Asthma

Abstract: Pulmonary function tests, such as the measurement of forced expiratory volume in 1 second (FEV1) and peak expiratory flow (PEF), provide an objective, standardized, and quantifiable method of patient assessment and can be essential in the evaluation of asthma. However, FEV1 and PEF are relatively insensitive for detecting changes in persons with good baseline pulmonary function, and they do not directly measure worsening airway inflammation. One way to deal with the shortcomings of these tests is to include multiple outcomes assessment. Evaluating patient-oriented variables, such as symptoms, need for rescue medication, nocturnal awakenings, and unscheduled medical care visits, can detect clinically relevant changes that pulmonary function tests do not identify. Composite outcomes provide a more comprehensive approach to patient follow-up. For example, a patient who is considered to be a "nonresponder" to a given therapy on the basis of pulmonary function criteria might, in fact, be responding favorably according to assessment of composite outcomes. Two patient-centric tools for measuring outcome are the asthma control questionnaire and the asthma control test.

Asthma is one of the most common chronic diseases worldwide, and its prevalence--particularly among children--is increasing in many countries.1,2 In 1997, an estimated 9.6% of persons in the United States had asthma (Table 1).3

Dr Storms: Given that a patient's asthma varies quite a bit from day to day, and that controller therapies can prevent exacerbations, is there any role for using a controller medication as-needed rather than using it regularly? Could exacerbations be prevented if the patient has been educated to start treatment as soon as symptoms occur or peak expiratory flow (PEF) falls?

Abstract: The coexistence of asthma and obstructive sleep apnea (OSA) in a given patient presents a number of diagnostic and treatment challenges. Although the relationship between these 2 diseases is complex, it is clear that risk factors such as obesity, rhinosinusitis, and gastroesophageal reflux disease (GERD) can complicate both asthma and OSA. In the evaluation of a patient with poorly controlled asthma, it is important to consider the possibility of OSA. The most obvious clues are daytime sleepiness and snoring, but the definitive diagnosis is made by polysomnography. Management of OSA may include weight loss and continuous positive airway pressure (CPAP). Surgical intervention, such as uvulopalatopharyngoplasty, may be an option for patients who cannot tolerate CPAP. Management may include specific therapies directed at GERD or upper airway disease as well as modification of the patient's asthma regimen. (J Respir Dis. 2005;26(10):423-435)

A 69-year-old woman was admitted to the hospital with wheezing and dyspnea. She also complained of hoarseness and slight dysphagia that had caused a loss of 12 lb during the past 4 months. The patient had been treated for bronchial asthma as an outpatient, but the worsening episodes of wheezing were not being controlled by bronchodilator therapy.

The 83-year-old woman whose hands are shown in photograph A had a severe flare of arthritis in the metacarpophalangeal and proximal interphalangeal (PIP) joints after corticosteroid therapy for her asthma was stopped. The clue to the diagnosis of psoriatic arthritis is in her fingernails, which show both pitting and onycholysis.

A 37-year-old woman presented with progressive dyspnea of 2 weeks' duration, a low-grade fever, and night sweats. She had been a healthy marathon runner until her exercise tolerance recently declined.

The onset of atopic dermatitis can be seen in infants who have a family history of inhalant allergies, (eg, seasonal allergy, allergic rhinitis, or allergy-induced asthma). The cheeks and large flexural folds of affected children are erythematous and scaly. Involved areas of the trunk and extremities may exhibit discrete patches or a generalized rash.

A chest roentgenogram from a 42-year-old man with asthma, primary hypoparathyroidism, and pectus excavatum showed a left suprahilar mass-like density.

This rash, which covered a 68-year-old woman's body, was noted to have worsened during the past 2 months. A cephalosporin antibiotic had failed to clear the condition. The patient, a nursing home resident, suffered from emphysema, asthma, and heart disease. She had been receiving oxygen therapy and prednisone for 1 year.

A 12-year-old boy with a history of atopy complained of pruritus and severe dryness of the hands. Over-the-counter moisturizers failed to resolve the condition. The patient did not wash his hands frequently and had no hobbies that exposed him to environmental irritants or allergens.

