From the Guidelines
The physical examination of a patient with asthma should focus on respiratory assessment, including vital signs, oxygen saturation, and a thorough lung examination, as this approach is crucial for assessing asthma severity and control, which are key components in managing the disease, as emphasized by the Expert Panel Report 3 (EPR-3) guidelines 1. When examining a patient with asthma, it is essential to listen for wheezing, prolonged expiration, decreased breath sounds, and accessory muscle use, as these signs can indicate the presence of airway obstruction and inflammation, which are hallmarks of the disease. Assessing for signs of respiratory distress, such as tachypnea, nasal flaring, and intercostal retractions, is also critical, as these signs can indicate the severity of the disease and the need for immediate intervention.
The management of asthma should be guided by the principles of assessing severity and control, as outlined in the EPR-3 guidelines 1. This approach involves classifying asthma severity into different categories, such as intermittent, persistent-mild, persistent-moderate, and persistent-severe, based on the patient's symptoms, lung function, and risk of future exacerbations. The degree of control is also determined by analyzing current impairment and future risk, and validated questionnaires, such as the Asthma Control Questionnaire (ACQ) and the Asthma Control Test (ACT), can be used to assess the impairment domain of control 1.
Some key points to consider when managing asthma include:
- Assessing asthma severity at the initial evaluation and control at all subsequent visits 1
- Using a stepwise approach for asthma management, with the goal of achieving and maintaining control of the disease 1
- Adjusting medication based on the category of disease control, with the goal of minimizing symptoms and preventing exacerbations 1
- Educating patients on proper inhaler technique, trigger avoidance, and the importance of adherence to medication regimens 1
In terms of specific treatments, bronchodilators, such as short-acting beta-agonists like albuterol, should be used as needed for acute symptoms, while inhaled corticosteroids, such as fluticasone or budesonide, should be used as the cornerstone of treatment for persistent asthma 1. For moderate to severe asthma, adding a long-acting beta-agonist, such as salmeterol or formoterol, to an inhaled corticosteroid can help improve control and reduce symptoms. Leukotriene modifiers, such as montelukast, may also be added for allergic asthma, and biologics, such as omalizumab or mepolizumab, may be considered for severe cases. Acute exacerbations require intensified treatment with bronchodilators, oral corticosteroids, and possibly oxygen therapy, as well as close monitoring and follow-up to prevent future exacerbations.
From the FDA Drug Label
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From the Research
Approach to Physical Exam
- A thorough physical exam is essential in assessing a patient with asthma, focusing on the respiratory system 2, 3
- The exam should include:
- Inspection of the chest for signs of hyperinflation or accessory muscle use
- Palpation of the chest for tactile fremitus or vibrations
- Percussion of the chest for hyperresonance
- Auscultation of the lungs for wheezing, rhonchi, or decreased breath sounds
Management of Asthma
- The management of asthma involves a stepwise approach, with the goal of achieving and maintaining control of symptoms 3, 4
- Treatment options include:
- Inhaled corticosteroids (ICS) as the preferred long-term control therapy
- Long-acting beta-agonists (LABA) as add-on therapy for patients not controlled on ICS alone
- Combination therapy with ICS and LABA for patients with moderate-to-severe asthma
- Short-acting beta-agonists (SABA) as rescue medication for acute symptoms
- The choice of treatment should be based on the severity of symptoms, patient preferences, and the presence of comorbidities 5, 6
Lung Function Assessment
- Lung function assessment is an essential component of asthma management, including:
- Spirometry to measure forced expiratory volume (FEV1) and forced vital capacity (FVC)
- Peak expiratory flow (PEF) monitoring to assess variability in lung function
- These assessments help to:
Health-Related Quality of Life
- Health-related quality of life (HRQoL) is an important outcome in asthma management, assessing the impact of asthma on daily life and well-being 6
- HRQoL can be measured using validated questionnaires, such as the Asthma Quality of Life Questionnaire (AQLQ)
- Improvements in HRQoL are strongly correlated with improvements in asthma control, highlighting the importance of effective treatment 6