Question

A 7-year-old female weighing 26 kg presents to the emergency department with an asthma exacerbation. Her mother reports she has had an upper respiratory tract infection for the last 2 days and has been using her albuterol inhaler more frequently. Today she has received treatments every 2 to 3 hours but still complains of shortness of breath and has frequent coughing. She reports taking her controller medication, Flovent 44 mcg 2 puffs bid as prescribed. Her mother states that the patient uses her controller medication every day. Your assessment reveals the following: an alert yet anxious 7-year-old, sitting on the edge of the bed leaning forward. She has moderate inter- costal retractions. You ask her to tell you her name and favorite activity at school, but she must stop and take a breath after four words. At this time, vitals are as follows: heart rate of 140 beats per minute, respiratory rate of 42 breaths per minute, SpO2 at 93% on room air, blood pressure of 90/60 mm Hg, temperature of 37.5°C. Upon auscultation, breath sounds are diminished with very faint expiratory wheezes throughout all lung fields.

1. You are called to the room.

   Your reassessment after an hour reveals the following: heart rate of 156 beats per minute, respiratory rate of 36 breaths per minute, SpO2 at 95% on room air. Mild intercostal retractions persist. Breath sounds reveal increased expiratory wheezes throughout all lung fields. The patient status has improved after an additional hour of observation (heart rate of 140 beats per minute, respiratory rate of 28 breaths per minute, SpO2 at 98%, blood pressure of 88/60 mm Hg). Intercostal retractions are no longer present. Breath sounds show improved air entry throughout all lung fields, and few expiratory wheezes persist. The patient is discharged home with follow up with her primary care physician in 2 days.

2. What key components are necessary for improving this patient’s asthma control?

Answer 1

1. What key components are necessary for improving this patient’s asthma control?

answer

Clinical background:

Patient is a 7 year old girl child with acute exacerbation of asthma hospitalized for it’s management.The patient is taking albuterol inhalation for the acute attacks and flovent inhalation 44mcg twice a day puffs as the controller medication for asthma..

Introduction:

Childhood asthma is a disease characterized by hypersensitivity of the airways causing acute airway obstruction thereby decreasing the oxygenation and increasing the effort of breathing.It occurs due to an allergen antibody reaction in the body which causes chronic inflammatory changes in the lungs. It is responsible for episodes of acute shortness of breath, breathing difficulty and cough and needs emergency treatment in cases of exacerbation. This is triggered in children generally by precipitating triggers which may be in the form of allergens or irritants/ weather/ emotions/exercise and is exacerbated by comorbid diseases which may be concomitantly present in the child.

The key components for improving this patient's asthma control are discussed below:

1. identification of the allergen/irritant/precipitating trigger

An effort to control/ eliminate the precipitating factor/trigger is one of the key components for the asthma control.

The common allergens responsible for triggering the asthma attack include pollen, dust ,mites dander or irritants like smoke, perfumes,wood insecticide sprays, fires etc. These precipitating factors of asthma attack must be identified during taking patient history and eliminated by thorough observation and collaborative correlation by the patient's family.

For example, the patient's family should be advised temporary to shift the housepet to a foster home/ adoption centre if that(hair,dander) is found to be the reason for the patient's asthma exacerbation.

The asthma attack can also be exacerbated by warm or cold weather or strong emotions/exercise and these triggers must be identified.

For example,the patient must be educated about taking precautions to cover the nose and wear a scarf when going out in cold air if the attacks are triggered by the cold air.

2. identification of the existing comorbid disease conditions

In the patients with concomitant diseases, treatment of those disease conditions in order to prevent exacerbation of asthma attacks is necessary.. The other diseases in the patient like rhinitis, sinusitis, obstructive sleep apnea syndrome etc all tend to predispose the patient to attacks of asthma with increasing frequency and severity.

These must be controlled by the use of appropriate medications. Control of the existing diseases is important to prevent exacerbation of asthma attacks and facilitate its control.

