergy (see Services below for relevant providers)

Consider referral for subcutaneous allergen immunotherapy if there is an obvious relationship between persistent asthma symptoms and sensitivity to a particular allergen, as well as management of asthma.

After assessing the child, the asthma action plan should be revised based on current symptoms.

Pediatric Allergy

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Pediatric Pulmonology

Pediatric Asthma Program, more info...
100 N Mario Capecchi Dr
Salt Lake City, UT 84103
Phone: 801-662-1765
http://intermountainhealthcare.org/xp/public/primary/docsclinics/clinics/asthma.xml

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Pulmonary Function Testing

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