NR603 Week 2 Discussion: Asthma Management for Michelle

Case Overview:Michelle, who works in a bakery, has a history of well-controlled asthma. She is on a low-dose inhaled corticosteroid (ICS), Singulair (Montelukast) 10mg daily, and uses Albuterol as needed (1-2 times per week). She presents with an acute respiratory illness, exhibiting signs of an asthma exacerbation possibly triggered by an Influenza A infection. Her current symptoms include a respiratory rate of 24, mild shortness of breath (SOB) with exertion, oxygen saturation (SpO2) of 94%, inspiratory and expiratory wheezing, a productive cough with white sputum, and a fever ranging from 101°F to 102°F over the last two days. She also reports mild work of breathing, a heart rate (HR) of 110 bpm, and blood pressure (BP) of 150/85 mmHg.

Appropriate Treatment Plan for Michelle

Given Michelle’s presentation, the treatment plan should focus on addressing both her acute asthma exacerbation and her influenza infection. The treatment plan includes:

1. Medications

• Increase Inhaled Corticosteroid (ICS) Dose:
  • Medication: Fluticasone Propionate (Flovent) 220 mcg inhaler
  • Dosage: 2 puffs twice daily
  • Rationale: Increasing the ICS dosage helps to control inflammation and prevent worsening of asthma symptoms during an acute exacerbation. Fluticasone is a potent anti-inflammatory agent that can reduce airway hyperresponsiveness, decrease the frequency of symptoms, and prevent exacerbations.
• Short-Acting Beta-Agonist (SABA):
  • Medication: Albuterol (ProAir, Ventolin) inhaler
  • Dosage: 2 puffs every 4-6 hours as needed for shortness of breath
  • Rationale: Albuterol, a SABA, is the first-line treatment for quick relief of acute asthma symptoms. It works by relaxing bronchial smooth muscle, thus relieving bronchoconstriction.
• Oral Corticosteroid:
  • Medication: Prednisone
  • Dosage: 40 mg orally once daily for 5 days
  • Rationale: A short course of oral corticosteroids is recommended for managing moderate to severe asthma exacerbations. Prednisone will help to reduce airway inflammation rapidly, preventing further deterioration of pulmonary function.
• Antiviral Treatment:
  • Medication: Oseltamivir (Tamiflu)
  • Dosage: 75 mg orally twice daily for 5 days
  • Rationale: Since Michelle has tested positive for Influenza A, initiating antiviral treatment with Oseltamivir is appropriate. This medication can reduce the severity and duration of influenza symptoms and decrease the risk of complications, which is particularly important in asthma patients.
• Continue Montelukast (Singulair):
  • Dosage: 10 mg orally once daily
  • Rationale: Montelukast is a leukotriene receptor antagonist that helps control chronic asthma symptoms. Continuing this medication will help manage underlying inflammation and prevent exacerbations.

2. Durable Medical Equipment (DME):

• Nebulizer Machine:
  • Medication: Albuterol Nebulizer Solution 2.5 mg/3mL
  • Dosage: Use every 4-6 hours as needed for shortness of breath
  • Rationale: If Michelle’s symptoms do not improve with the use of a metered-dose inhaler, or if she is unable to coordinate the inhaler correctly due to shortness of breath, a nebulizer may be more effective in delivering the medication.
• Peak Flow Meter:
  • Rationale: A peak flow meter is useful for monitoring Michelle’s lung function at home. Regular monitoring can help her identify early signs of worsening asthma and guide her in taking appropriate action.

3. Testing and Monitoring:

• Repeat Pulse Oximetry:
  • Rationale: Monitor oxygen saturation levels to ensure they remain above 94%. If SpO2 drops below this level, supplemental oxygen may be required.
• Follow-up Spirometry or Peak Expiratory Flow Rate (PEFR):
  • Rationale: Once Michelle’s acute symptoms have stabilized, spirometry or PEFR can be used to assess her baseline lung function and ensure that she has returned to her normal status.

4. Patient Education and Follow-up:

• Influenza and Asthma Management:
  • Educate Michelle on the importance of continuing her asthma medications as prescribed, even when feeling well. Emphasize the need to avoid known triggers and recognize early symptoms of asthma exacerbation.
  • Explain the significance of completing the full course of Oseltamivir and monitoring for any signs of worsening respiratory symptoms.
• Asthma Action Plan:
  • Review and update her asthma action plan, ensuring she understands when to increase medication use or seek emergency care based on her symptoms and peak flow readings.
• Follow-up Appointment:
  • Schedule a follow-up visit in 1-2 weeks to reassess her asthma control and ensure the resolution of the influenza infection.

Rationale with Evidence

Michelle’s current symptoms indicate an acute asthma exacerbation, likely triggered by her Influenza A infection. The treatment plan involves a combination of increased ICS dosing, SABA for immediate relief, oral corticosteroids to reduce inflammation, and antiviral therapy to treat the underlying influenza. These interventions are consistent with guidelines from the Global Initiative for Asthma (GINA) and the Centers for Disease Control and Prevention (CDC), which recommend a multi-pronged approach to managing asthma exacerbations, particularly in the presence of a respiratory infection.

References:

Centers for Disease Control and Prevention. (2021). Influenza (Flu) Treatment. Retrieved from https://www.cdc.gov/flu/treatment/index.html

Global Initiative for Asthma (GINA). (2021). Global Strategy for Asthma Management and Prevention. Retrieved from https://ginasthma.org/