What should be included in a case report on bronchial asthma, covering patient demographics, clinical history, diagnostic work‑up, treatment regimen, clinical course, and discussion?

Writing a Case Report on Bronchial Asthma

A well-constructed asthma case report should be factual, concise, logically organized, and include only pertinent positive and negative findings that advance clinical understanding, increase clinical skill, or suggest useful research. 1

Essential Components to Include

Patient Demographics and Initial Presentation

• Age, sex, occupation, and relevant environmental exposures (particularly smoking history ≥10 pack-years, workplace exposures, or inner-city residence) 2, 3
• Socioeconomic status and psychosocial factors including illicit drug use, major psychosocial problems, or chronic psychiatric disease, as these are risk factors for asthma-related death 2
• Chief complaint focusing on specific symptoms: wheezing, chest tightness, difficulty breathing, or cough (particularly nocturnal) rather than vague terms like "air hunger" or "gasping" which suggest alternative diagnoses 2, 4

Clinical History - Key Elements

• Symptom pattern: Time of onset, frequency (days per week), nocturnal awakenings, and triggers (exercise, viral infections, allergens, irritants, weather changes, emotional stress, menstrual cycles) 2, 5
• Previous asthma history: Number of ED visits (≥3 in past year), hospitalizations (≥2 in past year), ICU admissions, intubations, or use of >2 SABA canisters per month - all critical risk factors for death 2, 3
• Response to previous treatments and time of last medication dose, particularly noting any difficulty perceiving symptom severity 2
• Personal and family history of atopy: eczema, allergic rhinitis, food allergies (particularly important as confirmed food allergy is a death risk factor) 2, 5
• Comorbidities: GERD, obesity, obstructive sleep apnea, rhinitis, sinusitis, cardiovascular disease, other chronic lung disease, diabetes, or depression 2, 6

Physical Examination Findings

• Upper respiratory tract: Increased nasal secretion, mucosal swelling, nasal polyps 2
• Chest examination: Wheezing (though note that wheezing can be absent between episodes and is an unreliable indicator of obstruction severity), prolonged expiratory phase, hyperexpansion, accessory muscle use, hunched shoulders, respiratory rate, pulsus paradoxus 2, 4
• Skin: Atopic dermatitis or eczema 2
• Level of alertness, cyanosis, fluid status - particularly important in acute presentations 2
• Note: Physicians correctly diagnose asthma based on clinical examination only 63-74% of the time, emphasizing the need for objective testing 4

Diagnostic Work-Up - Mandatory Elements

• Spirometry results (mandatory for diagnosis): Pre- and post-bronchodilator FEV1, FVC, FEV1/FVC ratio 2, 5, 7
  • Reversibility defined as FEV1 increase >200 mL AND ≥12% from baseline after SABA 2, 3
  • Some evidence suggests ≥10% of predicted FEV1 may better differentiate asthma from COPD 2
• Bronchoprovocation testing (methacholine or histamine challenge) if spirometry is normal but asthma suspected, with provocative dose causing 20% FEV1 decrease 2, 3
• Peak expiratory flow variability if spirometry unavailable: ≥20% increase from baseline suggests asthma 3
• Biomarkers of type 2 inflammation:
  • Fractional exhaled nitric oxide (FeNO): ≥35 ppb suggests eosinophilic inflammation 3
  • Peripheral blood eosinophils: ≥150/μL identifies eosinophilic phenotype and predicts biologic therapy response 3
  • Induced sputum eosinophils (gold standard for airway inflammation assessment) 3
• Allergen testing if allergic asthma suspected, particularly for house dust mite, Alternaria (specific risk factor for death), pollens, animal dander 2, 5
• Rule out alternative diagnoses: Upper airway obstruction (flow-volume curves, laryngoscopy), GERD (particularly if no esophageal symptoms but laryngotracheal spasm), pneumonia, pneumothorax, vocal cord dysfunction 2, 6

