I. Hx of disease if not new in onset
- Age at onset and dx
- Progress of disease
- Characteristics of typical exacerbation and what has been effective as tx
- Present management of exacerbations
- ER visits, hospitalizations, intubations
- Limitation of activity
- Missed days from school/work due to asthma
II. In young infants, with lower airways dysfunction, differential includes:
- Pertussis (esp. in preemies)-us. no wheezing, though
- Chlamydia (50% also have conjunctivitis; 50% will have peripheral eosinophilia); us. no wheezing, though
- Bacterial pneumonia-us. no wheezing, though
- Bronchopulmonary Dysplasia due to prematurity or mechanical ventilation
III. Temporal pattern of sx (cough, wz, chest tightness, dyspnea)
- Continual, episodic, or both
- If episodic, frequency & duration
- Perennial, seasonal, or both
- Diurnal variation? (if so, look for corresponding precipitants)
IV. Precipitants (all of the following shown to be sig. in at least some pts)
- Inhalant allergens
- Exploration of this issue is indicated in any patients with persistent asthma requiring daily Rx
- For seasonal allergens, hx usually sufficient
- Early spring: trees
- Late spring: grass
- Summer-autumn: weeds
- For persistent asthma with suspected perennial indoor allergens, confirmation with skin testing or serology (IgE) is indicated. Here are some ?'s to ask:
- Do you have indoor pets (inc. Birds)?
- Is there visible dust in your home?
- Are there visible molds in your home?
- Are there damp rooms in house? (dust mites, molds)
- Do you have thick carpets in your home? (dust)
- Are there cockroaches in your home?
- Wood-burning stove in house?
- Unvented (gas, oil, or kerosene) stoves in house?
- Fume exposure (perfume, cleaning chemicals)?
- Sx worse inside vs. outside (or vice-versa)
- Are you exposed to pollution from traffic/industry?
- Tobacco smoking or secondhand exposure?
- Sx better on weekends? (work exposure)
- Airborne items at work?
- Sulfite containing foods exacerbate sx? (wine, beer, dried fruit, shrimp)
- Inhaled irritants (tobacco smoke, occupational irritants)
- Air pollution, esp. particulates, ozone, SO2, NO2
- Rhinitis and sinusitis
- For pts with persistent asthma and chronic rhinitis, intranasal steroids are indicated; may lower airways responsiveness
- For infants, will lead to resp. sx worse after vomiting or regurgitation or with feeding
- 62 adults with GERD & asthma randomized to ranitidine 150mg TID vs. PRN antacids vs. Nissen fundoplication x at least 2y; over > 2y f/u, nocturnal asthma sx were sig. more improved in surgical group than either of the other two groups; no sig. diff. in overall mortality. (Am. J. Gastroent. 98:987, 2003--abst)
- Viral respiratory infections
- Cold air
- Exercise (us. will see at 15% decrease in PEF or PEV with exercise)
- Emotional stress
- Medications, e.g. beta-blockers (including eyedrops), ASA, and other NSAIDS
- Ask all pts if ASA ever precipitated sx; if pt has nasal polyps, avoid ASA even if pt hasn't noticed a connection
V. History of early life airways injury (BPD, pneumonia, bronchiolitis, parental smoking)
- "Food allergens are not a common cause of asthma symptoms"
VI. Family hx of asthma or allergic disease
VII. Characteristics of work environment
VIII. Social/psych factors that may affect adherence
IX. Perceptions and expectations of disease course and effects of tx