Asthma diagnosis and long-term control — branching viva

Station opening

Examiner: "Define asthma in a child and explain why it is a clinical diagnosis rather than one made on a single test." [5]

Strong candidate (must-hit)

• Defines asthma as a chronic inflammatory disorder of the airways producing variable, reversible airflow obstruction, presenting as recurrent, trigger-provoked, nocturnal wheeze, cough, breathlessness and chest tightness that respond to a bronchodilator; explains that there is no single confirmatory test, so the diagnosis rests on the characteristic variable pattern, the objective demonstration of variable airflow limitation, and the exclusion of the mimics; and names variability and reversibility as the two defining features. [5] [10]

Weak candidate

• "Asthma is when a child wheezes and we give them a blue inhaler." [5]

Branch A — Confirming the diagnosis in a 7-year-old

Examiner: "A 7-year-old has recurrent nocturnal and exercise-related cough and wheeze, eczema and a mother with asthma. How would you confirm the diagnosis, and what would you do if the spirometry were normal?" [10]

Strong

• Identifies the classic pattern and atopic background; states that spirometry with bronchodilator reversibility is the key confirmatory test at this age, with a 12 percent or greater rise in FEV1 confirming reversible obstruction; explains that a normal spirogram does not exclude asthma because obstruction is variable, and that variability is then sought with a peak-flow diary, an exercise or bronchial challenge, FeNO as an adjunct marker of eosinophilic inflammation, or a documented response to a controller trial. [10] [5]

Weak

• "If the spirometry is normal then it isn't asthma." [10]

Branch B — The preschooler with recurrent viral wheeze

Examiner: "A 2-year-old has had four episodes of viral-triggered wheeze. The parents ask if he has asthma. How do you approach this?" [1]

Strong

• Explains that most preschool wheeze is transient and viral and resolves, so the task is to stratify risk rather than to label; distinguishes episodic (viral) from multiple-trigger wheeze; applies the Asthma Predictive Index (recurrent wheeze plus major criteria — parental asthma, eczema — or minor criteria — allergic rhinitis, wheeze apart from colds, eosinophilia) to estimate the risk of school-age asthma; and manages episodic viral wheeze with as-needed bronchodilator while considering a trial of inhaled corticosteroid for multiple-trigger wheeze with a positive index, noting that ICS controls but does not modify the natural history. [1] [2]

Weak

• "Four episodes means he has asthma, so start a preventer for life." [2]

Branch C — The stepwise controller ladder and the reliever

Examiner: "Take me up the controller ladder. What is the first-line controller, and what has changed about the reliever?" [10]

Strong

• States that the inhaled corticosteroid is the first-line controller because the disease is inflammatory, and that the leukotriene antagonist is inferior to it (Chauhan Cochrane review) and used as an alternative or add-on; describes the stepwise ladder from as-needed low-dose ICS-formoterol, through daily low-dose ICS, low-dose ICS-LABA, medium and high dose, to specialist add-on and biologics; explains the shift from a short-acting beta-agonist as sole reliever to the anti-inflammatory ICS-formoterol reliever established by the SYGMA trials; and states that treatment is stepped up for inadequate control and down when stable for about three months, at the lowest effective dose. [10] [11] [8]

Weak

• "Start a leukotriene tablet because it's easier than an inhaler." [11]

Branch D — The adolescent who looks uncontrolled

Examiner: "An adolescent has had two steroid courses this year but says he rarely uses his preventer. Before you increase his treatment, what do you do?" [10]

Strong

• States that most apparently uncontrolled asthma is untreated asthma, and that before any step-up he checks the four things — adherence (from the pharmacy record), inhaler technique (observed with the actual spacer), trigger control (tobacco smoke, vaping, allergens) and the diagnosis itself; recognises that heavy reliever use with controller under-use is a danger signal for severe attacks; simplifies the regimen to a single combination ICS-formoterol inhaler used as maintenance-and-reliever therapy to improve adherence; provides a written action plan and close follow-up; and reserves the label of severe treatment-resistant asthma and referral for after adherence and technique are confirmed. [10] [8]

Weak

• "Just double the preventer dose and give him another reliever." [10]

Branch E — The child whose 'asthma' never responds

Examiner: "A 4-year-old has been treated for asthma for two years with no response and now has a chronic wet cough and mild clubbing. What are you thinking?" [5]

Strong

• Recognises that this is not simple asthma: the failure to respond to an adequate trial of inhaled corticosteroid, the chronic wet (productive) cough and the clubbing are redirecting features that point to cystic fibrosis, bronchiectasis, primary ciliary dyskinesia, protracted bacterial bronchitis, an inhaled foreign body or immunodeficiency; states that he would re-take the history, examine for failure to thrive and focal signs, obtain a chest radiograph, consider a sweat test and immunological workup, and refer for specialist assessment and possible bronchoscopy — and would stop escalating asthma therapy. [5]

Weak

• "Increase the steroid dose again and add a long-acting bronchodilator." [5]

Station close

Examiner: "Summarise the long-term goal of asthma management in one sentence." [10]

Strong

• "The goal is to achieve good symptom control and to minimise future risk — of exacerbations, fixed airflow limitation and treatment side-effects — at the lowest effective dose, delivered through an inhaled-corticosteroid-based stepwise ladder with an anti-inflammatory reliever, a written action plan, and regular review that checks adherence, technique and triggers before any step-up." [10] [8]