ASMA AKUT My boy has trouble breathing and he keeps coughing. His albuterol isn’t helping.” _ HPI Peyton Harrison is a 3-year-old African-American boy who presents to the emergency department with a 3 -day history of cough and congestion. The mother was giving him albuterol, 2.5 mg via nebulization twice a day since the cough started. She was also giving him an allergy medicine. He did have a fever 3 days prior to admission, and he was given ibuprofen. The previous night before admission, he seemed to be gasping for air and during the day today, he has had a n increased work of breathing. Mother also notes that he has been fussy, not eating well, and has had only two to three urinations in the past 24 hours. His assessment in the emergency department revealed him to have labored breathing that was more difficult with activities. He had mild retractions with tachypnea at 52 breaths per minute. His other vital signs were a heart rate of 137 beats per minute, blood pressure of 100/68, temperature of 38.9°C, and a weight of 14.4 kg. The initial oxygen saturation was 88%, and he was started on oxygen at 1.5 liter/min via nasal cannula. His breath sounds were noted to have fair air exchange but with expiratory wheezes. His chest x-ray revealed patchy infiltrates consistent with pneumonia. Peyton was complaining of a runny nose and sore throat. He did not have any ear pain. While in the emergency department, he was given three albuterol/ipratropium nebulizations and one dose of prednisolone 15 mg orally. He received one dose of acetaminophen 210 mg. His breath sounds and oxygenation did not improve so he was started on hourly albuterol nebulizations at 5 mg. Peyton was then transferred to the Pediatric Intensive Care Unit for further treatment and monitoring. _ PMH Asthma, unknown unknown if previous hospitalizations S/P tonsillectomy/adenoidectomy tonsillectomy/adenoidectomy at 2 years of age _ FH Unknown _ SH Lives with foster mother and two siblings. Birth mother has visitations. Unclear as to reason for foster placement. Positive tobacco exposure in current home. _ Meds Albuterol 2.5 mg via nebulizer as needed Phenylephrine/chlorpheniramine/methscopolamine Phenylephrine/chlorphenirami ne/methscopolamine (Dallergy®), dose unknown _ All NKA _ ROS (+) Fever, cough, congestion, increased work of breathing _ Physical Examination Examination Gen NAD, moderate increase in work of breathing VS BP 103/55, P 154, T 36.4°C, R 29, O2 sat 94% at 1.5 L/min nasal cannula Skin No rashes, no bruises HEENT NC/AT, PERRLA Neck/Lymph Nodes Soft, supple, no cervical lymphadenopathy Chest Slight decrease in breath sounds bilaterally, minimal wheezing CV RRR, no MRG Abd Soft, NT/N
Ext No clubbing or cyanosis Neuro A & O, no focal deficits _ Labs Respiratory viral panel nasal swab: positive for parainfluenza 3 Na 134 mEq/L WBC 6.5 103/mm3 K 3.0 mEq/L RBC 3.84 106/mm3 Cl 103 mEq/L Hgb 10 g/dL CO2 19 mEq/L Hct 34% BUN 6 mg/dL Plt 252 103/mm3 SCr 0.4 mg/dL Glu 140 mg/Dl
_ Chest X-Ray Patchy infiltrates throughout lung fields _ Assessment Asthma exacerbation with pneumonia and dehydration
QUESTIONS Problem Identification 1.a. Create a list of the patient’s drug-related problems. 1.b. What information (signs, symptoms, laboratory values) indicates the severity of the acute asthma attack?
Desired Outcome 2. What are the acute goals of pharmacotherapy in this case?
Therapeutic Alternatives 3.a. What nondrug therapies might be useful for this patient? 3.b. What feasible pharmacotherapeutic alternatives are available for the treatment of acute asthma?
Optimal Plan 4.a. What drug, dosage form, dose, schedule, and duration of ther apy are best for this patient’s acute asthma exacerbation? 4.b. What other pharmacotherapy would you recommend in the acute treatment of this patient? ■
CLINICAL COURSE
Within 72 hours of initiation of the treatment plan for management of the acute exacerbation, Peyton was stable enough to transfer to the general pediatric floor. His vital signs were BP 111/67, P 108, R 26, T 36.7°C, O2 sat 99% on 0.5 L/min nasal cannula. Mother states that he is more li ke his normal self and doesn’t seem to have much trouble breathing now. 4.c. What drug, dosage form, dose, schedule and duration of therapy are best for this patient’s discharge plan?
