48-year-old woman with worsening cough and wheezing
A 48-year-old woman with a 10-year history of asthma presents for follow-up. Her symptoms have worsened over the past year, requiring near-daily use of her rescue inhaler and two courses of oral corticosteroids. Her current regimen is a high-dose fluticasone/salmeterol combination inhaler and an albuterol inhaler as needed. She works as a painter in an auto body repair shop. She mentions her cough and wheezing are most severe in the evenings after her shift but were almost absent during a recent week-long vacation. Examination reveals mild, diffuse expiratory wheezes. Spirometry shows an FEV1 of 68% of predicted. Her peripheral eosinophil count is 180 cells/mcL. Which of the following is the most appropriate next step in management?
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A
Explanation
Clinical Pearl:
When a patient's asthma symptoms show a clear temporal relationship with their work schedule, such as improving on days off or vacations, occupational asthma should be strongly suspected. The initial diagnostic step is to document variable airflow limitation correlated with work exposure using serial peak expiratory flow measurements.
Explanation:
This patient's poorly controlled asthma, with symptoms worsening on workdays and improving significantly during a vacation, is highly suggestive of occupational asthma due to exposures at her job as an auto body painter. According to current pulmonology society guidance, the most appropriate next step is to confirm the diagnosis by demonstrating a relationship between work exposure and airflow limitation. Obtaining serial peak expiratory flow (PEF) measurements, taken multiple times a day at work and at home (including on days off), is the recommended initial method to establish this link. Adding tiotropium is a potential escalation for severe asthma, but it is crucial to first investigate and address the likely occupational trigger. Initiating mepolizumab is not indicated as her peripheral eosinophil count is not significantly elevated, and this would not address the underlying exposure. A methacholine challenge test is used to diagnose asthma in cases of diagnostic uncertainty with normal spirometry and is not needed in this patient with a known history and obstructive findings. Advising immediate cessation of work is a drastic measure with significant socioeconomic impact that should only be considered after the diagnosis of occupational asthma is firmly established.
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