A 28-year-old man presents to his primary care provider because of shortness of breath, cough, and wheezing that has worsened over the past 6 months and now bothers him daily

QUESTION

A 28-year-old man presents to his primary care provider because of shortness of breath, cough, and wheezing that has worsened over the past 6 months and now bothers him daily. He occasionally had shortness of breath as a teenager and would wheeze after running. He wakes up from sleep wheezing approximately 3 times a week. His medical history is otherwise noncontributory. He doesn’t smoke or drink alcohol. Vital signs are all within the normal range. Physical examination is remarkable for expiratory wheezing bilaterally. Spirometry shows an FEV1 of 73% predicted, which improves to 92% after albuterol. What is the most appropriate therapy for this patient’s level of asthma, according to the National Asthma Education and Prevention Program (NAEPP)? SABA = short-acting beta-agonist ICS = inhaled corticosteroid LABA = long-acting beta-agonist

ANSWER

According to the National Asthma Education and Prevention Program (NAEPP) guidelines, the management and treatment of asthma are classified into different levels based on asthma severity and control. The appropriate therapy for this patient’s level of asthma can be determined by evaluating his symptoms, lung function, and response to treatment. In this case, the patient’s clinical presentation and spirometry results suggest the following:

1. Asthma Severity: The patient has experienced symptoms of shortness of breath, cough, and wheezing for the past 6 months, which have worsened and become more frequent. He also reports waking up from sleep wheezing approximately 3 times a week. These symptoms indicate persistent and ongoing asthma.

2. Spirometry Results: The spirometry results show an FEV1 (forced expiratory volume in one second) of 73% predicted, which is indicative of airflow obstruction.

3. Response to Albuterol: After administration of albuterol, the patient’s FEV1 improves to 92%. This bronchodilator response indicates reversible airflow obstruction, which is a characteristic feature of asthma.

Based on these findings and in accordance with NAEPP guidelines, the patient’s asthma management should fall into the category of persistent asthma with impaired lung function. The appropriate therapy for this level of asthma typically involves the use of inhaled corticosteroids (ICS) as the preferred long-term control medication, often in combination with other medications as needed.

The stepwise approach for managing asthma in adults and adolescents, as outlined by NAEPP, includes the following:

Step 2: Preferred Long-Term Control Medications for Persistent Asthma

Low-Dose Inhaled Corticosteroids (ICS)**: This is the preferred initial therapy for adults and adolescents with persistent asthma, especially when there is evidence of impaired lung function (FEV1 < 80% predicted).

For patients who continue to experience symptoms despite low-dose ICS therapy, the guidelines recommend stepping up treatment to include:

Step 3: Medium-Dose ICS or Low-Dose ICS/LABA

Medium-Dose Inhaled Corticosteroids (ICS): If symptoms persist, the dose of ICS may be increased to achieve better asthma control.

Low-Dose ICS/Long-Acting Beta-Agonist (LABA): Alternatively, the patient may be prescribed a combination inhaler containing a low-dose ICS and a long-acting beta-agonist (LABA) for improved control.

It’s important to tailor the treatment plan to the patient’s individual needs and response to therapy. In this case, starting with a low-dose ICS would be an appropriate initial therapy to address the patient’s persistent asthma symptoms and impaired lung function. However, the choice of medication should be made in consultation with the patient’s healthcare provider, taking into consideration any potential side effects and the patient’s preferences. Regular follow-up visits should be scheduled to assess asthma control and adjust the treatment plan as needed to achieve optimal outcomes.