Sumita Khatri, MD
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A 24-year-old man, a former ice hockey player and nonsmoker, presented to Cleveland Clinic’s Department of Pulmonary, Allergy and Critical Care Medicine for evaluation of severe persistent asthma/aspirin-exacerbated respiratory disease (AERD).
Asthma first became a problem for the patient at age 18, when his breathing difficulties resolved only after treatment with albuterol in the emergency department (ED). His symptoms had since worsened.
The patient had a history of aspirin sensitivity and at least one reaction to ibuprofen, as well as a shellfish allergy. His triggers included cold air exposure and sinus infections. At the time of presentation, he worked in an auto body shop with minimal ventilation. He was using rescue treatments more than three times a day and had been to the ED 12 times in the prior year.
Our patient’s other pertinent medical history included sinusitis, nasal polyps and reflux. Medications at the time of initial evaluation included combination high-dose inhaled steroids and long-acting ß-agonist, with additional inhaled steroid supplementation, leukotriene antagonist and prednisone (15mg daily). Spirometry demonstrated a diminished FEV1/FVC ratio of 58 percent, FEV1 of 4.18 l (73 percent) and FVC of 7.17 l (102 percent). Bronchodilator treatment improved FEV1 by 16 percent to 4.83 L.
Poor asthma control
At initial evaluation, our patient’s asthma control test score was 7, indicating very poor control. His upper airway symptoms of nasal stuffiness and sinus pain were considerable. Sinus CT imaging showed chronic pansinusitis and prompted referral to ENT rhinology. Functional endoscopic sinus surgery was performed two months later, when our patient’s FEV1 was 67 percent and his exhaled nitric oxide levels were severely elevated at 186 ppb (normal < 35 ppb).
Although our patient’s sinus disease improved, he continued to have upper airway symptoms and reflux. GI evaluation demonstrated ongoing severe reflux, despite optimization of medications.
Our patient next underwent laparoscopic Nissen fundoplication. Postoperative follow-up testing showed FEV1 of 71 percent with an 18 percent bronchodilator response, hyperinflation with a total lung capacity of 120 percent and air trapping with residual volume of 150 percent. At times when he was on higher-dose prednisone, our patient’s FEV1 improved to 100 percent.
Bronchial thermoplasty success
At this point, after management of multiple comorbidities, we pursued bronchial thermoplasty (BT). The Asthma Research Intervention 2 (AIR2) clinical trials, in which the Respiratory Institute participated, previously demonstrated the safety and efficacy of BT to improve disease control out to two years in patients with severe persistent asthma. Recently published longer-term findings from the AIR2 trial extend BT’s safety and efficacy record to at least five years. The AIR2 trial study group reported in August 2013 that one-time, three-session administration of BT resulted in sustained reduction in patients’ severe exacerbations and ED visits for respiratory symptoms. BT patients in the AIR2 trial showed no decrease in lung function (no deterioration of FEV1) and no significant structural changes in airways at five-year outpoints.
Our patient tolerated all three individual BT sessions well. Two months after the procedure, he had effectively been weaned from oral steroids. His rate of exacerbations is reduced, and those that remain may be due to allergies and reflux. He feels that the duration of exacerbations is shorter and recovery is quicker than before BT. Our patient’s asthma control test at last visit was 22 following a short prednisone burst the previous month. In the future we may reconsider aspirin desensitization.
The care and management of our patient demonstrates the need for concerted and multimodal therapy for those with severe persistent and refractory asthma. Proper management of comorbidities is necessary, and BT used at the appropriate time can help reduce the number of severe exacerbations and improve asthma-related quality of life.
We are pleased to report that our patient has returned to school and is studying to become a respiratory therapist.
Dr. Khatri is Co-Director of Cleveland Clinic’s Asthma Center.