MODULE 8

CASE STUDY: BRONCHIAL ASTHMA

Rationale: Between 100 and 150 million people around the globe suffer from asthma and this number is rising. World-
wide, deaths from this condition have reached over 180,000 annually. Mortality due to asthma is not comparable in size
to the day-to-day effects of the disease. Although largely avoidable, asthma tends to occur in epidemics and affects
young people. The human and economic burden associated with this condition is severe. The costs of asthma to society
could be reduced to a large extent through concerted international and national action.
Asthma attacks all age groups but often starts in childhood. It is a disease characterized by recurrent episodes of
breathlessness and wheezing, which vary in severity and frequency from person to person. In an individual, they may
occur from hour to hour and day to day.
This condition is due to inflammation of the air passages in the lungs and affects the sensitivity of the nerve endings in
the airways so they become easily irritated. In an attack, the lining of the passages swell causing the airways to narrow
and reducing the flow of air in and out of the lungs.

Objectives: After completing this case study, you should be able to:
 Recognize the signs and symptoms of an acute exacerbation
 Formulate therapeutic end points based on the initiation of a pharmacotherapy plan used to treat the acute
asthma symptoms.
 Identify appropriate dosage form selection based on the patient’s age, ability to take medication, or adherence
to technique.
 Determine an appropriate home pharmacotherapy plan, including discharge counselling, as the patient nears
discharge from a hospital setting.

Activity:
Read and understand the case study below. Take note of the following before answering the questions at the end of
the case presentation.

1. Give the meaning of the abbreviations used in the case

2. Pick out the medical terms given in the text of the case and give their meanings
3. Identify the medications currently being used and give its indications, mechanism of action, ADRs and drug
interactions
4. Comment on the physical assessment findings
5. Note any abnormal laboratory value/s and rationalize its alteration
6. Describe any diagnostic procedure performed and comment on the findings

CC
"My daughter has had a bad fever, and now she is having trouble breathing and albuterol doesn’t help."

HPI
Terri Collins is an 8-yo African-American girl who presents to the ED with a 2-day history of fevers, malaise, and nonproductive cough.
The mother gave acetaminophen and ibuprofen to help control the fever. The mother stated that “a lot of other kids in her class have been
sick this fall, too”. Terri started having trouble breathing the morning of admission, and the mother gave her albuterol, 2.5 mg via
nebulization twice within an hour. Terri still sounded wheezy to the mother after the albuterol, and Terri stated it was “hard to breath.”
Terri was previously well controlled regarding asthma symptoms. Previous clinic notes reported symptoms during the day only with active
play at school or at home and rare nighttime symptoms. She use PRN albuterol to help with symptoms after playing. Her assessment in the
ED revealed Terri to have labored breathing, such that she could only complete four to five-word sentences. She had subcostal retractions,
tracheal tugging with tachypnea at 54 breaths/min. Her other vital signs were a heart rate of 160 bpm, BP of 115/59, temperature of 38.8°C,
and a weight of 22.7 kg. The initial oxygen saturation was 88%, and she was started on oxygen at 1 L/min via nasal cannula. Bilateral
expiratory and inspiratory wheezes were noted on examination. A chest x-ray revealed a right lower lobe consolidation consistent with
pneumonia and possible effusion. After receiving three albuterol/ipratropium nebulizations, her breath sounds and oxygenation did not
improve; so she was started on albuterol via continuous nebulization at 10 mg/h, and her oxygen was titrated to 3 L/min. She was also
given a dose of 25 mg iv methylprednisolone and a dose of 600 mg IV magnesium sulfate. Terri was then transferred to the Pediatric
Intensive Care Unit for further treatment and monitoring.
PMH
Asthma, last hospitalization 4 years ago, and last course of oral corticosteroids over a year ago

FH
Asthma on father’s side of the family

SH
Lives with mother, father, and two siblings, both of whom have asthma. There are two cats and a dog in the home. Father is a smoker, but
states that he tries to smoke outside and not around the kids. She is in the second grade and is very active on the playground.

Meds
Albuterol 2.5 mg nebulized Q 4-6 h PRN wheezing
Fluticasone 44 mcg MDI two puffs BID
Acetaminophen 160/5 mL – 10 mL Q 4 h PRN fever
Ibuprofen 100 mg/5 mL – 10 mL Q 6 h PRN fever

All
NKA

ROS
(+) Fever, cough, increased work of breathing

PE
Gen
Alert and oriented but in mild distress with difficulty breathing

VS
BP 125/69, P 120, T 37.9ºC; RR 40, O2 sat 94% on 3 L/min nasal cannula

Skin
No rashes, no bruises

HEENT
NC/AT, PERRLA

Neck/LN
Soft, supple; no cervical lymphadenopathy

Chest
Wheezes throughout all lung fields, still with subcostal retractions

CV
RRR; no m/r/g

Abd
Soft, NTND

Ext
No clubbing or cyanosis

Neuro
A & O, no focal deficits

Labs Na 141 mEq/L Hgb 13 g/dL WBC 34.2 x 103/mm3

K 3.1 mEq/L Hct 41% Neut 91%
Cl 104 mEq/L RBC 5.07 x 106/mm3 Lymph 5%
CO2 29 mEq/L Plts 310 x 103/mm3 Mono 4%
BUN 16 mg/dL
SCr 0.52 mg/dL
Glu 154 mg/dL

Respiratory viral panel nasal swab: positive for influenza A (probably H1N1 strain)

Chest X-ray
RLL consolidation
QUESTIONS:

problem identification
1. a. Create a list of the patient's drug related problems.
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 non-drug therapies might be useful for this patient?
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 therapy are best for this patient’s acute asthma exacerbation?
b. What other pharmacotherapy would you recommend in the acute treatment of tis patient?

CLINICAL COURSE
Within 48 hours of initiation of the treatment plan for management of the acute exacerbation, Terri was stable enough to transfer to the
general pediatric floor. Her vital signs were: BP 103/70, P 82, R 35, T 37.2ºC and O2 sat 99% on 1 L/min nasal cannula. Mother states that
she is able to speak in full sentences now and no longer seems to have trouble breathing.

4. c. What drug, dosage form, dose, schedule, and duration of therapy are best for this patient’s discharge plan?

assessment parameters
5. a. Once the patient has transferred to the general medical floor and her vitals have improved, 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?
b. What clinical parameters are necessary to evaluate the efficacy of the patient’s asthma therapy after hospital discharge?

patient counseling
6. a. What should the family monitor for regarding the potential adverse effects from the drug therapy, and how should they be counseled
on the use of asthma medications, especially regarding the differences between quick-relief and controller medications?
b. Describe the information that should be provided to the family regarding medication delivery technique and possible asthma
triggers.

assignments
7. Should any cough and cold products be used for asthma symptoms? Why or why not?

8. What information should be given to patients/families regarding influenza?

9. What information can be given to families who are concerned about giving their child “steroids” for asthma treatment?

10. Conduct a literature search to obtain recent information on clinical trials comparing metered-dose inhalers to nebulizers for acute
bronchodilator administration.

11. Discuss the appropriate use of intravenous magnesium in an acute asthma exacerbation.

References: