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For Primary Care| Patient Scenarios

Patient Scenarios: GINA Asthma 2023

These scenarios are fictitious, but are similar to those experienced by real patients, and are designed to help you reflect on what you have learnt after reading the article. They could also be used for group discussion in an education or practice meeting. They are designed to highlight management approaches, and show some pitfalls to avoid.

The following case studies, written by Dr Kevin Gruffydd-Jones, relate to his article, The 2023 GINA strategy: implications for primary care, and GINA’s Global strategy for asthma management and prevention (2023 update).

These scenarios are based on GINA’s updated guidance, so the answers provided are given according to GINA recommendations rather than NICE or BTS/SIGN guidance. 

Case 1: Sabrina

Sabrina is a 45-year-old housewife who has never smoked. She presents with a recurrent night-time cough that she has had for the last 6 months. She also coughs when she rushes upstairs, and feels her chest is ‘wheezy’. There is no personal or family history of atopic disease (such as asthma, allergic rhinitis, or eczema), but she often has a blocked nose.

Questions for Reflection

  1. What else should you ask Sabrina about?
  2. Which investigations should you organise for Sabrina, and what would the criteria be for confirming a diagnosis of asthma?
  3. Are there any other investigations that may be advisable?

How to Manage this Patient

Patient History and Examination

It is important to ask Sabrina about any potential ‘red flags’, such as unintentional weight loss, haemoptysis, or risk of TB contact, to consider and minimise the risk of alternative pathologies. It would also be worth clarifying her description of ‘wheezy’—because true wheeze is a whistling expiratory sound (best explained through demonstration)—and asking whether she has been experiencing any chest pain suggestive of cardiac disease. Her present and past occupation should be determined, and any relationship to the symptoms noted. 

A possible differential diagnosis for Sabrina, even though she is a nonsmoker and is 45 years of age, is COPD; therefore, in addition to occupation, a family history of COPD should be asked about and alpha1 antitrypsin deficiency should be considered (in line with NICE COPD guidance)—this condition is seen in patients with, or with a family history of, COPD who are aged under 45 years.

In Sabrina’s case, the answers to the above questions do not raise any further suspicions of alternative diagnoses. Examination reveals that she is overweight (with a BMI of 29 mg/kg2), with scattered wheezes in her lung fields and polyps in her nose. This would suggest the possibility of late-onset asthma.

Investigations to Confirm Diagnosis

According to GINA’s guidance, confirmatory spirometry and reversibility testing should be performed for people with suspected asthma, possibly in conjunction with peak flow monitoring. A finding of an FEV1 lower than the LLN (usually around 0.75), together with a BD reversibility of FEV1 greater than 12% and 200 ml, would show reversible obstruction of the airways. A peak flow variability greater than 10% over 1–2 weeks would also be considered evidence of significant airflow variability. GINA recommends measuring peak flow variability in twice-daily PEF readings, and it is calculated as follows:

  • ([day’s highest reading – day’s lowest reading] ÷ [mean of day’s highest and lowest readings]) x 100 

The peak flow variability is the average of these daily results over 1 week.

Although GINA’s guidance does not mention this, it may be wise to carry out a CXR in a patient such as Sabrina in whom COPD is a possible diagnosis, as she has a higher risk of lung pathology and is presenting with a recurrent cough. 

Case 2: Hamid

Hamid is a 3-year-old boy who is brought in by his parents in March with ‘another wheezy cough’. He was last seen the previous November (4 months ago) with cough and wheeze associated with a cold. He was given a salbutamol MDI via a large volume spacer device and seemed to get better. Hamid’s parents say that he has since been well, until a week ago when he again developed cough, wheeze, and a runny nose. They are worried that he may be ‘getting asthma’, as his mother had asthma as a child.

Questions for Reflection

  1. What other questions could you ask Hamid and his parents to ascertain a probable diagnosis of asthma?
  2. If you think that Hamid may have asthma, how could you prove this?

How to Manage this Patient

Patient History

In patients aged 5 years and younger, objective testing is much more difficult, so it is important that a detailed history is taken to allow a clinician to make a presumptive diagnosis of asthma. Some important areas to consider when taking a history include: 
  • are there any ‘red-flag’ features, such as failure to thrive or high risk of TB, which may warrant referral?
  • are the patient’s symptoms only triggered by viral infections (suggesting viral-induced wheeze), or are they also triggered by other factors, especially exercise, laughter, crying, or allergens?
  • is there diurnal variation in symptoms?
  • is there a family history (especially maternal) of asthma or atopic disease?
  • is there a past history of atopic disease (such as rhinitis or atopic eczema)?
It emerges that Hamid also tends to cough and wheeze when he runs about, and he had atopic eczema when he was a baby. Examination reveals that he is in the 75th centile for height and weight, and his chest appears normal. This would all suggest that Hamid may have asthma.

Investigations to Confirm Diagnosis

To confirm an asthma diagnosis in patients aged 5 years and younger, GINA recommends that a 2–3 month trial of a low-dose ICS is given (by GINA’s definition, a low dose of ICS is equivalent to 50 mcg of beclometasone dipropionate twice daily [pMDI, standard particle, HFA]—see Box 6-7 of the strategy report). Additionally, a SABA should be prescribed for symptom relief. It may be advisable to review the child after a month to check adherence and inhaler technique.

If the patient’s symptoms improve, the ICS should be stopped. Then, if the symptoms return on cessation, a diagnosis of asthma can be made. If the symptoms persist despite this trial of asthma medication, referral to a paediatrician is recommended.

