Asthma diagnosis and long-term control — formative SAQs

SAQ 1 — The school-age child with recurrent cough and wheeze (20 marks, ~15 minutes)

A 7-year-old girl is referred with a two-year history of recurrent dry cough and wheeze, worse at night and when she runs, that improves with a borrowed salbutamol inhaler. She has eczema, and her mother has asthma. Between episodes she is well and her chest examination is normal. She has never had a productive cough, and she is growing along the 50th centile. [5]

Questions

1. Give the most likely diagnosis and the features in this history that support it. (4 marks) [5]
2. She is 7 years old. State the single most useful confirmatory investigation, what result would confirm the diagnosis, and why a normal result would not exclude it. (4 marks) [10]
3. Outline your initial long-term controller plan, naming the first-line controller and the current approach to the reliever, with the principle that governs stepping up and down. (6 marks) [10]
4. The mother is worried that a "steroid" inhaler will stunt her daughter's growth. What is your evidence-based response? (3 marks) [3]
5. State the four things you would check before ever stepping up her therapy, and the one written document every child with asthma should have. (3 marks) [10]

Model answer (must-hit)

1. The most likely diagnosis is asthma. The supporting features are the characteristic variable pattern (recurrent, episodic cough and wheeze that come and go), the nocturnal and exercise-induced timing, the response to a bronchodilator, the personal atopy (eczema) and family history (maternal asthma), the normal examination between episodes, and — importantly — the absence of any redirecting features (no wet cough, no failure to thrive, normal growth). Asthma is a clinical diagnosis based on this pattern. [5]
2. The single most useful confirmatory investigation is spirometry with bronchodilator reversibility, which she is old enough to perform reliably at 7 years. The result that confirms the diagnosis is an obstructive pattern (reduced FEV1/FVC) with an improvement in FEV1 of 12 percent or more after an inhaled bronchodilator, demonstrating the reversible airflow limitation that defines asthma. A normal spirogram does not exclude asthma, because the obstruction is by nature variable and may be absent between episodes; in that situation variability is sought with a peak-flow diary, an exercise challenge, FeNO, or a documented response to a controller trial. [10]
3. The first-line controller is an inhaled corticosteroid, because the underlying lesion is airway inflammation. In the current GINA framework the reliever is no longer a short-acting beta-agonist alone but an anti-inflammatory reliever — as-needed low-dose ICS-formoterol — so that every reliever actuation also delivers anti-inflammatory treatment; for a child of this age a regular low-dose inhaled corticosteroid with an appropriate reliever is a standard starting point. Treatment is delivered by a stepwise ladder: step up if control is inadequate and step down when control has been maintained for about three months, always aiming for the lowest effective dose. All inhalers are given with a spacer. [10] [8]
4. The evidence-based response is reassurance grounded in the CAMP trial (Szefler 2000), which randomised children to inhaled budesonide, nedocromil or placebo and found that budesonide improved control and reduced exacerbations. The much-discussed growth finding was a small reduction in attained height of about one centimetre that was largely a one-off effect and did not progress, and it is far outweighed by the benefit of controlling the disease. Controller-dose inhaled corticosteroid is safe, and poorly controlled asthma itself impairs growth; the child should use a spacer and rinse her mouth to minimise local side-effects. [3]
5. Before any step-up I would check adherence (is the controller actually being taken, from the pharmacy record), inhaler technique (watched with her actual spacer), trigger control (tobacco-smoke exposure above all, plus allergens), and the diagnosis itself. Every child with asthma should have a written asthma action plan telling the family what to do as symptoms change and when to seek help. [10]

SAQ 2 — The adolescent with apparently uncontrolled asthma (20 marks, ~15 minutes)

A 15-year-old boy with known asthma attends after two courses of oral steroids and an emergency-department visit in the last six months. He says he "hardly ever" uses his preventer but takes his blue reliever "when I need it." The pharmacy record shows eight salbutamol canisters dispensed this year and one preventer inhaler. He admits to vaping. His FEV1 is 68 percent predicted with 15 percent reversibility. [10]

Questions

1. Interpret his level of control and his future risk, and reconcile the discrepancy in his history. (5 marks) [10]
2. What is the most likely reason his asthma appears uncontrolled, and how would you confirm it? (4 marks) [10]
3. Outline your management, including the change to his regimen most likely to improve adherence. (6 marks) [8]
4. State the danger signal in his reliever use and why it matters. (2 marks) [10]
5. Name two other issues specific to this adolescent that you would address. (3 marks) [12]

Model answer (must-hit)

1. He is uncontrolled: two steroid courses and an emergency visit in six months, and a low FEV1 (68 percent predicted) with clear reversibility (15 percent) confirming active, reversible obstruction. His future risk is high on every count — high reliever use, low lung function, recent exacerbations and poor engagement. The discrepancy in his history — "hardly ever" using the preventer but eight reliever canisters and only one preventer dispensed in a year — is reconciled by the pharmacy record, which shows the true picture: massive under-use of the controller and heavy reliance on the reliever. Current control and future risk are both poor. [10]
2. The most likely reason is not severe disease but poor adherence to the controller combined with likely poor inhaler technique — the two commonest causes of apparently uncontrolled asthma. This is confirmed by the pharmacy dispensing record (one preventer in a year cannot control the disease) and by directly observing his inhaler technique with his actual device and spacer. The diagnosis of severe treatment-resistant asthma can only be made after adherence and technique have been confirmed adequate. [10]
3. Management is to build rapport and address adherence rather than simply escalate drugs: confirm and demonstrate correct inhaler technique, negotiate a simple regimen, and reduce triggers. The change most likely to improve adherence is to move him to a single combination ICS-formoterol inhaler used as maintenance-and-reliever therapy, so that one device does both jobs and every reliever actuation delivers anti-inflammatory treatment — a strategy supported by the SYGMA evidence and endorsed for exactly this problem. Provide a written action plan, arrange close follow-up, and reassess control and lung function. Only if control remains poor despite confirmed adherence and technique is he referred for specialist assessment. [8] [10]
4. The danger signal is his reliever use: eight canisters a year, far more than one a month. Over-reliance on the short-acting reliever with under-use of the controller is the pattern that precedes severe and fatal asthma attacks, and it identifies a child at high risk who needs the controller optimised, not more reliever. [10]
5. Two adolescent-specific issues are his vaping (which should be addressed directly, as it damages the airway and worsens control) and the broader challenges of adolescent self-management and transition — body image and reluctance to use inhalers in front of peers, the need to consult him directly rather than through his parent, and planning for transition to adult services. [12]