This case illustrates the importance of the distal airways in asthma and of developing a management plan that is unique for each patient. Dan’s test results and his symptoms indicate mild persistent asthma and, significantly, distal airway involvement. Had he not seen his physician and simply continued using a short-acting ß2-agonist as needed to treat his wheezing, he would have been at risk for symptom exacerbations and further deterioration of his pulmonary function. We know that even in mild asthma, fatal exacerbations are possible. Appropriate treatment during the early stages of chronic asthma may prevent airway remodeling. Early use of effective treatment is critical for all patients with asthma, regardless of severity.
The involvement of the distal airway is a critical factor when considering therapeutic options for patients like Dan. Conventional chlorofluorocarbon (CFC)-based corticosteroid preparations, and most of the corticosteroid dry powder inhalers (DPIs), are ineffective at reaching the distal airways, leading to diminished efficacy and suboptimal control of symptoms. The newer hydrofluoroalkane (HFA) propellants produce a smaller and less forceful aerosol that is more effective at reaching the distal lung with less oropharyngeal deposition. It would be the ideal first-line treatment for a patient like Dan.
If Dan’s nocturnal exacerbations are not controlled after 4 to 6 weeks of treatment with the HFA inhaled corticosteroid, or if immediate control is desired, it would be prudent to add on a secondary agent until the desired control is achieved. An inhaled long-acting ß2-agonist, a leukotriene receptor antagonist, or theophylline would be appropriate choices. These agents should only need to be employed for the short term, until Dan’s nocturnal symptoms have fully subsided; after that, stepping down to monotherapy with the corticosteroid would be appropriate and cost-effective for the patient.
Finally, it is important to consider the doctor-patient relationship as a partnership in the enterprise of wellness. Patient education is an important component of positive clinical outcomes. Dan should be instructed on the importance of adherence to therapy and the correct inhaler technique, both verbally and in writing. He should be asked to demonstrate his inhaler technique initially and at each office visit because patients may often forget these skills over time. And even in cases of mild asthma, a written asthma management plan is essential to ensure optimal clinical outcomes; one should be developed for Dan and it should include peak flow monitoring.
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