Sara is a 7-year-old girl with atopic asthma. She is sensitive to pollen and mites.
Since the diagnosis, Sara has been prescribed a twice-daily, 200-μg dose of budesonide. Her father reports that she has no symptoms, but she is tired and prefers reading over more physical activities.
• Is Sara really asymptomatic?
• Does her father fully understand how she feels?
• Is her asthma under control?
• Physical examination does not show any abnormalities
• FENO is 58 ppb.
• Lung function is normal.
The FENO value strongly suggests an ongoing eosinophilic inflammation, which should respond to steroid treatment. However, Sara is already on ICS.
• Does she take the medication?
• Does she use the correct inhalation technique?
• Has anything been changed in terms of allergen exposure?
• Is she taking the optimal steroid dose?
• Has her asthma deteriorated?
• Is she steroid-resistant?
Compliance was discussed with Sara and her father. Because the FENO value suggests poor compliance, Sara’s inhalation technique was reviewed and optimized. The ICS dose was increased to 800μg twice daily for one week and thereafter to 400μg twice daily. Special bed covers were advised, as Sara is also sensitized to house dust mite.
Four weeks later Sara’s FENO value is 24 ppb.
Despite the lack of clear symptoms and her apparently normal lung function, Sara has asthma. Her inflammation was not properly controlled. Non-compliance, as well as a suboptimal dose of ICS, contributed to her situation. It was only by testing the FENO value that this was discovered.
Sara’s inflammation is now under control, but has to be monitored on a regular basis.