Respiratory Disorders Essays

JR is currently experiencing an acute exacerbation of his chronic asthma.  The severity of his acute attack, given his tachycardia, tachypnea, and use of ancillary muscles places him in a severe category.  JR experiences asthma symptoms daily and experiences poor sleep secondary to waking up short of breath (SOB) leading me to say his chronic asthma is uncontrolled.

There are many triggers evidenced in the case study.  First, and seemingly most prominent, was the acute smell of smoke.  This trigger seems to have caused JR’s acute exacerbation, however, his uncontrolled chronic asthma is most likely being affected by his cats sleeping closely to his face, the probably second hand smoke coming from his neighbor’s smoking, and probable environmental contaminants he comes in contact with on his job as a carpenter.

Prior to JR’s acute asthma exacerbation, I would have placed him as a step 3 for controlling symptoms and minimizing future risk.  However, there were several errors noted in his medication regimen.  His albuterol dosage could have been increased to 2 puffs every 406 hours, not to exceed (NTE) 12 puffs in 24 hours.  His Solmeterol, was prescribed four (4) times per day and should have been every 12 hours.  He is on Ipratropium bromide MDI which is acceptable in an acute asthma exacerbation, but not for treating chronic asthma.  Instead, I would recommend tiotropium two (2) inhalations once daily.  Dahl et al. (2016) studied the use of tiotropium and found it to be safe and well tolerated, citing minimal anticholinergic side effects.  Lastly, in a small study conducted by Nageeb et al. (2019) the use of lovastatin was shown to improve lung function, so this is a good choice and provides dual therapeutic benefits.

Chisolm-Burns et al. (2019) recommends for patients presenting with an acute exacerbation of their chronic asthma, a short course of oral corticosteroids plus high dose inhaled corticosteroids or moderate dose of inhaled corticosteroid/LABA, so yes, I would prescribe a short course of oral corticosteroids such as methylprednisolone 40-60mg/day orally either once per day or twice per day in divided doses for a 3-10 day duration.  JR’s exacerbation seems to be a fairly mild exacerbation, so I would most likely air on the lower dosing with shorter duration for the OCS.

I would assess JR’s current response to treatment by evaluating vital signs, especially heart and respiratory rates, lung auscultation, and observe for use of accessory muscles.  Should heart and respiratory rates return to normal, lung sounds without wheezing, and absence of accessory muscle use, I would discharge the patient home on the medication regimen earlier described.

References

Chisolm-Burns, M. A., S, Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, J. M., & Bookstaver, P. B. (2019). Pharmacotherapy Principles & Practice (Fifth ed.). McGrraw-Hill Education.

Dahl, R., Engel, M., Dusser, D., Halpin, D., Kerstjens, H. A. M., Zaremba-Pechmann, L., . . . Bateman, E. D. (2016). Safety and tolerability of once-daily tiotropium respimat® as add-on to at least inhaled corticosteroids in adult patients with symptomatic asthma: A pooled safety analysis. Respiratory Medicine, 118, 102-111. doi:10.1016/j.rmed.2016.07.001

Nageeb, E., Abumossalam, A., Arram, E., & Aboshehata, M. (2019). Evaluation of the effect of statin therapy on airway inflammation and clinical outcome of moderate and severe bronchial asthma. The Egyptian Journal of Chest Diseases and Tuberculosis, 68(3), 328-337. doi:10.4103/ejcdt.ejcdt_175_18

The signs and symptoms that JR is exhibiting would be indicative to having severe, uncontrolled asthma.  I believe it is uncontrolled based on JR awakening twice a week during the night due to shortness of breath and he states that he wheezes on the daily basis. Readings below the normal range are a sign of airway narrowing in the lungs. A low peak flow measurement can occur before asthma symptoms, such as, wheezing or shortness of breath develop (Carr & Gerald, 2020).  JR’s usual peak flow of 325 L/min is more than 15% below his personal best which means he is not managing his asthma properly.  His current peak flow is also indicative of having severe asthma due to his current peak flow only being 175L/min while having a personal best of 480 L/min.  In the scenario, it was also stated that his body did not respond to the use of his albuterol inhaler, as well as him experiencing tachycardia, tachypnea, and the use of accessory muscles upon arrival to the hospital indicate that he has severe asthma.  In mild-to-moderate asthma, inhaled corticosteroids (ICS), bronchodilators and self-management education are the cornerstone of effective treatment.  However, 3% to 10% of the patients experience a severe form of asthma that fails to respond to standard therapy despite receiving maximal treatment (Clark et al., 2019).

