Discussion Based on the case, I would like to discuss 2 important learning issues that I think are very important

in order to become a good doctor, especially when dealing with asthma case. My learning issues are: What are the best treatments of acute asthma. Inhaled corticosteroid verses oral corticosteroid What are the best treatments of chronic asthma. I agreed with the patient management in terms of giving her Nebulizer Combivent, where it is clearly stated in CPG, that high dose of inhaled beta2-agonist combination with anticholonergic should be given via nebuliser. In addition, we must monitor her potassium level at the same time because one of the common side effects of beta agonist is hypokalemia. A part from that, we must assess again her lung, if he is not improving we should admit him. Meanwhile, if patient does not show good progression after received nebulizer, we can give subcutaneous terbutaline, as in this case, my patient received subcutaneous Bricanyl. Based in the CPG, prednisolone should be commenced immediately. It is not necessarily we give prednisolone in tablet form, we also can give nebulized if the patient is unable to tolerate orally. In relation to my patient, she had MDI Fluticasone 250mg. For second learning issue, I would like to discuss on effectiveness of inhaled corticosteroid compare to oral prednisolone. Inhaled corticosteroid has greater anti-inflammatory potency and fewer systemic side effects than oral corticosteroid. However in a study which was done by Volowitz.et all (1998) showed that oral prednisolone is better than inhaled corticosteroid in view of controlling acute asthma attack. In the ward, she had been given T. prednisolone 30mg BD instead of IV Hydrocort. This is because we want to reduce the steroid intake so that we can reduce the side effect of steroid. My patient also received Nebuliser Combivent 4 hourly. Besides that, she had MDI Seretide 2 puff BD in the ward. Seretide is consist of steroid and long acting beta agonist. Based on CPG, long acting beta agonist(LABA) it is not suitable to be given in acute case, it is best for preventive measure as in chronic asthma patient. However, this is contradict to study that was done by Shelley R. Salpeter (2010), showed that the use of long acting beta agonists, with and without concomitant inhaled corticosteroids, was associated with a significant increase in risk for asthma related intubations and deaths1. Since this meta-analysis study is still new, maybe there will be changes in chronic asthma management in the future, especially regarding the commencement of long acting beta agonist (LABA).