A 35-year-old woman went to the polyclinic to the local therapist with complaints of attacks of suffocation, which have become more frequent over the past 2 months. Attacks of suffocation are accompanied by wheezing, which can be heard at a distance, coughing with a small amount of viscous "glassy" light color sputum. After this attack, the condition usually improves. She has been having such symptoms for 2 years already. Symptoms are often worse at night or in the early morning. Attacks of suffocation mostly occur after exercises and viral infections. The patient was not examined at the polyclinic. The patient stopped suffocation attacks by inhalation Salbutamol on her own. During the last month symptoms occur daily, nighttime awakenings 3 times a week. She has moderate limitation of physical activity and sleep. Physical examination: The patient is in satisfactory condition. She has hypersthenic constitution. The body mass index - 32. Waist size is 82 cm. The waist/hips ratio is 0.87. The skin is pale pink, there are no rashes. There is no peripheral edema. Above the lungs, hard breathing and scattered dry whistling wheezes are heard. The respiratory rate is 25 per minute. There is an expansion of the boundaries of relative dullness of the heart to the left by 1 cm. Heart sounds are clear, the rhythm is correct and the heart rate is 72 beats per minute. Blood pressure - 150/95 mm Hg. The abdomen is soft and painless when palpated. Liver - the lower edge is palpated by 0,5 cm. The size of the liver according to Kurlov is: 11x9x8 cm. There is no dysuric phenomena. Laboratory and instrumental tests Complete blood count: red blood cells - 4.2×1019/l, hemoglobin - 123 g/l, white blood cells - 4.8×109/l, eosinophils - 4%, segmented neutrophils - 66%, lymphocytes - 18%, monocytes - 2%, ESR - 20 mm/h. Total cholesterol - 5.7 mmol/l. Fasting glucose – 5.8 mmol/l. Sputum analysis: mucosa, white blood cells - 5-7 in the field of vision, flat epithelium - 7-10 in the field of vision, detritus is in a small amount, there are Kurschmann spirals. X-ray of the lungs. Infiltrative shadows in the lungs are not detected. Diaphragm, heart shadow, sinuses are without features. Bronchodilator reversibility test. Baseline data: FEV1/FVC - 75%, FEV1 - 62%, FVC - 75%. 15 minutes after inhalation of Salbutamol 400 mcg: FEV1 became - 78%. Questions: 1. Preliminary diagnosis (full diagnosis with etiology, severity, level of control, comorbidities that may affect the course of the disease, complications). What risk factor could cause the development of the disease or its exacerbation? 2. How is the test with a bronchodilator performed? Evaluate the results. Determine whether there is an increase in indicators after the test? 3. Make a plan of additional laboratory and instrumental tests to confirm the diagnosis. 4. The plan of treatment – groups and names of drugs with dosage regimen for this patient. Is there any indication for hospitalization? 5. The plan of patients dispensary monitoring according to the severity (What specialists do the patient need to consult and how many times a year? What laboratory and instrumental tests should the general practitioner and pulmonologist prescribe to the patient as a part of the dispensary follow-up?).
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Comprehensive Case Analysis: Bronchial Asthma
1. Preliminary Diagnosis
Full Diagnosis:
Primary: Bronchial asthma, mixed form (allergic/non-allergic), moderate persistent severity, uncontrolled.
Rationale for diagnosis:
- 2-year history of episodic wheezing, breathlessness, cough with "glassy" sputum - classic triad
- Symptoms worse at night/early morning - circadian bronchospasm pattern
- Triggers: exercise and viral infections - hallmark provocations
- Reversibility of obstruction with salbutamol (SABA)
- Kurschmann spirals in sputum (pathognomonic - coiled mucus plugs from small airways)
- Spirometry: FEV1/FVC 75% (borderline obstruction), FEV1 62% predicted (moderate reduction), +FEV1 increase post-bronchodilator
Classification - Moderate Persistent (GINA / NAEPP criteria):
| Parameter | This Patient |
|---|---|
| Daytime symptoms | Daily |
| Night awakenings | 3x/week |
| SABA use for relief | Daily |
| Activity limitation | Moderate |
| FEV1 % predicted | 62% (Step 3 range) |
| FEV1/FVC | 75% |
Level of Control: Uncontrolled (GINA criteria - all 4 control parameters positive: daytime symptoms >2x/week, night awakenings, reliever use >2x/week, activity limitation).
Comorbidities that may affect the course:
- Arterial hypertension (BP 150/95 mmHg) - Stage 1 hypertension. This is relevant because: (a) beta-blockers (used in HTN) are contraindicated in asthma; (b) ACE inhibitors can cause cough that may worsen/mimic asthma; (c) RAAS inhibitors preferred (ARBs)
- Obesity (BMI 32 - Class I obesity; waist 82 cm, waist/hip ratio 0.87) - Obesity independently worsens asthma control, increases airway inflammation, reduces FRC, impairs response to ICS. Also a risk factor for metabolic syndrome.
