Respiratory Disorders Essays

JR is experiencing a severe asthma attack based on the severity of his symptoms. Also, he reports daily shortness of breath, wheezing, disturbed sleep two times a week, and increased variability in spirometry readings. I can conclude that he has uncontrolled asthma. Several external triggers contribute to his worsening condition, including pet dander, second-hand smoke, and occupational exposure. Additionally, methods to reduce exposure to allergens while tailoring modifications to the patient’s lifestyle and budget improve compliance (Reddel et al., 2015). For example, quitting his job may not be possible; however, instructing JR to wear a protective mask to limit work-related allergen exposure is a practical solution. JR should have been on step 4 before his E.R. admission. The Global Initiative for Asthma (GINA) recommendations for step 4 include; formoterol DPI a long-acting beta-2 agonist (LABA), 12 mcg capsule inhaled every 12 hours daily, tiotropium a long-acting muscarinic antagonist (LAMA), two inhalations of 1.25mcg  daily, and Albuterol MDI a short-acting beta-agonist (SABA), as needed (2109). While in the emergency room, JR requires supplemental oxygen and oral corticosteroids 2mg/kg daily. Systemic corticosteroids are proven to speed the resolution of symptoms and reduce reoccurrence when continued for 3-4 days after an acute attack (Alangari, 2014). Also, JR should be tested for a possible specific phenotype that predisposes him to attacks and schedule an appointment with an asthma specialist. Patient education should include inhaler skills to ensure proper administration of doses, a written asthma treatment plan, and regular spirometry monitoring. Unfortunately, there are no specific criteria for assessing control; however, three months of good control may include reducing exacerbations, symptom management, and peak flows with decreased variability. In conclusion, step down includes tapering oral corticosteroids first. Next, re-evaluate asthma medications every 3-6 months and reduce add-on treatments individually based on observed benefits and risk factors (GINA, 2019).

                                             References

 

Alangari A. A. (2014). Corticosteroids in the treatment of acute asthma. Annals of thoracic medicine, 9(4), 187–192.

 https://doi.org/10.4103/1817-1737.140120

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

Reddel, H. K., Bateman, E. D., Becker, A., Boulet, L. P., Cruz, A. A., Drazen, J. M., Haahtela, T., Hurd, S. S., Inoue, H., de Jongste, J. C., Lemanske, R. F., Jr, Levy, M. L., O’Byrne, P. M., Paggiaro, P., Pedersen, S. E., Pizzichini, E., Soto-Quiroz, M., Szefler, S. J., Wong, G. W., & FitzGerald, J. M. (2015). A summary of the new GINA strategy: a roadmap to asthma control. The European respiratory journal, 46(3), 622–639. https://doi.org/10.1183/13993003.00853-2015

 

https://docs.google.com/document/d/13K_O6edoqF-oyUY2An2JEkufqOeTizVFtwfyZ5goCH4/edit?usp=sharing

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    Karen Halter posted Oct 28, 2020 6:07 PM

    Pharm Module 9

    This week’s post is going to answer the following questions regarding JR and the exacerbation that he is having with his asthma.

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

    JR reports daily wheezing despite SABA use and daily medications on board. He also reports night awakening with symptoms. Daytime symptoms with nighttime awakening with shortness of breath combined with reliever use indicates poor control and increased risk for asthma exacerbation.(Gina-2019-main-report-june-2019-wms, 2019)  JR has had previous ED visit 2 months ago, and is at great risk for exacerbation due to poor control.

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

    JR is presenting with SOB for an hour even after using his rescue inhaler with symptoms of tachycardia, tachypnea, wheezing, accessory muscle use, and hypertension. His peak-flow is less than 50% of his personal best of 480. According to Chisholm his condition would be considered severe requiring inpatient hospitalization with combination therapy of inhaled SABA and ipratropium bromide in the ED setting with systemic corticosteroids and oxygen to maintain saturation above 93%. (Chisholm-burns et al., 2019)

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

    Trigger for JR today seems to be the burning smell that he experienced, but daily his cats sleeping in his room and a close neighbor that smokes are also triggers. As a carpenter, he may be exposed to sawdust frequently which is another trigger.  Avoiding asthma triggers will be an important part of JR’s educational plan.

