University of Phoenix NRP 507 Advanced Pharmacology - Week 5 Case Study Asthma

Patient Background

Nancy Smith, a 35-year-old female, presents with an asthma exacerbation. She was diagnosed with asthma at age 20 and has relied solely on albuterol as needed. Her medical records indicate multiple urgent care visits within the past year, with the most recent visit occurring four months ago. At that time, she was prescribed an inhaled corticosteroid (ICS), an albuterol inhaler, and oral steroids, but she did not fill the ICS prescription.

Two weeks ago, she experienced another flare-up and has been using her albuterol inhaler 3-4 times per day. Despite this, she continues to feel severe shortness of breath with activities such as climbing stairs or walking to the mailbox. Additionally, she reports nighttime coughing spells every night for the past week, requiring her to prop herself up on pillows to breathe. She states she has had similar flare-ups before and requests more albuterol and steroid pills.

Asthma that presents with frequent coughing, wheezing, breathlessness, or chest tightness at night is indicative of poorly controlled asthma, putting the patient at risk for an asthma attack.

Clinical Assessment

On examination, Nancy’s vital signs and spirometry results indicate suboptimal lung function:

• SPO2: 93% on room air
• FEV1: 58% (indicating airflow limitation)
• FEV1/FVC ratio: 69% (borderline between normal and abnormal)

FEV1/FVC is a critical marker for classifying asthma severity. A normal FEV1/FVC ratio is ≥70%. A lower value, such as Nancy’s, suggests airway obstruction and persistent lung abnormalities.

Analysis of Asthma Severity

Asthma exacerbations involve a worsening of symptoms and lung function, often triggered by viral infections, allergens, irritants, medication non-adherence, or unknown factors. Early recognition and intervention are essential to prevent severe, life-threatening attacks (Fanta, 2021).

Nancy’s asthma falls under the moderate persistent category, as per the Global Initiative for Asthma (GINA) guidelines. Her symptoms—daily use of a short-acting beta-agonist (SABA), frequent nighttime awakenings, and activity limitations—indicate that her current treatment regimen is inadequate.

Plan of Care and Treatment Adjustments

Nancy requires a revised treatment approach to manage her persistent symptoms effectively.

Medication Adjustments

1. Inhaled Corticosteroids (ICS) & Long-Acting Beta-Agonist (LABA) Combination

   • Recommended: Fluticasone/salmeterol (Advair HFA) 45 mcg/21 mcg, 2 puffs twice daily
   • Rationale: ICS reduces airway inflammation, while LABA improves bronchodilation for long-term control.

2. Short-Acting Beta-Agonist (SABA) as Rescue Medication

   • Recommended: Albuterol 90 mcg per actuation, 2 puffs every 4-6 hours as needed
   • Rationale: Provides immediate relief but should not be overused to avoid dependence and worsening symptoms.

3. Oral Corticosteroids for Severe Flare-Ups

   • Recommended: Prednisone 40 mg daily for 5 days
   • Rationale: Short courses of systemic steroids are critical for severe exacerbations, preventing further decline in lung function (Fanta, 2021).

4. Leukotriene Receptor Antagonists (LTRA) for Allergy-Induced Asthma

   • Recommended: Montelukast 10 mg daily
   • Rationale: Helps control airway inflammation caused by allergens and reduces bronchospasms.

Patient Education and Lifestyle Modifications

Nancy requires comprehensive asthma education to improve adherence and symptom control.

1. Proper Inhaler Technique:

   • Demonstration of correct inhaler use followed by teach-back method to confirm understanding.
   • Rinse mouth after ICS use to prevent oral thrush.

2. Asthma Action Plan:

   • Personalized management plan detailing daily medication use, symptom monitoring, and emergency steps.
   • Encourage peak flow monitoring to track lung function trends.

3. Allergy & Environmental Control:

   • Identify and avoid asthma triggers such as dust, mold, pollen, and pet dander.
   • Use high-efficiency particulate air (HEPA) filters and maintain clean living spaces.

4. Vaccinations:

   • Encourage influenza and pneumococcal vaccinations to prevent respiratory infections that can trigger exacerbations.

5. Smoking Cessation & Secondhand Smoke Avoidance:

   • If applicable, provide support for smoking cessation and advise against exposure to secondhand smoke.

Monitoring and Follow-Up

Nancy’s response to treatment should be closely monitored through scheduled follow-ups every 4-6 weeks.

1. Assess symptoms and medication adherence.
2. Monitor lung function (FEV1, peak flow readings).
3. Adjust treatment as needed based on symptom control and lung function.

Conclusion

Nancy’s frequent asthma exacerbations and persistent symptoms indicate poor control. A stepwise treatment approach using ICS/LABA therapy, short-term oral steroids, and leukotriene receptor antagonists is necessary. Patient education on medication adherence, inhaler technique, and trigger avoidance will be crucial in preventing future exacerbations and improving overall asthma management.

References

• Fanta, C. H. (2021). Acute exacerbations of asthma in adults: Home and office management. UpToDate. Retrieved from https://www.uptodate.com/contents/acute-exacerbations-of-asthma
• Han, M. K., Dransfield, M. T., & Martinez, M. (2020). Chronic obstructive pulmonary disease: Definition, clinical manifestations, diagnosis, and staging. UpToDate.
• UpToDate (2021). Classifying Asthma Severity in Youths 12 years of Age or Older and Adults. Retrieved from https://www.uptodate.com/contents/search?search=classification%20of%20asthma
• Woo, T. M., & Robinson, M. V. (2020). Pharmacotherapeutics for advanced practice nurse prescribers (5th ed.). Philadelphia, PA: F.A. Davis Company.