- Prediabetes (fasting glucose 5.8 mmol/L - impaired fasting glucose, range 5.6-6.9 mmol/L) - systemic corticosteroid use must be minimized; obesity + prediabetes = high risk of T2DM
- Mild hypercholesterolemia (total cholesterol 5.7 mmol/L - borderline high) - part of metabolic syndrome picture
- Mild anemia (Hb 123 g/L in a 35-year-old woman - below normal 120-140; borderline) - may contribute to exertional symptoms
- Mild eosinophilia (4%) - suggests allergic/eosinophilic phenotype
Risk factors for disease development and exacerbation:
- Obesity - the most prominent modifiable risk factor; increases airway hyperresponsiveness, promotes systemic inflammation, worsens control
- Allergic predisposition (eosinophilia)
- Physical exertion (exercise-induced bronchospasm)
- Viral respiratory infections (trigger documented by patient)
- Possible aspirin/NSAID sensitivity (needs to be asked - not documented)
- Uncontrolled hypertension requiring antihypertensive therapy that could worsen asthma (beta-blockers, ACE inhibitors)
2. Bronchodilator Reversibility Test - How It Is Performed and Interpretation
Performance:
- Patient avoids short-acting bronchodilators for at least 4-6 hours before the test, and LABAs for 12-24 hours
- Baseline spirometry is performed: FEV1 and FVC are measured (best of 3 acceptable maneuvers)
- The patient inhales salbutamol (albuterol) 400 mcg (4 x 100 mcg puffs) via spacer/MDI, or 2.5 mg via nebulizer
- 15-20 minutes after inhalation, spirometry is repeated under the same conditions
Evaluation of this patient's results:
| Parameter | Baseline | Post-Bronchodilator |
|---|---|---|
| FEV1/FVC | 75% | Not specified |
| FEV1 % predicted | 62% | 78% |
| FVC % predicted | 75% | Not specified |
Positive bronchodilator response criteria (ATS/ERS):
- Increase in FEV1 of ≥12% AND ≥200 mL from baseline absolute value
Calculation:
- Absolute FEV1 increase needed: FEV1 went from 62% → 78% predicted = increase of 16 percentage points = +25.8% relative increase from baseline [(78-62)/62 × 100 = 25.8%]
- Relative increase ≥12% is satisfied
- Assuming normal FVC ~3.0-3.5 L for this patient, FEV1 at 62% predicted ≈ ~1.7-1.9 L; at 78% predicted ≈ ~2.1-2.3 L → absolute increase ~400 mL (well above 200 mL threshold)
Conclusion: The bronchodilator test is POSITIVE - there is significant, clinically meaningful reversibility of airway obstruction, confirming bronchial asthma (as opposed to fixed obstruction in COPD). The baseline FEV1/FVC of 75% (borderline obstruction) normalizes post-bronchodilator, consistent with reversible obstructive ventilatory defect.
3. Plan of Additional Laboratory and Instrumental Tests
To confirm diagnosis and assess severity:
| Test | Purpose |
|---|---|
| Allergy panel - specific IgE (RAST) or skin prick tests (house dust mite, pollen, mold, animal dander, cockroach) | Identify allergic phenotype, guide avoidance |
| Total serum IgE | Elevated in atopic asthma; relevant for biologic therapy eligibility |
| Blood eosinophil count (absolute) | Already 4% - quantify absolute count; elevated >300/μL supports eosinophilic phenotype |
| Exhaled nitric oxide (FeNO) | Marker of eosinophilic airway inflammation; elevated (>25 ppb) predicts ICS response |
| Peak expiratory flow (PEF) monitoring (2-week diary, morning/evening) | Diurnal variability >10-20% supports asthma diagnosis; assess response to treatment |
| Full spirometry with flow-volume loop (repeat) | Confirm reversible obstructive pattern; establish baseline |
| Body plethysmography (if available) | Measure RV, TLC, FRC - exclude air trapping, mixed defect |
| ECG | Assess cardiac status given HTN, left border expansion |
| Echocardiography | Exclude pulmonary hypertension, assess cardiac function (relative dullness shifted left) |
| Chest X-ray (already done - normal) | Infiltrates excluded; may show hyperinflation in severe disease |
| Nasal endoscopy / ENT consultation | Evaluate for rhinosinusitis/nasal polyposis (comorbid upper airway disease) |
| Sputum cytology (induced sputum) | Confirm eosinophilic vs. neutrophilic inflammation |
| Urine analysis | Baseline; monitor for diabetic nephropathy, HTN-related changes |
| HbA1c | Assess glycated hemoglobin; fasting glucose 5.8 = prediabetes |
| Lipid panel (full: LDL, HDL, TG) | Already: total cholesterol 5.7 mmol/L; need full profile |
| Thyroid hormones (TSH, fT4) | HTN + weight gain: exclude hypothyroidism |
| Serum cortisol | If oral corticosteroids considered long-term |
| Blood pressure monitoring (ABPM) | Confirm arterial hypertension, exclude white-coat HTN |
| Aspirin provocation test | If aspirin-exacerbated respiratory disease (Samter's triad) suspected |
4. Treatment Plan
Non-pharmacological:
- Weight reduction (BMI 32 → target <25): central to improving asthma control, reducing HTN and insulin resistance
