SE is a twenty-two-year-old Caucasian woman who was diagnosed with asthma at age seven. According to her medical record, she has “mild persistent” asthma. Today, she reports that she has been using her albuterol metered-dose inhaler (MDI) approximately three to four days per week over the last two months. Over the past week, she admits to using albuterol once daily. She has been awakened by a cough three nights during the last month. She states she especially becomes short of breath when she exercises. However, she also admits that the shortness of breath is not always brought on by exercise. She also has a fluticasone MDI, which she uses “most days of the week.” She has been hospitalized twice in the last year for poorly controlled asthma and has been to the emergency department (ED) three times in the last six months for the same problem. Her lab work is all within normal limits, with the exception of a positive human chorionic gonadotropin (HCG). Answer the following questions:
- What information in the case study suggests that her asthma is not well controlled?
- What factors could possibly lead to this?
- How would you classify the symptoms based upon the National Institutes of Health (NIH) guidelines?
- With the recognition that she is pregnant, how would you alter her treatment for asthma?
Suggesting information that SE asthma is not well controlled
In the case of SE, there are some issues which reflect poor control of her asthma. The case provides some information which proves that her illness is not well controlled. First is the information about her uncontrolled or poorly controlled asthma is about the frequent appearance of symptoms of the disease regularly, basically more than twice in a single week. SE has recently experienced symptoms of asthma about two times a week which has disrupted her usual activities such as training and sleep. This shows that her condition is not adequately controlled since asthma has gone beyond the extent of disrupting her normal activities. According to the patient’s report, her sleep has been regularly interrupted by nocturnal coughs which reflect one of the main symptoms of untreated/uncontrolled asthma which include wheeze, cough, breathlessness, and tightness in the chest (Nathan et al., 2014)
These result to frequent coughs especially during the night Hence this shows that asthma is not well controlled in this patient. Another information that justifies uncontrolled asthma in the patient is the frequent use of rescue medication in a period of not less than twice a week. The patient reveals that she uses fluticasone drugs which are used to prevent chest tightness and breathing difficulties on most days of the week. In addition to this, the patient also uses corticosteroids which indicate that she experiences frequent attacks and asthmatic symptoms such as breathing shortness and wheezing. Frequency in the number of admissions in the emergency department is a regular sign attack and uncontrolled asthma. Harmful signs of asthma are precipitated by the effects of the condition which for instance hinder effective exercise.
Factors leading to the uncontrolled asthma
Some factors which may have led to the above condition in the patient include a contradiction between the patient’s factors and the factors related to the disease. For instance, the patient could be non-adherence to the asthma control medication. The patient explains that the interval in which she currently takes the asthma medication is not articulate to how she previously took medicine, hence proving some irregularity in her adherence to the medication. Missing from drug schedule by asthma patients can be caused by lack of close monitoring which turns to be severe regarding precipitating the asthma symptoms and attacks. The other factor which could be behind the uncontrolled asthma is comorbid infections such as rhinitis, gastrointestinal reflux or sleep apnea (Woo, & Wynne, 2012).These diseases if not properly diagnosed and treated can precipitate the symptoms of asthma. For example, rhinitis cause swelling of nasal canal therefore breathing becomes difficult as a result of a narrow pathway.
Based on the NIH (National Institutes of Health) guidelines, the asthma symptoms can be classified into four categories including mild persistent, mild intermittent, moderate and severe persistent asthma (Schatz et al., 2013) Considering the patterns of the asthma attacks on the patient, I would classify her condition as moderate persistent. This classification of asthmatic symptoms is characterized by breathing difficulties, wheezing cough, as well as tightness in the chest which the patient’s report has confirmed. The symptoms are more common especially during the night time as they may appear five or more times in a week. It is also characterized by the effect on the patient’s normal activities as well as the quality of their life. The patient’s asthmatic state is congruent to the symptoms of moderate persistent with about three-night symptoms in one month, although the night symptoms may not be very much common. The patient’s short breath is not exercise precipitated. The risk of the attacks’ precipitation has barred the patient from her usual life activities. The condition is further made severe by steroids use by the patient.
Considering the patient’s pregnancy, her treatment could be altered in some ways. The FDA has categorized management of pregnancy asthma as being in the C category. This implies that the treatment has been recommended in the cases which lack alternatives to treatment and the benefits of using it are more than the effects. After a couple of animal experimentations, teratogenic effects have been identified in albuterol; but because of the patient’s criticality, forgoing the drug for an alternative could be more severe, and therefore modification can only be done. Treating the pregnant asthma patient would entail maintaining short effect albuterol beta two agonists at a low dosage.
The long-term effect beta two agonist corticosteroid and albuterol dosage would as well be introduced but will vary on the patient’s reception to the medication. In the case of the patient’s non-responsiveness, the corticosteroid dosage would be increased in the patient’s treatment while still maintaining albuterol. Considering the condition of the patient, I would prefer to use salmeterol as the long-term beta two agonists. The treatment medication would be supplemented with Advair which is a combination of fluticasone and salmeterol. This will ease adherence of the patient (Vroegop, Aalbers & van Loon, 2012).
Nathan, R. A., Sorkness, C. A., Kosinski, M., Schatz, M., Li, J. T., Marcus, P., & Pendergraft, T. B. (2014). Development of the asthma control test: a survey for assessing asthma control. Journal of Allergy and Clinical Immunology, 113(1), 59-65.
Schatz, M., Dombrowski, M. P., Wise, R., Thom, E. A., Landon, M., Mabie, W., & Leveno, K. J. (2013). Asthma morbidity during pregnancy can be predicted by severity classification. Journal of Allergy and Clinical Immunology, 112(2), 283-288.
Vroegop, J. S., Aalbers, R., & van Loon, A. J. (2012). Treatment of asthma during pregnancy. Journal of Allergy and Clinical Immunology, 153, B361-B361.
Woo, T. & Wynne, A. (2012). Pharmacotherapeutics for Nurse Practitioner Prescribers. Philadelphia, PA: F.A. Davis Company