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Clinical Crossroads |

A 47-Year-Old Woman With Severe Asthma

William W. Busse, MD, Discussant
JAMA. 2000;284(17):2225-2233. doi:10.1001/jama.284.17.2225.
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DR AUDET: Ms A is a 47-year-old African American woman who has had asthma since childhood. She lives in Boston, receives public assistance, and has insurance through Medicaid.

During the past year, Ms A has felt short of breath more frequently than before, has experienced dyspnea with lower levels of exertion, and has been waking up at night with shortness of breath. She has required albuterol nebulizers as many as 4 times per night and increasing dosages of many medications. She has not had any emergency department visits nor required hospitalization.

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Figure 1. Early Life Origins of Allergic Sensitization and Asthma
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The development of allergic disease is influenced by the balance of T cell type 1 (TH1) and T cell type 2 (TH2) immunity. It is hypothesized that early in life, predominance of TH2 cytokine mediators and diminished stimulation of the TH1 immune response drives the immune system toward sensitization to environmental allergens and production of allergen-specific IgE. Allergen reexposure activates the allergic response, which, in asthma, leads to bronchoconstriction and acute airway inflammation and may result in persistent inflammation, airway injury, and remodeling. IL indicates interleukin; INF, interferon; and GM-CSF, granulocyte-macrophage colony–stimulating factor.
Figure 2. Assessment of Respiratory Symptoms When Asthma Is Suspected
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The process suggested is to assess symptoms and then to confirm the presence of reversible airflow obstruction. The option of a trial of anti-inflammatory medication is included. Adapted from National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma, 1991.31
Figure 3. Stepwise Approach for Managing Asthma in Adults and Children Older Than Age 5 Years
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FEV1 indicates forced expiratory volume in 1 second; PEF, peak expiratory flow. Based on National Heart, Lung, and Blood Institute Guidelines for the Diagnosis and Management of Asthma: Expert Panel Report 2.19 For complete details and information regarding asthma relief medications and education, refer to the original guidelines. Asterisk indicates that options were added by the author and do not appear in the original guidelines.
Figure 4. Flow-Volume Loop in Vocal-Cord Dysfunction
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A, Example of a normal flow-volume loop tracing. B, The tracing from a patient with vocal-cord dysfunction shows irregularity in the expiratory loop with a "cut-off" of the inspiratory loop.



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