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

    JR is on step 4 according to GINA guidelines-utilizing medium/high dose ICS/LABA treatment but I feel due to poor control and possibly a need for increased education on triggers and medication administration and compliance that he should be on step 5. (Gina-2019-main-report-june-2019-wms, 2019)

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

    JR is on salmeterol diskus 1 inhalation qid-and the dose would be one inhalation every 12 hours for long term control. I would put him on an inhaled corticosteroid such as a combination of Fluticasone/salmetrol diskus with high dose because they are preferred treatment for all age groups. (Phillips & Vega, 2019)

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

    If not already ordered, upon discharge JR should have a 5-7 day course or oral corticosteroids at 40-50mg per day, and he should be seen and evaluated before discontinuation. As long as oral therapy is less than two weeks a taper is not required. (Gina-2019-main-report-june-2019-wms, 2019)

    How would you assess that JR is well-controlled?

    At JR’s follow up I would ensure that he is being compliant with his discharge medications, that symptoms have abated and controlled and that his P-F is reaching his previous personal best.(Gina-2019-main-report-june-2019-wms, 2019)

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

    Patients  like JR, who at discharge would be on step 4 with a moderate to high dose ICS often in combination with another medication are frequently not able to move to step 3 due to the severity of their disease.(Phillips & Vega, 2019) His frequent exacerbation of his asthma would make me hesitant at this time to consider stepping down his plan.

     

    References

    Chisholm-burns, M. A., Schwinghammer, T. L., Malone, P. M., Kolesar, J. M., Lee, K. C., & Bookstaver, P. B. (2019). In Pharmacotherapy principles and practice, fifth edition (5th ed., pp. 256–257). Mcgraw-hill Education / Medical.

    Gina-2019-main-report-june-2019-wms [PDF]. (2019). https://ginasthma.org/wp-content/uploads/2019/06/GINA-2019-main-report-June-2019-wms.pdf

    Phillips, D., & Vega, C. (2019). https://www.medscape.org/viewarticle/909793

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    Last post Nov 1, 2020 7:16 PM by Shante Hunt
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    Candace Whitman-Workman posted Oct 28, 2020 9:44 PM

    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

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    Last post Nov 1, 2020 5:47 PM by Kathryn Mosholder
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    Carlita Lockett posted Oct 27, 2020 12:59 PM

    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

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    Last post Nov 1, 2020 1:57 PM by Anna McMullen
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    Robin Morgan posted Oct 26, 2020 8:45 PM

    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 Reviewshttps://doi.org/10.1002/14651858.cd013268.pub2

    Vollmer, W. M. (2019). Assessment of asthma control and severity. Annals of Allergy, Asthma & Immunology93(5), 409–414. https://doi.org/10.1016/s1081-1206(10)61406-8

     

     

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    Last post Oct 31, 2020 2:31 PM by Robin Morgan
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    Pawn Johnson-Hunter posted Oct 29, 2020 2:23 AM

     

    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 Nursing28(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.

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    Kathryn Mosholder posted Oct 28, 2020 10:01 PM

    Model IX Respiratory Disorders Asthma Patient

    The patient in this model named JR has presented to the ER after smelling smoke and is tachycardic, tachypneic, wheezing, using accessory muscles, and hypertensive. He tried to use his rescue inhaler, but it did not help. He has a history of asthma attacks, the last one being two months ago. He is short of breath during the night. He sleeps with two cats has secondhand smoke from the neighbor who smokes, and it comes through the walls, and he is a carpenter by trade, so he is around a lot of dust at work. His usual peak flow is 325min/L, which he measures once a week, but currently, it has decreased by 175 L/min.  His current medications are albuterol MDI 2 puffs BID-QID PRN, salmeterol Diskus 1 inhalation QID, Ipratropium bromide MDI 2 puffs QID, lovastatin 20 mg, and lisinopril 10mg PO QD.

