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On physical examination, she appears anxious; respiratory rate is 20 breaths per minute; BP 120/70 without change during respiration; and there is no cyanosis. Neck is supple with no masses, thyromegaly, jugular venous distension; or stridor. Heart has normal S1 and physiologically-splitting S2. There are no murmurs or rubs. Lungs reveal fine end-expiratory wheezing with scattered rhonchi and no rales.

The peak expiratory flow rate (PEFR) is 62% predicted and the forced expiratory volume in the first second (FEV1) is 65% predicted. Peripheral blood eosinophil count is 1,500/mm3.
Key findings
1. Lungs reveal fine end-expiratory wheezing with scattered rhonchi
2. peak expiratory flow rate (PEFR) is 62% predicted
3. (FEV1) is 65% predicted
4. Peripheral blood eosinophil count is 1,500/mm3.
X-ray and EKG (refer to slides)
1. normal x ray
2. EKG: RRR, normal sinus, normal axis
WDx & DDx
WDx:Asthma

DDx
Congestive Heart Failure
Pulmonary Embolus
COPD
Vocal Cord Dysfunction
GERD
Pulmonary infiltrates with eosinophilia
Airway obstruction – tumor, foreign body
Cough secondary to drugs (ACEI)
Define Asthma
1. chronic inflammatory disorder of the airways
2. recurrent episodes of coughing (particularly at night or early morning), wheezing, breathlessness and chest tightness
3. associated with variable airflow obstruction that is often reversible, either spontaneously or with treatment
4. Unlike COPD (neutrophils)
More Eosinophils, T cells
To Dx Asthma
Need Hx, PE, and spirometry to show
1. Episodic symptoms of airflow obstruction or airway hyper-responsiveness
2. Airflow obstruction which is at least partially reversible
3. Alternative diagnoses have been excluded
How would you establish airflow obstruction?
Peak Flow (meteres)
Pulmonary Function Testing
Peak Flow Meters
1. Advantages
easy to use and cheap
2. Disadvantages
a. Extremely patient dependent
b. Errors in under or over estimating lung function
c. A mild obstruction maybe seen as a normal PEF
d. Can not differentiate restrictive from obstructive defect
Spirometers
1. More accurate and reliable
2. discern between restrictive from obstructive defect
3. Reversibility check by inhaling SABRA; increase of FEV1 >200ml and >12% from baseline measured
After Dx of asthma
Need to assess the
1. severity
2. degree of control
3. Responsiveness to medications
Classfication of Asthma start and beyond age 12
1. Intermittent/normal: FEV1 > 80%, FEV1/FVC is normal
2. moderate: FEV1 <80% but >60%, FEV1/FVC reduced 5%
3. severe: FEV1 reduced to <60%, FEV1/FVC reduced 5%<
Assessing asthma control
1. well controlled: FEV1>80% predicted
2. not well controlled: FEV1 between 60 and 80% predicted
3. very poorly controlled: FEV1 60%< predicted
StepWise Approach for Asthma Control
1. Long term control medication: daily
Inhaled corticosteroids (ICS)
2. SABA: acute symptoms & exacerbations
3. intermittent asthma: (SABA) on a PRN basis
4. persistent asthma (above intermittent): lowest-step therapy, both SABA & ICS
5. use LABA + ICS than increasing ICS alone; LABA by itself is contraindicated; if low dose ICS is good, don't use LABA
6. Step up if not controlled.
If very poorly controlled, consider increase by 2 steps, oral corticosteroids, or both.
Follow up
1. Visits every 2-6 weeks until control achieved later contact every 3-6 months.
2. Step-down in therapy:
With well-controlled asthma for at least 3 months.
3. Patients may relapse with total discontinuation or reduction of inhaled corticosteroids.
Severe asthma exacerbation (life threatening)
1. sx/signs: Too dyspneic to speak; perspiring, LOC
2. PEF or FEV1: <25 percent predicted or personal best
3. development
a. initial asthma
b. Asthma exacerbation – CO2 low, pH high, (increased resp rate) – non hypoxemia, pH starts to normalize – red flag towards severe or life threatening , airways closing down with more inflam
c. Altered mental status – big sign of problem
4. Normalization – pH returning but symptoms are worsening, speaking in full sentences and mental status changing with rise in pCO2
Life threatening Asthma treatment
1. inhaled SABA barely or doesn't work
2. Intravenous corticosteroids
3. Adjunctive therapies are helpful
4. ED admission, ICU
Arterial Blood Gases
1. FEV1 < 1L or PEF <200L/min; recommend ABG
2. Early stages: mild hypoxemia & respiratory alkalosis
3. Severity of airflow obstruction increases, PaCO2 increases
4. Hypercapnia denotes severe disease