Childhood Asthma OSCE - Poorly Controlled Asthma Review | Free OSCE Practice

Case Overview

Age/Sex: 7-year-old male
Occupation: Primary school student
Setting: Paediatric clinic visit with parent as historian (follow-up after recent ED attendance)
Chief complaint: "He's been wheezing and coughing a lot — again."

Patient Script

Who I Am

I'm his mum; he's a 7-year-old primary school pupil and we've been coming to EDs a lot for his breathing.

What Brings Me In

He’s been wheezy and coughing more than usual for the last couple of weeks and the inhaler doesn't seem to help as much as it used to.

My Story

He's had cough and wheeze on and off for a while, but this time it started about 2 weeks ago after a cold. He has daily cough, worse at night, and he wakes up most nights with coughing. He’s been using his reliever inhaler (salbutamol) several times a day — sometimes every few hours — and it only helps a little. He went to the ED last month and got a nebuliser and a short course of oral steroids; he was better for a couple of weeks but now the cough and wheeze came back. He has had 3 ED visits in the past 12 months, and has had 2 courses of oral steroids in the past 3 months. He struggles with running and gets out of breath quickly at school. He sometimes coughs during playtime and sits out at gym class.

I was told he should be on a preventer inhaler, but I often only give it when he is wheezy because I worry about giving steroids every day. We have a spacer but I’m not sure we always put it together right. His dad smokes but says he smokes outside — there’s also a dog in the house. He had baby eczema but no food allergies that we know of.

My Medical Background

Past medical history: Asthma diagnosed at age 3; infantile eczema
Medications: Salbutamol (pressurised metered-dose inhaler) PRN; inhaled corticosteroid was prescribed (name unclear) but used irregularly
Recent treatments: Oral prednisolone courses twice in last 3 months; recent short course of amoxicillin from GP for chest infection (5 days, finished 10 days ago) — he didn’t seem to improve much on that
Allergies: None known
Social: Lives with both parents and younger sister; father smokes (smokes outside); house has a dog; attends primary school
Family history: Mother has hay fever; no family history of cystic fibrosis or congenital heart disease

What I Think & Worry About

I think he keeps getting chest infections and I worry he might get really poorly again and need to stay in hospital.
I worry that daily inhaled steroids might be bad for his growth, so I try to avoid giving them unless he’s really wheezy.
I want to know what else I can do at home so he doesn’t miss school and stop playing with his friends.

If You Ask Me About Other Symptoms...

Fever: He’s had a low-grade fever with the cold 2 weeks ago but not high fevers now.
Sputum: Mostly dry cough, sometimes brings up sticky clear phlegm.
Exercise: Gets breathless and coughs during running and PE; sits out sometimes.
Night symptoms: Wakes most nights coughing, sometimes needs salbutamol to settle him.
Growth/appetite: Eating OK, no vomiting, seems a bit tired because of poor sleep.
ENT: Some nasal congestion with colds; no obvious sinus pain.
Skin: Had eczema as a baby but not much now.
Travel/pets: No recent travel; yes there is a dog at home.
Smoking exposure: Dad smokes but says he goes outside; I try to keep him away but not always possible.
Red herrings: He was given antibiotics recently and we sometimes use cough syrup; he also had a brief bout of a rash last year after a mosquito bite.

Clinical Summary

Examination

General: Alert, comfortable at rest, interactive with parent; mild tachypnoea when asked to run briefly
Vital signs: HR 110 bpm, RR 24 breaths/min, SpO2 96% on room air, Temp 37.2°C
Growth: Weight 23 kg (50th centile), Height 122 cm (50th centile)
Respiratory exam: Audible expiratory wheeze bilaterally, prolonged expiratory phase, mild intercostal retraction on exertion, decreased air entry at bases but no focal bronchial breathing
Cardiac: Heart sounds normal, no murmurs
ENT: Nasal mucosa mildly congested; no tonsillar exudate
Skin: No active eczema rash

Investigations

Peak expiratory flow (at clinic): 180 L/min (predicted ~260 L/min) (reduced)
Spirometry (pre-bronchodilator): FEV1 70% predicted, FEV1/FVC reduced
Spirometry (post-bronchodilator): FEV1 86% predicted (approx. 22% improvement) (bronchodilator responsiveness)
Fractional exhaled nitric oxide (FeNO): 32 ppb (elevated, suggests eosinophilic airway inflammation)
Chest X-ray: Hyperinflation, no focal consolidation
CBC: WCC 8.6 x10^9/L, neutrophils 4.8 x10^9/L
CRP: <5 mg/L
Recent ED record: 3 presentations in past 12 months, 2 recent oral steroid courses, one brief overnight observation admission

Diagnosis

Primary: Poorly controlled asthma (supported by history of frequent symptoms, nocturnal cough, exercise limitation, multiple recent ED attendances and oral steroid courses, reduced peak flow/FEV1 with significant bronchodilator reversibility, elevated FeNO)
Differential diagnoses:
- Viral bronchospasm/reactive airways disease (recent URTI triggered worsening, but recurrent pattern and spirometry reversibility favour asthma)
- Protracted bacterial bronchitis (less likely: normal inflammatory markers, lack of persistent wet cough)
- Allergic rhinitis with cough contributing to poor control (possible comorbidity given family hay fever and nasal congestion)
- Foreign body aspiration (unlikely: gradual onset, bilateral symptoms, no choking episode)
- Primary ciliary dyskinesia or cystic fibrosis (unlikely given history and growth; no chronic productive cough or failure to thrive)

Management

Acute: If symptomatic now — administer short-acting bronchodilator (salbutamol via spacer/MDI with mask if needed) and reassess; consider a short oral steroid if moderate/severe exacerbation and per local guideline
Controller therapy: Explain the need for regular daily inhaled corticosteroid and step up to a preventive regimen (e.g., start/ensure adherence to low–moderate dose inhaled corticosteroid such as fluticasone 100 mcg twice daily via MDI with spacer) rather than intermittent use
Inhaler technique & equipment: Provide spacer and demonstrate correct spacer + MDI technique with child present; observe return demonstration at clinic
Education & written plan: Provide a written asthma action plan detailing daily controller use, reliever use, when to increase therapy, and clear red flags for ED return; advise regular peak flow or symptom monitoring
Address adherence and concerns: Discuss parental worries about steroid side effects and provide balanced information (growth monitoring plan, lowest effective dose) to improve adherence
Environmental measures: Advise on smoke cessation (offer referral/support to father), minimise indoor allergen exposure (pet access to child’s bedroom, bedding measures for dust mites)
Follow-up and escalation: Arrange asthma nurse review within 1–2 weeks for technique/adherence and follow-up spirometry in 4–6 weeks; if poor control despite good adherence, consider stepping up therapy or referral to paediatric respiratory clinic
Immunisations: Ensure influenza vaccine offered annually

Key Learning Points

Frequent ED visits, nocturnal symptoms, exercise limitation and repeated oral steroid courses are red flags for poorly controlled asthma and warrant stepping up controller therapy and review of adherence/technique.
Always check inhaler technique and use of a spacer; many treatment failures reflect poor delivery rather than drug failure.
Address modifiable factors (smoke exposure, allergens, parental concerns about steroids) with practical advice and a written asthma action plan to reduce exacerbations and ED use.