CORE: Asthma / COPD

Goal: Understand diagnosis and management of COPD and asthma.

Objectives:

1. Review the differential diagnosis and evaluation of chronic cough

2. Demonstrate diagnostic differences between asthma and COPD

3. Clarify COPD classification and management

4. Define recent changes in asthma management guidelines

5. Build COPD and asthma resource list in Epic

Case 1:

Albee Wheason is a 55 year old construction worker with HTN, DM2, GERD, obesity, and seasonal allergies. He has a history of persistent asthma in childhood but now uses albuterol once to twice a year as needed with respiratory infections. He has smoked 1 pack of cigarettes daily since age 17 and drinks 1-3 brandy old fashioneds on most nights. He presents to clinic today for evaluation of a nagging cough which has been present for the last 4-5 months ever since a “nasty cold” that he assures you was not COVID19 (confirmed by negative SARS-CoV-2 testing at urgent care last month). On exam he is afebrile, BP 135/86, HR 75, RR 16, O2 sat 95%, BMI 35 (-10 lbs since 2019), and clear breath sounds bilaterally though limited air movement in all fields.

• What is your differential diagnosis for chronic cough? What questions do you ask him to narrow the differential?

Additional History:

Mr. Wheason says the cough is productive of clear to opaque sputum and denies hemoptysis. He has had no fevers or chills. He denies lower leg swelling, orthopnea, bendopnea. He reports intentional weight loss of 10 pounds with diet and exercise over the past year which has really helped minimize his reflux. He had a dry cough in the past with lisinopril but this improved with transition to losartan. His allergies have been well controlled on cetirizine and fluticasone spray. Last year he was seen in Urgent Care twice for respiratory symptoms and treated for bronchitis with antibiotics on both occasions.

• What have you excluded from your differential? What is higher on your differential?

• What diagnostic steps do you pursue?

His Chest xray results are below:

His spirometry results as follows.

• What values are most important to you? What diagnosis does this imply?

• What if these were his spirometry results? What diagnosis would you consider?

• What are the diagnostic criteria for COPD?

• What risk factors does he have for the condition?

• Any other testing you would pursue?

• How do you assess COPD disease severity?

Albee reports that he gets short of breath at shorter distances than his friends do. What is his mMRC? He also scores an 11 on the CAT questionnaire.

• How would you classify his COPD at this point?

• What are your options for initial treatment of Albee’s COPD and what would you choose?

• What other aspects of Albee’s overall health care would you address?

Albee cuts down on smoking to half-pack daily and is feeling much better since you started him on a salmeterol (LABA) inhaler. About three months later he comes to the clinic with complaints of difficulty breathing. He started to have upper respiratory symptoms of runny nose, cough and has felt progressively short of breath despite using his inhaler as prescribed. On exam he is afebrile, HR 95, pulse ox 93%, and has diffuse wheezes without any focal findings. The remainder of his exam and review of systems are normal.

• What diagnosis do you suspect?

• What steps do you consider in evaluation?

• How would you treat him?

• Would you send him to the hospital? What guidance would you give?

Case 2:

Flo Spetter is a 27 yo woman with asthma who you meet in clinic for an annual physical exam. She had 4 hospitalizations for asthma during childhood including one PICU stay. She formerly used a daily (controller) inhaled corticosteroid inhaler but for the past 5 years she has only used albuterol as needed. Her asthma triggers are allergies and viral respiratory tract infections, but lately her allergies have not been bothering her with daily montelukast. Her last asthma exacerbation requiring steroids was about 2 years ago. She denies any daytime wheezing or shortness of breath and denies nighttime breathing difficulty or coughing. She feels overall well and requests that you refill her albuterol today.

• How would you classify her asthma control and severity?

• Discuss treatments for levels of asthma control and severity. Do you continue the albuterol? What is the recommended inhaler for her level of asthma control?

• What guidance can you give her about managing asthma symptoms in the future?

Resources:

GOLD and GINA 2020

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