Severe Asthma ToolkitSevere Asthma Toolkit
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  • What is Severe Asthma?
    • Overview
    • Definition
    • Prevalence & Burden
    • Pathophysiology
    • Symptoms
    • Severe Asthma Attacks / Exacerbations / Flare-ups
    • Asthma Phenotypes
  • Diagnosis & Assessment
    • Overview
    • Diagnosis Overview
    • Assessment Overview
    • Lung Function Assessments
    • Questionnaires
    • Allergy Assessments
    • Phenotyping
    • Bronchoscopy
    • Imaging
    • Occupational Asthma
  • Management
    • Overview
    • Asthma Education
      • About Severe Asthma
      • Asthma Pathophysiology
      • Medications Education
      • Self-Monitoring
      • Triggers
      • Review
    • Written Action Plans
    • Adherence
    • Inhaler Technique
    • Physical Activity & Exercise
    • Interdisciplinary Approach & Multidimensional Assessment
    • Referral
  • Medications
    • Overview
    • Relievers
    • Preventers / Controllers
    • Add-on Therapies
    • Monoclonal Antibodies
      • Travelling with Monoclonal Antibodies
    • Bronchial Thermoplasty
  • Co-Morbidities
    • Overview
    • Pulmonary & Upper Airways
      • Allergic & Non-Allergic Rhinitis
      • Chronic Rhinosinusitis
      • Dysfunctional Breathing
      • Vocal Cord Dysfunction
      • Chronic Obstructive Pulmonary Disease
      • Bronchiectasis
      • Obstructive Sleep Apnoea
    • Extra-Pulmonary
      • Obesity
      • Anxiety & Depression
      • Gastro-oesophageal Reflux Disease (GORD)
      • Osteoporosis
      • Cardiovascular Disease & Metabolic Disease
  • Living with Severe Asthma
    • Overview
    • Daily Symptom Burden
    • Mental & Emotional Health
    • Intimacy & Relationships
    • Self-Management Support
    • Medication Use & Costs
    • Experience of Care
    • Experience of Asthma Attacks
    • Prognosis
  • Establishing a Clinic
    • Overview
    • Set-up
    • Staffing & Multidisciplinary Team Approach
    • Facilities
    • Delivery Approach
    • Tailored Referrals
    • Evaluation
    • Opportunities for Training & Research
    • Barriers & Hurdles
  • Paediatrics
    • Overview
    • Management in Paediatrics
    • Assessment in Paediatrics
    • Alternative Diagnosis & Co-Morbidities in Paediatrics
    • Psychosocial Issues in Paediatrics
    • Medications in Paediatrics
    • Asthma in the Adolescent Population
  • Resources
    • Overview
    • Clinic Recommendations
    • Infographics
    • Asthma Assessment Resources
    • Systematic & Multidimensional Assessment Resources
      • Airway Components
      • Comorbidity Components
      • Risk Factor Components
    • Translation & Implementation
    • Case Studies
    • Presentations
    • Videos
    • Relevant Links
    • Key References

Assessment Overview

Home Diagnosis & Assessment Assessment Overview

LAY OVERVIEW

Asthma assessment by symptoms alone can be misleading. Other medical problems can strongly impact symptoms. Addressing these comorbidities improves outcomes. Medication therapy is then adjusted accordingly. Targeted treatments should only be prescribed after detailed assessment.

Why is detailed assessment of severe asthma beneficial?

  • Symptom-only assessment can be misleading – both over- and under-perception is common
  • Comorbidities strongly influence symptoms, especially rhinitis, age and obesity and addressing comorbidities improves outcomes
  • Unnecessary medications can be discontinued or inappropriate doses can be adjusted
  • Targeted treatments (e.g. omalizumab, mepolizumab) require detailed assessment to ensure appropriate prescription. For more information see Monoclonal Antibodies

Asthma Assessment Tools

Note: There is no suggested order for assessments. Rather assessments will be performed in parallel and informed by initial diagnostic findings.

Questionnaires
Characterise Asthma Inflammatory Phenotype
Exhaled Nitric Oxide (FeNO)
Aspergillus serology
ANCA
High-resolution CT Scan
Sputum Microbiology and/or Inflammatory Cells
Bronchoscopy
Questionnaires
  • May be useful in certain clinical environments and are useful for screening, documentation and recording of symptoms for audit or follow-up. For more information see Questionnaires
Characterise Asthma Inflammatory Phenotype
  • Assess FBC (including peripheral blood eosinophils), total IgE, serum-specific IgE
  • Elevated eosinophil count , IgE and FeNO suggest the presence of Type-2 inflammation
  • Specific IgE to common allergens (house dust mite, pollens, moulds, animals) indicate atopy and Type-2 inflammation
  • Allergy assessment tools include questionnaires, skin prick testing, specific antibody testing, rhinoscopy, challenge testing (inhaled and ingested) and upper airway CT imaging
Exhaled Nitric Oxide (FeNO)
  • Provides evidence of Type-2 inflammation in the airways. For more information see Phenotyping – FeNO
Aspergillus serology
  • Aspergillus specific IgE indicates sensitisation to aspergillus fumigatus
  • Additional diagnostic tests indicate possible allergic bronchopulmonary aspergillosis (ABPA) , such as elevated serum IgE >1000 IU/mL, elevated aspergillus specific IgG, Positive Aspergillus precipitins, blood eosinophilia.
ANCA
  • Positivity may be consistent with Eosinophilic Granulomatosis with Polyangiitis (Churg-Strauss Syndrome)
High-resolution CT Scan
  • HRCT is done to rule out or identify coexistent disease (e.g. bronchiectasis, mucous plugging, parenchymal infiltrates, fibrosis, cystic lung disease, emphysema). For more information see Imaging
Sputum Microbiology and/or Inflammatory Cells
  • Microbiology may be useful when there is persistent mucous hypersecretion and co-existent bronchiectasis.
  • Inflammatory cell assessment may be useful to determine inflammatory phenotype in certain clinical situations. However, it is only available in specialised research units. For more information see Phenotyping – Sputum Assessment
Bronchoscopy
  • Selecting appropriate severe asthma patients for invasive biopsy has been recently reviewed (Doberer et al. 2015)
  • There are no guidelines on the use of invasive biopsy in the workup of severe asthma and this remains an individual decision. For more information see Bronchoscopy