    Before JR presented to the ER and was in his current health, he had moderate persistent asthma. In his current state, he is a step 4 (Bookstaver et al., 2019). Once presenting to the ER, this patient was a step 5. PEF measurements are more useful in determining symptoms and when to increase medication because they allow an objective evaluation of dyspnea (Souma et al., 2018). Many patients with severe asthma are not always aware of their dyspnea (Souma et al., 2018). When PEF is decreased, 88.9% or more medications should be increased (Souma et al., 2018). In this patient’s life, he has several triggers, including secondhand tobacco smoke from the neighbor through the wall, smoke from the outdoors, most likely wood smoke, cat dander from his cats that sleep with him, and dust from his occupation. In my opinion, you could change most of his medications. He will need to be in the ER setting have and inhaled SABA and ipratropium bromide (Bookstaver et al., 2019). O2 titrated to a pulse Ox above 94%, IV corticosteroids, oral corticosteroids once he stabilizes, and possibly IV magnesium depending on how he tolerates the other interventions (Bookstaver et al., 2019). I would probably discharge this patient on Advair Diskus because it combines fluticasone and salmeterol. After all, it will help with chest tightness and wheezing (Bookstaver et al., 2019). I would also discharge him with an albuterol inhaler for emergencies on the go and a nebulizer at home to use albuterol and Ipratropium bromide twice a day and prn. He should also continue to take his lisinopril unless he feels it is causing a cough(Bookstaver et al., 2019). Lovastatin can cause chest tightness, so if he feels it is causing this side effect, I will change him to a different drug (Bookstaver et al., 2019). Beta-blockers can make asthma worse, so they are not recommended in this case (Bookstaver et al., 2019). I would discontinue his salmeterol Diskus.

    Providers should be aware when deciding on a longer-term regiment. Research suggests that even though inhaled corticosteroids effectively treat asthma patients’ exacerbations, they do not improve lung function or reduce future exacerbations (Iida Vähätalo et al., 2018).  Once JR is discharged home, I would continue to assess his PFTs, and if they stabilize back to his normal, and he has no other extreme signs or symptoms, I would consider him stable. I would also educate JR to try to avoid as many triggers as possible. I would encourage him to wear a mask when it is dusty at work, paint, and seal the wall on the side of his apartment where his smoking neighbor lives and come inside when there is smoke in the air. I also would encourage him to have his cats sleep somewhere else besides his bed. All of these suggestions may reduce exacerbations of his asthma.

     

    References

    Bookstaver, P. B., Chisholm-Burns, M. A., Kolesar, J. M., Lee, K. C., Malone, P. M., & Schwinghammer, T. L. (2019). Pharmacotherapy principles & practice. McGraw-Hill Education.

    Iida Vähätalo, Ilmarinen, P., Tuomisto, L. E., Niemelä, O., & Kankaanranta, H. (2018). Inhaled corticosteroids and asthma control in adult-onset asthma: 12-year follow-up study. Respiratory Medicine, 137, 70-76. http://dx.doi.org.wilkes.idm.oclc.org/10.1016/j.rmed.2018.02.025

    Souma, R., Sugiyama, K., Masuda, H., Arifuku, H., Nakano, K., Watanabe, H., . . . Kurasawa, K. (2018). Effect of adjusting the combination of budesonide/formoterol on the alleviation of asthma symptoms. Asthma Research and Practice, four doi:http://dx.doi.org.wilkes.idm.oclc.org/10.1186/s40733-018-0043-8

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    Last post Oct 29, 2020 5:38 PM by Karen Halter
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    Gisselle Mustiga posted Oct 29, 2020 1:00 AM

    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 allergy10, 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 Malaysia3(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

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    Shante Hunt posted Oct 28, 2020 8:49 PM

    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 ratehttps://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

     

     

     

