ASMA AKUT

My boy has trouble breathing and he keeps coughing. His albuterolisn’t helping.”_ HPIPeyton Harrison is a 3-year-old African-American boy who presentsto the emergency department with a 3-day history of cough andcongestion. The mother was giving him albuterol, 2.5 mg vianebulization twice a day since the cough started. She was also givinghim an allergy medicine. He did have a fever 3 days prior toadmission, and he was given ibuprofen. The previous night beforeadmission, he seemed to be gasping for air and during the daytoday, he has had an increased work of breathing. Mother also notesthat he has been fussy, not eating well, and has had only two to threeurinations in the past 24 hours. His assessment in the emergencydepartment revealed him to have labored breathing that was moredifficult with activities. He had mild retractions with tachypnea at52 breaths per minute. His other vital signs were a heart rate of 137beats 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%, andhe was started on oxygen at 1.5 liter/min via nasal cannula. Hisbreath sounds were noted to have fair air exchange but withexpiratory wheezes. His chest x-ray revealed patchy infiltrates consistentwith pneumonia. Peyton was complaining of a runny noseand sore throat. He did not have any ear pain. While in theemergency department, he was given three albuterol/ipratropiumnebulizations and one dose of prednisolone 15 mg orally. Hereceived one dose of acetaminophen 210 mg. His breath sounds andoxygenation did not improve so he was started on hourly albuterolnebulizations at 5 mg. Peyton was then transferred to the PediatricIntensive Care Unit for further treatment and monitoring._ PMHAsthma, unknown if previous hospitalizationsS/P tonsillectomy/adenoidectomy at 2 years of age_ FHUnknown_ SHLives with foster mother and two siblings. Birth mother has visitations.Unclear as to reason for foster placement. Positive tobaccoexposure in current home._ MedsAlbuterol 2.5 mg via nebulizer as neededPhenylephrine/chlorpheniramine/methscopolamine (Dallergy®), doseunknown_ AllNKA_ ROS(+) Fever, cough, congestion, increased work of breathing_ Physical ExaminationGenNAD, moderate increase in work of breathingVSBP 103/55, P 154, T 36.4°C, R 29, O2 sat 94% at 1.5 L/min nasalcannulaSkinNo rashes, no bruisesHEENTNC/AT, PERRLANeck/Lymph NodesSoft, supple, no cervical lymphadenopathyChestSlight decrease in breath sounds bilaterally, minimal wheezingCVRRR, no MRGAbdSoft, NT/N

ExtNo clubbing or cyanosisNeuroA & O, no focal deficits_ LabsRespiratory viral panel nasal swab: positive for parainfluenza 3Na 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/dLCO2 19 mEq/L Hct 34%BUN 6 mg/dL Plt 252 103/mm3

SCr 0.4 mg/dLGlu 140 mg/Dl

_ Chest X-RayPatchy infiltrates throughout lung fields_ AssessmentAsthma exacerbation with pneumonia and dehydration

QUESTIONSProblem Identification1.a. Create a list of the patient’s drug-related problems.1.b. What information (signs, symptoms, laboratory values) indicatesthe severity of the acute asthma attack?

Desired Outcome2. What are the acute goals of pharmacotherapy in this case?

Therapeutic Alternatives3.a. What nondrug therapies might be useful for this patient?3.b. What feasible pharmacotherapeutic alternatives are availablefor the treatment of acute asthma?

Optimal Plan4.a. What drug, dosage form, dose, schedule, and duration oftherapy are best for this patient’s acute asthma exacerbation?4.b. What other pharmacotherapy would you recommend in theacute treatment of this patient?

■ CLINICAL COURSEWithin 72 hours of initiation of the treatment plan for managementof the acute exacerbation, Peyton was stable enough to transfer tothe general pediatric floor. His vital signs were BP 111/67, P 108, R26, T 36.7°C, O2 sat 99% on 0.5 L/min nasal cannula. Mother statesthat he is more like his normal self and doesn’t seem to have muchtrouble breathing now.4.c. What drug, dosage form, dose, schedule and duration oftherapy are best for this patient’s discharge plan?