- Trigger avoidance: dust mites, pollen, pets (based on allergy testing results)
- Smoking cessation if applicable
- Influenza and pneumococcal vaccination (Pneumovax 23)
- Breathing exercises; avoid NSAIDs, aspirin, non-selective beta-blockers
- Patient education on inhaler technique, action plan, peak flow monitoring
Pharmacological - Stepwise Treatment (Step 3, GINA 2024):
This patient has moderate persistent, uncontrolled asthma (daily symptoms, frequent night awakenings, FEV1 62%) - she requires Step 3 controller therapy:
Preferred approach (GINA Track 1):
| Drug | Group | Dosage |
|---|---|---|
| Budesonide/Formoterol (e.g., Symbicort 160/4.5 mcg) | Low-dose ICS + LABA (MART - Maintenance and Reliever Therapy) | 1-2 inhalations TWICE daily as maintenance; 1-2 inhalations as needed for relief (max 8/day) |
Alternative approach (GINA Track 2):
| Drug | Group | Dosage |
|---|---|---|
| Beclomethasone dipropionate 200 mcg | Inhaled corticosteroid (low-to-medium dose ICS) | 2 inhalations (400 mcg/day) in 2 divided doses |
| Salmeterol 50 mcg or Formoterol 12 mcg | Long-acting beta-2 agonist (LABA) | 1 inhalation BID (always with ICS, never as monotherapy) |
| Salbutamol 100 mcg MDI | Short-acting beta-2 agonist (SABA) reliever | 1-2 inhalations PRN for breakthrough symptoms (max 6-8 puffs/day) |
| Montelukast 10 mg | Leukotriene receptor antagonist (add-on if needed) | Once daily at bedtime (add-on to ICS/LABA at Step 3) |
For arterial hypertension (in a patient with asthma - key drug selection):
- Avoid: beta-blockers (relative contraindication - worsen bronchospasm), ACE inhibitors (cause cough, which can mask/worsen asthma)
- Preferred: ARB (e.g., Losartan 50 mg once daily, or Valsartan 80 mg once daily) or calcium channel blocker (Amlodipine 5 mg once daily) as first line
- Target BP: <130/80 mmHg
For prediabetes/obesity: lifestyle modification, dietary counseling, reassess in 3-6 months; consider metformin if progression to T2DM
Hospitalization Indications:
Not indicated at present. This patient is in satisfactory condition, RR 25/min (mild elevation), SpO2 not given but not in acute distress, and salbutamol provides relief. Outpatient escalation of controller therapy is appropriate.
Indications to hospitalize would be:
- Severe exacerbation: FEV1/PEF <40-50% predicted, SpO2 <92%, RR >30, use of accessory muscles, failure to respond to 3 doses of SABA in 1 hour, altered consciousness, silent chest on auscultation, or previous near-fatal asthma
5. Dispensary Monitoring Plan
Specialist consultations:
| Specialist | Frequency |
|---|---|
| General Practitioner (Therapist) | Every 3 months (quarterly) for the first year; then every 6 months if controlled |
| Pulmonologist | 2 times per year (every 6 months); more frequently if uncontrolled |
| Allergist/Immunologist | 1-2 times per year (to monitor allergen sensitization, consider immunotherapy) |
| Cardiologist | 2 times per year (arterial hypertension monitoring) |
| Endocrinologist | 1 time per year (prediabetes, dyslipidemia monitoring) |
| ENT Specialist | 1 time per year (upper airway comorbidity) |
| Nutritionist/Dietitian | 2-4 times per year (obesity management) |
Laboratory and instrumental monitoring at each visit:
By General Practitioner (every 3-6 months):
- Assessment of symptom control (ACQ or ACT questionnaire)
- Measurement of BP, BMI, waist circumference
- Peak expiratory flow (PEF) measurement
- CBC - 1-2 times/year (eosinophil count, anemia follow-up)
- Fasting glucose, HbA1c - 1 time/year
- Lipid panel - 1 time/year
- Urinalysis - 1 time/year
- Review inhaler technique at every visit
By Pulmonologist (every 6 months):
- Spirometry with bronchodilator reversibility test - 2 times/year (monitor FEV1 trajectory)
- FeNO - 1-2 times/year (assess airway inflammation, guide ICS dose titration)
- Blood eosinophils (absolute) - 1-2 times/year
- Total IgE - 1 time/year
- PEF diary review
- Sputum analysis (if symptoms change)
- Evaluation for step-up or step-down therapy
- Assess for development of irreversible obstruction (COPD overlap)
Additional periodic tests:
- ECG - 1 time/year (cardiovascular monitoring with HTN)
- Echocardiography - 1 time/year initially, then as indicated
- Chest X-ray - as clinically indicated (not routine annual; for exacerbations, new symptoms, or exclusion of complications)
- Spirometry (baseline) at diagnosis and annually, or after therapy changes
Summary of GINA Control Target for this Patient:
After initiating Step 3 therapy, reassess in 2-3 months. Goal: achieve "well controlled" status (daytime symptoms ≤2x/week, no night awakenings, SABA use ≤2x/week, no activity limitation, FEV1 ≥80% predicted). Step down if well controlled for ≥3 months; step up if still uncontrolled.
