A 17-year-old woman presents to clinic for cough and wheeze. Her symptoms have been present for the past 12 weeks, and she has not received any medications for these symptoms in the past. She states her symptoms are present daily, but not throughout the day, and denies nocturnal symptoms; she has only minor limitation with physical activity. Her baseline FEV1 = 62% of predicted, which increases 10 minutes later by 14% and 240 mL after a one-time bronchodilator use. What is the appropriate classification of her asthma severity?
e. Very severe persistent
The most correct answer is c, moderate persistent.
The NAEPP recommends classifying the initial severity of asthma based on the frequency of symptoms, nocturnal awakenings, use of rescue bronchodilator and functional impairment (Table 21.6). The patient has moderate persistent asthma since the patient has daily symptoms and an FEV1 = 62% of predicted.
Table 21.6. Classification of asthma severitya
|Components of Severity ||Classification of Asthma Severity ≥12 years of age |
|Intermittent ||Persistent |
|Mild ||Moderate ||Severe |
8-19 yr 85%
20-39 yr 80%
40-59 yr 75%
60-80 yr 70%
|Symptoms ||≤2 days/week ||>2 days/week but not daily ||Daily ||Throughout the day |
|Nighttime awakenings ||≤2×/month ||3-4 × /month ||>1× /week but not nightly ||Often 7 × /week |
|Short-acting beta2-agonist use for symptom control [not prevention of exercise-induced bronchospasm (EIB)] ||≤2 days/week ||>2 days/week but not daily, and not more than 1× on any day ||Daily ||Several times per day |
|Interference with normal activity ||None ||Minor limitation ||Some limitation ||Extremely limited |
|Lung function || |
Normal FEV1 between exacerbations
FEV1 >80% predicted
FEV1 >80% predicted
FEV1 >60% but <80% predicted
FEV1/FVC reduced 5%
FEV1 <60% predicted
FEV1/FVC reduced >5%
A 27-year-old woman presents to clinic for follow-up of her asthma. Over the past 6 months, she has been on fluticasone 100 μg/salmeterol 50 μg, one puff b.i.d. She reports no daytime symptoms, no nocturnal symptoms, and has not used albuterol for rescue in the past 3 months. She reports no interference with daily activities from her asthma and has not required any systemic steroids for asthma over the past year. Spirometry reveals an FEV1 = 97% predicted, FVC = 100% predicted, and an FEV1/FVC = 0.84. What is the most appropriate next step in this patient's care?
a. Discontinue salmeterol and continue fluticasone
b. Discontinue fluticasone and continue salmeterol
c. Continue current medications and reassess her symptoms in 3 months
d. Continue current medications and reassess her symptoms in 6 months
e. Discontinue current medications and conduct methacholine challenge to verify that patient has asthma
The most correct answer is a, discontinue salmeterol and continue fluticasone.
Based on the "Stepwise Approach to Asthma Therapy," this patient has had good asthma control for at least 3 months on the lowest dose of fluticasone plus salmeterol and should have her therapy de-escalated. Since the patient has persistent asthma, she still requires a controller anti-inflammatory medication, here fluticasone. Thus, salmeterol should be discontinued since it has no anti-inflammatory action and has been associated with increased mortality when used as monotherapy for asthma.