JR has a lot of triggers in his daily life.  He has 2 cats that he allows to sleep next to him in the bed and on the same pillows he lays on.  He should not allow the cats in his bedroom to reduce the likelihood of their dander triggering an attack.  The idea that he works as a carpenter could expose JR to a lot of potential triggers also.  He should wear a mask and goggles if possible, during work to keep particles away from his mouth and eyes.  Presence of a specific trigger, other allergic diseases, such as, allergic rhinitis, a history of improvement of symptoms following past use of bronchodilator drugs (commonly salbutamol), personal or family history of asthma increase the likelihood of asthma (de Jong et al., 2015).  Another possible trigger, could be his neighbor in the apartment complex smoking.  Although he may not smell intense cigarette smoke, he is being affected.  Secondhand smoke can seep into multi-unit dwellings from many places, including vents and cracks in walls or floors (American Lung Association, 2020).  JR could speak with his landlord to see if HEPA filters can be placed to reduce his exposure.

JR should be on step 3 prior to ER because he has moderate, persistent asthma.  He should have been given a prescription for Albuterol MDI that helps with severe asthmatic episodes.  His current prescription does not even provide him relief in dealing with acute symptoms.  His current prescription should be Albuterol MDI 2 puffs q 4-6 hours prn.  Also, his current dose of Salmeterol Diskus is incorrect, it is causing him to receive too much medication for one day. This prescription should read Salmeterol Diskus 1 inhalation BID.  It is contraindicated for JR to take Lovastatin because they could cause him to have an asthma attack.  In addition to these risk factors, some anti-asthmatic drugs may worsen hypertension and vice versa and several anti-hypertensive drugs are contraindicated in asthma. For example, beta-blockers used to control blood pressure cause asthma attacks and therefore are contraindicated for asthma patients (Bragina et al.,2019).  Instead of Lovastatin, JR could take a calcium channel blocker like Procardia or Norvasc.

A short-burst of oral corticosteroid would be indicated at this time, but due to corticosteroids causing hypertension he would need to monitor his blood pressure closely for duration period.  JR would receive 40-50 mg/day of oral corticosteroids for 2 weeks. JR could be assessed for having well controlled asthma if he can sleep throughout night without awakening.  Also, if he doesn’t have any wheezing throughout the day or he does not have to use his inhaler more than twice a week.  Lastly, if his peak flow levels stay close to his personal best than it will show that he is controlling his asthma well.  To move JR down from Step 3 to Step 2, I would reduce the frequency of his albuterol and ipatropium bromide inhalers and monitor its effectiveness.

References:

American Lung Association. (2020, April 7).  Is secondhand smoke infiltrating your apartment

or condominium? https://www.lung.org/policy-advocacy/tobacco/smokefree-environment/multi-unit-housing/secondhand-smoke-apartments

Bragina, E.Y., Dosenko, V.E., Freidin, M.B., Goncharova, I.A., Hofestadt, R., Ivanisenko, V.A.,

Konigs, C., Saik, O.V., & Zolotareva, O. (2019).  Comorbidity of asthma and

hypertension may be mediated by shared genetic dysregulation and drug side effects.

Scientific Reports, 16302 (2019), 1-11.

https://doi.org/10.1038/s41598-019-52762-w

Carr, T.F. & Gerald, L.B. (2020).  Patient education: How to use a peak flow meter (Beyond the

Basics). UpToDate. Retrieved August 13, 2020, from

https://www.uptodate.com/contents/how-to-use-a-peak-flow-meter-beyond-the-basics#H1

Clark, V.L., Gibson, P.G., Majellano, E.C., McDonald, V.M., & Winter, N.A. (2019).

