Worsening Asthma in a Young Inmate

Carleen M. Risaliti, MD

Clinical Instructor and Pulmonary/Critical Care Fellow

Department of Internal Medicine

The Ohio State University Wexner Medical Center

Columbus, Ohio

Jonathan P. Parsons, MD

Professor of Internal Medicine

Department of Internal Medicine

The Ohio State University Wexner Medical Center

Columbus, Ohio

The patient is a 35 year-old year old male inmate at a regional correctional facility with a history of asthma who is admitted to the hospital for persistent shortness of breath. The patient had been admitted to the hospital for dyspnea a week prior and symptoms initially improved but then became acutely worse again upon discharge back to prison. Aside from his history of asthma, the patient has no other past medical history or surgical history.

With respect to his asthma, the patient was diagnosed at the age of two. He was hospitalized several times as a young child but then was relatively asymptomatic until he was incarcerated two years ago. Since his incarceration, he has been hospitalized seven times. He has also been intubated twice within the past two years due to his asthma and has been in the ICU at least three times. The patient’s current medications include mometasone/formoterol 200mcg/5mcg 2 puffs BID, montelukast 10mg P.O. and albuterol as needed. The patient also has received several oral steroid bursts over the course of the past several months and has not been completely off of oral steroids for three months. He is a never smoker.</p

On physical exam, the patient was afebrile with a HR of 92, BP 115/57 and O2 saturation of 98% on 2L. Pulmonary exam revealed diffuse inspiratory and expiratory wheezes. There was no clubbing of his digits. No nasal polyps. The patient had significant kyphoscoliosis but the remainder of the exam was unremarkable.

Pulmonary function tests completed several months prior revealed FEV1 of 3.3L (76%), FVC 5.36L (101%), FEV1/VC 60%. Post-bronchodilator FEV1 increased to 3.70 (+12%) and FVC increased to 5.54 (+1%).

Answer: D

All of the above conditions should be considered in the evaluation of a patient who presents with a history of severe or difficult-to-control asthma. In recent studies, 26-51% of patients with a previous diagnosis of asthma or COPD were found to have a misdiagnosis of obstructive lung disease.1,2 According to the most recent ERS/ATS guidelines, patients should see an asthma specialist for at least three months to ensure that their symptoms are due to asthma, and they are on the appropriate therapy before they are labeled severe or difficult-to-control.3

In addition to considering alternate diagnoses, comorbid conditions including rhinosinusitis, GERD, obesity, anxiety, and depression should also be assessed and treated, if present, as these could also be contributing to the patient’s symptoms.

Answer: D

According to the ATS 2013 Guidelines on Definition, Evaluation and Treatment of Severe Asthma, “severe asthma is defined as ‘asthma which requires treatment with high dose inhaled corticosteroids plus a second controller (and/or systemic corticosteroid) to prevent it from becoming “uncontrolled” or which remains “uncontrolled“ despite this therapy.’” ³

In this case, the patient had been on both high dose inhaled corticosteroids and systemic steroids and has continued to be uncontrolled.

According to the most recent ATS guidelines, patients are considered uncontrolled if they meet any of the following four criteria:

Poor symptom control: Asthma Control Questionnaire (ACQ) consistently >1.5 or Asthma Control Test (ACT) <20 (or “not well-controlled” over the 3 months of evaluation)
Frequent severe exacerbations: 2 or more bursts of systemic corticosteroids (>3 days each) in the previous year
Serious exacerbations: at least one hospitalization, Intensive Care Unit stay or mechanical ventilation in the previous year
Airflow limitation: FEV1<80% predicted (in the presence of reduced FEV1/FVC defined as less than the normal lower limit) after withholding both short- and long-acting bronchodilators.

Our patient meets at least three of the four criteria for severe, uncontrolled asthma (only one is necessary). He has had frequent severe exacerbations, serious exacerbations requiring hospitalization or ICU stay and airflow limitation (FEV1 60% - see above).

Work-related asthma (WRA) consists of both work-exacerbated asthma (WEA) and occupational asthma (OA).4 WEA applies to patients who had a previous diagnosis of asthma whose symptoms worsened after a particular job/environment while OA refers to new cases of asthma that are presumably secondary to some exposure in the patient’s workplace.