Case 3: Pieter

Pieter is a 35-year-old software engineer who is reattending after he saw one of the other GPs in the practice a month ago (in April). He mentioned that he always has ‘hay fever’ symptoms—a runny nose and itching eyes—but was also concerned about having a tight chest and shortness of breath when he plays football (once a week). This GP colleague thought that Pieter may have asthma, and spirometry has revealed that he has an FEV1/FVC ratio of 0.7, with a reversibility of 15% or 300 ml, confirming a diagnosis of asthma. Pieter has come to discuss the results.

Questions for Reflection

  1. What should be done before pharmacotherapy is commenced?
  2. What is GINA’s recommended pharmacological method of initial management?

How to Manage this Patient

Before commencing pharmacotherapy, clinicians should carry out the following:
  • explain the diagnosis, using patient information leaflets where useful, such as those provided by Asthma + Lung UK—
  • in addition to assessing the frequency and impact of symptoms, assess the future risk of exacerbations, considering:
    • smoking status
    • significant comorbidities, such as obesity, GORD, or confirmed food allergy
    • psychological and socioeconomic status
    • FEV1
    • previous exacerbations in the last year
  • discuss minimising exposure to any potential trigger factors.
In this case, Pieter is a nonsmoker with an FEV1 that is 80% of predicted. He has had no exacerbations in the last year, and has no significant night-time waking. Other than his pollen-induced rhinitis, he is well.

Therefore, as Pieter does not experience symptoms on most days and does not wake with asthma, GINA would categorise him as requiring step 1 or 2 therapy, and advises prescribing as-needed-only ICS–formoterol anti-inflammatory reliever therapy to manage his intermittent symptoms and low risk of exacerbations. At the time of writing (July 2023), the only UK-licensed preparation for this indication is a budesonide–formoterol 200/6 mcg inhaler, delivered via a DPI (Symbicort Turbohaler® 200/6 inhalation powder [budesonide, formoterol fumarate dihydrate]). Once this therapy is prescribed, it is important to make sure that both the patient and the clinician have access to a mutually agreed written or digital asthma action plan.

Case 4: Jade

Jade is a 9-year-old girl who was diagnosed with asthma 2 years ago, via spirometry. She has since been taking beclometasone dipropionate 100 mcg twice daily via an MDI, with as-needed salbutamol (also via an MDI). She was admitted to hospital with an asthma attack 9 months ago and has come to the practice because she has been waking several nights per week, in the last month, with cough and wheeze that is relieved by salbutamol. 

Questions for Reflection

  1. What should be done initially, before considering pharmacotherapy?
  2. If the decision is made to escalate Jade’s drug therapy, what is the recommended method of escalation?

How to Manage this Patient

Before stepping up pharmacotherapy, GINA recommends checking the following:
  • inhaler technique
  • adherence to therapy
  • new trigger factors (such as allergens, stress, environmental pollution)
  • new significant comorbidities
  • whether the symptoms likely to still be caused by asthma.
Jade’s adherence and inhaler technique appear to be good, but there seems to have been a worsening of her symptoms when she moved to a new house with her parents, where there was a lot of dust. 

In this case, it seems wise to escalate Jade’s drug therapy. Her ICS dose is considered ‘low’, so she is currently on step 2 of GINA’s preferred treatment pathway. Therefore, the GINA strategy recommends considering:

  • increasing Jade’s maintenance dose of ICS from ‘low’ to ‘medium’ (which would be 200–400 mcg of beclomethasone [pMDI, standard particle, HFA], or equivalent, per day)
  • changing Jade’s maintenance therapy from a low-dose ICS to a low-dose ICS–LABA (still equivalent to 100–200 mcg beclomethasone [pMDI, standard particle, HFA] per day)
  • changing to a very low dose of ICS–formoterol as MART, and no longer using a SABA as a reliever.

It is important to note that MART is not licensed in children in the UK, and the only combination ICS–LABA treatment that is licensed for this age group is budesonide–formoterol given via DPI (Symbicort 100/6 Turbohaler® [budesonide, formoterol fumarate dihydrate]). Therefore, before choosing this option, one would need to ensure that Jade is happy with this change of inhaler (from MDI to DPI), and is able to use the new inhaler. 

GINA=Global Initiative for Asthma; BTS=British Thoracic Society; SIGN=Scottish Intercollegiate Guidelines Network; TB=tuberculosis; COPD=chronic obstructive pulmonary disease; BMI=body mass index; FEV1=forced expiratory volume in 1 second; LLN=lower limit of normal; BD=bronchodilator; PEF=peak expiratory flow; CXR=chest X-ray; MDI=metered-dose inhaler; ICS=inhaled corticosteroid; pMDI=pressurised metered-dose inhaler; HFA=hydrofluoroalkane propellant; SABA=short-acting beta2 agonist; FVC=forced vital capacity; GORD=gastro-oesophageal reflux disease; DPI=dry powder inhaler; LABA=long-acting beta2 agonist; MART=maintenance and reliever therapy
Note: At the time of publication (August 2023), some of the drugs discussed in this article did not have UK marketing authorisation for the indications discussed. Prescribers should refer to the individual summaries of product characteristics for further information and recommendations regarding the use of pharmacological therapies. For off-licence use of medicines, the prescriber should follow relevant professional guidance, taking full responsibility for the decision. Informed consent should be obtained and documented. See the General Medical Council’s Good practice in prescribing and managing medicines and devices for further information.