Assessment for alternative diagnoses and comorbidities

It is important to also perform assessments for alternative diagnoses and comorbidities, which affect asthma severity and response to treatment.

Upper Airway Assessment for VCD
Cardiac Assessment
Mood, Anxiety, Depression
Obesity
Gastro-Oesophageal Reflux Disease (GORD)
Bronchitis (±Bronchoscopy)
Diagnostic Sleep Study (±Berlin Questionnaire)
Dysfunctional Breathing
Dietary Assessment - Food Chemical Intolerance
Occupational history
Upper Airway Assessment for VCD
  • For a detailed overview see: Comorbidities – Vocal Cord Dysfunction
  • Asthma assessments include: Formal vocal cord assessment ±challenge, dynamic upper airway CT Scan (Low et al. 2011)
  • Forced Oscillation Technique (Ioan et al. 2016) and questionnaires (e.g. LHQ, PVCDI)
  • Useful Reference: Official Joint ERS / ELS Statement on Inducible Laryngeal Obstruction (Halvorsen et al. 2017)
Cardiac Assessment
  • Electrocardiogram
  • Echocardiogram
  • Cardiac risk assessment tool
Mood, Anxiety, Depression
  • For a detailed overview see: Comorbidities – Anxiety & Depression
  • Assessments include: formal psychological assessment and questionnaires (e.g. HADS)
  • Mood disorders may either cause asthma-like symptoms or worsen the symptoms of asthma.
  • Objective tests may help determine the relative contributions of fixed and intermittent airway narrowing, and mood disorders to symptomatology.
Obesity
  • For a detailed overview see: Comorbidities – Obesity
  • Obesity adds an additional elastic load to breathing and hence may cause asthma-like symptoms, including wheeze, particularly during exertion
  • May accentuate asthma symptoms, and make them less drug-treatment responsive
Gastro-Oesophageal Reflux Disease (GORD)
  • For a detailed overview see: Comorbidities – GORD
  • GORD may trigger airway narrowing, thereby worsening asthma symptoms.
  • Assessments include: Formal gastroenterological assessment and GERD-Q questionnaire
Bronchitis (±Bronchoscopy)
  • Bronchitis is a common cause of asthma-like symptoms and may co-exist with asthma
  • Separating the mucous hypersecretory component from the asthmatic component may be difficult or impossible
    • Subjectively via symptoms assessment
    • Objectively via peak flow variability
  • Cough variant asthma was first described by (Corrao et al. 1979)
    • In 6 cases – cough alone was present with normal spirometry, AHR to methacholine, reduced sGaw, increase phase III of the nitrogen washout.
    • This study reported a complete and prompt response to bronchodilator treatment.
    • Subsequent reports highlighted the presence of eosinophilic inflammation in cough variant asthma.
Diagnostic Sleep Study (±Berlin Questionnaire)
  • For a detailed overview see: Comorbidities – Obstructive Sleep Apnoea
  • Obstructive sleep apnoea (OSA) is common in asthma & treatment of OSA may benefit asthma
Dysfunctional Breathing
  • For a detailed overview see: Comorbidities – Dysfunctional Breathing
  • This may mimic asthma symptoms, and often coexist with asthma. It therefore may worsen symptoms and lead to apparent severe asthma due to lack of response to asthma treatment.
  • Assessments include: History, questionnaire (e.g. Nijmegen), and investigations where appropriate e.g. arterial blood gas (ABG) analysis and tidal breathing monitoring (Boulding et al. 2016).
Dietary Assessment - Food Chemical Intolerance
  • Intolerance to common food components may worsen asthma symptoms and contribute to treatment resistance.
  • Common chemicals responsible for intolerance in asthma are salicylates (aspirin intolerance), sulphites, amines, monosodium glutamate (MSG).
  • A good dietary history, food diary and assessment by a dietitian with appropriate expertise and allergy clinic review. ASCIA provides a useful resource for reference here
Occupational history
  • Occupational exposures may contribute to symptom burden
  • Further information is available at:
    • (Malo et al. 2011).
    • Australian Asthma Handbook.
    • The Official American Thoracic Society Statement: Work-Related Asthma (Henneberger et al. 2011)

Recent publication on occupational lung diseases in Australia (Hoy et al. 2017)

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Last Updated on September 30, 2022

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