This patient’s disease includes features of WEA. Though he is not currently employed, the patient’s asthma got much worse when he became incarcerated. Though some of his worsened control could be due to lack of medications or access to specialists, it is also possible that his increased symptoms were caused by exposure to a particular antigen within his new environment. This theory is further supported by the fact that after his recent hospitalization, his symptoms acutely worsened when he was discharged back to the correctional facility.

As above, occupational asthma (OA) is diagnosed with patients who did not have a history of asthma or obstructive airways disease prior to entering a particular workplace. Occupational asthma can be subdivided into two groups: sensitizer-induced or allergic OA and irritant-induced or nonallergic OA. These two groups differ with respect to their presentation, pathogenesis, treatment, and prognosis.5 Sensitizer-induced asthma or allergic asthma is typically due to exposure to high-molecular-weight proteins or low-molecular-weight chemicals and is thought to be IgE-mediated.6 After a latency period, re-exposure to these antigens causes shortness of breath, cough and/or chest tightness as well as occasional conjunctivitis and allergic rhinitis. Symptoms are often worse in the peri-work period and improve over the weekends or holidays away from the place of employment. Prognosis ranges from complete resolution of symptoms to development of severe, uncontrolled asthma. However, in many cases, symptoms improve with avoidance or decreased exposure to the allergen.

In cases of irritant-induced asthma, high levels of irritant-exposure lead to symptoms without any latency period or previous symptoms. Reactive airways dysfunction syndrome (RADS) is a type of irritant-induced asthma that results within 24 hours following exposure to a high-levels of irritants. Since our patient was diagnosed with asthma as a young child, neither type of occupational asthma nor RADS would not apply to him. Additionally, our patient does not have a history consistent with acute onset of asthma symptoms following an isolated exposure to a high-level of an irritant.

Our patient has no history of aspirin use or nasal polyps to suggest aspirin-sensitive asthma.

The American Thoracic Society improves global health by advancing research, patient care, and public health in pulmonary disease, critical illness, and sleep disorders. Founded in 1905 to combat TB, the ATS has grown to tackle asthma, COPD, lung cancer, sepsis, acute respiratory distress, and sleep apnea, among other diseases.

AMERICAN THORACIC SOCIETY
25 Broadway
New York, NY 10004
United States of America

Phone: +1 (212) 315-8600
Fax: +1 (212) 315-6498
Email: atsinfo@thoracic.org

	A.	Vocal cord dysfunction Incorrect!
	B.	Hypersensitivity pneumonitis Incorrect!
	C.	Allergic Bronchopulmonary Aspergillosis Incorrect!
	D.	All of the above Correct!

	A.	Moderate persistent asthma, controlled Incorrect!
	B.	Moderate persistent asthma, uncontrolled Incorrect!
	C.	Severe asthma, controlled Incorrect!
	D.	Severe asthma, uncontrolled Correct!
	E.	Not enough information Incorrect!

	A.	Occupational asthma Incorrect!
	B.	Reactive airways dysfunction syndrome Incorrect!
	C.	Work-exacerbated asthma Correct!
	D.	Aspirin-sensitive asthma Incorrect!

	A.	Macrolide antibiotics Incorrect!
	B.	Anti-IgE antibody (Omalizumab) Correct!
	C.	Steroid-sparing agent (i.e. Methotrexate) Incorrect!
	D.	A and B Incorrect!

Overview

Annual Report

Governance

Newsroom

ATS Awards

ATS Social Media

ATS Videos

Breathe Easy Podcasts

Ethics & COI

Health Equity

Industry Resources

In Memoriam

Global Health

Membership

Chapters

Peer Organizations

Careers at ATS

Staff

Contact Us

Affordable Care Act

ATS Comments and Testimony

Clean Air

Forum of International Respiratory Societies

Hill Day

Research

Tobacco Control

Tuberculosis

Washington Letter

Clinical Resources

Career Development

Education

ATS Podcasts

ATS Webinars

Best of ATS Video Lecture Series

Professional Accreditation

Pulmonary Function Testing (PFT)

Calendar of Events

Ethics & COI

Job Board

APCCSD

Patient Resources

Lung Disease Week

Public Advisory Roundtable

Assemblies & Sections

Sections

Assemblies

Committees

Membership

Member Newsletters

Chapters

Corporate Membership

Asthma Center

Professionals

Submitted by

History

Physical Exam

Lab

Question 1

Question 2

Question 3

Question 4

References