Outcome Evaluation 5.a. Once the patient has transferred to the general medical floor and his vitals have improved (see Clinical Course), what clinical and laboratory parameters are necessary to evaluate the therapy for achievement of the desired therapeutic outcome and to detect or prevent adverse effects at that point in the patient’s care? 5.b. What clinical parameters are necessary to evaluate the e fficacy of the patient’s asthma therapy after hospital d ischarge?
Patient Education 6.a. Describe the information that should be provided to the family regarding nebulization technique, the differences between quickrelief and controller medications, and possible asthma triggers. 6.b. What should the family monitor for regarding the potential adverse effects from the drug therapy? ■
FOLLOW-UP QUESTIONS
1. Should any cough and cold products be used for asthma symptoms? Why or why not? 2. What methods could be used to help a pediatric patient and the family to be compliant with nebulization t reatments? 3. What information can be given to families who are concerned
about giving their child “steroids” for asthma treatment (either in an acute asthma exacerbation or for controller therapy)? ■
SELF-STUDY ASSIGNMENTS
1. Research the e fficacy of systemic corticosteroids for treatment of acute asthma exacerbation when given intravenously versus orally (enterally). 2. Discuss the differences i n acute asthma exacerbation symptoms in an adult patient versus a pediatric patient, and describe when you would refer a patient (or family) to the physician or emergency department based on his or her asthma action plan. 3. Discuss the appropriate use of ipratropium bromide in an acute asthma exacerbation.
CLINICAL PEARL For proper treatment of an acute asthma exacerbation, the patient (or family) needs to be aware of the first symptoms of an exacerbation and possible triggers. At this point, the patient (family) should initiate his or her asthma action plan to minimize the symptoms, duration of drug therapy, and severity of the exacerbation. This in turn, should decrease the number of severe exacerbations and hospital admissions.
(Jennifer A. Donaldson, PharmD)
ASMA KRONIS _ Chief Complaint “I can’t…breathe…and my albuterol…doesn’t seem to be helping!” _ HPI Madison Bradley is a 29-year-old woman who presents to the ED for an acute visit due to shortness of breath. She reports feeling especially short of breath since awakening this morning. She states that she has been using her albuterol every hour for the past 6 hours and that it doesn’t seem to be helping. Her peak flows have been running between 180 L/min and 200 L/min today (personal best = 400 L/ min). In addition to her albuterol MDI, which she uses PRN, she also has a fluticasone MDI, which she uses “most days of the week.” She reports having to use her albuterol inhaler approximately 3 –4 times per week over the past 2 months, but over the past week she admits to using albuterol almost daily. She reports being awakened by a cough three times over the past month. She states she especially becomes short of breath when she exercises; although she admits that her shortness of breath is not al ways brought on by exercise and sometimes occurs when she is not actively exercising. She indicates that her morning peak flows have been running around 300 L/min (personal best = 400 L/min) over the past several weeks. _ PMH Asthma (previously documented as “mild persistent”) since childhood; no prior history of intubations; hospitalized twice in the past year for poorly controlled asthma; three visits to the ED in the past 6 months; treated with oral systemic corticosteroids during both hospitalizations and at each ED visit. Migraine headache disorder (diagnosed at age 21); currently taking prophylactic medication; has had only one migraine attack in the past year. _ FH Both parents living; mother 52-years-old with HTN, osteoporosis; father 54-years-old with COPD (33 pack-year smoking history) and Type 2 DM; brother, age 34 (smoker); sister, age 32 (non-smoker) _ SH No alcohol or tobacco use. Married, sexually active. Lives with husband (cabinetmaker; non-smoker) and two cats. _ Meds Fluticasone HFA 110 mcg, 2 puffs BID Albuterol HFA 2 puffs Q 4 –6 h PRN shortness of breath