Sources: Murray & Nadel's Textbook of Respiratory Medicine (9780323655873); Fishman's Pulmonary Diseases and Disorders (9781260473940); GINA 2024 Strategy Report; Textbook of Family Medicine 9e (9780323239905)
A 35-year-old woman went to the polyclinic to the local therapist with complaints of attacks of suffocation, which have become more frequent over the past 2 months. Attacks of suffocation are accompanied by wheezing, which can be heard at a distance, coughing with a small amount of viscous "glassy" light color sputum. After this attack, the condition usually improves. She has been having such symptoms for 2 years already. Symptoms are often worse at night or in the early morning. Attacks of suffocation mostly occur after exercises and viral infections. The patient was not examined at the polyclinic. The patient stopped suffocation attacks by inhalation Salbutamol on her own. During the last month symptoms occur daily, nighttime awakenings 3 times a week. She has moderate limitation of physical activity and sleep. Physical examination: The patient is in satisfactory condition. She has hypersthenic constitution. The body mass index - 32. Waist size is 82 cm. The waist/hips ratio is 0.87. The skin is pale pink, there are no rashes. There is no peripheral edema. Above the lungs, hard breathing and scattered dry whistling wheezes are heard. The respiratory rate is 25 per minute. There is an expansion of the boundaries of relative dullness of the heart to the left by 1 cm. Heart sounds are clear, the rhythm is correct and the heart rate is 72 beats per minute. Blood pressure - 150/95 mm Hg. The abdomen is soft and painless when palpated. Liver - the lower edge is palpated by 0,5 cm. The size of the liver according to Kurlov is: 11x9x8 cm. There is no dysuric phenomena. Laboratory and instrumental tests Complete blood count: red blood cells - 4.2×1019/l, hemoglobin - 123 g/l, white blood cells - 4.8×109/l, eosinophils - 4%, segmented neutrophils - 66%, lymphocytes - 18%, monocytes - 2%, ESR - 20 mm/h. Total cholesterol - 5.7 mmol/l. Fasting glucose – 5.8 mmol/l. Sputum analysis: mucosa, white blood cells - 5-7 in the field of vision, flat epithelium - 7-10 in the field of vision, detritus is in a small amount, there are Kurschmann spirals. X-ray of the lungs. Infiltrative shadows in the lungs are not detected. Diaphragm, heart shadow, sinuses are without features. Bronchodilator reversibility test. Baseline data: FEV1/FVC - 75%, FEV1 - 62%, FVC - 75%. 15 minutes after inhalation of Salbutamol 400 mcg: FEV1 became - 78%. Questions: 1. Preliminary diagnosis (full diagnosis with etiology, severity, level of control, comorbidities that may affect the course of the disease, complications). What risk factor could cause the development of the disease or its exacerbation? 2. How is the test with a bronchodilator performed? Evaluate the results. Determine whether there is an increase in indicators after the test? 3. Make a plan of additional laboratory and instrumental tests to confirm the diagnosis. 4. The plan of treatment – groups and names of drugs with dosage regimen for this patient. Is there any indication for hospitalization? 5. The plan of patients dispensary monitoring according to the severity (What specialists do the patient need to consult and how many times a year? What laboratory and instrumental tests should the general practitioner and pulmonologist prescribe to the patient as a part of the dispensary follow-up?).
I already provided a comprehensive answer to this exact clinical case in my previous response. Here is the complete structured answer for all 5 questions:
Comprehensive Case Analysis: Bronchial Asthma in a 35-Year-Old Woman
1. Preliminary Diagnosis
Full Clinical Diagnosis:
Bronchial asthma, mixed form (allergic-infectious), moderate persistent severity, uncontrolled. Comorbidities: Arterial hypertension Stage 1, Grade 1. Obesity Class I (BMI 32). Prediabetes (impaired fasting glucose). Borderline hypercholesterolemia.
