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]