Gender/Age: Female, teenager
History:Multiple hospital admissions for acute asthma exacerbations and one suspected case of anaphylaxis, complex mental health issues

• Cough
• Wheeze
• Chest tightness
• Shortness of breath

The patient had been nebulised and treated with oral corticosteroids during hospital admissions. Despite being started on inhaled corticosteroids (ICS), she showed no improvement, which raised concerns about the asthma diagnosis.

She had been stepped up to combination therapy (ICS-LABA), but still had no response. However, she reported that her blue inhaler (short-acting bronchodilator) was helpful, indicating a possible bronchodilator response.

Spirometry: Normal, even on a symptomatic day when readings were expected to be abnormal. The patient’s effort during spirometry was inconsistent, but after multiple attempts, the results suggested normal lung function.

Serial Peak Flow: No significant variability typical of asthma, though there were concerns about the accuracy of the readings as the patient had trouble completing the chart consistently.

The combination of normal spirometry, lack of peak flow variability, and very low FeNO indicated that asthma was not the correct diagnosis, despite her classic asthma-like symptoms. This allowed her healthcare team to stop escalating asthma treatments, which were not helping, and consider alternative diagnoses and treatment approaches.

• The patient avoided unnecessary increases in asthma medications, including high-dose inhaled corticosteroids, which would not have addressed the root cause of her symptoms. A new treatment plan was developed that focused on non-asthma-related causes of her symptoms.