Refractory Asthma

1. What is the differential diagnosis for presentations which might be consistent with asthma (Ann Intern Med. 2014;160(5):ITC3-1.): 

A. COPD: Less reversible. Older patients with smoking history. 

B: Vocal Cord Dysfunction: Abrupt onset. Monophonic wheeze. More common in younger patients. Confirm with laryngoscopy and/or flow-volume loop. 

C: Heart Failure: Crackles. Limited response to usual asthma therapy. Edema. BNP elevation. 

D: Bronchiectasis: Large amounts of sputum. Rhonchi and crackles common. CT imaging will confirm. 

E: ABPA: Recurrent infiltrates on radiogram. Eosinophilia. High IgE levels. Frequent exacerbations.  

F: CF: Cough productive of large amounts of purulent sputum. Rhonchi. Clubbing. 

G: Mechanical Obstruction: More localized wheezing. If central, may show inspiratory blunting on flow-volume loop. 

2. How does one manage severe asthma in adults (same In The Clinic article as above)?