Physical Findings

In the completely asymptomatic patient, results of chest examination will be normal, although head, eye, ear, nose, and throat examination may disclose concomitant serous otitis media, allergic conjunctivitis, rhinitis, nasal polyps, paranasal sinus tenderness, signs of postnasal drip, or pharyngeal mucosal lymphoid hyperplasia. Clubbing of the fingers is extremely rare in uncomplicated asthma, and this finding should direct the physician's attention toward diseases such as bronchiectasis, cystic fibrosis, pulmonary neoplasm, or cardiac disease. With an acute exacerbation, patients may be restless, agitated, orthopneic, tachypneic, breathing through pursed lips with a prolonged expiratory

Table 12 Peak Flow Meter Characteristics

Inexpensive Easy to use Accurate

Provide "real-life" measurements at worst and best time of day am and pm, monitor range between the measurements Obtain "personal-best" measurement phase, using accessory muscles of respiration, diaphoretic, coughing frequently, or audibly wheezing and cyanotic. Cyanosis occurs only with profound arterial oxygen desaturation and is a grave sign that appears late in the course of severe asthma. Vital signs will confirm the physician's impression that the patient is tachypneic, and evaluation of the blood pressure may show that the patient has a widened pulse pressure and a pulsus paradoxus. The latter sign, when present, is a relatively reliable indicator of severe asthma. Although a low-grade fever may be of viral origin, the presence of an elevated temperature should alert the physician to search for a possible bacterial infection requiring antibiotic therapy.

Examination of the chest will often show signs of hyperinflation, such as hyperreso-nance on percussion and low, immobile diaphragms. In milder stages of asthma, wheezing may be detected only on forced expiration, but with increasing severity, wheezing may also be heard on inspiration. In some episodes of severe asthma, wheezing may be heard early in the course of disease, but with increasing obstruction of the airways, the wheezing may seem to "improve" as increasing difficulty in ventilating develops. This abatement of wheezing may, unfortunately, be taken as a clinical sign of improvement and result in less than optimal treatment. As the patient does improve, one may notice the reverse situation; namely, that wheezing may increase in intensity. Again, this finding should not be erroneously interpreted as worsening of the asthma. The major point is that in judging the severity of asthma, the physician must rely on many physical findings (such as the use of accessory muscles and the presence of paradoxical pulse) as well as the degree of wheezing. As the patient recovers, the improvement takes place most often in reverse order of the appearance of symptoms,that is, there is a sequential loss of mental status abnormalities, cyanosis, pulsus paradoxus, use of accessory muscles, dyspnea, tachypnea, and, finally, wheezing. It is important to note, however, that when the attack appears to have ended clinically, abnormal pulmonary function test results are still present and may persist for several days. At this point in the course of the illness, there is usually a residual volume twice that of normal, an FEV1 60% of that predicted, and a maximum mid-expiratory flow rate 30% of that predicted. Such findings support the contention that treatment should be continued well past the symptomatic period and that close outpatient follow-up is indicated.

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