Station 37

Adele Anderson

Age: 16 years old female

Examiner

Station List
Doctor
Patient
Full Case

Marking Scheme

Data Gathering and Diagnosis  

  • Clarify whether asthma symptoms occur only with exercise or if there are other triggers.  
  • Ask if the patient experiences night-time cough, wheeze, or breathlessness.  
  • Ask about any associated symptoms, including palpitations, chest pain, and whether the patient has a cough, and if so, whether it is productive of phlegm.
  • Ask about the number of asthma attacks, use of oral corticosteroids, and any hospital or ICU admissions due to asthma.  
  • Confirm if the patient takes their inhalers as prescribed and how often they take reliever inhaler 
  • Ask about exposure to tobacco smoke – whether the patient smokes or has anyone that smokes around them  
  • Check for exposure to moulds or pets in the home.
  • Ask about a history of eczema, hay fever, or other medical conditions. 
  • Ask if the patient takes NSAIDs, over-the-counter medications, or has any known allergies.
  • Assess the impact of asthma on the patient’s education, sports participation, and overall quality of life.
  • Check if the patient is up to date with vaccinations, particularly flu and COVID-19 vaccines.  
  • Give a working diagnosis of poorly controlled asthma and/or exercise-induced asthma

Example of explanation to patient​

Adele, thank you for explaining everything so clearly. Based on what you’ve told me, it sounds like your asthma is not fully controlled, particularly during exercise. The fact that you’re needing your blue inhaler during football, and that it takes a while for your breathing to settle, suggests that your current treatment may need adjusting.

What you’re experiencing is often referred to as exercise-induced asthma, where physical activity triggers narrowing of the airways, leading to shortness of breath, wheeze, and chest tightness. In someone like you who’s active and aiming to progress in sports, it’s really important that we get this under control so you can train and compete without restriction.

Adele, even though you’ve been using your inhalers regularly, it sounds like your asthma is still not fully under control, especially during exercise. The good news is that we now have a newer, simplified approach to managing asthma, which might be a better fit for someone active like you.

Instead of using two separate inhalers—one brown preventer and one blue reliever—we can now manage your asthma with just one inhaler called Symbicort. It’s used in a way called MART, which stands for Maintenance and Reliever Therapy.

Here’s how it works:

  • You take 1 puff twice a day as your regular preventer, similar to the way you use your brown inhaler
  • And you use 1 puff as needed for symptom relief—like you would with your blue inhaler
  • You can take 1 puff before playing football to help prevent symptoms during exercise
  • You can take up to a maximum of 8 puffs per day for relief of symptoms such as shortness of breath, chest tightness, or wheeze, just like you would have done with your blue inhaler. 

This approach has been shown to work well for people, and the best part is, you’ll only need one inhaler instead of two.

I’d really like to see you face to face today, just to listen to your chest, check your inhaler technique, and make sure we’re not missing anything else. How does that sound?

Management 

  • Offer a face-to-face appointment to assesschest and check vital signs, including oxygen saturation, respiratory rate, and peak flow measurement.
  • Switch from her current inhaler regimen (SABA + ICS) to a low-dose MART regimen, in line with current asthma guidelines. You can offer Low dose MART such as  Symbicort 100/6 or Fostair 100/6, to be used as follows: 1 puff twice daily for maintenance, and 1 puff as needed for symptom relief, with a maximum of 8 puffs per day. Inform her this replaces her current two inhalers with a single combination inhaler.
  • Advise patient to take one puff of her MART inhaler before exercise, such as football, to help prevent exercise-induced asthma symptoms.
  • Prescribe with a spacer device if using a pMDI, such as Fostair pMDI; note that a spacer is not needed for dry powder inhalers, such as Symbicort Turbuhaler or Fostair Nexthaler.
  • Encourage her to stay up to date with influenza and COVID-19 vaccinations, as viral infections can trigger asthma flare-ups.
  • Provide a personalised asthma action plan (PAAP) if she does not already have one, outlining her daily medication use, proper inhaler technique, how to recognise worsening symptoms, what to do in an asthma attack, and when to seek medical help.
  • If she already has a PAAP, update it to reflect her new MART treatment plan.
  • Advise Adele to always carry her inhaler and ensure those around her—such as family, teachers, and coaches—are aware of her asthma management plan and know what to do in an emergency.
  • Arrange a follow-up in 4–8 weeks with yourself or the asthma nurse to review her response to the MART regimen and adjust treatment if needed.
  • Provide safety netting advice, explaining that if symptoms worsen despite using the MART inhaler, or she experiences severe shortness of breath, she should seek urgent medical attention via GP, out-of-hours services, or call 999 or attend A&E if severe.

Learning point from this station: ​

Asthma management has evolved with updated national guidelines. Clinicians must be familiar with these new guidelines and understand how to appropriately convert patients from older regimens to new regimens. 

Additionally, asthma reviews should always include:

  • Assessment of control and adherence
  • Inhaler technique checks
  • Evaluation of impact on quality of life, including physical activity and sleep
  • Review or creation of a Personalised Asthma Action Plan (PAAP)
  • Informing patient of the importance of vaccinations and trigger avoidance
Further reading