Outcome Evaluation5.a. Once the patient has transferred to the general medical floorand his vitals have improved (see Clinical Course), whatclinical and laboratory parameters are necessary to evaluate thetherapy for achievement of the desired therapeutic outcomeand to detect or prevent adverse effects at that point in thepatient’s care?5.b. What clinical parameters are necessary to evaluate the efficacyof the patient’s asthma therapy after hospital discharge?

Patient Education6.a. Describe the information that should be provided to the familyregarding nebulization technique, the differences between quickreliefand controller medications, and possible asthma triggers.6.b. What should the family monitor for regarding the potentialadverse effects from the drug therapy?

■ FOLLOW-UP QUESTIONS1. 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 thefamily to be compliant with nebulization treatments?3. What information can be given to families who are concerned

about giving their child “steroids” for asthma treatment (eitherin an acute asthma exacerbation or for controller therapy)?

■ SELF-STUDY ASSIGNMENTS1. Research the efficacy of systemic corticosteroids for treatment ofacute asthma exacerbation when given intravenously versus orally(enterally).2. Discuss the differences in acute asthma exacerbation symptomsin an adult patient versus a pediatric patient, and describe whenyou would refer a patient (or family) to the physician oremergency department based on his or her asthma action plan.3. Discuss the appropriate use of ipratropium bromide in an acuteasthma exacerbation.

CLINICAL PEARLFor proper treatment of an acute asthma exacerbation, the patient (orfamily) needs to be aware of the first symptoms of an exacerbation andpossible triggers. At this point, the patient (family) should initiate hisor her asthma action plan to minimize the symptoms, duration ofdrug therapy, and severity of the exacerbation. This in turn, shoulddecrease 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!”_ HPIMadison Bradley is a 29-year-old woman who presents to the ED foran acute visit due to shortness of breath. She reports feeling especiallyshort of breath since awakening this morning. She states that she hasbeen using her albuterol every hour for the past 6 hours and that itdoesn’t seem to be helping. Her peak flows have been runningbetween 180 L/min and 200 L/min today (personal best = 400 L/min). In addition to her albuterol MDI, which she uses PRN, she alsohas a fluticasone MDI, which she uses “most days of the week.” Shereports having to use her albuterol inhaler approximately 3–4 timesper week over the past 2 months, but over the past week she admitsto using albuterol almost daily. She reports being awakened by acough three times over the past month. She states she especiallybecomes short of breath when she exercises; although she admits thather shortness of breath is not always brought on by exercise andsometimes occurs when she is not actively exercising. She indicatesthat her morning peak flows have been running around 300 L/min(personal best = 400 L/min) over the past several weeks._ PMHAsthma (previously documented as “mild persistent”) since childhood;no prior history of intubations; hospitalized twice in thepast year for poorly controlled asthma; three visits to the ED inthe past 6 months; treated with oral systemic corticosteroidsduring both hospitalizations and at each ED visit.Migraine headache disorder (diagnosed at age 21); currently takingprophylactic medication; has had only one migraine attack in thepast year._ FHBoth parents living; mother 52-years-old with HTN, osteoporosis;father 54-years-old with COPD (33 pack-year smoking history) andType 2 DM; brother, age 34 (smoker); sister, age 32 (non-smoker)_ SHNo alcohol or tobacco use. Married, sexually active. Lives withhusband (cabinetmaker; non-smoker) and two cats._ MedsFluticasone HFA 110 mcg, 2 puffs BIDAlbuterol HFA 2 puffs Q 4–6 h PRN shortness of breath