Ortho-Tri-Cyclen 1 po daily Propranolol 80 mg po BID Maxalt-MLT 5 mg po PRN acute migraine _ All Sulfa (rash) _ Physical Examination Gen Anxious-appearing Caucasian female; moderate respiratory distress with audible wheezing noted; unable to speak in complete sentences; suprasternal muscle retractions noted; hunched forward VS BP 134/78, HR 110, RR 22, T 37°C; Wt 68 kg, Ht 5'5''; Pulse Ox 88% on RA HEENT PERRLA; mild oral thrush; TMs intact Neck/Lymph Nodes Supple; no l ymphadenopathy or thyromegaly Lungs/Thorax High-pitched, diffuse expiratory wheezes bilaterally, two-thirds o f the way up Breasts Nontender without masses CV Tachycardia; Regular rhythm; no MRG Abd Soft, NTND; (+) BS Genit/Rect Deferred Ext Normal ROM; peripheral pulses 3+; no CCE Neuro No motor deficits; CN II –XII grossly intact; A & O 3 _ Labs _ Chest X-Ray Hyperinflated lungs; no infiltrates Na 134 mEq/L Hgb 12 g/dL WBC 8.0 103/mm3 K 3.0 mEq/L Hct 36% PMNs 56% Cl 99 mEq/L RBC 5.0 106/mm3 Bands 1% CO2 28 mEq/L MCH 28 pg Eosinophils 3% BUN 22 mg/dL MCHC 34 g/dL Basophils 2% SCr 0.7 mg/dL MCV 90 m3 Lymphocytes 33% Glu 117 mg/dL Plts 192 103/mm3 Monocytes 5%
_ Assessment 29 yo woman with moderate to severe exacerbation of asthma; uncontrolled chronic asthma _ Clinical Course The patient is admitted overnight for treatment with oxygen, inhaled bronchodilators, and oral prednisone 60 mg daily. She is discharged home with her previous regimen plus nebulized albut erol 2.5 mg every 8 hours for 5 days and prednisone 60 mg orally once daily to complete a 10-day burst. She was also gi ven nystatin swish and swallow for treatment of her oral thrush infection. On follow-up at day 4 in the clinic, her lungs are clear without wheezing; her respiratory rate is 16 breaths per minute; and her pulse oximetry is 97% on room air. Her peak flow readings have improved to 300 L/min.
QUESTIONS Problem Identification 1.a. Create a list of the patient’s drug therapy problems. 1.b. What information indicates the presence of uncontrolled chronic asthma and an acute asthma exacerbation? 1.c. What factors may have contributed to this patient’s poorly controlled asthma and acute exacerbation? 1.d. How would you classify this patient’s level of asthma control (well controlled, not well controlled, or very poorly controlled), according to NIH guidelines?
Desired Outcome 2. What are the goals of pharmacotherapy in this case?
Therapeutic Alternatives 3.a. What nonpharmacologic therapies might be useful fo r this patient? 3.b. What feasible pharmacotherapeutic alternatives are available for treatment of this patient’s chronic asthma?
Optimal Plan 4.a. Outline an optimal plan of treatment for this patient’s chronic asthma. 4.b. What alternatives would be appropriate if the initial therapy fails?
Outcome Evaluation 5. What clinical parameters are necessary to evaluate the therapy for achievement of the desired therapeutic effect and to detect or prevent adverse effects?
Patient Education 6. What information should be provided to the patient regarding the use of her asthma medications and how she can use her peakflow readings to better manage her disease? ■
SELF-STUDY ASSIGNMENTS
1. Review the NIH guidelines on the management of asthma during pregnancy, and develop a pharmacotherapeutic treatment plan for this patient’s asthma if she were t o become pregnant. 2. Review the literature on the impact of chronic inhaled corticosteroid use on the risk for development of osteoporosis, and write a two-page paper summarizing the available published literature on this topic.
CLINICAL PEARL Patients with asthma who report that taking aspirin makes their asthma symptoms worse may respond well to leukotriene modifiers. Aspirin inhibits prostaglandin synthesis from arachidonic acid through inhibition of cyclooxygenase. The leukotriene pathway may play a role in the development of asthma symptoms in such patients, as inhibition of cyclooxygenase by aspirin may shunt the arachidonic acid pathway away from prostaglandin synthesis and toward leukotriene production. Although inhaled corticosteroids are still the preferred anti-inflammatory medications for patients with asthma and known aspirin sensitivity, leukotriene modifiers may
(Julia M. Koehler, PharmD ; Carrie Maffeo, PharmD, BCPS, CDE)
Pharmacotherapy Case File, Terry L. Schwinghammer, 2009
