Asthma on the CCFP exam

Approach

• Think of asthma with cough, wheeze, chest tightness or shortness of breath that comes and goes, at any age.
• Age 6 and up: spirometry is the preferred proof. You need a low FEV1/FVC (first-second air over all the air blown out). FEV1, the first-second air, must also rise at least 12% after a reliever.
• Normal spirometry does not rule asthma out. If doubt remains, use peak flow tracking or a methacholine challenge (a breathing test that uses an inhaled irritant to provoke narrowing).
• Ages 1 to 5: a trained clinician documents wheeze and sees it improve with a reliever, with or without an oral steroid. A parent's report alone only suggests it.
• In a young child, two or more documented episodes make it asthma. One episode makes it suspected. Viral triggers do not rule it out.
• Two or more reported episodes but no signs on the day? With frequent symptoms or a severe flare, try 3 months of medium-dose inhaled corticosteroid (ICS). Otherwise watch and reassess.
• Watch for red flags of another cause. Up to half of children under 6 outgrow their symptoms.

Approach

• Time the noise. A whistle on breathing out points to the small airways. A harsh noise on breathing in, with a barking cough, points to croup.
• Ask about a choking or gagging spell, even days ago, and what was in the child's mouth. Listen for wheeze or poor air entry on one side.
• Bronchiolitis is usually a first wheezy illness in an infant, after a few days of a cold.
• Asthma brings repeat episodes and wheeze that eases with a reliever.
• No routine chest film for asthma, bronchiolitis, croup or a first wheeze. Image with low oxygen, focal chest findings, a long course or severe distress.
• Wheeze without a cold or allergy history needs a case-by-case look for another cause, imaging included.
• Skip the viral panel unless the result would change care. Viruses set off both bronchiolitis and asthma, so a positive swab separates nothing.

Approach

• Grade control with set questions, not 'how is your asthma?'. Missing any item in the table below means poorly controlled.
• A severe flare needs a systemic steroid, an emergency visit or a hospital stay. A mild flare is worse than usual, with none of these.
• Do not take 'it's fine' at face value. Most people with asthma think it is controlled when it is not.
• Check pharmacy refills. More than 2 reliever inhalers in a year is overuse and needs a talk.
• Ask about flare risk every visit: any past severe flare, poor control, reliever overuse, or current smoking.
• Even mild asthma can bring severe flares and death.

Approach

• Treat the flare with the reliever. Under-treating a flare is the classic error.
• When a flare needs a systemic steroid: prednisone 30 to 50 mg a day for at least 5 days in adults. In children, 1 mg/kg a day, up to 50 mg, for at least 3 days.
• In a child, no routine chest film. Get one when something does not fit: low oxygen, focal chest signs, severe distress or a long course.
• Something new, such as chest pain, means look for a complication or a mimic. In older adults, think of heart failure or chronic obstructive pulmonary disease (COPD).
• No antibiotics for an adult with an asthma flare.
• Signs of higher risk of a fatal attack: a past intensive care stay or breathing machine, or repeat visits this year. Also reliever overuse, poor adherence, mental illness, substance use or heavy stress.
• Every severe flare means starting a daily controller, or reviewing the one in place. Refer after any hospital stay, 2 or more emergency visits, or 2 steroid courses in a child.

Approach

• Give every patient education and a written action plan: how to check control, what to change when it slips, and when to get urgent help.
• Well controlled on a reliever alone and lower risk: stay on it or start daily ICS. From age 12, as-needed budesonide/formoterol is another option.
• Poorly controlled, or higher risk: daily ICS plus an as-needed reliever, at every age. Montelukast (a leukotriene receptor antagonist) is second line to it.
• From age 12, as-needed budesonide/formoterol replaces daily ICS when adherence stays poor despite real teaching and support.
• Not controlled on a low dose: ages 1 to 11, go to a medium dose. From 12, add a long-acting bronchodilator in the same inhaler as the ICS.
• Losing control: do not double the ICS. From age 16, after a severe flare in the past year, try 4 times the dose for 7 to 14 days.
• Once controlled for 3 to 6 months with no severe flares, step down to the lowest dose that holds.

Approach

• Before any step-up, check adherence, inhaler technique, and whether the inhaler is empty.
• Watch the patient use the device. Poor technique is common. Use a spacer (valved holding chamber) with every puffer, above all with an ICS.
• Check refills. More than 2 reliever inhalers a year means higher flare risk and calls for a review of control.
• Ask about smoking, second-hand smoke, vaping and cannabis. Counsel to quit.
• Take a work history. About 36% of adult-onset asthma is probably or possibly work-related.
• If allergens trigger symptoms, cut exposure with two or more measures together, such as cleaning, filters and removing a pet.
• Look for rhinosinusitis, reflux, vocal cord problems, anxiety and depression.