Asthma is a common heterogeneous inflammatory chronic disorder of the airways. it is one of the most common chronic diseases in Saudi Arabia, with increasing prevalence. It has significant impact on patients, their families, and the community as a whole in terms of lost work and school days, poor quality of life, frequent emergency department (ED) visits, hospitalizations, and deaths.

The overall prevalence of asthma in children from Saudi Arabia has been reported to range from 8% to 25%, based on studies conducted over the past three decade. This increasing in prevalence of asthma is considered one of the main challenges facing our health systems and society as a whole.

1. Take patient History

   • Take the current symptoms - both day and night time.
   • Pattern of symptoms - over a day week or year.
   • Triggers

     • Exercise
     • Allergens (e.g., moulds, pet hair, pollens)
     • Weather (e.g., aspirins, NSAIDs)
     • Occupational exposure
     • Irritants (e.g., cigarettes, cold air, fumes)
     • Viral illness
   • Symptom relief with bronchodilator treatment
   • Impact on work and lifestyle
   • Home and work environment
   • Any presentations to an emergencydepartment, and hospitalor intensive care unit (ICU) admissions.
   • Smoking history - tobacco exposure to other people's smoke.
   • Personal history of allergies, inclusing atopic dermatitis (eczema) or allergic rhinitis.
   • Family history of asthma and allergies.
2. Physical Examination

   • Measure height and weight.
   • Look for signs of allergic rhinitis, nasal polyps, atopic dermatitis.
   • Examine the chest for deformities (pectus carinatum), wheezes, reduced respiratory sounds, crepitations, heart murmurs.
     • Peripheral airway expiratory wheezing suggesrts asthma, but wheeze may also occur with COPD, viral or bacterial respiratory infection, tracheomalacia, inhaled foreign body,or obesity.
     • High-pitched stridor due to upper airway dysfunction can be mistaken for wheeze.
     • Crepitations suggest an alternate or concurrent diagnosis.
   • Look for clubbing (does not occur in asthma)
   • Therefore a careful considerationsof any alternative diagnoses prior to commencing asthma treatment by a physician should be made.
3. Perform or arrange pre- and post- bronchodilator spirometry in every patient with suspected asthma. Look for evidence of:

   • Expiratory airflow limitation

     • Expiratory airflow limitation is defined as an FEV1/FVC less than the lower limit of normal for age.

     • FEV1/FVC aged based cut offs:
       • Up to 19 years: < 0.85
       • 20 to 39 years: < 0.80
       • 40 to 59 years: < 0.75
       • 60 years and over: < 0.70
   • Bronchodilator responsive expiratory airflow limitation

     In adults and adolescents , an increase in FEV1 ≥200mL and ≥ 12% from baseline 10 to 15 minutes after bronchodilator is a positive bronchodilator response.

     
     
4. Asthma symptom control

   In adults and adolescents, asthma control is based on assessing asthma symptoms, use of reliever medications, and impact on daily activities.

   There are several methods of assessing symptoms control, including:

   • Using an asthma control test

     The ACT is a commonly used tool to assess asthma control. The score of ACT is the sum of the five questions where each is scored from 1 (worst) to 5 (best), leading to a maximum best score of 25. The level of asthma control is categorized into:

     • Controlled: An ACT score of ≥20
     • Partially controlled: An ACT score of 16-19
     • Uncontrolled: An ACT score of <16
     • Asthma Control Test items

       

      

   • checking history of symptoms based on 4 weeks

         The ACT is a commonly used tool to assess asthma control. The score of ACT is the sum of the five questions where each is scored from 1 (worst) to 5 (best), leading to a maximum best score of 25. The level of asthma control is categorized into:

·      Controlled: An ACT score of ≥20

·      Partially controlled: An ACT score of 16-19

·      Uncontrolled: An ACT score of <16

Total score of 1-3: low risk and manage in PHC

Total score of 4-7: moderate risk, refer to hospital ER

Total score of 8-12: high risk, refer to hospital ER

Level 1 (Visit Primary care facilities only)

·      BA patient had asthma control test ≥ 20

·       PEFR > 80% of predicted personal best

·      Spirometry > 70%

Level 2 (Visit Primary care facilities if not controlled within 6 months referred to secondary care)

·      Asthma control test: 16- 19

·      PEFR: 60 -80 % of predicted personal best

·      Spirometry: 60 - 70 %

Level 3 (Visit secondary care within 2 weeks)

·      Asthma control test:  < 16

·      PEFR: < 60 % of predicted personal best

·      Spirometry: <60 %

Level 1 (Visit Primary care facilities only)

·      Physician assessment of control: 0

·      Spirometry: >70%

Level 2 (Visit Primary care facilities if not controlled within 3 months referred to secondary care)

·      Physician assessment of control:  1-2

·      Spirometry: 60 % - 70%

Level 3 (Visit secondary care within 2 weeks)

·      Physician assessment of control: >= 3

·      Spirometry: <60 %

Bronchial Asthma Toolkit