Asthma diagnosis and long-term control — structured clinical encounter

Station brief (candidate)

You are the paediatric registrar in a general clinic. A 6-year-old girl is referred with an 18-month history of recurrent dry cough and wheeze, worse at night and when she runs, that improves within minutes of using a friend's blue salbutamol inhaler. She has eczema, and her mother has asthma. She is thriving on the 50th weight centile, has never had a productive cough, and her chest is clear today. The team asks you to establish the diagnosis, classify the level of control, build the long-term plan, and counsel the family. You have 12 minutes with the family and 5 minutes for examiner discussion. [5]

Information available on request

• Recurrent, variable, episodic dry cough and wheeze for 18 months; worse at night and with exercise; relieved by salbutamol. [5]
• Personal atopy (eczema) and family history (maternal asthma); no productive cough, no failure to thrive, no neonatal-onset symptoms. [5]
• Over the past four weeks: daytime cough or wheeze most days, night waking twice a week, reliever used most days, and she has stopped keeping up in school sport. [10]
• Examination: normal chest between episodes; no clubbing, no focal signs; growth on the 50th centile; eczema in the flexures. [5]
• Spirometry (on request): obstructive pattern with FEV1 rising 14 percent after bronchodilator; FeNO elevated. [10]

Tasks

1. Give the diagnosis and the features that support it, and explain how you have confirmed it objectively. [5] [10]
2. Classify her current level of control and comment on her future risk. [10]
3. Build the initial long-term controller plan, naming the first-line controller, the current reliever approach, and the step-up/step-down principle. [8] [10]
4. Counsel the mother, who fears the "steroid" inhaler will stunt growth. [3]
5. State the non-drug elements of the plan and what you would check before any future step-up. [10] [12]

Expected approach (examiner notes)

1. The diagnosis is asthma. It is supported by the classic variable, episodic, nocturnal and exercise-provoked pattern of cough and wheeze that responds to a bronchodilator, the personal and family atopy, the normal chest between episodes, and the absence of redirecting features (no wet cough, normal growth). It is confirmed objectively by spirometry showing an obstructive pattern with an FEV1 rise of 14 percent after bronchodilator — reversible airflow limitation of 12 percent or more — supported by an elevated FeNO indicating eosinophilic inflammation. [5] [10]

2. She is uncontrolled: over the past four weeks she has daytime symptoms most days, night waking twice a week, reliever use most days and activity limitation — all four GINA control features are present. Her future risk is also increased by the frequent reliever use and the exercise limitation, so she needs a controller started and close review. Current control and future risk are both assessed and both are poor. [10]

3. The first-line controller is an inhaled corticosteroid, because the disease is inflammatory. She should start regular low-dose inhaled corticosteroid, delivered by metered-dose inhaler and spacer. The reliever, in the current GINA framework, is an anti-inflammatory reliever (as-needed low-dose ICS-formoterol) rather than a short-acting beta-agonist alone, so that reliever use also delivers anti-inflammatory treatment. Treatment follows a stepwise ladder — step up if control remains inadequate, and step down when control has been maintained for about three months — aiming for the lowest effective dose. [8] [10]

4. I would reassure the mother using the CAMP trial: inhaled budesonide improved control and reduced exacerbations, and the growth effect was a small, largely one-off reduction of about one centimetre in attained height that did not progress and is far outweighed by the benefit. Poorly controlled asthma itself harms growth and quality of life. Using a spacer and rinsing the mouth minimises local side-effects, and controller-dose inhaled corticosteroid is safe. [3]

5. The non-drug elements are a written asthma action plan, education on inhaler and spacer technique demonstrated by the child, trigger reduction (tobacco-smoke elimination first, plus relevant allergens), treatment of the eczema and any allergic rhinitis, influenza immunisation, and a scheduled review to reassess control and step therapy down when stable. Before any future step-up I would check adherence, inhaler technique, trigger control and the diagnosis itself. [10] [12]

Examiner probes

• "Why is a normal chest examination today reassuring about the airway but not about control?" Because asthma is variable and the examination is typically normal between exacerbations; control is judged from the four-week symptom history, not the single clear chest. [10]
• "She is 6. What if she could not perform spirometry reliably?" Then the diagnosis would rest on the characteristic pattern, atopy, exclusion of mimics and a documented response to a controller trial, with objective testing repeated when she is older. [5]
• "What single feature in her history would most make you doubt the diagnosis?" A chronic wet (productive) cough, clubbing, failure to thrive or a failure to respond to inhaled corticosteroid — any of which would redirect toward cystic fibrosis, bronchiectasis or a foreign body. [5]