Asthma is a complex disorder characterized by airway narrowing and is the most prevalent chronic disease of childhood that causes significant morbidity and mortality in both adults and children (Chisholm-burns et al., 2019). According to the Global Initiative for Asthma (GINA), JR is classified as severe persistent based on his symptoms. He reports wheezing and shortness of breath daily with exacerbations at least two days a week where he is unable to sleep due to waking up with shortness of breath (SOB). He also uses his rescue inhaler daily and reports SOB for at least 45 minutes at rest. He must have some degree of activity limitations with his asthma. According to GINA guidelines, JR is positive for 4 out of the four categories and is considered poorly controlled with his asthma step 5. To answer question two, I would classify JR’s exacerbation severity as having a severe asthma attack. He presented to the ER with shortness of breath, tachycardia, tachypneic, wheezing, and using his accessory muscles. JR’s personal best peak expiratory flow (PEF) is 480L/min. He monitors his PEF once a week and generally runs about 325L/min. In the ER, his current peak flow is 175L/min even after using his rescue inhaler with no improvement, which represents a severe decline in his lung capacity. Triggers that may exacerbate JR’s asthma are environmental ones such as inhaling the burning smell that brought him to the ER, cat dander from the two cats that sleep next to him on the same pillow, and secondhand smoke from his neighbor’s apartment. Psychological factors that contribute to his comorbidities are anxiety and depression. As a carpenter, he is probably in contact with mold and sawdust. JR should be at step 5 before ER based on his severity and current medications. JR is poorly controlled and is currently presenting with severe symptoms with his asthma attack
now only uses his short and long-acting beta-agonist (SABA and LABA) and a muscarinic antagonist to control his asthma. According to (Chisholm-Burns, 2019), this would place him on step 5 of the GINA stepwise approach. The need to use an inhaled SABA is one key that indicates uncontrolled asthma, and regular use of SABA decreases the duration of bronchodilation, which he is currently experiencing. He has several medications that are dosed incorrectly and inappropriately. JR’s current prescription for his albuterol is two puffs BID-QID prn. The correct dose should be two puffs every 4-6 hours. It can be increased to four inhalations every 4 hours during an exacerbation until symptoms resolve. His LABA is incorrectly prescribed at one inhalation QID. It should be ordered at one inhalation every 12 hours BID because they provide 12-24 hours of bronchodilation after a single dose. According to Chisholm-Burns 2019, LABA’s should not be used because there is an increased risk of severe asthma exacerbations and death. There is a black box warning against their use with an inhaled corticosteroid (ICS). This may be one of the contributing factors to his severe asthma exacerbation. He is also taking Ipratropium bromide two puffs QID. There is a lack of evidence to support its use as part of a chronic asthma regimen. It is a drug primarily used in COPD. It is recommended t use up to 3 puffs every 6 hours when treating acute severe asthma exacerbations. A short burst of oral corticosteroids such as prednisone would be indicated as they are recommended to be started early in acute exacerbations. Therapy is continued until PED is 70% or more of the patient’s personal best. The dose should be 1-2 mg/kg/day by mouth in two divided doses for 3-10 days.
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