Justification of Each Diagnostic Element
"Bronchial asthma" is supported by:
- 2-year episodic history of expiratory dyspnea, audible wheezing, and cough with viscous "glassy" (mucoid) sputum - the classic triad
- Symptoms worse at night and early morning (circadian bronchospasm)
- Triggers: exercise and viral respiratory infections
- Relief with inhaled salbutamol (SABA)
- Scattered dry whistling (sibilant) wheezes on auscultation
- Kurschmann spirals in sputum - coiled mucus casts shed from small airways; highly characteristic of asthma
- Positive bronchodilator reversibility test (see Question 2)
- Exclusion of pneumonia or infiltrative disease on chest X-ray
"Mixed form" - both allergic (eosinophilia 4%, likely atopic sensitization) and non-allergic/infectious (viral infection as trigger) components are present.
Severity: Moderate Persistent (GINA / NAEPP criteria)
| Component | This Patient | Moderate Persistent Threshold |
|---|---|---|
| Daytime symptoms | Daily | Daily |
| Nighttime awakenings | 3x/week | >1x/week but not nightly |
| SABA use for relief | Daily | Daily |
| Activity limitation | Moderate | Some limitation |
| FEV1 % predicted | 62% | 60-80% |
| FEV1/FVC | 75% | Reduced |
All parameters place this patient squarely in moderate persistent asthma.
Level of Control: Uncontrolled (GINA 2024)
GINA defines control based on the past 4 weeks. The patient has all 4 control parameters positive:
| GINA Control Parameter | Patient Status |
|---|---|
| Daytime symptoms >2x/week | YES - daily |
| Any night waking due to asthma | YES - 3x/week |
| Reliever needed for symptoms >2x/week | YES - daily salbutamol |
| Any activity limitation due to asthma | YES - moderate |
Score: 4/4 = Uncontrolled (0 = well controlled; 1-2 = partly controlled; 3-4 = uncontrolled).
Comorbidities Affecting the Course of Asthma
1. Arterial Hypertension (BP 150/95 mmHg)
- Stage 1, Grade 1 hypertension (ESH/ESC: 140-159 / 90-99 mmHg)
- Relevant because: non-selective beta-blockers (used in HTN) are contraindicated in asthma - block beta-2 receptors, trigger bronchospasm; ACE inhibitors cause chronic cough in 10-15% of patients, which can mask/worsen asthma symptoms and is often confused with asthma exacerbation
- Safe antihypertensive choices in asthma: ARBs (losartan, valsartan) or calcium channel blockers (amlodipine)
- The left border expansion (+1 cm) suggests early left ventricular hypertrophy - a complication of uncontrolled HTN
2. Obesity (BMI 32, Class I; waist 82 cm; W/H ratio 0.87)
- Obesity is an independent risk factor for asthma development and is strongly associated with worse control, reduced FRC, increased airway hyperresponsiveness, systemic inflammation (adipokines, IL-6, TNF-alpha), and attenuated response to ICS
- Central obesity (waist 82 cm is borderline; W/H ratio 0.87 is elevated for women - normal <0.80) contributes to metabolic syndrome
3. Prediabetes (fasting glucose 5.8 mmol/L)
- Normal: <5.6 mmol/L; prediabetes: 5.6-6.9 mmol/L; diabetes: ≥7.0 mmol/L
- This limits the use of systemic corticosteroids (worsen glucose metabolism)
- Obesity + prediabetes + dyslipidemia = metabolic syndrome; systemic inflammation worsens asthma control
4. Borderline Hypercholesterolemia (total cholesterol 5.7 mmol/L)
- Normal: <5.2 mmol/L (200 mg/dL); borderline high: 5.2-6.2 mmol/L
- Combined with HTN, obesity, and prediabetes - high cardiovascular risk; warrants full lipid panel
5. Mild Eosinophilia (4% eosinophils)
- Suggests eosinophilic/allergic phenotype; absolute count should be calculated (if WBC 4.8 × 10⁹/L → eosinophils = 0.19 × 10⁹/L = 190/μL - borderline but notable)
- Relevant for consideration of biologic therapy if disease escalates
6. Mild Anemia (Hb 123 g/L)
- Normal for women: 120-140 g/L; this is borderline low
- May contribute to exertional dyspnea, worsening perceived severity of attacks
Risk Factors for Disease Development and Exacerbation
| Category | Specific Factor |
|---|---|
| Host factors | Obesity (most prominent modifiable risk); female sex; atopic constitution (eosinophilia) |
| Environmental/behavioral | Viral respiratory infections (documented trigger); physical exertion (exercise-induced bronchospasm) |
| Pharmacological | Use of NSAIDs/aspirin (not documented but must be excluded - aspirin-exacerbated respiratory disease); potential beta-blocker use for HTN |
| Disease-related | Uncontrolled asthma itself is a risk factor for future exacerbations; low FEV1 (<60% predicted is high-risk threshold - this patient is at 62%) |
| Comorbidity-related | Obesity drives airway hyperresponsiveness; HTN treatment choices; prediabetes limits OCS use |
The single most clinically important modifiable risk factor in this patient is obesity - it directly worsens asthma control, reduces lung function (through reduced FRC and expiratory reserve volume), promotes systemic inflammation, and is associated with poor ICS response.
