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sputum is being investigated Skin testing or in vitro testing to assess sensitivity to relevant environmental allergens may be useful in patients with persistent asthma Evaluations for paranasal sinus disease or gastroesophageal reflux should be considered in patients with pertinent symptoms and in those who have severe or refractory asthma

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reversibility of airflow obstruction is defined by an increase of 12% and 200 mL in FEV1 or 15% and 200 mL in FVC after inhaling a short-acting bronchodilator However, the absence of improvement in airflow after administration of a bronchodilator is not proof of irreversible airflow obstruction Peak expiratory flow (PEF) meters are handheld devices designed as home monitoring tools PEF monitoring can establish peak flow variability, quantify asthma severity, and provide both the patient and the clinician with objective measurements on which to base treatment decisions There are conflicting data about whether measuring PEF improves asthma outcomes, but doing so is recommended as part of a comprehensive approach to asthma management in Expert Panel Report 2 of the National Asthma Education and Prevention Program (NAEPP) of the National Heart, Lung and Blood Institute Predicted values for PEF vary with age, height, and gender but are poorly standardized Comparison with reference values is less helpful than comparison with the patient s best baseline PEF shows diurnal variation It is generally lowest on first awakening and highest several hours before the midpoint of the waking day PEF should be measured in the morning before the administration of a bronchodilator and in the afternoon after taking a bronchodilator A 20% change in PEF values from morning to afternoon or from day to day suggests inadequately controlled asthma PEF values less than 200 L/ min indicate severe airflow obstruction Measurement of sputum eosinophilia or nitric oxide concentration in exhaled breath condensates may have a role in asthma management in the future As these technologies mature, they may result in earlier treatment, preventing or reducing clinically significant long-term changes in lung function Bronchial provocation testing with histamine or methacholine or exercise challenge testing may be useful when asthma is suspected and spirometry is nondiagnostic Bronchial provocation is not generally recommended if the FEV1 is less than 65% of predicted A positive test is defined as a decrease in FEV1 of at least 20% at exposure to a dose of 8 mg/mL or less A negative test has a negative predictive value for asthma of 95% Arterial blood gas measurements may be normal during a mild asthma exacerbation, but respiratory alkalosis and an increase in the alveolar-arterial oxygen difference (A a DO2) are common During severe exacerbations, hypoxemia develops and the PaCO2 returns to normal The combination of an increased PaCO2 and respiratory acidosis is a harbinger of respiratory failure and may indicate the need for mechanical ventilation.

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Complications of asthma include exhaustion, dehydration, airway infection, cor pulmonale, and tussive syncope Pneumothorax occurs but is rare Acute hypercapnic and hypoxic respiratory failure occurs in severe disease

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Disorders that mimic asthma typically fall into one of three categories: upper and lower airway disorders, systemic vasculitides, and psychiatric disorders It is prudent to consider these conditions in patients who have atypical asthma symptoms or response to therapy Upper airway disorders that mimic asthma include vocal cord paralysis, vocal cord dysfunction syndrome, foreign body aspiration, laryngotracheal masses, tracheal narrowing, tracheomalacia, and airway edema as in the setting of angioedema or inhalation injury Lower airway disorders include nonasthmatic COPD (chronic bronchitis or emphysema), bronchiectasis, allergic bronchopulmonary mycosis, cystic fibrosis, eosinophilic pneumonia, and bronchiolitis obliterans Systemic vasculitides that often have an asthmatic component include Churg-Strauss syndrome and other systemic vasculitides with pulmonary involvement Psychiatric causes include conversion disorders, which have been variably referred to as functional asthma, emotional laryngeal wheezing, vocal cord dysfunction, or episodic laryngeal dyskinesis M nchausen syndrome or malingering may rarely explain the patient s complaints

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The Expert Panel of the NAEPP has developed asthma classification schemes that are useful in directing asthma therapy and identifying patients at high risk for developing life-threatening asthma attacks Table 9 1 is used to classify the severity of chronic, stable asthma; Table 9 2 is used to classify the severity of asthma exacerbations A patient s clinical features before treatment are used to classify the patient The presence of only one of the severity features is sufficient to place a patient in that category; patients should be assigned to the most severe grade in which any feature occurs

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