Approaches to the assessment of severe asthma: barriers and strategies.  Journal of

Asthma and Allergy, 12, 235-251.

https://doi.org/10.2147/JAA.S178927

de Jong, C., Kirenga, B.J., Okot-Nwang, M., Schwartz, J.I., & van der Molen, T. (2015).

Guidance on the diagnosis and management of asthma among adults in resource limited

settings.  African Health Sciences, 15(4), 1189-1199.

https://doi.org/10.4314/ahs.v15i4.18

Week 8 Respiratory Disorders

Asthma is a long-term inflammatory disease of the airways of the lungs. Asthma is presented by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasm(Vollmer, 2019). Asthma can be highly manageable with the right short active bronchodilators, long acting bronchodilators and inhaled corticosteroids.

In our case study JR has been experiencing uncontrolled and severe asthma. JR uses his albuterol daily, has wheezing and shortness of breath on a daily basis, and reports waking about twice per week for shortness of breath at night. All of these are signs that JRs asthma is not controlled at this time.

JR is in the ER with a severe asthma attack, as evidenced by is albuterol not offering him relief, tachycardia, tachypnea, wheezing, using accessory muscles to breath and hypertension. JR also has a PEF of 175L/min. Under 200 is a concern and contributes to the diagnoses of severe asthma attack(Vollmer, 2019).

When reviewing JRs medication, I would increase his Albuterol MDI to 2 puffs every 4-6 hours to help with his wheezing and shortness of breath. I would decrease his Salmeterol Diskus to three times a day, the maximum recommended dose. JR is on a statin and it is thought that statins anti-inflammatory action may actually benefit asthma(Naing & Ni, 2020). I would discontinue Lisinopril as ace inhibitors are contraindicated in asthma patients due to the potential for coughing and triggering an asthma attack. A good alternative to Lisinopril would be a beta blocker such as Inderal or Coreg.

JR is on the first step of medications to control asthma and should have been started on inhaled corticosteroids long ago. I would suggest adding inhaled corticosteroids at a low dose and starting to utilize the treatment steps for asthma. JR is on two SABA’s and one LABA and is still severe and uncontrolled.

JR needs some education on his asthma triggers. JR has cats and cat dander can be a major trigger for asthma attacks. JR also is exposed to his neighbors second hand smoke, and possible exposed to mold or chemicals in his job.

References

Naing, C., & Ni, H. (2020). Statins for asthma. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd013268.pub2

Vollmer, W. M. (2019). Assessment of asthma control and severity. Annals of Allergy, Asthma & Immunology, 93(5), 409–414. https://doi.org/10.1016/s1081-1206(10)61406-8

JR’s asthma severity and control are poorly controlled based on his most recent exacerbations and emergency visits. Before his emergency room, visit the patient express that he has frequent episodes of shortness of breath daily and while sleeping. His peak flow rate is regularly in the range of 325L/min, approximately 60% of his personal best rate, and he is possibly at a step 5-6. PEF is an objective test to measure lung function and to support the assessment of airway obstruction or inflammation. It is recorded using a peak flow meter, readings will vary from person to person and depend on height and age, and how constricted the patient’s airways are (Hill, 2019). He also continues to be symptomatic daily and has had recent visits to the emergency room. The fact that many patients still experience severe symptoms that negatively affect the quality of life suggests that asthma control remains an objective to be achieved (Chipps et al., 2017). His Ipratropium bromide is prescribed inappropriately, this medication is not intended for chronic us in asthma patients; however, it can be used in acute asthmatic situations. Evidence lacks anticholinergics, producing added benefits to beta-2-agonists in long-term asthma control therapy (Papadakis, 2020).

