Pediatric Primary Care (66 page)

b.  Conjunctivitis.

c.  Boggy, pale nasal mucosa, mucosal swelling, clear rhinorrhea, nasal polyps, nasal flaring.

d.  Grunting.

2.  Chest exam.

a.  Normal chest examination does not rule out asthma.

b.  Bilateral wheezing, end-expiratory wheezing on forced expiration.

c.  Prolonged expiratory phase; rapid, shallow respirations.

d.  Hyperresonance to percussion.

e.  Hyperexpansion of chest, increased anterior-posterior diameter.

f.  Intercostal, suprasternal, and/or subcostal retractions.

g.  In infants, paradoxical breathing.

h.  In young children, pushing with abdominal musculature on expiration.

i.  Dry, tight-sounding cough.

E.  Diagnostic tests.

1.  Detailed medical history.

a.  Family history of allergy, asthma, eczema, dermatitis.

b.  Identify symptoms consistent with asthma.

c.  Identify pattern of symptoms that occur or worsen in presence of specific triggers.

•  Consider diagnosis after 3 episodes of cough and/or wheezing, once alternative diagnoses are excluded.

2.  Focused physical examination with special attention on the upper respiratory tract, chest, and skin.

3.  Laboratory procedures.

a.  Spirometry.

•  Age limited; difficult to accurately test children younger than 5-7 years of age in most settings.

•  Pre- and postbronchodilator to validate reversibility.

i.   May be normal.

ii.  Essential for diagnosis.

iii. Test annually to establish baseline pulmonary function. b. Peak flow is monitoring tool, not diagnostic tool.

4.  Chest X-ray: important in newly diagnosed asthmatic, rules out alternative diagnoses.

5.  Special studies.

a.  Sinus X-rays or CT to evaluate sinusitis.

b.  pH probe or barium swallow to evaluate gastroesophageal reflux (GER).

c.  Allergy testing.

•  Referral to board-certified allergist to administer skin tests and interpret.

•  RAST testing: not as sensitive as skin testing, results not immediate.

•  Allergic bronchitis, wheezy bronchitis.

•  Recurrent bronchiolitis or pneumonia.

i.   Even children with mild persistent asthma have significant airway inflammation.

ii.  Without adequate anti-inflammatory therapy, there may be airway remodeling or irreversible changes in asthma airway.

6.  Asthma classification.

a.  Severity: intrinsic to the disease process.

•  First step in initiating therapy for patient who has not been taking long-term controller medication.

b.  Control: fluctuates over time.

c.  Impairment: assessment component for severity and control; effect of asthma on quality of life and functional capacity.

d.  Risk: assessment component for severity and control; refers to future impact on quality of life and functional capacity.

e.  Four categories: intermittent, mild persistent, moderate persistent, and severe persistent.

•  Symptoms > 2 times per week, nighttime symptoms > 2 times a month.

•  Asymptomatic and normal peak flow between exacerbations.

•  Exacerbations brief; intensity may vary.

•  May have severe or lethal episodes.

f.  Mild persistent asthma.

•  Symptoms 2 times per week but less than daily. Nighttime symptoms 2 times a month.

•  Exacerbations may affect activity.

•  Nighttime symptoms 2 times per month.

g.  Moderate persistent asthma.

•  Daily symptoms, daily use of inhaled quick-relief bronchodilators.

•  Nighttime symptoms 1 time a week.

•  Exacerbations affect activity, occur 2 times per week; may last days.

h.  Severe persistent.

•  Continual symptoms; frequent exacerbations, nighttime symptoms.

•  Limited physical activity.

F.  Differential diagnosis.

1.  Vocal cord dysfunction: paradoxical adduction of vocal cords during inspiration (often in adolescent girls). Symptoms of distress including inspiratory wheezing and are out of proportion to clinical exam, including normal oxygen saturations. Diagnosis established by direct visualization of vocal cords using flexible rhinolaryngoscopy or flexible laryngoscopy.

2.  Congenital pulmonary malformations: radiologic testing, bronchoscopy to rule out abnormality.

a.  Tracheoesophageal fistula.

b.  Vascular ring, sling, or extrinsic mass.

3.  Foreign body aspiration: focal findings on auscultation; medical history key.

4.  Bronchopulmonary dysplasia: history of prematurity, treatment with oxygen therapy, mechanical ventilation during neonatal period.

5.  Viral bronchiolitis: virus may be identified by antigen testing or culture; may be trigger for asthma. Asthma differentiated by pattern of symptoms over time.

6.  Gastroesophageal reflux: reflux of barium into esophagus by barium swallow or esophageal pH monitoring. Can be aggravating factor in asthma control.

7.  Cystic fibrosis: genetic disease characterized by excessive production of thick, tenacious respiratory secretions, chronic pulmonary infection, malabsorption, subsequent poor growth.

G.  Treatment.

1.  Goals of treatment.

a.  No coughing, shortness of breath/rapid breathing, wheezing, chest tightness.

b.  No waking up at night because of asthma symptoms.

c.  Normal activities including play, sports, exercise.

d.  No absences from school or activities or work (for parent or caregiver).

e.  Normal lung function.

2.  Key principles.

a.  Prevent airway inflammation by eliminating or avoiding triggers.

b.  Asthma can be controlled, not cured.

c.  Reverse and suppress inflammation.

3.  Nonpharmacologic therapy.

a.  Patient education.

b.  Objective measures of lung function using peak flow monitoring and follow-up spirometry.

c.  Control or avoid aggravating factors.

4.  Pharmacologic therapy.

a.  Simplify treatment plan whenever possible.