For example, if the patient has allergic rhinitis, she must be given the medications for the control of the same regularly along with the asthma control medications

3. precautionary measures against upper respiratory tract infections:

The child and his family must be explained about the general precautionary measures against upper respiratory tract infections which include general hygiene,washing hands, maintaining a safe distance,using masks and avoiding close contact with people suffering from the flu.

The patient and her caregiver must be educated about the yearly flu shot that the patient must receive along with complete immunization in order to prevent the complications of asthma exacerbations like pneumonia and sepsis.

Additionally, they must be also guided to seek physician referral early in case of acute upper respiratory tract infection as the breathlessness increases and the symptomatology is not controlled by medications.

3. Modification of the controller medications in view of the poor control as documented by the episode of hospitalization must be done on priority basis, The dose of fluvent may be increased as permissible by the patient's age/weight or another controller drug /other drug combinations may be added to the patient's treatment plan in view of poor asthma.control

4. patient /patient family/ caregivers education regarding the disease, it’s triggers and the use of medications.

The patient family must be explained about  the role of allergy in the disease and that the identification of the trigger is important to prevent the acute attacks. It is equally important to educate that the patient uses the controller medications regularly and correctly in order to prevent the acute exacerbation of asthma and its complications.

Along with the patient's immediate family ,the patient's caregivers at school must also be educated about the patient's disease and involved in the patient's treatment plan.

5. use of peak flow meter must be taught to the patient wherever available and instructions of use must be demonstrated to the patient and his or her family. The instructions of use along with the importance of recording the readings in a diary must be explained. They must also be asked to note down if they find any suspected allergen or precipitating factor correlation along with the changes in the peak flowmetry readings. This helps to give an associative dimension to the exacerbation episodes of asthma with the triggers. thus  facilitating the planning of the treatment drugs and other control measures to prevent acute exacerbations.

6. developing an individualized asthma action Plan with medications in each of the green zone, yellow zone and the red zone explained to the patient's family and caregivers. The patients medications must be individualized as per the patients requirements,the prior history of exacerbation episodes, patients weight and allergy pattern. The drugs in the green zone are the ones which the patient must take regularly at his regular activities. The drugs in the yellow zone are to be taken when the patient has episodes of breathlessness,, cough chest tightness however if the patient's symptoms do not improve in the yellow zone on the medications in the action plan, the patient must come to the hospital .Red zone indicates severe breathlessness with chest wall retractions, use of accessory muscles of respiration, inability to speak and needs emergency attention.

The action plan must be prepared and handed over to the patient’s family/ patient's caregivers and thoroughly explained to them

7. demonstrating and documenting the correct the use of medications/ inhalers by the patient /patient's family

It is important for the nursing staff to ensure the patient/family education regarding the use of the inhaler. The patient/caregiver must be able to demonstrate the correct use of the inhaler and his or her understanding regarding the instructions of the use of the same must be perfect.

The common instructions/ patient education regarding the use of inhalers is briefed below:

a)The patient must shake the inhaler before use

b)The patient must use the inhaler with the mouth slightly closed around it to prevent the drug from escaping

c) The patient's mouth must be empty before using the inhaler and should not eat/drink with it.

d)The patient must be asked to inhale deeply while taking the drug so that it reaches the airways.

e)After using the inhaler, the patient must rinse the mouth and throw/spit out the fluid after gargling.

8.Regular physician checkups: The patient must be brought regularly to the pediatrician or respiratory physician treating the patient for checkup and review along with the peak flow meter diary and the individualized asthma action plan.The patient must receive her regular vaccinations and yearly flu shot. Consistent treatment under proper supervision is essential to the control of asthma.

All the above listed measures are the key components to improve the patient's asthma control

Summary: Identification and avoidance of the allergan or precipitating trigger, appropriate use of medications, controller drug modifications for control of asthma, treatment of comorbid diseases, use of peak flow meter and it's diary recordings, the development of an individualized asthma action plan for patient and holistic patient/family/caregiver education about the disease its causation,its triggering factors, the medications usage  are the key components to improve the patient’s asthma. control