Endgames Case Study

A man with poorly controlled asthma and exercise induced symptoms

BMJ 2008; 337 doi: http://dx.doi.org/10.1136/bmj.a1963 (Published 22 October 2008) Cite this as: BMJ 2008;337:a1963
  1. Hilary Pinnock, senior clinical research fellow
  1. 1Allergy and Respiratory Research Group, Division of Community Health Sciences: GP Section, University of Edinburgh, Edinburgh EH8 9DX
  1. hilary.pinnock{at}ed.ac.uk

    A 38 year old office worker who had recently taken up jogging as part of a fitness campaign presented to you because his efforts had not proved as successful as he had hoped. He reported a history of asthma since childhood and still had occasional symptoms throughout the year, although normally he was troubled by his wheezing only for a few weeks after viral upper respiratory tract infections. He was being prescribed beclometasone 100 μg regularly twice a day and salbutamol as needed to relieve symptoms. It had been two years since he last had a course of steroids to treat an acute exacerbation.

    He had set himself the long term goal of running for an hour after work every day, but had had to curtail his phased exercise programme because of shortness of breath. Using his salbutamol inhaler before running had some effect but was not preventing the problem.

    Questions

    • 1. How would you approach the problem?

    • 2. What treatment choices would you offer the patient?

    • 3. How would you help him self manage his condition?

    Answers

    Short answers

    • 1. Before suggesting stepping up treatment, go back to basics. Clarify that asthma is the cause of his symptoms (he may just be unfit), ask about smoking status, explore compliance, check his inhaler technique, ask about rhinitis, and consider possible triggers.

    • 2. Once you have established that he has exercise induced symptoms related to seasonal loss of his usually good asthma control and have dealt with any problems of compliance or inhaler technique, you may follow the guideline from the British Thoracic Society-Scottish Intercollegiate Guideline Network, which recommends adding a long acting β2 agonist as first line strategy.1 Other options include increasing the dose of inhaled steroids, adding a leucotriene receptor antagonist, or combining the long acting β2 agonist and inhaled corticosteroid in …

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