Caroline’s primary complaint was a cough that hadn’t let up since a bout of influenza 18 months earlier. She sometimes woke up coughing, making it difficult for her to get a good night’s rest. Caroline works as a customer service rep, and her supervisor has commented that she sometimes sounds breathless and wheezy on the phone.
Because she had little energy and felt short-winded, Caroline had given up her nightly walks and had subsequently gained weight. Also, her eyes sometimes felt itchy and watery, and she was experiencing rhinorrhea. Recently, Caroline had experienced some chest pain, and she wondered whether she had a heart problem.
Concerned about the chest pain, Caroline went to see a cardiologist. After performing an electrocardiogram (EKG) and an echo-cardiogram, he had ruled out heart disease. Still, Caroline was worried about her coughing and her breathing difficulties. Her grandmother—a lifelong smoker—had died of emphysema, and Caroline was haunted by memories of her gasping for air.
Since Caroline wasn’t a smoker, the cardiologist thought that emphysema was unlikely but that some of her symptoms might be the result of allergic rhinitis. He suggested that she see an allergist and referred her to my office.
The Evaluation I thought Caroline might have allergies as well as adult-onset asthma. I performed a spirometer test and did scratch tests to see whether Caroline was allergic to dust mite allergens, pollen, pet dander, grass, or other common allergens.
The scratch tests revealed that Caroline was in fact allergic to all these allergens, and the pulmonary function test using a spirometer showed that she wasn’t able to achieve full exhalation, which often indicates asthma.
The Diagnosis At that point, I was fairly certain that Caroline had asthma, though diagnosing asthma in adults is complicated because the symptoms mimic chronic obstructive pulmonary diseases such as emphysema or chronic bronchitis.
In order to confirm the diagnosis, I needed to see how Caroline responded to asthma medications: An improvement in her symptoms would enable me to make a definitive diagnosis.
The Treatment The fact that Caroline periodically had tightness in her chest and breathing trouble made it likely that she had been suffering mild asthma attacks without realising it. I wanted to help her feel better on a regular basis and avert a life- threatening attack. As I explained to Caroline, asthma is characterised by constriction of the airways as well as inflammation of the bronchial tubes.
To reduce the inflammation, I prescribed two drugs: an inhaler containing a drug called fluticasone (Flovent) and a pill called montelukast (Singular). I also prescribed albuterol (Proventil), a short-acting drug that, when inhaled, opens the airways. I also suggested that Caroline lose some weight. Although being overweight does not cause asthma, it can make symptoms worse by limiting lung capacity.
In addition, I recommended regular exercise. To do that, I suggested that Caroline use the albuterol 5–20 minutes before exercising on days when she felt asthmatic. I also suggested that she stay with low-impact activities, such as walking on an indoor track, away from allergens, or swimming. I advised her to use a HEPA (high-efficiency particulate air filter) air purifier in her bedroom and to sleep with the windows closed.
When Caroline came back to see me a month later, she was no longer wheezing, coughing, or experiencing tightness in the chest, so I told her that the asthma diagnosis was on target.
Although she was initially shocked at this diagnosis (like many others, Caroline never knew that asthma can strike adults), she was pleased to be able to resume her nightly walks, with help from the albuterol. When I saw Caroline again 3 months later, she had lost 5 pounds, and her asthma was under control.
Discussion Questions 1. What is emphysema?