09-15-2010, 06:16 PM
An 8-year-old girl is brought to her pediatrician becasue her asthma medication has "stopped working". She was first diagnosed at age 3 years following a cough that occurred 2 to 3 times per week, usually at night or in the early morning hours, and three episodes of acute bronchitis over a 12 month period. At the time physical examination and follow-up sinus films showed no signs of sinusitis. History and skin testing identified no inciting allergenic factors. Her condition has been stable since, but with one emergency department visit 2 years ago for an acute exacerbation that resolved with a short course of oral steroids. Historically 1 to 2 puffs of her albuterol inhaler 2 to 3 times per day during symptomatic episodes provided satisfactory relief. Today the child reports that there is no change in frequency of symptomatic episodes (3 to 4 times per week), but that over the past 3 months, she required increased albuterol dosages, sometimes as much as 6 puffs every 4 to 5 hours to achieve desired relief. She also complains that she experiences tremulousness of the hands and very unpleasant overall œjitteriness for several hours after these episodes. Her asthma diary shows that recent acute episodes remain associated with a historically consistent expiratory flow (PEF) between 70% to 75% of predicted value and PEF variation of 20% to 25%. During asymptomatic periods her PEF is equal to predicted values. Medication, in addition to her quick relief albuterol inhaler, is inhaled fluticasone 440 mcg/day. Vital signs are temperature 37.1 °C (98.7 °F), blood pressure (BP) 115/65 mm Hg, heart rate 58 beats/minute, respiration rate 14 breaths/minute. Physical examination is normal as has been typical on her previous every 6-month appointments since her ED visit 2 years ago. What change to the current pharmacotheraputic regimen will likely provide greatest benefit to this patient?
a. Addition of daily montelukast to the long-term control regimen
B. Addition of twice daily inhaled salmeterol to the long-term control regimen
C. Substitute cromolyn sodium via nebulizer for albuterol during symptomatic episodes
D. Substitute inhaled levalbuterol via nebulizer for albuterol during symptomatic episodes
E. Trial of monthly subcutaneous omalizumab injections
a. Addition of daily montelukast to the long-term control regimen
B. Addition of twice daily inhaled salmeterol to the long-term control regimen
C. Substitute cromolyn sodium via nebulizer for albuterol during symptomatic episodes
D. Substitute inhaled levalbuterol via nebulizer for albuterol during symptomatic episodes
E. Trial of monthly subcutaneous omalizumab injections