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    Augusta Ibeh posted Oct 28, 2020 8:40 PM

     

    Sickle cell disease (SCD) is a group of autosomal recessive disorder characterized by the production of hemoglobin S (Hb S; sickle hemoglobin) within the erythrocytes. The Hb S is formed due to a genetic mutation in which one amino acid (valine) replaces another (glutamic acid) Huether et. al., (2020 p. 551). Sickle cell disease (SCD) is a group of inherited disorders caused by mutations in Beta Globin-related Hemoglobinopathies (HBB), which encodes hemoglobin subunit β. The incidence is estimated to be between 300,000 and 400,000 neonates globally each year, the majority in sub-Saharan Africa Kato, Piel & Reid et al., (2018).

    Hemoglobin molecules that include mutant sickle β-globin subunits can polymerize; erythrocytes that contain mostly hemoglobin polymers assume a sickled form and are prone to hemolysis. Sickle cell disease is characterized by red blood cells that assume an abnormal, rigid, sickle shape Ilesanmi (2018). The Hb S is soluble and there is no problem when it has enough oxygen, but it is a problem when there is low oxygen supply (hypoxemia), PH and dehydration. These causes the Hb S to sickle, hemolysis of the red blood cells occurs, the sickled erythrocytes make the blood viscous leading to vascular occlusion, pain and organ infarction. Poor oxygenation some time causes hemolysis of the hemoglobin in the spleen or sequestration, blood pooling, infarction of the spleen, this leads to erythropoiesis in the bone marrow due to anemia and sometimes in the liver when severe Huether et. al., (2020 p. 553).

    Sickle cell disease does not manifest until at the age of 6 months old and this is time that postnatal concentration of hemoglobin F is reduced, causing the concentration of Hb S to increase. The clinical manifestations include pallor, fatigue, jaundice, and irritability as a result of hemolysis. When there is severe hemolysis, it could cause acute crisis such as:

    1.   Vaso-oclussive crisis (thrombotic crisis): Thicrisis starts with the smallest blood vessels, as the blood flow is blocked through the vessels causing spasms and pain. When this occur in the brain it may result to stroke and if it is in the kidney it will cause end-stage renal disease Huether et. al., (2020 p. 553).

    2.  Sequestration crisis: This type of crisis is seen in children less than 5 years. This is a condition where large amount of blood is pulled to the spleen and liver, if not corrected it can cause death Huether et. al., (2020 p. 554). Crizanlizumab, a P-selectin inhibitor, was approved by the FDA in November 2019 to reduce frequency of vaso-occlusive crisis (VOC) in adults with sickle cell disease. Binding P-selectin on the surface of activated endothelium and platelet cells blocks interactions between endothelial cells, platelets, red blood cells, and leukocytes Maakaron, (2020).

    3.  Aplastic crisis: Profound anemia that is caused by the lowered erythropoiesis even though there is need for new erythrocytes. In sickle cell the erythrocytes survive 10 to 20 days, the bone marrow manufactures and replaces it but when there is infection such as viral infection, aplastic crisis occurs Huether et. al., (2020 p. 554).

    Hyperhemolytic crisis: It may occur due to certain drugs or infections. It could be acute or chronic due to blood transfusion Huether et. al., (2020 p. 554).

    The methods of diagnosis of sickle cell disease differs with age of the person, but there are four tests done to detect SCD or prevent children born with this condition. These are done preconception, prenatal, neonatal and post-neonatal. The testing is done to identify potential of parents giving birth to children with SCD. The laboratory testing uses protein chemistry to separate Hb species to their protein structure, Hb electrophoresis, high-performance liquid chromatography (HPLC) and isoelectric focusing Kato, Piel & Reid et al. (2018). Couple that test positive during this screen may opt for in vitro fertilization with pre-implantation genetic diagnosis before the embryo is transferred to the mother Kato, Piel & Reid et al. (2018).

    The prenatal is done at 9 weeks of pregnancy and it is an invasive test. It done for couple that tested positive during preconception screen. It requires fetal DNA samples collected from the chorionic villus analysis Kato, Piel & Reid et al. (2018).

