Question

Respiratory Case Study 11

Instructions: Read the case study. Use the Rosdahl, Timby and drug books. For each question answered, cite the page number(s) of your reference(s). All questions apply to this case study. Your response should be brief and to the point. When asked to provide several answers, they should be listed in order of priority or significance. Do not assume information that is not provided.

Frances Johnson is a 31-year-old woman who presents to her healthcare provider with mild shortness of breath and a non-productive cough, worse at night. Her symptoms deteriorated slightly with a cold several weeks previously and have not improved. She also complains of itchy eyes, sneezing and persistent blockage of her nose. She was diagnosed with asthma at the age of 12 and given a blue and a brown inhaler. She remembers undergoing skin prick testing, which was positive for house dust mite allergy. Her asthma was not a problem until the last few years when she restarted inhaled salbutamol. She now needs this 3–4 times per day to help her breathing. She does not measure her peak flow rates as she has lost her peak flow meter but remembers her best was around 400 L/min.

1. Summarize Miss Johnson’s problems.
2. How should you approach assessment of her asthma?
3. What other information do you need to complete this assessment?

On examination: She is speaking in full sentences Respiratory rate is 20 breaths/min. Pulse rate is 90 beats/min. Her peak expiratory fl ow rate (PEFR) is 320 L/min (best 400 L/min.) She has a mild expiratory wheeze to hear on auscultation of her chest.

4. How does this new information alter your assessment?
5. What are the aims of asthma treatment?
6. What treatment will best achieve control of her asthma symptoms?

Answer 1

First question

Answer: The approach to assessment of her asthma is as follows:

History:

1. History of symptoms and its duration
   1. Symptom duration less than 2 times a week = well controlled
   2. Symptoms duration more than 2 times a week = partial controlled
   3. Symptoms throughout the week = uncontrolled.
2. Night time symptoms leading to awakening
   1. once a month - well controlled asthma
   2. More than once a month - partially controlled asthma
   3. More than once a week - uncontrolled asthma
3. Interference with daily activity
   1. None - well controlled
   2. Some limitation - partially controlled
   3. Extreme limitation - uncontrolled
4. Usage of short acting beta agonist ( blue color inhaler)
   1. Less than 2 days / week - well controlled
   2. More than 2 days / week - partially controlled
   3. several times per day - uncontrolled
5. Exacerbation requiring oral steroid
   1. 0 - 1 / year - well controlled
   2. 2 - 3 / year - partially controlled
   3. more than 3 times a year - uncontrolled

Calculating the asthma control test

• This is a type of questionnaire.
• 5 questions are asked to the patient and the patient is asked to score it between 0 - 5
• 0 = more symtoms and 5 = no symptoms at all
• The questions are
  • Are you able to do work in the last 4 week?
  • Have you experience shortness of breath?
  • Have you had night time symptoms?
  • Did you use nebulizer or rescue inhaler ( blue inhaler ) in the past 4 weeks
  • How you you rate your asthma control?
• Each question is scored and the scores are then totalled.
• Higher the score better is the control (>19)

Measuring the peak flow with a peak flow device - if the peak flow is > 80 % of the personal best - the asthma is well controlled

If the value is less than 60% of the personal best - it signify exacerbation or poor control. It also indicates the need for hospitalization or informing the health care worker.

Second question

Answer - The additional information that I need is :

1. Duration of symptoms
2. The peak flow value of the patient
3. The personal best value of the patient
4. The inhaler technique of the patient ( most common problem)
5. Does the patient regularly change the inhaler ( Most inhaler have 120 or 200 doses in them. If the patient uses them beyond this number, the patient is basically using an empty inhaler)
6. Comorbidites of the patient ( hypothyroidism, hypertension)

Third question

Answer - The addition information tells us that the patient is suffering from mild exacebation

Characteristics of mild exacerbation of asthma

1. Speaks in sentence
2. Respiratory rate in increased
3. The oxygen saturation is 90 - 95 % on room air
4. The pulse rate is less than 100 beats/ min
5. PEFR is more than 80% predicted
6. the patient is not aggitated
7. Wheeze is pressure
8. Blood pressure is normal

Fourth question:

Answer - The aims of asthma treatment:

1. To reduce daytime symptoms
2. To eradicate night time symptoms
3. to reduce the symtoms to a level that they don't interfere with daily activity
4. Reduce the usage of reliever medication
5. Improve the lung function
6. To prevent exacerbations in the future.
7. To prevent fibrotic remodelling of the airways. In other words prevent the development of fixed airway asthma.

Fifth question

Answer - The following treatment will best achieve control is as follows

1. The patient should be given a short course of steroid ( tablet prednisolone 40 mg for 7 days)
2. Antibiotic course with macrolide antibiotics to treat infections due to atypical organisms and also due their antiinflammatory activity. ( Tablet azithromycin 500 mg for 5 days)
3. Start the patient on Meter dose inhaler consisting of inhaled corticosteroids (ICS) - Example - Budesonide or beclomethasone
4. Start the patient of Meter dose inhaler consisting of long acting beta agonist (LABA)- Example - Formoterol
5. Use a 2 in 1 combination MDI ( ICS + LABA) if available.
6. The patient can be given MDI salbutamol or salbutamol through nebulization route. Both have equivalent effects.
7. Difficulting in using MDI is a common problem. In such patient's spacers should be used.
8. Start the patient of Montelukast (10mg ) and levocetrizine (5 mg) for itchy eyes and nasal blockage.