Five days before this 1-year-old girl was brought to her doctor's office, a rash had developed on her left shoulder and the left side of her chest. The abrupt onset of a high fever (temperature, 41°C [105.8°F]) and irritability accompanied the outbreak of the rash. The child had a history of asthma and eczema.

With a 1-year history of episodic wheezing, a 62-year-old woman (a smoker for the past 30 years) was being treated for bronchial asthma, but bronchodilator therapy did not control her symptoms. She was hospitalized with worsening dyspnea and a 4.5-kg (10-lb) weight loss over the past 3 months. There was no hemoptysis.

A 40-year-old man was being treated as an outpatient with inhaled corticosteroids and bronchodilators for a presumed diagnosis of bronchial asthma. Worsening episodes of shortness of breath during the past few months sent him to the emergency department for a second opinion.

For 1 month, an 82-year-old woman had had episodes of coughing. Chronic bronchitis had been diagnosed; however, antibiotics and bronchodilators failed to control symptoms.

An acute exacerbation of asthma brought this 52-year-old Russian emigré to the emergency department (ED). Examination revealed the well-demarcated round erythema and ecchymosis on the patient's back. This circular pattern was created by cupping performed 2 days earlier by the patient's wife in an effort to treat her husband's asthma.

A 35-year-old man was hospitalized with severe dehydration secondary to necrosis of the throat. He found oral intake impossible because of severe discomfort when swallowing. The patient took no prescription medications; he had not been hospitalized or seen by a medical practitioner recently.

For 2 months, a 31-year-old woman had had dyspnea and dull, continuous retrosternal pain. She was admitted to the hospital, and a helical CT scan of the thorax identified a saddle pulmonary embolism. An ultrasonogram revealed deep venous thrombosis (DVT) in the left leg. Intravenous heparin was given; the patient was discharged, and warfarin was prescribed.

Abstract: The idiopathic interstitial pneumonias (IIPs) are the most commonly diagnosed forms of interstitial lung disease. These diseases represent specific clinicopathologic entities characterized by varying degrees of lung parenchymal inflammation and fibrosis. While most patients present with chronic dyspnea and have evidence of restriction on pulmonary function testing, certain findings can help differentiate among the IIPs. For example, patients with idiopathic pulmonary fibrosis (IPF)--the most common IIP--commonly present in the sixth or seventh decade of life, while those with desquamative interstitial pneumonia or respiratory bronchiolitis with interstitial lung disease typically present in the third or fourth decade of life and have a history of smoking. IPF is characterized by usual interstitial pneumonia (UIP) on lung biopsy; a UIP pattern can also be identified by high-resolution CT. (J Respir Dis. 2005;26(9):372-378)

Studies have indicated that the use of acetaminophen is associated with an increased risk of asthma. Now there is evidence linking acetaminophen use to an increased risk of chronic obstructive pulmonary disease (COPD).

Studies have indicated that depression occurs more frequently in adults with asthma than in the general population; however, few studies have investigated the relationship between depression and asthma outcomes. A recent study by Eisner and associates revealed noteworthy findings: depressive symptoms appear to be associated with poorer outcomes, including increased risk of hospitalization for asthma.

A 51-year-old man with a 20-year history of asthma and seasonal allergies presented with low-grade fever, progressive dyspnea on exertion, and wheezing that had persisted for 2 weeks. Four days earlier, he had been seen by his primary care physician and had started levofloxacin therapy. However, his respiratory symptoms had worsened, warranting hospitalization. He also reported pain in the abdomen and left flank and pain and swelling in the right metacarpophalangeal and right shoulder joints.

As the incidence of asthma continues to increase worldwide, current studies have indicated that the most prevalent challenge to the alleviation of asthma symptoms is undertreatment. Results of a controlled study in Denmark suggest that a physician-managed Internet-based asthma monitoring system can help patients optimize control over their asthma.

