History summary The patient, male, born in May 1958, married, had a history of asthma since childhood with allergic rhinitis and allergic dermatitis, recurrent asthma attacks, long-term use of aminophylline and use of salbutamol aerosol, emergency room visits for asthma attacks several times a year, intravenous use of glucocorticoids and aminophylline can make symptoms better, but long-term failure to use control drugs such as inhaled glucocorticoids. The patient was forced to retire early due to progressive exacerbation of asthma since 2004, with marked activity limitation and inability to perform daily activities, and was hospitalized several times for asthma exacerbation and type II respiratory failure due to severe hypoxia with long-term home oxygen therapy. Initial diagnosis: The patient came to the asthma clinic of Zhongshan Hospital on July 25, 2007, with obvious shortness of breath, cyanosis of lips, pestle finger, heart rate of 110 beats, rhythmical, extensive croup in both lungs, swelling of both lower limbs, arterial oxygen saturation (SaO2) of 68%, ACT score of 7. The patient did not want to stay in the emergency room. At that time, chest X-ray showed emphysema changes in both lungs, blood count showed: leukocytes 10.5×109/L, eosinophils 10.6%, 1.11×109/L, serum IgE 1530 IU/mol, allergen skin test showed strong positivity to house dust mite, dust mite and various pollens. Ultrasound showed: right atrial right ventricular hypertrophy, severe pulmonary hypertension (80 mmHg), pulmonary function tests were not performed due to the severity of the disease. Diagnosis: allergic asthma combined with chronic obstructive pulmonary disease (COPD), type II respiratory failure, pulmonary heart disease, cardiac insufficiency. Treatment regimen: prednisone 10 mg Tid, sulforaphane 500 1 inhaled Bid, sulforaphane 0.2 Bid, and diuretics with dihydrocoumarotide and aminoglutethimide. Intensive home oxygen therapy was ordered and followed up after 1 week. Second visit (07.8.1.): significant improvement in symptoms, ACT score 20, SaO 275%,. The treatment plan was the same as before. Follow-up after 1 week. Third visit (07.8.8.): further improvement of symptoms, ACT score 22, SaO 280%. Prednisone was reduced to 5 mg Tid and the rest of the treatment regimen was the same as before. A follow-up visit was ordered in 2 weeks. Fourth visit (07.8.22): complained of living like a normal person, no asthma symptoms, ACT score 24, clear breath sounds in both lungs, no dry or wet rales, SaO 281%. Pulmonary function tests showed FEV10.90L, accounting for 26.1% of the expected value, FVC1.62, accounting for 37.8% of the expected value, and a negative bronchial reversibility test, which was a severe obstructive ventilatory function obstruction. Prednisone was continued to be reduced to 5mgBid, diuretics were discontinued, and sulforaphane 250 1 inhaledBid and sulforaphane 0.2Bid were continued. and prednisone was ordered to be continued to be reduced to 5mg qd after 1 week, then prednisone was discontinued and followed up after 1 month. The fifth visit (07.9.22): complained of frequent chest discomfort when prednisone was reduced to 5mg qd, and the symptoms worsened after stopping prednisone, with an ACT score of 20 and a SaO of 275%. Considering the severity of the patient’s disease and the failure of level 4 treatment to bring asthma under control, it was decided to upgrade to level 5 treatment, adding prednisone 5mg/day as a control therapy drug and continuing to use sulforaphane 500 1 inhaled Bid and sulforaphane 0.2 Bid. Continued monthly follow-up: the patient had an ACT score between 23 and 25 at each subsequent follow-up visit, no asthma symptoms, no use of relievers. has stopped home oxygen therapy and returned to work in December 2007. At the follow-up visit on December 23, 2009: pulmonary function test: FEV 11.20L, 39.0% of the expected value, FVC 2.04, 48.3% of the expected value, still severe obstructive ventilation dysfunction, negative bronchial reversibility test. Arterial blood gas test: PH 7.38, PO 265 mmHg, PCO 248 mmHg, SaO 92% (type II expiratory failure, compensated phase), but significantly improved from before. Cardiac ultrasound: mild enlargement of right atrium and right ventricle, mild pulmonary hypertension (33mmHg), chest CT: chronic inflammatory changes in both lungs. Current medications: sulforaphane 500 1 inhaled Bid, prednisone 5mg/day, sulforaphane 0.1 Bid. Treatment experience: 1, Asthma patients have severe airway remodeling with irreversible airway obstruction and consequent pulmonary heart disease and type II respiratory failure due to long-term irregular treatment without standardized use of inhaled glucocorticoids to control airway inflammation during the 50-year course of asthma. 2, Even in the most severe asthma, anti-inflammatory therapy for airway inflammation and the standardized use of controlled medications according to guidelines can be of great benefit to the patient, significantly improving symptoms and quality of life. 3.In the graded treatment of asthma, for severe patients, if level 4 treatment cannot achieve asthma control, if necessary, it can be upgraded to level 5 treatment with the addition of small doses of glucocorticoids as the controlling drug, which can bring benefits to patients. 4. For asthmatic patients with severe airway remodeling, lung function cannot be significantly improved even after standardized treatment and significant improvement of symptoms. For such patients, ACT score is a good supplement and can be used to determine the patient’s asthma control.