A 25-year-old woman comes to the office due to poor sleep quality and daytime sleepiness. She has a 10-year history of intermittent asthma symptoms, which had been well-controlled with a combination inhaled corticosteroid and long-acting beta agonist (ICS-formoterol) as needed once every few days. The patient relocated to the Southeast for work 3 months ago and now has frequent awakenings throughout the night due to cough and wheezing. Lately, she has been using her rescue inhaler at night 2 or 3 times a week. The patient does not get enough rest at night and feels sleepy during the day. She has no other medical concerns but reports occasional indigestion. She does not report heartburn or regurgitation during the episodes of nocturnal coughing. The patient has gained 3.7 kg (8.2 lb) since moving, which she attributes to interruption of her usual exercise routine and a difficult work schedule. Her roommate has told her that she snores.
Vital signs are within normal limits and BMI is 26 kg/m². Neck circumference is 35.5 cm (14 in) . On examination, the nares are clear, the pharyngeal mucosa appears normal, the tonsils are not enlarged, and the uvula is fully visible. Retrognathia is not present. Heart sounds are regular and jugular venous pressure is normal. The lungs are clear to auscultation. The abdomen is soft and nontender. There is no lower extremity edema.
Pulmonary function testing shows FEV₁ of 2.76 L (72% of predicted value) and FEV₁/FVC ratio of 0.65. Bronchodilator responsiveness is present. Complete blood count and metabolic panels are within normal limits.
Which of the following is the best next step in management of this patient?

Question

Quizplus · Accepted Answer

11ec193a_98d4_c0ab_853d_63ed93f09829_MD0002_00 Nocturnal symptoms affect over two-thirds of patients with asthma, leading to poor sleep quality. Increasing nighttime symptoms are often the earliest indicator of poor asthma control. This effect may be explained by circadian variation in sympathetic-parasympathetic balance and decreased vital capacity during sleep. Symptoms typically peak around 4 AM on a regular sleep schedule. Because the central process involves leukocyte-induced bronchoconstriction, adult asthma guidelines recommend an inhaled corticosteroid plus long-acting beta agonist (ICS/LABA) at every step. Formoterol is the preferred LABA because it has fast-onset kinetics and is therefore effective for acute relief. Depending on the degree of disease control, an appropriate step-up in treatment may be needed. In patients with previously intermittent symptoms who now have worsening disease control (eg, more frequent nocturnal awakenings), scheduled ICS/LABA is the next step. adult asthma guidelines (Choice A) Allergic rhinitis and upper airway cough syndrome can trigger nocturnal asthma and be treated with an intranasal corticosteroid (eg, fluticasone). However, this patient's clear nares and lack of pharyngeal erythema or cobblestoning make significant postnasal drip unlikely. (Choice B) High-resolution chest CT scan is used in the diagnosis of hypersensitivity pneumonitis (HP), which can be triggered by new exposures after relocation. However, HP is characterized by dyspnea worsening over weeks with little or no diurnal variation. Inspiratory crackles and squeaks (rather than wheezing) would be expected on lung examination. (Choice C) Obstructive sleep apnea (OSA) is highly comorbid with asthma and can present with excessive daytime sleepiness. However, this patient's sleep disturbance is due to nighttime coughing ascribed to poor asthma control. Although the patient snores, she is only mildly overweight with normal neck circumference (<40.6 cm [16 in]). Therefore, the pretest probability of OSA is low. Polysomnography may be warranted if her nocturnal arousals continue despite intensification of asthma inhaler therapy. pretest probability of OSA (Choice D) Gastroesophageal reflux disease (GERD) is highly comorbid with asthma and may worsen cough and wheezing. Empiric proton pump inhibitor therapy (twice daily for 3 months) should be considered for moderate-to-severe asthma with coexisting GERD symptoms. The patient has no dyspepsia or regurgitation associated with her nocturnal cough and wheezing, and onset following relocation is supportive of asthma. Educational objective: Nocturnal worsening of respiratory symptoms is common in patients with underlying asthma, signifies loss of prior control, and is treated with a step-up in asthma therapy involving scheduled inhaled corticosteroids and long-acting (fast-onset) beta agonists. Comorbid aerodigestive conditions (eg, gastroesophageal reflux disease, obstructive sleep apnea, postnasal drip) can mimic or contribute to nocturnal asthma. __________ References: Nocturnal asthma: underlying mechanisms and treatment. (http://www.ncbi.nlm.nih.gov/pubmed/15683618) Efficacy of esomeprazole for treatment of poorly controlled asthma. (http://www.ncbi.nlm.nih.gov/pubmed/19357404) Nocturnal asthma: effect of salmeterol on quality of life and clinical outcomes. (http://www.ncbi.nlm.nih.gov/pubmed/10084473)

A 25-Year-Old Woman Comes to the Office Due to Poor