 Oct. 19, 2002 |
| ASSEMBLY EDITION • SAN DIEGO |
A family physician need answer only five basic questions to know whether continuous steroid therapy is indicated for suspected asthma.
Unfortunately, chart reviews suggest that many of these questions are never asked, said Barbara Yawn, M.D., senior investigator, Rural Health Research Center, Minneapolis, Minn.
"Appropriate treatment cannot occur without an accurate diagnosis," she said in her Thursday clinical seminar, "Dealing with Asthma: Who Needs Steroids in Five Easy Questions."
Yawn said asthma is often diagnosed, or misdiagnosed, and steroids prescribed on the basis of wheezing.
"Not everything that wheezes is asthma, and not all asthma wheezes," she said.
Yawn presented the questions to ask before prescribing steroids:
• Does the patient really have asthma? "Did you make a careful diagnosis?" Yawn said. Symptoms should be recorded, and other conditions such as gastroesophageal reflux must be ruled out.
• What is the patient's symptom level? "Go beyond the symptoms of their latest attack and ask about the symptom level three or four weeks ago, how they felt at night and during the day," Yawn advised.
• If symptoms are confusing, the third question to ask is: Were the right pulmonary function tests done? Testing for FEV1 is predictive, Yawn said, but peak flow is not a good diagnostic tool even though it is helpful in gauging improvement on therapy.
• Are any allergen or irritant triggers involved, and if so, can they be removed? Steroids might be avoided if the triggers can be removed, but Yawn said this is sometimes an uphill battle. "You might be able to talk them into getting rid of the family cat, but as for cockroaches or dust mites, forget it," she said. Tobacco smoke, both first- and second- hand, is a very common irritant that requires considerable patient education to eliminate.
• The final question: Is the patient having life-threatening exacerbations that probably can't be avoided in the future? Yawn recommended reserving oral corticosteroids for attacks that can't turned around in a half hour or so in the emergency department. Chronic use of oral drugs is associated with too many complications for routine prescribing, she said. "But everybody with persistent asthma of any degree needs inhaled corticosteroids; it is a chronic inflammatory disease," she said. Patient education about proper inhaler technique should not be taken for granted, she added.
Physicians who are confident that they answered these questions for every asthma patient might be surprised if they randomly pull charts with ICD-9 code 493, then check just how many of these questions were asked before steroids were prescribed, Yawn said.
"Less than 30 percent of asthma encounters document the frequency of asthma symptoms in the weeks and months prior to the asthma visit," Yawn said. "And less than 20 percent of asthma visits to primary care physicians include documentation of the severity of the patient's asthma."
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Copyright © 2002 by
American Academy of Family Physicians.