1. A  24 year old man is seen in the respirology clinic for wheezing in the early morning and nocturnal shortness of breath. He has no other medical history and currently on no medications. He denies any nocturnal cough or any symptoms of acid reflux. His family history is unremarkable for any history asthma or eczema. He also denies any history of shortness of breath as a child and grew up in a household where his were parents were non-smokers. On physical examination, he appears to be in no distress. Blood pressure is 124/82 mm Hg with no pulsus paradoxus, heart rate is 89 bpm, oxygen saturation on room air is 99%. His spirometry revealed:

pre-bronchodilator therapy

FEV1: 2.5L (72% predicted)
FVC: 3.3 L ( 81% predicted)
FEV1/FVC : 76%

post-bronchodilator therapy with 400 mcg of salbutamol

FEV1: 2.68L (76% predicted)
FVC: 3.4 L ( 82% predicted)
FEV1/FVC : 79%
ΔFEV1 in litres: 0.18L
ΔFEV1 in %:  7.2%

What should be the next step in the management of this patient?

A. Start patient on puffer therapy with symbicort immediately.
B. Arrange a methacholine challenge test.
C. Place patient only on PPI therapy.
D.  Start patient on singulair (monteleukast).

ANSWERS

1. B –  This patient has a clinical history that is very suggestive of asthma, particularly the early morning wheezing. It is postulated that the diurnal nature of cortisol is likely why most patients experience early morning and late night wheezing as the serum cortisol levels have a nadir during this time accounting for relative bronchoconstriction.  As it pertains to this case, this patient does not satisfy diagnostic criteria for asthma as his FEV1 did not increase by≥ 200 mL and ≥ 12% post-bronchodilator therapy. Given the diagnostic uncertainty of this case, he will need a methacholine challenge test to assess for airway hyper-responsiveness.  This patient does not need an allergy test at this point in his management. Also initiation of singulair (monteleukast) which is an anti-IgE therapy is not required. Monteleukast is also associated with the development of Churg-Strauss Syndrome (eosinophilic granulomatosis with polyangiitis) and should be used with close follow up with a respirologist.