Patient with "asthma" and restrictive defect on spirometry turns out to have large hiatal hernia

A 60-year-old man was evaluated at the allergy clinic for cough for 5 years. He was previously treated for asthma with ICS/LABA and for postnasal drip with INS nose spray but the symptoms have not improved. In the past, spirometry showed restrictive pattern.

Physical exam is unremarkable apart from slightly diminished air entry on left.

What would you suggest?


What happened?

Fractional nitric oxide (NO) concentration in exhaled breath (FENO): 12 ppb.

Spirometry showed FVC 64% and FEV1 70% of predicted. After administration of albuterol, there was 5% improvement in FEV1, which is considered insignificant for the diagnosis of asthma.

CXR: large hiatal hernia on the left.

Skin test was positive for trees and grasses.

What is the most likely diagnosis?

The cough is likely related to a restrictive lung defect due to large hiatal hernia. Dietary options and evaluation by thoracic surgery were discussed.

Instructions provided for dietary changes. Considering the test results, HH is probably the reason for the symptoms.

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