Question

Case scenario:

Maria, a 55 year-old patient, was recently diagnosed with bronchial asthma. Her mother and three brothers also have asthma. In the past year, Maria has had three asthmatic attacks that were treated with prednisone and an albuterol inhaler. At a clinic visit today, prednisone is prescribed for 4 weeks and the order is written as follows:

Day 1: 1 tablet four times a day

Day 2: 1 tablet three times a day

Day 3: 1 tablet two times a day

Day 4: 1 tablet in the morning

Day 5: ½ tablet in the morning

Questions:

1. Explain the purpose for the use of prednisone during the asthmatic attack. Explain why the dosage is decreased (tapered) over a period of 5 days.

2. Can Cromolyn sodium be substituted for prednisone during the asthmatic attack? Explain your answer.

3. Maria is prescribed Albuterol. What effect does albuterol have in controlling asthma?

4. For each drug dose, Maria is to take two puffs of albuterol administered by inhaler. What instructions should she be given concerning the use of inhaler?

To minimize the frequency of Maria’s asthmatic attacks, the doctor prescribes aminophylline 1200 mg/day in divided doses. The albuterol inhalation is to be taken as needed. Nursing interventions include patient history of asthmatic attacks and physical assessment.

5. When taking the patient’s history, what should the nurse include concerning asthmatic attacks? What physical assessment would suggest an asthmatic attack?

6. What type of drug is aminophylline? Why should the nurse asks Maria if she smokes?

7. What are the side effects, adverse reaction, and drug interactions related to aminophylline?

8. What nonpharmacologic measures can the nurse suggest that may decrease the frequency of asthmatic attacks?

9. Which are appropriate rescue medications used for acute asthmatic attack? Which drugs are used as preventive medications?

Answer 1

answer:

Explanation of the asthma pathophysiology:

The Pharmacotherapy  of asthma and the rationale of the drugs use can be understood by understanding the pathophysiology of asthma.

External stimuli or allergens, internal stress, exercise ----> antigen antibody reaction---->activation of the eosinophils,of mast cells,neutrophils-------> release of inflammatory cytokines------> cellular inflammation and edema------>bronchial obstruction  due to inflammation, mucosal edema and reactive bronchospasm -------->decrease in the air entry ------->airway obstruction------->precipitation of the asthma attack

Explain the purpose for the use of prednisone during the asthmatic attack. Explain why the dosage is decreased (tapered) over a period of 5 days.

answer:

The purpose for the use of prednisone during the asthmatic attack is for its anti-inflammatory action.

Prednisone is an anti inflammatory drug and systemic therapy of prednisone causes decrease in the inflammation of the respiratory tract by decreasing the antigen antibody reaction and inhibiting inflammatory response.It also decreases the mucosal edema and the ensuing airway obstruction in asthma. It decreases the irritability of the bronchioles and increases their responsiveness to the sympathomimetic drugs in cases where resistance has developed to them. Because of its anti-inflammatory action and potentiation of the action of sympathomimetic drugs(in cases of resistance), it is indicated during the asthmatic attack. It decreases inflammation,obstruction and promotes oxygenation and provides relief to the patient.

The reasons why the dosage is decreased (tapered) over a period of 5 days are explained below:

Prednisone given systemically inhibits the hypothalamus adrenocortical axis and causes pituitary adrenal suppression by feedback response thereby decreasing the body cortisol secretion. As a result when prednisone is withdrawn, it should be tapered slowly to allowed recovery for the adrenal glands to start secreting cortisol.Low cortisol levels cause weakness,fatigue and low blood pressure.

Hence Prednisone tablets must be tapered slowly to allow the adrenal to recover and maintain normal cortisol levels and prevent the occurrence of hypotension, weakness and fatigue in the patient by sudden withdrawal of prednisone.

Can Cromolyn sodium be substituted for prednisone during the asthmatic attack? Explain your answer.

answer:Cromolyn sodium cannot be substituted for prednisone during the asthmatic attack:

explanation: Cromolyn sodium is a mast cell stabilizer and acts by decreasing the inflammation.it is used for long-term control of asthma as a prophylactic therapy.It is a mast cell stabilizer and decreases inflammation by inhibiting the release of inflammatory cytokines from the mast cells activation.It is slow in action and the therapeutic effect of chromolyn sodium is seen slowly over two to four weeks of its oral administartion  and the effect lasts for 1 to 2 weeks after discontinuing .On account of its slow action and selective mast cell action,cromolyn sodium cannot be used as a substitute for prednisone in acute attack.

In an acute attack there is an allergic antigen antibody reaction which should be inhibited to decrease the severity of the inflammatory response.This effect is brought about by the prednisone but not by cromolyn Sodium .The inhibitory  actions of prednisolone on the antigen antibody reaction, the wider antiinflammatory effects and rapid onset of action within 1-2 hours of oral administration makes it a highly effective antiinflammatory therapy during the asthmatic attack and hence it is used for flareups.

Hence Cromolyn sodium (on account of slow and limited anti -inflammatory role) cannot be substituted for prednisone(fast acting,wider anti -inflammatory role) during the asthmatic attack.It is used for long term control of asthma as a prophylactic therapy.

Maria is prescribed Albuterol. What effect does albuterol have in controlling asthma?

answer:

Albuterol-salbutamol-beta 2 adrenergic agonist.(fast acting)-episodic asthma relief-relief in acute asthma.

Albuterol contains the compound Salbutamol which belongs to the group of Beta 2 sympahomimetic drugs. These drugs selectively act on the bronchial smooth muscle and cause their relaxation. Albuterol  acts in asthma by causing bronchodilation and relieving the airway obstruction due to its beta 2 adrenergic sympathomimetic effect.

Albuterol is a fast acting drug (action with 15-40 mins )and has a role in the episodic management of asthma and acute exacerbation of asthma by relieving the airway obstruction due to its bronchodilatory effect.

It relieves the patient of the sudden onset breathlessness ,the coughing, the tightness and constricting feeling present in the chest during asthma attack.

For each drug dose, Maria is to take two puffs of albuterol administered by inhaler. What instructions should she be given concerning the use of inhaler?

Answer: Instructions regarding the use of inhaler to be given to Maria are :

1.Maria should be instructed to shake the medicine before use.

2.She must be instructed not to eat anything when she is planning to use the inhaler;mouth must be empty.

3.She must be instructed to confirm the dose and the expiry date of the drug.

4.She should also be instructed to open the mouth and direct the inhaler towards the open mouth,close lips around it and breathe in slowly for 3-5 seconds as the medicine is being pressed.

5.The patient should also be instructed to close the mouth for about 10 to 15 seconds after the inhalation and let the drug travel and reach the lungs without escaping before taking the next dose.

6.The patient should be instructed to rinse the mouth after the inhalation and spit the water out after rinsing to prevent the medication side effects, both systemic and local. Use of corticosteroid inhalers can predispose to oral thrush if not mouth is not rinsed well after use.

7.The propellant used in the inhaler or the active medication itself can be responsible for acute hypersensitivity reactions and the patient must be educated about the same. Instruction to the patient to seek immediate medical help in such an event occuring must be given before hand.She must  report.immediately in case of any new allergic symptoms noticed on the drug inhaler usage or any worsening of her existing  symptoms.