2. Bronchodilator Reversibility Test - Performance and Interpretation
How the Test Is Performed
Patient preparation (before the test):
- Withhold short-acting bronchodilators (salbutamol) for ≥4-6 hours
- Withhold long-acting beta-2 agonists for ≥12-24 hours
- Withhold theophyllines for ≥12-24 hours
- Patient should be stable (not during acute severe exacerbation)
- No smoking for ≥4 hours before the test
Protocol (ATS/ERS standard):
- Patient rests seated for 5-10 minutes
- Baseline spirometry is performed: at least 3 technically acceptable and 2 reproducible maneuvers; record best FEV1 and FVC
- Patient inhales salbutamol (albuterol) 400 mcg via metered-dose inhaler (MDI) with spacer (4 × 100 mcg puffs at 30-second intervals) - OR 2.5 mg via nebulizer
- Wait 15-20 minutes (standard: 15 min for salbutamol; 30 min for ipratropium)
- Post-bronchodilator spirometry is repeated under identical conditions (best of 3 maneuvers)
Evaluation of Results in This Patient
| Parameter | Baseline | Post-Salbutamol 400 mcg |
|---|---|---|
| FEV1/FVC | 75% | Not specified |
| FEV1 (% predicted) | 62% | 78% |
| FVC (% predicted) | 75% | Not specified |
Positive bronchodilator response criteria (ATS/ERS 2022):
A response is considered significant (positive) if:
- FEV1 increases by ≥12% AND ≥200 mL from the pre-bronchodilator baseline absolute value
Calculation:
- Relative increase in FEV1: (78 - 62) / 62 × 100 = +25.8% (far exceeds the ≥12% threshold)
- Absolute increase: For a 35-year-old woman of hypersthenic build, predicted FEV1 ≈ 2.8-3.0 L. Baseline FEV1 at 62% predicted ≈ 1.74-1.86 L; post-bronchodilator at 78% predicted ≈ 2.18-2.34 L → absolute increase ≈ ~440-480 mL (far exceeds the ≥200 mL threshold)
Conclusion: The bronchodilator test is STRONGLY POSITIVE.
Both criteria (≥12% relative and ≥200 mL absolute) are met. This demonstrates significant reversibility of airway obstruction, which:
- Confirms the diagnosis of bronchial asthma (as opposed to fixed irreversible obstruction seen in COPD)
- Indicates that bronchospasm is the primary mechanism of obstruction (rather than structural remodeling)
- Suggests good potential response to bronchodilator therapy
The baseline FEV1/FVC of 75% (borderline obstruction pattern by GOLD criteria <70%) normalizing post-bronchodilator is a further hallmark of asthma.
3. Plan of Additional Laboratory and Instrumental Tests
To Confirm the Diagnosis of Asthma
| Test | Rationale |
|---|---|
| Spirometry with flow-volume loop (full, repeat) | Confirm reversible obstructive ventilatory defect; establish baseline for monitoring |
| Peak expiratory flow (PEF) monitoring - morning/evening diary over 2 weeks | Diurnal variability >10% (moderate) or >20% (severe) supports asthma; track response to therapy |
| Methacholine/histamine bronchoprovocation test (if bronchodilator test equivocal) | Confirms airway hyperresponsiveness; useful if spirometry is normal between attacks |
| Exercise challenge test | Confirm exercise-induced bronchoconstriction; important given this trigger |
| Exhaled nitric oxide (FeNO) | Biomarker of eosinophilic airway inflammation; ≥25 ppb supports allergic/eosinophilic asthma and predicts ICS responsiveness |
| Induced sputum cytology | Distinguish eosinophilic (>3%) vs. neutrophilic phenotype; guides therapy |
To Identify Allergic Etiology and Phenotype
| Test | Rationale |
|---|---|
| Skin prick tests (SPT) or Specific serum IgE (ImmunoCAP/RAST) to common aeroallergens (house dust mite, cat/dog dander, Alternaria, grass/tree pollens, cockroach) | Identify sensitization; guide allergen avoidance; assess eligibility for allergen immunotherapy |
| Total serum IgE | Elevated in atopic asthma; required for eligibility assessment for anti-IgE therapy (omalizumab) if escalation needed |
| Blood eosinophil count (absolute) | Elevated >300/μL supports eosinophilic phenotype; threshold for biologic eligibility (mepolizumab, benralizumab) |
To Assess Comorbidities
| Test | Rationale |
|---|---|
| ECG (12-lead) | Assess for LVH (left border shifted), arrhythmia with HTN |
| Echocardiography | Evaluate LV function, LVH, pulmonary pressures; rule out pulmonary hypertension |
