Asthma

Question 1

A mother accompanies her 10 year old son to see you in the outpatient clinic following a hospital admission for acute asthma attack two months ago. He presented to the ED 3 times for his asthma in the last 6 months, with the most recent ED presentation resulting in his hospital admission. He was prescribed Fluticasone 50mcg two puffs twice daily 3 months ago.

Answer 1

Impression
Given recent hospital admission and regular ED presentations for Asthma flares, my impression is that this patient has frequent intermittent uncontrolled asthma, and is on inadequate medical therapy to manage this.

DDx to consider;
- Acute mimics: Anaphylaxis,
- Eosinophilic asthma
- infective: Pneumonia, bronchitis (doesn’t fit recurrent attack picture),
- Chronic asthma mimics: CF, congenital heart disease, sarcoidosis
- Predominantly cough: post viral

Goals
- take thorough Hx/Ex/Ix to ascertain severity and nature of symptoms, rule out DDx,
- establish appropriate asthma management plan and optimise medical management with SABA and any other correct ICS dosing.

Question 2

Uncontrolled asthma - History

Answer 2

History
- sx: how regular exacerbations, what are triggers, review details of hospital admission, has ICS modified sx at all?
- sx of poor control: night time cough/waking, day time symptoms, dyspnoea on exercise, wheeze, chest tightness, cough, seasonal variation?, limitation of activities,
- triggers: exercise, cold air, URTIs, allergens
- ask about adherence; inhaler technique
- Characterise: chest tightness, wheeze, cough, pain,
- Risks: smoking at home, fam hx, other atopic conditions (eczema), fam hx of asthma/atopic disease, vaping/smoking, how many times hospitalisation, how many times used of pred.
- PMHx, other meds, ?chronic lung disease
- Paediatric assessment, developmental milestones, immunisations/vaccinations (particularly influenza)

Question 3

Uncontrolled asthma - Examination

Answer 3

Examination
- General observation + vital signs - growth and development
- ENT exam: polyps suggestive of atopic conditions
- Respiratory examination: expiratory wheeze, cough, may have no signs in rooms
- Peak flow: look for age-appropriate limitation

Question 4

Uncontrolled asthma - Investigations

Answer 4

Investigations
Key/diagnostic
- Spirometry: looking for restriction (FEV1:FVC<0.7) and airway reversibility with 12% increase in FEV1
- Allergy testing (patch testing)
- CXR for other pathology

Labs: FBC (eosinophilic asthma - >0.3), total IgE

No other investigations particularly indicated, altho if concerned could do sputum MCS/nasopharyngeal aspirate for ?infective causes? and PCR

Question 5

Uncontrolled asthma - Management

Answer 5

Management
Aim good asthma control and improved quality of life:

Pharmacological
1 - Saba
2 - SABA + low dose ICS (or montelukast if can’t tolerate inhaler, has significant A/E including suicidality)
3 - SABA + high dose ICS +/- LABA
4 - refer to resp physician, potentially monoclonal antibody treatment (Omalizumab).

If eosinophilic asthma then need to be on ICS for life.

Management of additional conditions;
o allergic rhinitis (nasal sprays)

Other non-pharmacological
- Asthma action plan
- Patient education: What is disease, how to manage, expected outcome, how to take preventer/inhaler technique
- regular review every 3 months for degree of control
- Paeds resp referral if still poorly controlled as per asthma management hierarchy.
- Routine vaccination including COVID-19
- ?respiratory nurse referral and education
- Asthma buddy app to track symptoms and regularity