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Patient With A Wheeze CASE STUDY NURSING 870 Case 20 Y.O. male presents with “allergy problems” HPI He states his allergies are “acting up” for the past 3 days. Developed mild SOB x 2 day ago and has some wheezing today. He’s been taking OTC allergy medications and inhalers without relief. History What else do you want to know?? Significant History He uses OTC inhaler before and after working out and occasionally before bed He had multiple infections as a child with “allergy” symptoms Told by provider that he may have asthma, but it was never confirmed He’s been in the ED 3 times last year for his allergies and wheezing, but never hospitalized History Other than SOB and mild wheezing, intermittent coughing and a runny nose her has no other positive findings in the ROS He does not smoke, use alcohol or illicit drugs He is fully immunized College student, works part-time in a convenient store Lives at home with parents, has 2 dogs in the house PE What do you want to perform?? PE General: Alert and no distress VS: 98.2-92-22 106/62 O2 sat: 99% RA Wgt. 165 lbs. Skin: Atopic dermatitis HEENT: All negative, except for gray nasal mucosa with clear discharge Resp. No use of accessory muscles, decreased inspiration, with diffuse wheezing. No crackles or egophony, bronchophony CV: HR reg, no murmurs or extra sounds What are the Clues to Diagnosis Here? Clues Allergy symptoms with wheeze Atopic Dermatitis Pets in Home Use of inhaler with exercise What’s the Differential? For Adults: Asthma URI Allergic rhinitis or sinusitis Other Differential for Asthma in Adults COPD Heart Failure Pulmonary Embolism Obstruction Vocal cord dysfunction ACE cough What’s Most Likely Asthma URI R/O pneumonia Diagnosis Review The presence of multiple key indicators increases the probability Wheezing—A lack of wheezing and a normal chest examination do not exclude asthma. History of any of the following: Cough (worse particularly at night) Recurrent wheeze Recurrent difficulty in breathing Recurrent chest tightness Symptoms occur or worsen in the presence of: Exercise Viral infection Inhalant allergens Irritants (tobacco or wood smoke, airborne chemicals) Changes in weather Strong emotional expression Stress Menstrual Cycles Symptoms occur or are worse at night, may awaken patient Now What? Diagnostics Do you need any diagnostics? Diagnostics None 100% definitive for asthma Spirometry FEV1 common to monitor treatment Predicted based on age, gender, ethnicity http://www.cdc.gov/niosh/topics/spirometry/nhanes.html Pre and post SABA Administer 4 inhalations (400 mcg) via spacer Measure FEV1 after 10-15 minutes See at least 12% improvement post (ATS) Chest x-ray Allergy testing Methacholine challenge Usually in adults if diagnosis uncertain Diagnostics Spirometry: Aids in diagnosis and differential of asthma Demonstrates reversible airway obstruction Often done pre and post SABA Goals of Treatment: Control of Asthma Reduce impairment Prevent chronic symptoms Reduce need for SABA Maintain pulmonary function Maintain normal activity Meet family expectations Reduce risk Loss of lung function Recurrent exacerbations Minimize adverse effects of treatment What Category of Asthma? Classification Classification Severity of Symptoms Mild Intermittent Nighttime Symptoms FEV Treatment < 2x/week < 2/month No limitations daily routine >80% predicted Step 1 Mild Persistent 2x/week, < 1x day Minor limitations daily routine > 2/month > 80% predicted Step 2 Moderate Persistent Daily, with daily use of B2 agonist Some limitations in daily routine > 2/week, but > 60%, < not daily 80% predicted Step 3 or Step 4 Severe Persistent Daily, use of SABA several x/day Interferes with daily routine Often Daily Step 5 or Step 6 > 60% predicted Classification of Severity Exacerbations Symptoms Mild Moderate Severe Subset Respiratory Arrest Imminent Alertness May be agitated Usually agitated Usually agitated Drowsy or confused Breathlessness With walking, can lie down and speak in sentence At rest, prefers At rest, sits up, Severe sitting, speaks uses words in phrases Respiratory RR Increased, RR Increased end expiratory wheeze RR often > 30/min May see paradoxical thoracoabdom inal movement and absence of wheeze Pulse <100 bpm 100-120 bpm >120 bpm May also be bradycardic SaO2 >95% RA 90-85% <90% What’s the Treatment Mild Intermittent Step 1 approach SABA as needed Initial Treatment Goals Mild to Moderate Exacerbation Achieve O2 sat > 90% Inhaled SABA by MDI or nebulizer up to 3 times in first hour Oral corticosteroid if no immediate response or if pt. recently on oral corticosteroid What are the other considerations for this episode? Other Considerations An acute flare r/t URI or allergies Treatment of allergic rhinitis Intranasal corticosteroids Antihistamines Consider immunotherapy Treatment of flare SABA q 6 hours for mild symptoms Albuterol May consider continuous nebs if PEFR < 40% If moderate to severe symptoms: Short course of systemic steroids + SABA Prednisone 40-60 mg po 5-10 