    The newborn screening is done at birth before symptoms occur. There are in two ways, selective screening for infants born by high risk parents and universal screening which identifies newborn babies with the SCD, and this helps to initiate treatments and precautions to prevent infections and deaths Kato, Piel & Reid et al. (2018).

    Post-neonatal testing requires the testing for SCD and tis is mostly done on immigrant at risk older patients that has not been tested before but at risk for SCD but attended clinic for family planning Kato, Piel & Reid et al .The knowledge of one’s is sickle cell carrier (HbAS)  is good to help in family planning to avoid having a baby with SCD.

    The treatments of patient with sickle cell disease is comprehensive and usually to help control pain, reduce complications and increase life expectancy. The administration of hydroxycarbamide which is a ribonucleotide reductase inhibitor. This helps to increase fetal hemoglobin (HbF). This drug reduces incidences of sickle cell anemia in vaso-occlusive crises, hospitalizations and mortality Kato, Piel & Reid et al. (2018).

    Erythrocyte transfusion improves microvascular flow by reducing the number of circulating sickle erythrocytes and it helps to reduce endothelial injury and inflammatory injury

    Hematopoietic stem cell transplantation is used to cure SCD. Usually the human leukocyte antigen (HLA)-matched family donor. Survival of patients in USA and Europe had exceeded 90% according to studies Kato, Piel & Reid et al. (2018).

    The National Herat, lung, and Blood Institute instituted guidelines on how the treatment of SCD patients on experiencing Vaso-occlusive crisis. Pain management therapy should be initiated within 30 minutes of arrival to the emergency or 60 minutes of registration. Pain medication should be based on the patient’s SCD provider or an SCD protocol. In severe pain, morphine should be started per intravenous, or subcutaneously if unable to access vein, dosage should be calculated according home opioid use and morphine dosage should individualized. Pain reassessment every 15-30 minutes and opioid dosage re-adjusted according to pain scale. Opioid may be administered round the clock using PCA and monitor for sedation. Opioid should be titrated before discharging home and short-acting opioid ordered to prevent withdrawal. Do not use meperidine unless it is the only effective opioid for that patient. Use oral NSAIDs as an adjuvant analgesic, unless contraindicated

    Prescribe oral antihistamines for patients who require these agents for itching from opioids; give repeat doses every 4-6 hours, if needed, rather than with each dose of opioid Maakaron (2020).

    After this 38 years African American woman pain has been stabilized, vital signs should be reassessed to check the status of her heart rate and blood pressure which was elevated to see if her medications should be adjusted before discharged or if the elevations were due to pain. Hematocrit level should be rechecked to evaluate if patient requires blood transfusion. Empirical antibiotics depending if infection was detected administered according to the causative organism, or antiviral if the infection was due to virus infection.

    Patient should be encouraged to modify her diet by eating meat, fish, eggs, broccoli, green leafy vegetables, nuts, green beans, fruits and drinking plenty of fluids to prevent dehydrations. Patient should be advised to follow up with her primary doctor for sickle cell disease after discharge.

    Reference

    Huether, S. E., McCance, K. L., & Brashers, V. L.       (2020). Understanding Pathophysiology (7th ed.). Mosby/Elsevier

    Joseph E Maakaron, M. (2020, August 21). Sickle Cell Anemia Treatment & Management:    Approach Considerations, Hydroxyurea Therapy, Transfusion. Retrieved from       https://emedicine.medscape.com/article/205926-treatment#d12

    Kato, G., Piel, F., Reid, C. et al. Sickle cell disease. Nat Rev Dis Primers 4, 18010 (2018).       https://doi.org/10.1038/nrdp.2018.10

    Ilesanmi O. O. (2010). Pathological basis of symptoms and crises in sickle cell disorder:         implications for counseling and psychotherapy. Hematology reports2(1), e2.          https://doi.org/10.4081/hr.2010.e2