Classification of Severity and Control

• Pre-treatment severity classification (if patient not on long-term control medication):
  • Intermittent: Step 1 treatment level
  • Mild persistent: Step 2
  • Moderate persistent: Steps 3-4
  • Severe persistent: Steps 5-6 2, 3
• Assessment of current control (impairment and risk domains):
  • Impairment: Symptom frequency, SABA use, activity limitations, lung function 2
  • Risk: Exacerbation frequency, progressive lung function decline, medication adverse effects 2
• Note: After treatment initiation, classify severity based on treatment step required to maintain control, not pre-treatment symptoms 3

Treatment Regimen - Specific Details

• Initial therapy step based on severity classification 8, 3
• Specific medications, doses, and delivery devices:
  • ICS type and dose (low/medium/high)
  • LABA if combination therapy
  • LAMA if triple therapy
  • Biologic agents (anti-IgE, anti-IL-5, anti-IL-5Rα, anti-IL-4Rα) with specific indications 8, 3
• Oral corticosteroid use: Dose, duration, and tapering schedule (note: ≤7.5 mg/day prednisone equivalent for severe asthma as last resort) 3
• Written asthma action plan details 2, 8
• Environmental control measures and allergen immunotherapy if applicable 8, 3
• Treatment of comorbidities 2, 8

Clinical Course and Follow-Up

• Response to treatment: Symptom improvement, SABA use reduction, lung function changes (FEV1, FEV1/FVC) 2, 8
• Follow-up schedule: 2-6 weeks after starting therapy, then 1-6 months when controlled, 3 months when stepping down 8, 3
• Exacerbations: Frequency, severity, triggers, management (home vs. ED vs. hospitalization) 2, 8
• Adverse effects from medications, particularly systemic effects from high-dose ICS (osteoporosis, HPA axis suppression, pneumonia risk) or oral corticosteroids 3
• Achievement of clinical remission if applicable: ≥1 year symptom-free, no exacerbations, normal/near-normal lung function, no oral corticosteroids 3

Discussion Section - Critical Elements

• Emphasize salient features that make this case educational or unusual 1
• Relate findings to established guidelines: Compare patient's presentation, risk factors, and treatment response to NAEPP Expert Panel Report 3 or GINA guidelines 2, 5, 8, 7
• Phenotype identification: Allergic asthma, cough-variant asthma, occupational asthma, aspirin-induced asthma, asthma-COPD overlap, or severe asthma with specific inflammatory endotype 5, 3
• Address any diagnostic challenges: Cases where spirometry was initially normal requiring bronchoprovocation, or presumptive diagnostic pathway with anti-inflammatory therapy trial 3
• Highlight pitfalls avoided or encountered: Misdiagnosis as "wheezy bronchitis" or "reactive airway disease," failure to recognize GERD as cause of symptoms, underestimation of severity due to poor symptom perception 2, 7, 6
• Treatment decisions and rationale: Why specific step chosen, why biologic therapy selected (if applicable), how comorbidities influenced management 8, 3
• Unusual adverse reactions if relevant (e.g., vaccine-induced exacerbations) 9

Common Pitfalls to Avoid

• Do not rely solely on clinical examination: Physicians correctly predict pulmonary function only 50% of the time; objective spirometry is mandatory 4
• Do not use vague diagnostic labels: Avoid terms like "wheezy bronchitis," "recurrent pneumonia," or "reactive airway disease" which delay appropriate asthma treatment 7
• Do not exclude asthma based on single cutoff values: If clinical suspicion high but initial testing negative, consider presumptive diagnostic pathway with anti-inflammatory therapy trial 3
• Do not overlook psychosocial assessment: Patients with normalized lung function, eosinophils, and FeNO but persistent dyspnea require anxiety/depression screening 3
• Do not include irrelevant details: Excessive information obscures the educational value; include only pertinent positive and negative findings 1
• Do not neglect risk stratification: Always document risk factors for asthma-related death, as these guide intensity of monitoring and treatment 2, 3

Visual Supplements

• Include spirometry tracings showing pre- and post-bronchodilator curves 2
• Tables summarizing: Serial lung function measurements, medication adjustments over time, or comparison of biomarkers before and after treatment 1
• Keep all visual elements simple, compact, and self-contained 1