Case 3 R.J. is a 15-year-old boy with a history of asthma diagnosed at age 8. His asthma episodes are triggered by exposure to cats and various plant pollens. He has been using his albuterol inhaler 10 to 12 times per day over the last 3 days and is continuing to wheeze. He normally needs his inhaler only occasionally (2 or 3 times per week). He takes no other medications and has no other known medical conditions. Physical examination reveals moderate respiratory distress with a respiratory rate of 32, oximetry 90%, peak expiratory flow rate (PEFR) 60% of predicted, and expiratory wheezing. Discussion Questions 1. What is the underlying mechanism of R.J.’s asthma? What are the three airway responses that occur during an asthma episode? 2. In addition to bronchodilator therapy with intermittent albuterol, what other pharmacotherapy is important in the management of asthma? 3. What is the significance of a PEFR at 60% predicted? If spirometry were performed at this time, what would be th
Asthma is a respiratory disorder characterized by airway inflammation. Asthmatic attacks often proceed the exposure to environmental triggers. Exposure to triggers such as animal dander and pollen triggers an inflammatory response in asthmatic patients due to bronchial hypersensitivity. This results in airway inflammation and increased mucous production with consequent narrowing and blockade of the airway (Papi et al., 2020). The manifestations of wheezing, cough, and shortness of breath result and are due to the narrowing of the airway and the body’s reflex to clear the airway. The three airway responses in an asthmatic episode are airway inflammation, smooth muscle contraction, and mucous hypersecretion.
Pharmacotherapeutic Options in Asthma Management
Several pharmacotherapeutic options are available in asthma management. Corticosteroids such as fluticasone, muscarinic antagonists such as ipratropium bromide, long-acting beta-agonists such as formoterol, leukotriene antagonists such as montelukast and methylxanthines such as theophylline are effective in managing asthma.
Significance of a PEFR at 60% Predicted
PEFR shows the amount of air that can be forcefully exhaled. PEFR at 60% predicted signifies that the patient’s airway is narrowing. It informs the need for corrective action. If spirometry is conducted at PEFR 60% predicted, the amount of air that the patient can forcefully exhale will only be 60% of the predicted amount.
Managing R.J.’s Problem and Monitoring Response to Therapy
The patient can be best managed by adding low-dose inhaled corticosteroids to the albuterol. Findings reveal poor response to the albuterol medications as demonstrated by continuous wheezing and an increase in asthmatic episodes prompting multiple inhaled albuterol use. Treatment response can be monitored by assessing symptoms recurrence, the need for inhaler use, night-time symptoms, and the activity level of the patients (Papi et al., 2020).
Preventive and Treatment Measures for Inclusion in R.J.’s Discharge Teaching
During discharge, the patient should be educated on conservative measures against the disease. This includes avoiding asthmatic triggers, environmental control to ensure that the environment is free from allergens, and education on bronchial thermoplasty, which is effective in preventing acute asthmatic attacks. The patient should also be educated on effective inhaler techniques to optimize the effect of the medications.
References
Fazleen, A., & Wilkinson, T. (2020). Early COPD: Current evidence for diagnosis and management. Therapeutic Advances in Respiratory Disease, 14, 175346662094212. https://doi.org/10.1177/1753466620942128
Freund, Y., Cohen-Aubart, F., & Bloom, B. (2022). Acute pulmonary embolism. JAMA, 328(13), 1336. https://doi.org/10.1001/jama.2022.16815