| Ambulatory blood pressure monitoring (ABPM) 24-hour | Confirm HTN diagnosis, exclude white-coat hypertension, assess diurnal pattern |
| HbA1c | Quantify glycemic control; fasting glucose 5.8 = prediabetes |
| Full lipid panel (LDL, HDL, triglycerides) | Total cholesterol 5.7 - need LDL/HDL ratio; assess cardiovascular risk |
| Thyroid function (TSH, free T4) | Exclude hypothyroidism contributing to obesity, dyslipidemia, and HTN |
| Urinalysis with microscopy | Baseline renal function; detect hypertensive nephropathy |
| Serum creatinine, eGFR | Renal function; important before initiating antihypertensive therapy |
| Liver ultrasound | Liver edge palpable 0.5 cm below costal margin, Kurlov 11x9x8 cm (upper limit of normal); exclude NAFLD/steatohepatitis (common in obesity/prediabetes) |
| Iron studies (serum iron, ferritin, TIBC) | Hb 123 g/L - evaluate iron deficiency anemia |
| ENT consultation + rhinoscopy/nasopharyngoscopy | Evaluate chronic rhinosinusitis, nasal polyposis (upper airway-lower airway link; present in ~40% of asthma patients) |
| GERD evaluation (if symptoms) | GERD is a common asthma trigger and comorbidity; pH-metry or empiric PPI trial |
4. Treatment Plan
Non-Pharmacological Treatment
- Weight reduction program: The single most impactful intervention. Caloric restriction, low glycemic index diet, aerobic physical activity (swimming, walking - well-tolerated in controlled asthma). Target: BMI reduction toward <27 over 6-12 months
- Trigger avoidance: Based on allergy test results - encasing mattresses/pillows (dust mites), pet avoidance if sensitized
- Inhaler technique education: At every visit; use spacer device with MDI
- Written asthma action plan: Self-management guide based on symptoms/PEF
- Smoking cessation (if applicable - not stated in case)
- Avoid: NSAIDs, aspirin, non-selective beta-blockers (both topical and systemic), ACE inhibitors
- Vaccination: Annual influenza vaccine; single-dose Pneumovax 23 (pneumococcal polysaccharide vaccine) - recommended for adults 19-64 with chronic respiratory illness
Pharmacological Treatment
Step 3 therapy (GINA 2024) - Moderate persistent, uncontrolled asthma:
Track 1 (Preferred - GINA 2024, MART approach):
| Drug | Class | Dose / Regimen |
|---|---|---|
| Budesonide/Formoterol (Symbicort Turbuhaler 160/4.5 mcg or 80/4.5 mcg) | Low-dose ICS + LABA (MART = Maintenance And Reliever Therapy) | Maintenance: 1-2 inhalations (160/4.5 mcg) twice daily; Reliever (as-needed): 1 inhalation as needed (max 8 inhalations/day total) |
This MART approach is preferred because it uses a single inhaler for both maintenance and relief, reduces exacerbation risk, and is suitable for this patient's uncontrolled status.
Track 2 (Alternative - if formoterol-based MART not available):
| Drug | Class | Dose / Regimen |
|---|---|---|
| Beclomethasone dipropionate 250 mcg/dose MDI | Inhaled corticosteroid (medium-dose ICS) | 2 inhalations (500 mcg) twice daily (total 1000 mcg/day) |
| Salmeterol 50 mcg/dose MDI | Long-acting beta-2 agonist (LABA) - always combined with ICS | 1 inhalation twice daily; or as fixed combination: Fluticasone/Salmeterol 250/25 mcg, 2 puffs twice daily |
| Salbutamol (Ventolin) 100 mcg/dose MDI | SABA reliever | 1-2 inhalations as needed for acute symptoms (maximum 6-8 puffs/day; if requiring more - indicates poor control) |
Add-on if symptoms persist on ICS/LABA (Step 3 add-on):
| Drug | Class | Dose / Regimen |
|---|---|---|
| Montelukast 10 mg | Leukotriene receptor antagonist (LTRA) | 1 tablet orally, once daily at bedtime |
Arterial Hypertension Treatment (asthma-safe):
| Drug | Class | Dose / Regimen |
|---|---|---|
| Losartan | ARB (Angiotensin II receptor blocker) - safe in asthma | 50 mg orally once daily (can increase to 100 mg if needed); avoid ACE inhibitors (cough) and beta-blockers (bronchospasm) |
| OR Amlodipine | Dihydropyridine calcium channel blocker - safe in asthma | 5 mg orally once daily (can increase to 10 mg) |
If both drugs are needed for BP control, losartan + amlodipine combination is appropriate. Calcium channel blockers also have a mild bronchodilatory effect.
