Reviewer: S. Randhawa, M.D., Allergist/Immunologist and Assistant Professor at LSU (Shreveport) Department of Allergy and Immunology
A 34-year-old female saw an ad in the newspaper last week and came to the clinic to be evaluated for shortness of breath. She has had shortness of breath, cough and chest tightness for the last 3 years. Her symptoms have gradually gotten worse to the point that she used 80 puffs of albuterol last week. She has symptoms at night 2-3 times per week and "goes through" 2 albuterol inhalers per month ($25 each). She goes into coughing spasms and passed out in her car 2 weeks ago. She has had 4-5 of these episodes in the past 2 years.
When seen in the clinic last week, she was diagnosed with severe asthma and placed on oral steroid course and Advair (fluticasone and salmeterol) 250/50 mcg b.i.d. At the time, her Asthma Control Test (ACT) score was 6, FEV1 was 49% of predicted and FeNO was 69.
Since then, her condition has improved a lot, she has no night symptoms and only used albuterol once.
Advair (fluticasone and salmeterol) Diskus 250/50 INH b.i.d., Flonase (fluticasone) 1 EN spray bid, Lipitor (atorvastatin) PO daily.
The physical examination is positive for pale boggy turbinates on both sides and slightly diminished air entry bilaterally. The rest of her examination is normal.
Procedures: Spirometry, FEV1 76%, 2.26L, FVC 69%, 2.57 L. FEV1 improved from 49% and 1.36L just a week ago. FeNO is 29 now, it was 69 last week. ACT is 20, it was 6 last week.
What is the most likely diagnosis?
Severe asthma that improved significantly with oral steroids and Advair (fluticasone and salmeterol) 250/50 mcg b.i.d. both in terms of symptoms and spirometry, FeNO and ACT.
She also has allergic rhinitis that improved with nasal steroids.
What would be the next step in the management of this patient?
Stop oral steroids. Increase Advair (fluticasone and salmeterol) Diskus to 500/50 mcg b.i.d. Continue nasal steroid. Follow-up at the clinic in 4-6 weeks for consideration of adjustment of the inhaled steroid dose. Consider skin prick testing for allergens avoidance and possible immunotherapy in the future.
Severe asthma - differential diagnosis and management (click to enlarge the image).
Asthma is the most common chronic respiratory disease, affecting up to 10% of adults and 30% of children (JACI, 2011).