Known or Suspected Asthma Clinical Pathway — Primary Care

History and Physical Exam, Spirometry

History, physical exam and spirometry are usually adequate to determine a diagnosis of asthma. Refer to GINA pocket guide for additional information on diagnosis.

History	Assess for recurrent symptoms of airway obstruction Cough, wheezing, WOB, chest tightness Symptoms worse at night or with exercise Triggered by viral infection, allergen exposure, weather change Risk factors Estimate number of: Previous office, ED visits for asthma exacerbations Hospitalizations for asthma, especially in the last year Respiratory insufficiency due to asthma (intubation, ICU admissions) Modifiable factors Environmental history (smoking, pets) School attendance Housing characteristics Comorbidities Presence of complicating illnesses Pulmonary, cardiac Diseases aggravated by steroid therapy Diabetes, hypertension, ulcers, psychosis History of recurring infections History of mental illness Other history Allergies Family history Growth Current medications, time of last dose Response to treatments Last course of systemic steroids Pregnancy
Physical Exam	General appearance VS Height, weight RR, HR BP, pulse oximetry as indicated Spirometry, as clinically indicated Asthma-specific Cough, wheezing, aeration Prolonged expiratory phase Signs of acute/chronic respiratory infection Allergy Pale, swollen turbinates Nasal polyps Atopic dermatitis Allergic shiners
Spirometry	Perform in children ≥ 6 yrs of age Demonstration of reversible airflow obstruction confirms asthma diagnosis Consider measuring before and after beta-agonist administration to confirm reversibility Measurements include FVC (Forced Vital Capacity), FEV (Forced Expiratory Volume) FEV1 normal is > 80% predicted FEV1/FVC normal is > 85% predicted Spirometry Guidance

History

Assess for recurrent symptoms of airway obstruction
- Cough, wheezing, WOB, chest tightness
- Symptoms worse at night or with exercise
- Triggered by viral infection, allergen exposure, weather change

Risk factors
Estimate number of:
- Previous office, ED visits for asthma exacerbations
- Hospitalizations for asthma, especially in the last year
- Respiratory insufficiency due to asthma (intubation, ICU admissions)

Modifiable factors
- Environmental history (smoking, pets)
- School attendance
- Housing characteristics

Comorbidities
- Presence of complicating illnesses
  - Pulmonary, cardiac
- Diseases aggravated by steroid therapy
  - Diabetes, hypertension, ulcers, psychosis
- History of recurring infections
- History of mental illness

Other history
- Allergies
- Family history
- Growth
- Current medications, time of last dose
- Response to treatments
- Last course of systemic steroids
- Pregnancy

Physical Exam

General appearance
VS
- Height, weight
- RR, HR BP, pulse oximetry as indicated
Spirometry, as clinically indicated

Asthma-specific
- Cough, wheezing, aeration
- Prolonged expiratory phase
- Signs of acute/chronic respiratory infection

Allergy
- Pale, swollen turbinates
- Nasal polyps
- Atopic dermatitis
- Allergic shiners

Spirometry

Perform in children ≥ 6 yrs of age
Demonstration of reversible airflow obstruction confirms asthma diagnosis
Consider measuring before and after beta-agonist administration to confirm reversibility
Measurements include FVC (Forced Vital Capacity), FEV (Forced Expiratory Volume)
- FEV1 normal is > 80% predicted
- FEV1/FVC normal is > 85% predicted
Spirometry Guidance

If you have questions about any of the clinical pathways or about the process of creating a clinical pathway, please contact us.

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The clinical pathways are based upon publicly available medical evidence and/or a consensus of medical practitioners at The Children’s Hospital of Philadelphia (“CHOP”) and are current at the time of publication. These clinical pathways are intended to be a guide for practitioners and may need to be adapted for each specific patient based on the practitioner’s professional judgment, consideration of any unique circumstances, the needs of each patient and their family, and/or the availability of various resources at the health care institution where the patient is located.

Accordingly, these clinical pathways are not intended to constitute medical advice or treatment, or to create a doctor-patient relationship between/among The Children’s Hospital of Philadelphia (“CHOP”), its physicians and the individual patients in question. CHOP does not represent or warrant that the clinical pathways are in every respect accurate or complete, or that one or more of them apply to a particular patient or medical condition. CHOP is not responsible for any errors or omissions in the clinical pathways, or for any outcomes a patient might experience where a clinician consulted one or more such pathways in connection with providing care for that patient.

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History and Physical Exam, Spirometry

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Known or Suspected Asthma Clinical Pathway — Primary Care

History and Physical Exam, Spirometry