Clinical Cases

Asthma Comorbidities

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Martin Smith MD

Clinical Fellow, Allergy/Immunology

Cleveland Clinic

Cleveland, OH

Mark A. Aronica, MD

Respiratory Institute

Department of Pathobiology

Cleveland Clinic

Cleveland, OH

Submit your comments to the author(s).

History

A 46 year old male, with past medical history significant for allergic rhino conjunctivitis, GERD (gastro esophageal reflux), hiatal hernia, OSA (obstructive sleep apnea) and a former smoker (20 pack year history) presents with an 8 month history of cough. He describes the cough as dry during daytime, but productive of clear sputum at night, often causing nocturnal awakenings. It is associated with chest tightness, wheezing, shortness of breath at rest and dyspnea on exertion (< 1 flight of stairs). At times he would feel chest pain prior to the onset of the cough, which he attributes to GERD.

The patient feels that triggers of the cough include exercise, pollens, reflux symptoms and weather changes.  Medications used in the past to treat these symptoms include inhaled combination ICS/LABA, which have provided poor relief of symptoms, and has since been discontinued.

The patient has no contributing family history of asthma.

Physical Exam

No wheezing or other significant findings on exam. BMI of 32.4

Lab

Initial spirometry showed reversible obstructive physiology, FEV1/FVC 0.64, FEV1 1.9L (60% predicted), and post-bronchodilator, the FEV1 increases to 2.2L (390cc, 15%). His skin prick testing showed positive wheal/flare reactions to dust mite, cat dander, tree, grass and weed pollens.

Diagnosis and Management

The patient was resumed on high dose ICS/LABA (Fluticasone/Salmeterol), intranasal steroid spray was prescribed for his rhinitis. Symptoms improved on six month follow-up and due to being well controlled he was stepped down to a medium dose ICS/LABA.

With step down his symptoms worsened at next six month follow-up. He was resumed at high dose ICS/LABA. At the next follow-up he voiced that the cough had improved, but he still had symptoms of chest tightness, dyspnea on exertion. He also described a sensation of lung burning. He added that he was experiencing frequent episodes of GERD, despite being on BID dosing of omeprazole.

The patient was referred to gastroenterology (GI) and cardiology. Cardiology ruled out CAD via stress testing and commented that chest tightness was likely related to his reflux. GI commented that the patient had gained an additional 20 lbs in the last year.  They switched the patient to maximal dose of BID esomeprazole, encouraged him to lose weight and ordered eesophageal manometry, pH monitoring and an EGD. pH monitoring revealed significant reflux, EGD confirmed erosive esophagitis, and biopsies showed Barrett's esophagus, without dysplasia. The patient improved marginally with weight loss, but continued to have reflux symptoms. GI then referred the patient to surgery for a Nissen fundoplication. He subsequently underwent a Collis gastroplasty and Nissen fundoplication.

He returned for follow-up 5 months after his procedure, his coughing was minimal, dyspnea was much improved and he reported no use of his as needed SABA. He was stepped down to medium dose ICS/LABA. The patient called 2 months later, reporting that he had no residual cough and enquired if he may stop his ICS/LABA. He was advised to continue current regimen until next follow-up, at which time we stepped down to low dose ICS/LABA. We ultimately discontinued his ICS/LABA due to resolution of cough, chest tightness and SOB. He continues on as needed SABA.

Question 1

Which of the following is a postulated mechanism of bronchoconstriction caused by esophageal acid reflux:


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