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Mr. T is a 40-year-old recreational athlete with a history of asthma, for which he has used an albuterol rescue inhaler three times per week for the past year. During this time, he has also had three unscheduled asthma visits for mild flares and waking up with asthma symptoms approximately twice a month. Mr. T has uncontrolled asthma, according to the National Asthma Education and Prevention Program guidelines.

1. Asthma Care Quick Reference: National Asthma Education and Prevention Program

Spirometry was performed as a result of these symptoms, revealing a 78% predicted forced expiratory volume in the first second (FEV1). Mr. T has then prescribed a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice daily. He remained symptomatic, however, and continued using his rescue inhaler thrice weekly. As a result, his primary care doctor switched him to a combination of inhaled steroids and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day).


Initial pulmonary evaluation Despite this increase in medication, Mr. T remained symptomatic and required the use of a rescue inhaler. As a result, he was referred to a pulmonologist, who performed the following initial work-up:


Spirometry, pre-albuterol: 79% improvement in FEV1, post-albuterol: 12% improvement

PC20: 1.0 mg/mL methacholine challenge

X-ray of the chest: Normal.

Continued pulmonary evaluation His ICS and LABA dosages were increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to experience symptoms and was referred to a pulmonologist for further evaluation, as shown here:


CT scan of the chest reveals normal lung parenchyma with no scarring or bronchiectasis.

Sinus CT reveals mild mucosal thickening.

Complete blood count (CBC): White blood cells (WBC) 10.0 K/mcL, 3% eosinophils, within normal limits.

IgE (immunoglobulin E): 25 IU/mL

Skin allergy test: positive for dust and trees

Exhaled NO: 53 parts per billion fractional exhaled nitric oxide (FeNO) (PBB)

Examination for comorbidities that may be causing asthma symptoms Tiotropium was added to his medication regimen following this work-up. He remained symptomatic, however, and had two more flares over the next three months. He was evaluated for comorbid conditions that could be causing his symptoms, and the results revealed:


Harmful esophageal/barium swallow

Negative esophageal manometry

The esophageal impedance is typical.

ECG: Within normal parameters

Genetic testing revealed no evidence of cystic fibrosis or alpha1 antitrypsin deficiency.

He was referred to an ear, nose, and throat specialist, who recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a regular vocal cord evaluation.


Mr. T’s symptoms persisted despite the extensive work-up that took place for a year. He returned to the pulmonologist to discuss additional asthma treatment options.


Diagnosis Mr. T has refractory asthma. Other causes of the symptoms, such as allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, should be considered in the work-up for this condition, as was done for Mr. T by his pulmonary team.


Options for treatment When a patient has refractory asthma, treatment options include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or participation in a clinical trial evaluating the use of agents that.


Treatment result Mr. T had bronchial thermoplasty to treat his asthma. He reports feeling great a year after the procedure. He has not taken systemic steroids in a year, and his asthma is under control with a moderate dose of ICS and LABA. He has also been able to resume regular physical activity.




Please provide complete, thorough, and detailed answers to all questions in the case study attached. Multiple choice answers should include the correct choice and rationale for that choice and/or rationale why other choices are incorrect.

Please see attached document.

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