2008 Guidelines 2.4 DIAGNOSIS IN ADULTS (1) -based on the recognition of a characteristic pattern of...

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

7

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

8

High Probability

Patient with symptoms that may be due to asthma


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)

9



High Probability

Trial of Treatment

Response?


Yes

10



High Probability

Trial of Treatment

Response?


Yes No



or referral

11



High Probability

Trial of Treatment

Response?


Yes No



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

12



High Probability

Trial of Treatment

Response?


Yes No



or referral

Low Probability



Response?Yes

13



High Probability

Trial of Treatment

Response?


Yes No



or referral

Low Probability


Response?


YesReconsider probable

diagnosisFurther investigation

No

14



High Probability

Trial of Treatment

Response?


Yes No



or referral

Low Probability


Response?




No

Intermediate Probability


NormalFEV/FVC >70%

15



High Probability Low Probability


Response?




No



NormalFEV/FVC >70%

Trial of Treatment

Response?


Yes No



or referral

16

Trial of Treatment

Response?


Yes No



or referral



High Probability Low Probability


Response?


YesNo



NormalFEV/FVC >70%

Reconsider probable diagnosis

Further investigation

© Imperial College London

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)

Adults

www.sign.ac.uk/guidelines/fulltext/102/index.html

2008 Guidelines 2.4 DIAGNOSIS IN ADULTS (1) -based on the recognition of a characteristic pattern of...

Documents

Transcript of 2008 Guidelines 2.4 DIAGNOSIS IN ADULTS (1) -based on the recognition of a characteristic pattern of...