Continuity Clinic Case #8 A 6 year old female patient presents to clinic with her mother.

Her mother states that she has been coughing on a daily basis since the air started being gross on further questioning, this has been for about 1 month but happened last year also. She coughs during the day and at night. In the past week, she has woken at least twice with symptoms and she has been coughing every day while awake. Mom says she has tried giving her diphenhydramine without clear improvement in her symptoms. When asked, the patient denies runny nose or congestion; she also denies stomach pain or vomiting. She hasnt been allowed to go outside at recess for the past week but when she was sledding with her older brother, she felt like she had to stop to catch her breath before getting to the top of the hill. She has also had to take longer to walk to school than she normally would. There is no family history of allergies or asthma. On exam, vitals: Wt: 45# Ht 42 T 99.0 BP 95/60 RR 20 SpO2 96%. Gen: alert, calm, no respiratory distress HEENT: eyes clear, nasal mucosa slightly swollen, OP moist without erythema. Lungs: prolonged expiratory phase with end-expiratory wheezes throughout. CV: nl s1, S2, no murmur Ext: 2+ pulses, no clubbing or cyanosis.

R1: What diagnosis is most likely for this patient? Is there more information you need to make the diagnosis?

R2: What medication(s) would you prescribe? What other information would you provide for her management?

R3: When would you see this patient in follow-up? She comes back at that time and is no longer having nighttime symptoms. She coughs during the day but only when she is exercising during her gym class (this is 3 times per week). Would you change her management?

Answers for Discussion

R1: What diagnosis is most likely for this patient? This patient most likely has asthma due to history (type of symptoms, recurrence of symptoms, triggers) and physical exam findings. The best way to classify severity is to look at frequency of daytime symptoms, nighttime awakenings, interference with normal activity and, when applicable, use of short-acting medications and systemic steroids.

This patient would be classified as moderate persistent asthma based on the information daily cough and waking at night twice in the last week. She has also had limitations in some of her activity (longer to walk to school, pausing to walk up the hill).

Is there more information you need to make the diagnosis? The recommendation for diagnosis in children 5 is to demonstrate reversible airway obstruction. Spirometry should be performed before and after bronchodilator administration (short-acting beta agonist) to show reversibility shown by improvement in obstruction by 12% from baseline. When there is reversibility, this strongly supports the diagnosis of asthma, but normal spirometry doesnt exclude asthma. Because formal spirometry is not feasible in many office settings, it is important to know that peak flow cannot be used as a reliable substitute for spirometry for diagnosis but may be helpful for monitoring. While peak flow should be equivalent to FEV, peak flow is more effort dependent than formal spirometry.

National Asthma Education and Prevention Program: Expert panel report 3 (EPR3): Guidelines for the diagnosis and management of asthma. Bethesda, MD: National Heart, Lung, and Blood Institute, 2007. (NIH publication no. 08-4051). http://www.nhlbi.nih.gov/guidelines/asthma/08_sec4_lt_0-11.pdf This is an interesting discussion point for trainees how often do attendings use formal spirometry for initial diagnosis prior to starting medication?

R2: What medication(s) would you prescribe? She should be started on a short-acting beta-agonist (albuterol) and also, based on her severity, an inhaled medium-dose corticosteroid. See prior diagram for initiating medication step 3 is recommended for moderate symptoms.

What other information would you provide for her management? A written asthma action plan should be provided. Several studies recommend that written action plans that are symptom based are more appropriate for children than those that are peak-flow based. (see attached) Arch Pediatr Adolesc Med. 2008;162(2):157-163. Many EMRs have an action plan that is incorporated. Please see attached for other suggestions.

R3: When would you see this patient in follow-up? The recommendation is to see patients every 2-6 weeks to assess control then increase support if control is not appropriate.

She comes back at that time and is no longer having nighttime symptoms. She coughs during the day, but only when she is exercising during her gym class (this is 3 times per week). Would you change her management? At this point, she is considered well-controlled with exercise induced bronchospasm you should discuss pre-treating with albuterol prior to gym class. When she is well-controlled for 3 months, you can consider step-down in therapy.