Prediabetes / Metabolic Management:
- Lifestyle modification first (weight loss + diet + exercise)
- Reassess HbA1c and fasting glucose in 3-6 months
- If progression to T2DM: Metformin 500 mg twice daily (first-line; does not worsen asthma)
Hospitalization Indications
Hospitalization is NOT indicated for this patient at this time.
Her condition is satisfactory, she is hemodynamically stable (HR 72, BP controllable), RR 25/min (mildly elevated but not critically so), and salbutamol provides relief. This is moderate persistent uncontrolled asthma managed in outpatient setting.
Criteria for hospitalization (for reference):
- FEV1 or PEF <40% predicted after initial bronchodilator therapy
- SpO2 <92% on room air
- RR >30/min, use of accessory respiratory muscles
- Inability to speak in full sentences
- "Silent chest" (absent breath sounds - indicates critical obstruction)
- Failure to improve after 3 back-to-back salbutamol doses in 1 hour
- Altered consciousness, exhaustion, cyanosis
- History of near-fatal asthma or prior ICU admission
- No social support at home for safe outpatient management
5. Dispensary Monitoring Plan
Specialist Consultations
| Specialist | Frequency per Year | Purpose |
|---|---|---|
| General Practitioner / Therapist | 4 times/year (quarterly) in year 1; 2 times/year when controlled | Symptom assessment, control evaluation (ACT/ACQ score), BP check, inhaler technique, compliance |
| Pulmonologist | 2 times/year (every 6 months) | Spirometry review, treatment adjustment, step-up/step-down decisions, complication screening |
| Allergist / Immunologist | 1-2 times/year | Monitor allergen sensitization, consider specific allergen immunotherapy (SCIT/SLIT) |
| Cardiologist | 2 times/year | Arterial hypertension control, LVH monitoring, cardiovascular risk assessment |
| Endocrinologist | 1 time/year | Prediabetes/metabolic syndrome monitoring; if T2DM develops - more frequent |
| ENT Specialist | 1 time/year | Chronic rhinosinusitis, nasal polyposis (upper-lower airway united airways disease) |
| Nutritionist/Dietitian | 2-4 times/year | Weight reduction program, dietary counseling for metabolic syndrome |
Laboratory and Instrumental Tests in Dispensary Follow-up
By the General Practitioner (every 3-6 months):
| Test | Frequency |
|---|---|
| Symptom control assessment (ACT questionnaire score, symptom diary review) | Every visit |
| Peak expiratory flow (PEF) measurement in clinic | Every visit |
| Blood pressure measurement, BMI, waist circumference | Every visit |
| Inhaler technique check | Every visit |
| Complete blood count (CBC) with eosinophil count | 2 times/year |
| Fasting plasma glucose | 2 times/year |
| HbA1c | 1 time/year |
| Full lipid panel (total cholesterol, LDL, HDL, TG) | 1 time/year |
| Urinalysis with microscopy | 1 time/year |
| ECG | 1 time/year |
| Review PEF diary from home | Every visit |
By the Pulmonologist (every 6 months):
| Test | Frequency |
|---|---|
| Spirometry (FEV1, FVC, FEV1/FVC, FEF25-75) | 2 times/year; after every therapy change |
| Bronchodilator reversibility test | 1 time/year (or when clinical picture changes) |
| FeNO (exhaled nitric oxide) | 2 times/year (guide ICS dose titration) |
| Blood absolute eosinophil count | 2 times/year |
| Total serum IgE | 1 time/year |
| Induced sputum cytology (if phenotype change suspected) | As indicated |
| Chest X-ray | As clinically indicated (not routine annual); mandatory during significant exacerbations |
| Body plethysmography (if available) | 1 time/year for severe/complicated cases |
| Allergen sensitization review (IgE panel) | 1 time/year (by allergist) |
Key Monitoring Targets for This Patient
| Parameter | Target |
|---|---|
| ACT score | ≥20 (well controlled) |
| FEV1 % predicted | ≥80% |
| PEF diurnal variability | <10% |
| Daytime symptoms | ≤2 days/week |
| Night awakenings | 0 |
| SABA use | ≤2 days/week |
| Blood pressure | <130/80 mmHg |
| BMI | Target <27 (weight loss) |
| Fasting glucose | <5.6 mmol/L |
| HbA1c | <5.7% |
| Blood eosinophils | <300/μL |
References: Murray & Nadel's Textbook of Respiratory Medicine, 7th ed.; Fishman's Pulmonary Diseases and Disorders; GINA 2024 Strategy Report (ginasthma.org); Textbook of Family Medicine 9e.
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