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Negotiating the Therapeutic Landscape in Persistent Asthma

Reviewed By Allergy, Immunology & Inflammation Assembly

Submitted by

Amitesh Agarwal MD

Senior Fellow, Division of Pulmonary and Critical Care Medicine

University of Texas Medical Branch

Galveston, TX

John Kelley MD

Senior Fellow, Division of Allergy and Clinical Immunology

University of Texas Medical Branch

Galveston, TX


Professor and Vice Chair for Research

Divisions of Pulmonary and Critical Care Medicine, and Allergy and Clinical Immunology, Department of Internal Medicine

University of Texas Medical Branch

Galveston, TX

Submit your comments to the author(s).


A 56-year-old Caucasian female is being referred by a primary care physician for evaluation and management of ‘bad asthma’.  She has a history of asthma and allergic rhinitis since childhood and she has taken inhaled medications for many years.  She was hospitalized 3 times for asthma, most recently 18 months ago, but was never intubated.  Her PCP has prescribed prednisone bursts for her 4 times in the last 3 years.

Her asthma symptoms are principally cough and wheezing, with minimal exertional dyspnea.  She reports daily asthma symptoms requiring albuterol for relief, and has nocturnal symptoms about three times monthly.

She is a lifetime non-smoker.  She does not have a history of GERD and denies reflux symptoms. A twin sister also has asthma, and her daughter has allergic rhinitis.

Current medications are formoterol/budesonide 160/4.5 mcg combination inhaler two puffs twice daily, daily inhaled tiotropium, daily oral montelukast, intranasal fluticasone two sprays in each nostril twice daily and cetirizine occasionally for rhinitis symptoms, most commonly in the spring months. 

She reports that she has occasional dysphagia and dysphonia that have responded to local antifungal treatment, but that with meticulous with inhaler and spacer technique, she has had no such episodes for the past 18 months.

Physical Exam

The nasal turbinates are pale with clear mucoid drainage present. There is no conjunctival injection. The oropharyngeal mucosa appears normal.

Examination of the chest reveals good air entry, with minimal adventitious sounds. Forced expiration results in diffuse audible wheezes.

There are no other physical findings of significance.


CBC demonstrates WBC 12 k/µL, Hgb 12.6 g/dL, and Hct 38%.  The differential includes 0.320 K/µL eosinophils.

Basic metabolic panel, HbA1c and random serum glucose are normal.

IgE is elevated at 360 IU/ml.  Serum reactivity to a panel of regionally relevant allergens shows positivity for tree pollens, grass pollens, and both common house dust mites.

PFT Table

FeNO is 18 ppm.


High resolution CT Imaging

Inspiratory (left) and expiratory (right) images were obtained. Representative images from approximately the same cross sectional level are shown.

Question 1

How would you characterize her asthma severity?


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