What signs and symptoms should be monitored in a patient with asthma?

Key Signs and Symptoms to Monitor in Asthma Patients

Monitoring for symptoms of wheezing, shortness of breath, chest tightness, and cough is essential in asthma patients, as these cardinal symptoms indicate potential worsening of the condition and may require prompt intervention. 1, 2

Core Symptoms to Monitor

• Wheeze - A high-pitched whistling sound during breathing, particularly during expiration, which should be documented in clinical notes 1
• Shortness of breath - Difficulty breathing or breathlessness, especially with activity 1, 2
• Chest tightness - Sensation of pressure or constriction in the chest 1, 2
• Cough - May be the predominant symptom in some patients (cough variant asthma) 1, 2

Patterns and Characteristics of Symptoms

• Variability - Symptoms that fluctuate in intensity throughout the day or over time 1
• Intermittent nature - Symptoms that come and go rather than being constant 1
• Nocturnal worsening - Symptoms that are worse at night, a hallmark of asthma 1
• Trigger-induced symptoms - Worsening after exposure to specific triggers including exercise, allergens, viral infections, chemicals, and environmental tobacco smoke 1

Objective Measurements to Monitor

• Peak Expiratory Flow (PEF) - Should be measured regularly to assess airflow limitation 1

  • PEF <50% of predicted normal or best indicates severe asthma 1
  • PEF <33% of predicted normal or best indicates life-threatening asthma 1
  • PEF falling below 60% of patient's best may indicate need for rescue steroid course 1

• Spirometry - To measure FEV1 (Forced Expiratory Volume in 1 second) when available 1

  • Both PEF and FEV1 may be normal between episodes 1

• Exhaled Nitric Oxide (FeNO) - Can help monitor airway inflammation in patients with asthma 1

Warning Signs of Severe/Life-Threatening Asthma

• Inability to complete sentences in one breath due to breathlessness 1
• Respiratory rate >25 breaths/min 1
• Heart rate >110 beats/min 1
• Silent chest (absence of wheezing due to severe airflow limitation) 1
• Cyanosis or feeble respiratory effort 1
• Use of accessory muscles for breathing 3
• Bradycardia or hypotension in very severe cases 1
• Exhaustion, confusion, or altered mental status 1
• Pulsus paradoxicus (abnormal decrease in systolic blood pressure during inspiration) 3

Monitoring for Exacerbations

• Progressive worsening of symptoms day by day 1
• Decreasing response to rescue medications 1
• Increasing need for rescue medications 1
• Nocturnal awakenings due to asthma symptoms 1
• Reduced ability to perform normal activities 1

Monitoring Comorbidities and Risk Factors

• Allergic conditions - Such as rhinitis (present in up to 76% of asthma patients), eczema, or allergic rhinitis 1, 2
• Potential anaphylaxis - Especially in patients receiving biological therapies like omalizumab 4
• Medication adherence - Poor adherence is associated with worse outcomes 1
• Inhaler technique - Improper technique can lead to inadequate medication delivery 1

Monitoring Special Populations

• Children - Growth should be monitored regularly, as both uncontrolled asthma and some medications can affect growth 1
• Patients with history of severe attacks - Require closer monitoring, especially if onset was rapid 1
• Patients with poor perception of symptoms - May need more frequent objective measurements 1

Frequency of Monitoring

• Symptomatic patients - More frequent monitoring required 1
• Asymptomatic patients with established diagnosis - Regular monitoring still needed to ensure adequate control 1
• After medication changes - Close monitoring for 4 weeks to assess response 1

Careful and consistent monitoring of these signs and symptoms allows for early intervention, which can prevent severe exacerbations and reduce morbidity and mortality in asthma patients 5.