ASTHMA CASE STUDY
Ø Presenting symptoms and signs of patient
Kristina is a 64-year-old retired teacher who lives with her 66-year-old husband Kevin. On weekdays they just stay home and do household chores like cleaning the house and gardening. On weekends they would go to see their children and grandchildren or play golf. Kristina and Kevin has two daughters and three grandchildren.
Kristina has been admitted to the hospital for complaints of breathing changes, sneezing frequently, headache, coughing and having trouble sleeping. Upon questioning at the hospital, Kristina revealed that she has been feeling tired lately, has become increasingly moody, and has chin or throat itches. Her breathing changes specifically refer to shortness of breath. She also reported a feeling of tightness in the chest.
Ø Formulation of the patient’s problem and therapeutic objective
Asthma is characterized by episodic or chronic wheezing, cough, and a feeling of tightness in the chest as a result of bronchoconstriction. Its morbidity and mortality is increasing, and its fundamental cause is still unknown despite intensive research (2001).
Asthma is characterized by spastic contraction of the smooth muscle in the bronchioles, which causes extremely difficult breathing. It occurs in 3 to 5 percent of all people at some time in life. The usual cause of asthma is contractile hypersensitivity of the bronchioles in response to foreign substance present in the air. In about 70 percent of patients younger than 30 years old, the asthma is caused by allergic hypersensitivity, especially sensitivity to plant pollens. In older people, the cause is almost always hypersensitivity to non-allergenic types of irritants found in the air, such as irritants in smog (2000).
Three abnormalities are present in asthma: airway obstruction that is at least partially reversible, airway inflammation, and airway hyper-responsiveness to a variety of stimuli. A link to allergy has long been recognized, and plasma IgE levels are often elevated ( 2001).
The clinical approach to an asthmatic patient should be to first exclude other diseases that can present with cough and wheezing, and then identify and control exacerbating environmental or other factors. Drug therapy is an important therapeutic modality and enables most patients to lead relatively normal lives with few adverse drug effects. Drug therapy will be used as the therapeutic choice for Kristina over fluid and electrolyte therapy or oxygen therapy.
Ø Therapeutic choice
There are four classes of drug useful in the treatment of asthma. The first class is the B-adrenergic agents, including epinephrine, isoproterenol, ephedrine, and some more selective B2-adrenergic agents. The B2-adrenergic agents include metaproterenol, terbutaline, isoetharine, and albuterol. The second class of drugs includes theophylline and its derivatives. The third group of drugs is the corticosteroids. Finally, cromolyn sodium represents a class of agents which appear to directly inhibit mediator release independently of the cAMP system.
Ø An outline of the pharmacology of the drug including its pharmacodynamics and significant aspects of its pharmacokinetics
Beta-adrenergic agonists (albuterol, epinephrine, isoproterenol, metaproterenol, pirbuterol, and terbutaline) produce bronchodilation by stimulating the production of cyclic adenosine monophosphate (cAMP). Newer agents (albuterol, metaproterenol, pirbuterol, and terbutaline) are relatively selective for pulmonary (beta2) receptors, whereas older agents produce cardiac stimulation (beta2-adrenergic effects) in addition to bronchodilation (2005). B-adrenergic receptors mediate bronchodilation, and treatment with inhaled B-adrenergic agonists is a standard therapy for asthma (2001).
The second class of drugs also cause bronchial smooth muscle relaxation and inhibition of mediator release by elevating the intracellular concentration of cAMP by inhibiting its degradation by the enzyme phosphodiesterase (2005). Theophylline has an important effect on calcium flux across cell membranes and part of its beneficial effect may be related to this property.
Corticosteroids’ multiple mechanisms of action are not well understood. In addition to reducing edema and inflammation, they appear to increase the sensitivity of the B-adrenergic receptor to catecholamines. The general action of corticosteroids includes profound and varied metabolic effects, in addition to modifying the normal immune response and suppressing inflammation. It is available in a variety of dosage forms, including oral, injectable, topical, and inhalation. Prolonged used of large amounts of topical or inhaled agent may result in systemic absorption and/or adrenal suppression (2005).
Cromolyn inhibits release of mast cell products (2001). This drug interferes with calcium transport across cell membrane, which may account for its beneficial effect. Muscarinic receptors mediate bronchoconstriction, and muscarinic cholinergic blocking drugs are also used for treatment. Glucocorticoids are also used for treatment which inhibits inflammatory response (2001).
In general, the adrenergic agents epinephrine and isoproterenol are most useful for treating the acute attack. Theophylline is a valuable adjunct to adrenergic drugs in the management of acute episodes; many consider it to be the drug of choice for long term continuous therapy. Because of their potentially dangerous long-term side effects, corticosteroids, while exceptionally effective, are withheld except for short-term use until all other treatments have failed.
Bronchodilators are used in the treatment of reversible airway obstruction due to asthma. Recently revised recommendations for management of asthma recommend that rapid-acting inhaled beta-agonist bronchodilators (not salmeterol) be reserved as acute relievers of bronchospasm; repeated or chronic use indicates the need for additional long-term control agents, including inhaled corticosteroids, mast cell stabilizers, and long-acting bronchodilators (oral theophylline or beta-agonists) and leukotriene modifiers (montelukast, zafirlukast).
Ø Information, instructions and warnings to the patient and/or the relatives of the patient, if appropriate
The patient and/or the relatives of the patient should be taught of the importance of taking only the prescribed dose of the drugs at the prescribed time intervals. They should also be advised to contact health care professional promptly if the usual dose of medication fails to produce the desired results, symptoms worsen after treatment, or toxic effects occur. In addition, the patient and/or the relatives of the patient has to be informed to avoid beta-blocker drugs (Inderal, Tenormin, Visken, and Lopressor) because they may worsen asthma or precipitate an episode.
Ø Treatment monitoring
Treatment should be continually monitored since individual patients may exhibit varying susceptibility to the beneficial or adverse effects of a certain drug used in therapy. Greater caution should be exercised and lower dosages should be used in patients who have abnormalities like congestive heart failure or advanced liver disease or those that are elderly. Patients who show no improvement or whose signs and symptoms of asthma progress despite the drug therapy used should be started on another kind of therapy.
Ø Stopping treatment
Treatment should be continued in the route specified until the patient’s condition has stabilized and there is no danger of progression of the asthma to respiratory failure. Only after the healthcare staff is sure that the patient’s condition has stabilized should the treatment be stopped.
Credit:ivythesis.typepad.com
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