Peter is a 5-year old boy who has had a chronic cough for 8 weeks. Tests show his FENO level is elevated and he tests positive for house dust mite allergies. He is diagnosed with persistent atopic asthma and prescribed ICS or LTRA, which resolve his cough within 2 weeks as his FENO level decreases.
Sebastian has had asthma since age 5 but now has a normal FENO level, indicating no ongoing eosinophilic inflammation from allergies. Discontinuing his ICS and further testing reveals he has sinusitis, not allergic asthma.
Eric has a high FENO of 75 ppb, indicating eosinophilic inflammation, so he is
2. Improved asthma diagnosis
Case 1:
Peter is a 5 year old boy who has had
a chronic cough for the last 8 weeks.
• History of bronchitis
• No food allergy
• No atopic dermatitis
Differential diagnosis
• Post-viral cough
• Habit cough
• Allergíc rhinitis
• Sinusitis
• Asthma
• Pnemonia
• Foreign body
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3. Case 1:
Peter is a 5 year old boy who has had
a chronic cough for the last 8 weeks.
Questions:
• Does Peter have an allergy?
• Is there an inflammation in the airways?
• Does Peter have normal lung function?
Results of lab tests:
• FENO: 22 ppb
• Peak flow: 100% predicted
• Spirometry: -
• Specific-IgE (skin test/RAST test): Positive to house dust mite
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4. Case 1:
Peter is a 5 year old boy who has had
a chronic cough for the last 8 weeks.
Diagnosis:
• Persistent atopic asthma
Actions:
• ICS or LTRA
Results:
• Cough remitted by the end of the second week and he became asymptomatic
• FENO: 7 ppb after 4 weeks
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5. Improved asthma diagnosis
Case 2:
Sebastian is a 10 year old boy
who has had asthma since the age of 5.
• Is using ICS
• Nocturnal coughing
• Fatigued during physical exercise
• Compliant and correct inhalation technique
• FENO is 8 ppb
Questions:
• Does Sebastian have (allergic) asthma or should another diagnosis be
considered?
• In what way is the FENO value informative?
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6. Case 2:
Sebastian is a 10 year old boy
who has had asthma since the age of 5.
• The FENO value shows that he has no ongoing eosinophilic inflammation,
i.e. no allergic asthma
• IgE tests were negative and indicated that he was non-atopic
Actions:
• Discontinue Sebastian’s ICS
• Find an explanation for the symptoms
-Non-allergic asthma (no eosinophils)
-Gastrointestinal reflux
-Port-nasal drip
-Nervous hyperventilation
-Rhinitis
-Sinusitis
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7. Case 2:
Sebastian is a 10 year old boy
who has had asthma since the age of 5.
• Further investigations showed that he had sinusitis, which was treated
• FENO remained stable after ICS was discontinued
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8. Prediction of steroid response / dose titration
Case 3:
Eric is 31 and suffers from chronic rhinitis and seasonal
allergies during spring and midsummer.
In addition he has recently developed breathing problems.
He is using antihistamines
Results of examination:
• Physical examination is normal
• FENO is 75 ppb
• Spirometry is normal
Question:
• What does the examination and especially the FENO value tell you?
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9. Case 3:
Eric is 31 and suffers from chronic rhinitis and seasonal
allergies during spring and midsummer.
In addition he has recently developed breathing problems.
• Eric is in addition to his rhinitis and allergy having an ongoing
eosinophilic inflammation
• He is prescribed ICS as he will most probably respond to steroids as he is
having a high FENO value
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10. Case 3:
Eric is 31 and suffers from chronic rhinitis and seasonal
allergies during spring and midsummer.
In addition he has recently developed breathing problems.
Figure showing ICS dose adjustment with maintained control
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11. Rapid identification of non-compliance
Case 4:
Eva is 21 years old and has suffered from allergies for
many years. She was diagnosed with asthma 5 years ago.
• Eva has been prescribed ICS / LABA and SABA when needed
• She is experiencing breathing problems
Results of examination:
• RAST shows that she is sensitized towards cat (25.1 kU/l), dog (9.2 kU/l),
horse (8.1 kU/l), birch (22.3 kU/l), timothy (21.6 kU/l) and cladosporium (1.5 kU/l)
• FENO is 55 ppb
Questions:
• Why does Eva have symptoms despite the fact she is prescribed medication?
• What does the FENO value reveal about the inflammation?
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12. Case 4:
Eva is 21 years old and has suffered from allergies for
many years. She was diagnosed with asthma 5 years ago.
Further questions:
• Does she take the medication?
• Does she have the correct inhalation technique?
• Has anything been changed in the allergen exposure?
• Has she the optimal steroid dose?
• Has her asthma deteriorated?
• Is she steroid resistant?
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13. Case 4:
Eva is 21 years old and has suffered from allergies for
many years. She was diagnosed with asthma 5 years ago.
Actions:
• Eva gets detailed instructions for how to use the inhaler
• The dose of ICS/LABA is gradually increased
Figure showing decreased inflammation following 13
improved compliance and increased dose of ICS/LABA
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14. Notification of loss of control
Case 5:
Sara is a 7 year old girl with atopic asthma.
She is sensitive to pollen and mites.
• Sara is on ICS
• She is having no symptoms (according to her father)
• She is tired and spends a lot of time reading
Questions:
• Is Sara really asymptomatic?
• Does her father fully understand how she feels?
• Is her asthma under control?
Results of examination:
• Physical examination does not show any abnormalities
• FENO is 58 ppb
• Lung function is normal
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15. Case 5:
Sara is a 7 year old girl with atopic asthma.
She is sensitive to pollen and mites.
Further questions:
• Does she take the medication?
• Does she have the correct inhalation technique?
• Has anything been changed in the allergen exposure?
• Does she have the optimal steroid dose?
• Has her asthma deteriorated?
• Is she steroid resistant?
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16. Case 5:
Sara is a 7 year old girl with atopic asthma.
She is sensitive to pollen and mites.
Actions:
• Inhalation technique was reviewed and optimized
• ICS dose was increased
• Bed covers
Result:
• FENO dropped to 24 ppb after 4 weeks
Sarah’s asthma is under control but has to be monitored on a
regular basis.
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17. Notification of loss of control
Case 6:
Francesca is a 14 year old girl with atopic asthma.
She has been treated with ICS since she was
diagnosed at the age of 7.
• On a fixed dose of ICS
• Compliant
• FENO normally 7-13 ppb
Stable, symptomless and with low FENO values for > 6 months
The steroid dose is reduced
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18. Case 6:
Francesca is a 14 year old girl with atopic asthma.
She has been treated with ICS since she was diagnosed
at the age of 7.
Francesca returns after two months
Results of examination:
• No symptoms
• Physical examination is normal
• FENO shows a slight increase to 18 ppb
• Spirometry is normal
Francesca is later on experiencing breathing problems while training
during the pollen season
Results new of examination:
• Physical examination is normal
• FENO is now 30 ppb
• Spirometry is normal
Actions:
Francesca is advised to use the original dose of ICS during the
pollen season as she was symptom free on that dose 18
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19. Prediction of asthma relapse
Case 7:
Simon is a 15 year old boy who has had mild asthma and
has been on a low dose of ICS for the past several years.
Results of examination:
• No symptoms.
• Physical examination is normal.
• FENO is 15 ppb.
• Spirometry is normal.
Stable, symptomless and with normal FENO values for > 6 months
The steroid dose is reduced
Simon returns after two months
Results of examination:
• No symptoms.
• Physical examination is normal.
• FENO is now 17 ppb.
The steroids are discontinued 19
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