Based on the severity of and current medication JR could benefit from combination therapy, a short dosed inhaled corticosteroid, and a systemic corticosteroid. A short course of methylprednisolone prednisolone 40-60 mg daily or bid for 3-10 days with gradual dose reduction while initiating the ICS therapy along with beclomethasone HFA 240-480mcg (dose range for step 5 or 6) with medium daily dose in adult (Papadakis, 2020). To access the effectiveness and control, JR would be provided education to identify when to notify for adverse reactions and symptoms related to ineffective therapy, 2-3 week follow-up appointment for management and treatment goals, and referrals to pulmonology if goals are not met in 3 months of treatment. The various triggers that contribute to JR’s exacerbations include sleeping with his cats, occupation, and potential of second-hand smoke from his neighbor. His environment produces allergens that increase his heightened sensitivity to cause acute episodes. Education should be provided on environmental triggers and the reduction of allergy-producing behaviors.

References

Chipps, B. E., Corren, J., Israel, E., Katial, R., Lang, D. M., Panettieri, J., Reynold A, Farrar, J. R. (2017). Asthma yardstick: Practical recommendations for a sustained step-up in asthma therapy for poorly controlled asthma. Annals of Allergy, Asthma, & Immunology, 118(2), 133

Hill, B. (2019). Measuring peak expiratory flow in adults with asthma. British Journal of Nursing, 28(14), 924–926. https://doi-org.wilkes.idm.oclc.org/10.12968/bjon.2019.28.14.924

Papadakis, M. A., McPhee, S. J., & Rabow, M. W. (2020). Current medical diagnosis & treatment 2020. McGraw-Hill Education.

1. Classify JR’s asthma severity and control based on signs and symptoms prior to this most recent exacerbation and visit to the ED.

JR suffers from moderate persistent asthma. This type of asthma is characterized by the daily presentation of symptoms and more than one-time occurrence of asthma symptoms at night, just as seen in JR’s scenario.

2. Classify JR’s exacerbation severity based on PEF and symptoms.

Based on the GINA classification of asthma severity, the patient has moderate persistent asthma. JR has a PEF of more than 30% (Khajotia, 2008). He also uses the albuterol inhaler daily. Moreover, he experiences shortness of breath daily, and his condition becomes severe if he inhales a strange stimulus.

3. Identify the various triggers in JR’s life that may exacerbate asthma and prevent control.

According to Gautier and Charpin (2017), asthma can be triggered and exacerbated by passive smoking, indoor allergens, outdoor allergens, and occupational exposure. JR’s neighbor is said to be a smoker; therefore, indirect inhalation of the smoke may have triggered his condition. Also, JR is a carpenter; thus, the condition may have been exacerbated by dust and timber particles. The patient also has two cats in the house. This implies that he is exposed to indoor allergens such as fur and dander. Inhaling the cat dander may have triggered the exacerbation.

4. Which step should JR have been on prior to ER based on severity and current medications?

Step 3: Taking low doses of ICS/LABA in conjunction with SABA PRN or taking med-dose ICS.  The LABA reduces exacerbations; however, it requires 1% of oral steroids. This step is ideal for patients with daily asthma symptoms and existing risk factors and asthma triggers (Www2, 2015). It is also essential for patients like JR, with more than one awakening asthma symptoms per week.

5. Which medications are dosed incorrectly and/or inappropriate for JR’s asthma severity?

Albuterol MDI 2 puffs BID-QID PRN should be Q4 PRN

Salmeterol Diskus 1 inhalation QID should be BID.

6. Would a short-burst of oral corticosteroid be indicated at this time? If so, what dose and duration?

Yes. Since the patient’s symptoms continued to worsen, a short-burst of oral corticosteroid would be useful at this time.  JR should take a dose between 40 to 60 mg QD as a single dose or two divided doses of Methylprednisolone, Prednisolone, or Prednisone for 3-10 days.

7. How would you assess that JR is well-controlled?

I would assess JR through clinical observation and lung function tests. Clinical observation will involve physical assessment of the symptoms’ states to determine whether they have gone down. Lung function test involves measurement of the forced expiratory volume using spirometry.

8. If JR is well-controlled, how would you step down in therapy?

The approach for each patient “should be individualized according to the patient’s current treatment, risk factors, values, and preferences. For JR, I would recommend Once-daily low-dose ICS monotherapy or once-daily low-dose ICS/long-acting beta-antagonist (LABA).

