Priority Topic: Asthma & Priority Topic: Pneumonia

Asthma

Key Feature 3: In a known asthmatic, presenting either because of an acute exacerbation or for ongoing care, objectively determine the severity of the condition (ex: with history, including the pattern of medication use), physical examination, spirometry. Do not underestimate severity.
Skill: Clinical Reasoning
Phase: Diagnosis

Key Feature 4a: In a known asthmatic with an acute exacerbation: Treat the acute episode (ex: use beta-agonists repeatedly and early steroids, and avoid under-treatment).
Skill: Clinical Reasoning, Selectivity
Phase: Treatment 

Key Feature 4b: In a known asthmatic with an acute exacerbation: Rule out comorbid disease (ex: complications, congestive heart failure, chronic obstructive pulmonary disease).
Skill: Selectivity, Clinical Reasoning
​Phase: Hypothesis generation, Diagnosis

Key Feature 4c: In a known asthmatic with an acute exacerbation: Determine the need for hospitalization or discharge (basing the decision on the risk of recurrence or complications, and on the patient’s expectations and resources).
Skill: Selectivity, Clinical Reasoning
Phase: Treatment

Pneumonia

Key Feature 4a: In patients with pre-existing medical problems (ex: asthma, diabetes, congestive heart failure) and a new diagnosis of pneumonia: Treat both problems concurrently (ex: with prednisone plus antibiotics).
Skill: Clinical Reasoning, Selectivity
Phase: Treatment

Key Feature 4b: In patients with pre-existing medical problems (ex: asthma, diabetes, congestive heart failure) and a new diagnosis of pneumonia: Adjust the treatment plan for pneumonia, taking into account the concomitant medical problems (ex: be aware of any drug interactions, such as that between warfarin [Coumadin] and antibiotics).
Skill: Clinical Reasoning, Selectivity
​Phase: Treatment, Hypothesis generation

As a disease that ebbs and flows, optimal management of asthma requires more than just regular use of a medication. It requires efforts to avoid triggers that lead to exacerbations, which may vary somewhat between individuals, adjusting medications to the severity of symptoms that fluctuate (to avoid unnecessary medication use that can also have negative long-term consequences), and early treatment of acute exacerbations of asthma and other comorbid conditions that make good asthma control more difficult to achieve. Perfect control may be impossible, but with ongoing followup and patient education better control is realistic. Ultimately the goal of this followup is to assist the patient/families to manage the disease as best as possible to decrease symptoms, improve quality of life, and decrease long-term repercussions from both poorly controlled asthma or excess medication use. 

Routine asthma assessment and management
UpToDate provides an excellent array of tables to classify asthma severity, which can be reassessed at every routine followup visit (see below), with classification varying according to age. UpToDate also summarizes the gist of what to assess in followup, provides guidance on how frequently to reassess, and provides a table that outlines how to adjust therapy based on control after pharmacotherapy has already been initiated previously. And last but not least, UpToDate provides an overview of recommended therapy depending on initial and followup reassessment of asthma severity.

"Routine follow-up visits for patients with active asthma are recommended, at a frequency of every one to six months, depending upon the severity of asthma. These visits should be used to assess multiple aspects of the patient's asthma and to discuss steps that patients can take to intervene early in asthma exacerbations (an asthma "action plan"). The aspects of the patient's asthma that should be assessed at each visit include the following: signs and symptoms over the past two to four weeks, pulmonary function, quality of life, exacerbations, adherence with treatment, medication side effects, and patient satisfaction with care.... By consensus from panels of asthma experts, well-controlled asthma is characterized by daytime symptoms no more than twice per week and nighttime symptoms no more than twice per month. SABAs for relief of asthma symptoms should be needed less often than three days out of the week, and there should be no interference with normal activity (preventative use of a SABA, such as prior to exercise, is acceptable even if used in this way on a daily basis). Peak flow should remain normal or near-normal. Oral glucocorticoid courses and/or urgent care visits should be needed no more than once per year."

Assessment and management of an episode of acute exacerbation
​Early recognition and treatment of an episode of acute exacerbation of asthma is important so as to avoid it from getting more severe and life-threatening as well as to avoid unnecessary emergency department visits and hospital admissions. Per UpToDate, "Patients and their caregivers should be educated on how to take appropriate steps upon recognition of increased asthma symptoms. These include immediate treatment with short-acting inhaled beta agonists (SABAs), monitoring of medication response, and early administration of oral glucocorticoids, when needed." (See an overview table below) If patients present for medical assessment during an episode of acute exacerbation, UpToDate also provides summary tables of the features to assess to determine severity upon presentation and in response to therapy, the latter of which provides guidance for disposition planning, as well as a table outlining when to suspect and how to evaluate for comorbidities. Treat any complications or comorbidities with vigour, as patients with underlying chronic disease are more at risk of decompensation given that they are fighting more of a battle. Consideration also needs to be given to modifying treatment of comorbidities as it would usually be done in a person without chronic disease, as disease states and medications may interact with negative implications.