RESPIRATORY 1

A 35-year old male presents to the office with complaints of wheezing and tightness of the chest for the past 3 months. The patient also complains of hoarseness of voice. He has no history of bronchial asthma, hypertension or diabetes. He is a non-smoker but occasionally drinks alcohol. On examination, he is not in any distress. His vitals are, Pulse rate: 84/min, Blood Pressure: 130/80 mmHg, Respiratory rate: 18/min, and afebrile. Examination of the upper respiratory tract reveals a red and inflamed larynx. Chest is clear to auscultation and percussion. Based on the above scenario, what is the most appropriate initial treatment for this patient?

A.	Daily salbutamol inhalations
B.	Salbutamol 2 puffs only at bed time
C.	Oral theophylline
D.	Omeprazole before break fast
E.	Oral prednisone

the answer is

D.	Omeprazole before break fast

Explanation:

Any nocturnal, newly diagnosed asthma in a middle-aged patient should raise a suspicion for gastroesophageal reflux disease (GERD). The characteristic features of GERD such as the associated laryngitis are due to acid reflux. In this patient, hoarseness of voice and inflammation of larynx point towards a laryngitis. Therefore, with all these features it is better to give a trial of proton pump inhibitors (omeprazole), which would be both therapeutic and diagnostic.

Daily inhalation of salbutamol (Choice A) is the treatment when GERD is not suspected as an etiology or as an add-on therapy with Proton Pump Inhibitors (PPI).

Salbutamol at bedtime (Choice B) would be a good treatment for mild nocturnal asthma.

Oral theophylline (Choice C) is not indicated in this patient or for that matter as a first line drug in any newly diagnosed case of bronchial asthma.

Again, oral prednisone is not a medication of choice here because of two reasons. Steroids cause worsening of the GERD symptoms. Even if you use steroids in the treatment of bronchial asthma, inhaled steroids are more efficacious and have less systemic effects.