References

Gautier, C., & Charpin, D. (2017). Environmental triggers and avoidance in the management of asthma. Journal of asthma and allergy, 10, 47–56. https://doi.org/10.2147/JAA.S121276 https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5349698/

Khajotia, R. (2008). Classifying asthma severity and treatment determinants: national guidelines revisited. Malaysian family physician: the official journal of the Academy of Family Physicians of Malaysia, 3(3), 131–136. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4170364/

Www2 (2015). BCGuidelines.ca: Asthma in Adults – Recognition, Diagnosis, and Management: Appendix B. Www2.gov. https://www2.gov.bc.ca/assets/gov/health/practitioner-pro/bc-guidelines/asthma_adults_appendixb.pdf

JR is a 56 year old with a history of asthma, HTN, and hyperlipidemia.  He presents to the ED two months after his last exacerbation with tachycardia, tachypnea, and wheezing.  JR reports daily shortness of breath and wheezing, and reports that he is using his rescue inhaler daily and wakes up at night with shortness of breath.  His peak flow in the ED is 175 L/min; his baseline is 325 L/min with a personal best of 480 L/min.  Based on his clinical presentation and report of  daily symptoms and use of rescue therapy, JR’s asthma is poorly controlled.  According to the American Lung Association (2020) peak flow readings should be 80%-100% of a patient’s normal readings to be considered in the “green zone”.  Based on JR’s PEV of 175 L/min which is much lower than it should be; his PEV should be at least 260 L/min to reach 80% of his normal values.  This indicates significant exacerbation of his asthma.  JR’s asthma triggers include his cats sleeping on his pillows, his occupation as a carpenter which exposes him to wood dust, and assuming that he lives in a home with a connecting wall, his neighbor smokes which delivers second-hand exposure.

JR should have been started on a low dose inhaled corticosteroid, such as Budesonide, during his last exacerbation.  If this was administered with his short-acting Albuterol MDI he may not have exacerbated and may have experienced better asthma control (Global Initiative for Asthma, 2019).  He is currently experiencing an acute exacerbation so my recommendation would be to give Prednisone 40 mg daily for 10 days, and Budesonide/formoterol 160/4.5 mcg, one inhalation twice daily as maintenance. Sobieraj et al (2018) demonstrated that single maintenance and reliever therapy (SMART) is more effective for reducing asthma exacerbations than treatment with inhaled budesonide alone.  The Global Initiative for Asthma guidelines (2019) state that the use of short-acting bronchodilators alone for asthma do not demonstrate safety benefits and are not recommended as monotherapy so I would discontinue JR’s Ipratropium and Albuterol.  Evidence of well controlled asthma would include decreased incidence of exacerbations at 3 months of therapy and improved peak flow measurements.  I would ask JR to keep an asthma diary to assess frequency, duration, and severity of exacerbations, in addition to a peak flow log to look for trends in improved lung function.  If indicated, I would start step down therapy with decreasing his SMART therapy to Budesonide/formoterol 80/4.5 mcg twice daily and see how he responds.  If he continues to do well in another 3 months, I would consider decreasing the frequency to daily at the lower dose of 80/4.5 mcg.

References:

American Lung Association. (2020). Measuring your peak flow rate. https://www.lung.org/lung-health-diseases/lung-disease-lookup/asthma/living-with-asthma/managing-asthma/measuring-your-peak-flow-rate

Global Initiative for Asthma. (2019). Global strategy for asthma management and prevention. Global Initiative for Asthma. https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf

Sobieraj, D., Weeda, E., Nguyen, E., Coleman, C., White, M., Lazarus, S., Blake, K., Lang, J., & Baker, W. (2018). Association of inhaled corticosteroids and long-acting ß-agonists as controller and quick relief therapy with asthma exacerbations and symptom control in persistent asthma: A systematic review and meta-analysis. JAMA: Journal of the American Medical Association, 319(14), 1485-1496. http://dx.doi.org.wilkes.idm.oclc.org/10.1001/jama.2018.2769