Abstract: The standard therapies for acute exacerbations of chronic obstructive pulmonary disease include short-acting bronchodilators, supplemental oxygen, and systemic corticosteroids. For most patients, an oxygen saturation goal of 90% or greater is appropriate. Bilevel positive airway pressure (BiPAP) is usually beneficial in patients with progressive respiratory acidosis, impending respiratory failure, or markedly increased work of breathing. However, BiPAP should not be used in patients with respiratory failure associated with severe pneumonia, acute respiratory distress syndrome, or sepsis. Systemic corticosteroids are appropriate for moderate to severe acute exacerbations; many experts recommend relatively low doses of prednisone (30 to 40 mg) for 7 to 14 days. Antibiotic therapy is controversial, but evidence supports the use of antibiotics in patients who have at least 2 of the following symptoms: increased dyspnea, increased sputum production, and sputum purulence. (J Respir Dis. 2005;26(8):335-341)

A 62-year-old woman with a 25-year history of dyspnea was hospitalized because of hypoxemia. The dyspnea had become more severe during the past few years; it was worse in the standing position, was not exacerbated by walking, and was immediately relieved on lying down. She had no seasonal variation or environmental trigger of the dyspnea.

Abstract: All children with asthma should have periodic office visits, usually every 3 to 6 months, in which asthma action plans are updated. Periodic assessment of lung function by peak expiratory flow or office spirometry can help determine the appropriate treatment strategy. Low daily doses of inhaled corticosteroids remain the first and most effective choice of therapy for persistent asthma. If this approach is inadequate, adding a second medication, such as a leukotriene modifier or a long-acting ß2-agonist, is suggested. Short-acting ß2-agonists remain the most important therapy for intermittent asthma. For most children, the best route is via a metered-dose inhaler with either a spacer or valved holding chamber. If these agents are inadequate, a short course of oral corticosteroids may be required. (J Respir Dis. 2005;26(8):348-358)

How can repeated visits to the emergency department (ED) for asthma exacerbations best be avoided?

Abstract: The classic presentation of anaphylaxis includes urticaria, angioedema, dyspnea, and systemic hypoperfusion. However, anaphylaxis may be more difficult to recognize if syncope, bronchospasm, or cardiovascular collapse is the predominant feature. Essential components of the history include previous allergic reactions, medication use, recently ingested foods, and exposure to latex. Although angioedema is often obvious, it also can be subtle and may require asking patients about changes they have observed. Other findings include tachypnea; wheezing; inspiratory stridor; conjunctival injection; rhinorrhea; and hoarseness, which may suggest laryngeal edema. Oxygen with ventilatory support, epinephrine, and crystalloid volume resuscitation are the mainstays of therapy for anaphylactic shock. Additional therapy often includes H1 antagonists, H2 antagonists, and corticosteroids. (J Respir Dis. 2005;26(7):308-316)

Abstract: Although smoking cessation is still the most impor- tant intervention in chronic obstructive pulmonary disease (COPD), a variety of pharmacologic therapies are available to help manage symptoms. Short-acting ß2-agonists and/or ipratropium should be taken as needed, and the use of additional therapies is based on the severity of disease. Patients with moderate or severe COPD should regularly take 1 or more long-acting bronchodilators. The long-acting ß2-agonists salmeterol and formoterol have been demonstrated to improve health-related quality of life. Newer therapies include the long-acting anticholinergic tiotropium and a salmeterol-fluticasone combination. These agents improve forced expiratory volume in 1 second and may reduce the rate of acute exacerbations. For patients with moderate to very severe COPD, participation in a pulmonary rehabilitation program can improve health status, quality of life, and exercise tolerance. (J Respir Dis. 2005;26(7):284-289)

Stories about community-associated infections with methicillin-resistant Staphylococcus aureus (MRSA) have been making headlines in recent months in both the medical and popular press. A familiar problem in hospitals and nursing homes for decades, growing numbers of MRSA infections have been documented over the past few years in prison inmates, soldiers, athletes, Pacific Islanders, Alaska Natives, Native Americans, and men who have sex with men.