Ortho-Tri-Cyclen 1 po dailyPropranolol 80 mg po BIDMaxalt-MLT 5 mg po PRN acute migraine_ AllSulfa (rash)_ Physical ExaminationGenAnxious-appearing Caucasian female; moderate respiratory distresswith audible wheezing noted; unable to speak in complete sentences;suprasternal muscle retractions noted; hunched forwardVSBP 134/78, HR 110, RR 22, T 37°C; Wt 68 kg, Ht 5'5''; Pulse Ox 88%on RAHEENTPERRLA; mild oral thrush; TMs intactNeck/Lymph NodesSupple; no lymphadenopathy or thyromegalyLungs/ThoraxHigh-pitched, diffuse expiratory wheezes bilaterally, two-thirds ofthe way upBreastsNontender without massesCVTachycardia; Regular rhythm; no MRGAbdSoft, NTND; (+) BSGenit/RectDeferredExtNormal ROM; peripheral pulses 3+; no CCENeuroNo motor deficits; CN II–XII grossly intact; A & O 3_ Labs_ Chest X-RayHyperinflated lungs; no infiltratesNa 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%

_ Assessment29 yo woman with moderate to severe exacerbation of asthma;uncontrolled chronic asthma_ Clinical CourseThe patient is admitted overnight for treatment with oxygen, inhaledbronchodilators, and oral prednisone 60 mg daily. She is dischargedhome with her previous regimen plus nebulized albuterol 2.5 mgevery 8 hours for 5 days and prednisone 60 mg orally once daily tocomplete a 10-day burst. She was also given nystatin swish andswallow for treatment of her oral thrush infection. On follow-up atday 4 in the clinic, her lungs are clear without wheezing; her respiratoryrate is 16 breaths per minute; and her pulse oximetry is 97% onroom air. Her peak flow readings have improved to 300 L/min.

QUESTIONSProblem Identification1.a. Create a list of the patient’s drug therapy problems.1.b. What information indicates the presence of uncontrolledchronic asthma and an acute asthma exacerbation?1.c. What factors may have contributed to this patient’s poorlycontrolled 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 Outcome2. What are the goals of pharmacotherapy in this case?

Therapeutic Alternatives3.a. What nonpharmacologic therapies might be useful for thispatient?3.b. What feasible pharmacotherapeutic alternatives are availablefor treatment of this patient’s chronic asthma?

Optimal Plan4.a. Outline an optimal plan of treatment for this patient’s chronicasthma.4.b. What alternatives would be appropriate if the initial therapy fails?

Outcome Evaluation5. What clinical parameters are necessary to evaluate the therapy forachievement of the desired therapeutic effect and to detect orprevent adverse effects?

Patient Education6. What information should be provided to the patient regardingthe use of her asthma medications and how she can use her peakflowreadings to better manage her disease?

■ SELF-STUDY ASSIGNMENTS1. Review the NIH guidelines on the management of asthma duringpregnancy, and develop a pharmacotherapeutic treatment planfor this patient’s asthma if she were to become pregnant.2. Review the literature on the impact of chronic inhaled corticosteroiduse on the risk for development of osteoporosis, andwrite a two-page paper summarizing the available publishedliterature on this topic.

CLINICAL PEARLPatients with asthma who report that taking aspirin makes theirasthma symptoms worse may respond well to leukotriene modifiers.Aspirin inhibits prostaglandin synthesis from arachidonic acidthrough inhibition of cyclooxygenase. The leukotriene pathway mayplay a role in the development of asthma symptoms in such patients,as inhibition of cyclooxygenase by aspirin may shunt the arachidonicacid pathway away from prostaglandin synthesis and toward leukotrieneproduction. Although inhaled corticosteroids are still the preferredanti-inflammatory medications for patients with asthma andknown aspirin sensitivity, leukotriene modifiers may

(Julia M. Koehler, PharmD ; Carrie Maffeo, PharmD, BCPS, CDE)

Pharmacotherapy Case File, Terry L. Schwinghammer, 2009