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Stable Mild Persistent Asthma in a Young Adult

Case Editor - Judd Flesch

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Cathy Benninger, RN, MS, CNP

The Ohio State University

Columbus, OH

John Mastronarde, MD

The Ohio State University

Columbus, OH

Submit your comments to the author(s).

History

A 29-year-old man with mild persistent asthma presented to an outpatient office for a follow-up visit.  He was originally referred 6 months ago by his primary care provider after having an asthma exacerbation which required treatment in an emergency room.

At his initial visit, he reported wheeze and cough 4 days a week and nocturnal symptoms three times a month.  Spirometry revealed forced vital capacity (FVC) 85% predicted, forced expiratory volume in 1 second (FEV1) 75% predicted, FEV1/FVC 65%, and an increase in FEV1 of 220 ml or 14% following an inhaled short-acting bronchodilator.  He was placed on a low-dose inhaled corticosteroid twice a day and a short-acting inhaled beta-agonist as needed.  He returned 4 weeks later improved, but with continued daytime symptoms 2 days a week.  He also had symptoms of rhinitis; therefore he was referred to an allergist for evaluation. Skin testing was positive for trees, ragweed, dust mites, and cats, and he was prescribed a nasal steroid spray and nonsedating oral antihistamine.   He presents today and reports no asthma exacerbations since his last visit.  Furthermore, during the past 4 weeks, he has not been awakened by his asthma, experienced morning breathing symptoms, missed work, had any limitations in activities due to asthma, or required the use of rescue albuterol.  He currently denies shortness of breath or wheezing.  He performs aerobic exercise 4 days a week for 45 minutes per session without symptoms, provided he premedicates with a short-acting inhaled beta-agonist.  His review of symptoms is otherwise unremarkable.  His current medications include low-dose inhaled corticosteroid, 1 puff twice a day; steroid nasal spray, 2 puffs each nostril daily; a nonsedating antihistamine, 1 tablet daily; and inhaled beta-agonist, 2 puffs as needed.    His past medical history is significant for intermittent asthma diagnosed at age 13 and frequent “colds.”  He has never required hospitalization for an asthma exacerbation He works as a hospital microbiologist and does not smoke, drink alcohol, or use illicit drugs.  He recently moved to a pet-free apartment complex and instituted dust mite protective barriers for his bedding.  His family history is noncontributory.

Physical Exam

On physical exam, he is an age-appropriate man in no acute distress.  His height and weight are proportionate and resting oxygen saturation as measured by pulse (SpO2) is 98% on room air.  Head and neck exam revealed mild erythema of the nasal mucosa.  Heart exam revealed normal heart tones, no murmurs, gallops or rubs, and the lungs were clear to auscultation.  Extremities were free of edema, cyanosis, or clubbing.

Lab

In the office, spirometry is completely normal. He states he feels great and inquires about stopping his inhalers, particularly his inhaled steroid.

Question 1

Based on current evidence, which of the following would be the most appropriate recommendation regarding his asthma medication regimen?

References

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