Two brothers, ages 8 and 10 years, with poorly controlled asthma present for a follow-up visit. The boys’ mother reports that both use their albuterol inhaler 3-4 days per week for cough at rest and occasionally audible wheezing. Both experience nocturnal night-awakenings due to cough 1-2 nights per week, and the oldest reports cough and chest tightness during physical education class and recess. Despite these symptoms, the oldest does not use albuterol prior to exercise. Though both have had multiple hospitalizations in the past (one for each in the pediatric intensive care unit), neither boy has been hospitalized for asthma in the past year. The youngest was treated and released from the emergency department 3 weeks ago and both were prescribed a course of oral corticosteroids for an asthma exacerbation several weeks prior to the youngest’s emergency department visit. Historically, the boys have averaged 2-3 courses of oral corticosteroids per year. Approximately every 6 weeks they have less severe exacerbations controlled with 7-10 days of four-times daily albuterol. These exacerbations are mostly in association with an upper respiratory tract infection. The boys and their mother received asthma education at their first visit in the clinic, and with each hospitalization. In addition, “refreshers” are given at each clinic visit, including an assessment of inhaler technique with coaching as needed.
Both boys have intermittent allergy symptoms of nasal stuffiness, itchy red eyes and scratchy throat. When the symptoms become severe enough for them to complain their mother will tell them to take an over-the-counter antihistamine, which provides transient relief. Neither boy has had a formal evaluation for allergies, and the family is not aware of what provokes the symptoms. They have no other medical problems.
Both boys had been prescribed monotherapy with medium-dose fluticasone HFA taken twice daily; however, the mother reports that neither boy consistently remembers to take it. She feels that both are old enough to manage their medication without supervision. She does monitor their medication supply and makes sure that the medications are refilled when needed. A call to the pharmacy used by the family indicates that the fluticasone HFA was filled for each boy six times in the past year. Albuterol HFA was dispensed 5 times for the youngest boy, 4 times for the oldest. The boys acknowledge forgetting to take their controller medication (“the orange one”), saying that they don’t feel any different right after taking it so don’t feel it helps. They take their rescue inhaler (“the red one”) most often for coughing and chest tightness. They use it whenever they feel the need, not always telling an adult they are doing so. Both boys occasionally carry their rescue inhaler at school. However, on occasion they have needed a rescue inhaler on days when they have not carried one to school, so they have gone to the nurse’s office where they have an action plan on file and an inhaler in the medication locker.
Both parents had asthma in childhood, but neither has currently active asthma. The boys’ two sisters (one older, one younger) also have asthma, but both are currently well controlled. The oldest sister has symptoms of allergic rhinitis as well. There are no other chronic illnesses in the immediate family.
The family has no pets. The family lives in public housing that is 17 years old and has forced-air heat/central air conditioning (“heat pump”). All appliances are electric. There is no basement, attic, fireplace or wood stove. The boys share a carpeted room with bunk beds. The family has lived in the home for two years. The previous occupant was evicted for violating the housing authority’s no pets policy by having two cats that were “mostly outside”. The father smokes a cigar 2-3 nights per week, but only does so outside; the mother does not smoke. The mother has contacted the housing authority regarding the presence of cockroaches coming up through the drains, but the housing authority defers action to the city water department who annually fumigates the storm drains and sewers in the area.
Physical Exam
8 year-old
Gen: well developed, well nourished male
VS: HR 86 RR 24 BP 96/64 SpO2 96% in room air Ht 134 cm (75%) Wt 28.5 Kg (50%)
HEENT: conjunctivae non-injected; nares patent without polyps, mildly erythematous mucosa, scant clear discharge; oropharynx clear with cobblestoning, but no post-nasal drip
Neck: supple with midline trachea
Chest: no retractions; mildly hyperexpanded and hyperresonant on palpation and percussion; good air entry throughout with scattered polyphonic, high-pitched, bibasilar end expiratory wheezes
Cardiac: PMI displaced slightly inferomedially, but of normal intensity; normal S1S2 without murmurs or gallops; peripheral pulses 2+/5+, symmetric and without palpable pulsus paradoxus
Abdomen: bowel sounds present; soft, nondistened, nontender without masses or organomegaly
Extremities: no clubbing or cyanosis
10 year-old
Gen: well developed, well nourished male
VS: HR 82 RR 20 BP 94/68 SpO2 96% in room air Ht 145 cm (75%) Wt 38.5 Kg (75%)
HEENT: conjunctivae non-injected; nares patent without polyps, normal mucosa, without discharge; oropharynx clear with cobblestoning, but no post-nasal drip
Neck: supple with midline trachea
Chest: no retractions; normal palpation and percussion; good air entry throughout with rare polyphonic, high-pitched, bibasilar end expiratory wheezes
Cardiac: PMI normal; normal S1S2 without murmurs or gallops; peripheral pulses 2+/5+, symmetric and without palpable pulsus paradoxus
Abdomen: bowel sounds present; soft, nondistened, nontender without masses or organomegaly
Extremities: no clubbing or cyanosis
Lab
Data:
Spirometry
8 year-old
10 year-old
FVC
2.17 L (105%)
2.64 L (104%)
FEV1
1.23 L (68%)
1.65 L (74%)
FEV1/FVC
56% (65%)
63% (73%)
Childhood ACT
13
15
Question 1
Questions: (3-6 acceptable, minimum 3; must be at least 4 answers)
With respect to asthma control, an aggressive, community-based household environmental remediation intervention program
A. has an impact that persists for at least 12 months beyond the intervention period.
B. has not been shown to be helpful.
C. is only effective as long as the community-based intervention is continued.
D. decreases household levels of allergen triggers, but does not reduce asthma symptoms.
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