days Make decision in < 1 hour Consider IM methylprednisolone 80 mg for potential nonadherent patients Other Considerations Treatment Plan for Long Term Control ICS : most effective at all steps of care Monitoring Control in Clinical Practice Referral If difficulty achieving or maintaining control If required > 2 oral corticosteroids in 1 yr. or pt. required hospitalization for asthma If step 4 or higher required If additional testing, immunotherapy, or omalizumab (Xolair) indicated This patient has persistent asthma Sample Patient Self-Assessment Your Asthma Control How many days in the past week have you had chest tightness, cough, shortness of breath, or wheezing (whistling in your chest)? _____ 0 _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 _____ 6 _____ 7 How many nights in the past week have you had chest tightness, cough, shortness of breath, or wheezing (whistling in your chest)? _____ 0 _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 _____ 6 _____ 7 Do you perform peak flow readings at home? ______ yes ______ no If yes, did you bring your peak flow chart? ______ yes ______ no How many days in the past week has asthma restricted your physical activity? _____ 0 _____ 1 _____ 2 _____ 3 _____ 4 _____ 5 _____ 6 _____ 7 Have you had any asthma attacks since your last visit? ______ yes ______ no Have you had any unscheduled visits to a doctor, including to the emergency department, since your last visit? ______ yes ______ no Sample Patient Self-Assessment How well controlled is your asthma, in your opinion? ____ very well controlled ____ somewhat controlled ____ not well controlled Average number of puffs per day of quick-relief medication (short acting beta2-agonist) ____________________ Taking your medicine What problems have you had taking your medicine or following your asthma action plan? Please ask the doctor or nurse to review how you take your medicine. Your questions What questions or concerns would you like to discuss with the doctor? How satisfied are you with your asthma care? ____ very satisfied ____ somewhat satisfied ____ not satisfied * These questions are examples and do not represent a standardized assessment instrument. Other examples of asthma control questions: Asthma Control Questionnaire (Juniper); Asthma Therapy Assessment Questionnaire (Volmer); Asthma Control Test (Nathan Treatment for Acute Flare SABA Treatment of choice for acute symptoms Via nebulizer or inhalation Anticholinergics Added to SABA to provide additional benefit Corticosteroids Oral systemic short course to gain control High Risk Asthma Related Death Previous severe exacerbation (e.g., intubation or ICU admission for asthma) Two or more hospitalizations or >3 ED visits in the past year Use of >2 canisters of SABA per month Difficulty perceiving airway obstruction or the severity of worsening asthma Low socioeconomic status or inner-city residence Illicit drug use Major psychosocial problems or psychiatric disease Comorbidities, such as cardiovascular disease or other chronic lung disease When Will You Re-Evaluate? Re-Evaluation 2-6 weeks Dependent oncontrol Regular follow-up Patient contact at 1-6 month intervals Based on level of control and treatment required Consider step down therapy if well controlled x 3 months Can step down ICS by 25-50% q 3 months to lowest dose Treatment can be seasonal Other Considerations Exercise Induced Pre-treatment with SABA Pregnancy Albuterol preferred SABA Budesonide preferred ICS Surgery Review control Consider oral systemic corticosteroids prior Use hydrocortisone 100 mg q8h during surgical period Reduce dose rapidly within 24 hrs post-op Other Considerations Older adults Consider short course of oral systemic corticosteroids to establish reversibility Chronic bronchitis or emphysema may co-exist Adjust meds to address coexisting problems IE. Vitamin D for patients on ICS and risk osteoporosis If patients on meds that may exacerbate asthma • NSAIDS • B blockers Disparities Higher rates poor control for African Americans and Latinos Another Case 35 year old Caucasian female presents with severe asthma attack What else do you want to know? HPI URI x few days, feels very SOB x 2 hrs prior to presentation. On albuterol and ipratropium prn and ICS Asthma diagnosis at age 25 Has PCP and medicaid insurance 2 ED visits last year + 1 asthma hospitalization + intubation PE Increased RR, HR, BP normal, normal temp PEF 150 (< 40% predicted) Diffuse wheezing despite poor air movement Initial Management What severity of asthma does this patient have? Severity Severe Exacerbation (PEF < 50%) O2 to saturation > 90% Inhaled high dose SABA and anticholinergics via neb q 20 min or continuous x 1 hour 60-70% of patients respond adequately to initial 3 doses and are sent home (Comargo, Rachelefsky, & Schatz, 2009) Oral corticosteroid What if Impending Respiratory Arrest?? If in office Start treatment, O2, nebs, and transfer If in hospital Intubation and mechanical vent with 100% O2 SABA and anticholinergic via nebulizer IV corticosteroids Admit to ICU