CASE STUDY CRITIQUE: ASTHMA
Case Study Critique: Asthma
Overview of Initial Therapy Treatment
Ms. Sample’s case study about asthma was very well written and covered a very complex
and complicated disease based on a patient’s clinical presentation of an asthma exacerbation. She
addressed patient FC’s current medications, FC’s symptoms, and outlines a plan of care to
establish how she would treat FC and follow up with her. Ms. Sample also recognized that the
patient was not controlling her asthma with her current medications, the Proventil inhaler. She
noticed FC would need immediate treatment for the exacerbation and trial new medications to
take home and evaluate how well the new medications treat her asthma on a long term basis. By
prescribing new inhaled corticosteroids (ICS), a six-day course of oral corticosteroids (OCS),
and a new long-acting beta-2 agonist (LABA), she is treating her not only for the short term
exacerbation, but for the long term effects of her asthma and finding a new medication regiment
that works to treat her asthma.
Treatment Plan
I agree with Ms. Sample’s plan and recommendations for non-pharmacological therapy
and pharmacological therapy. One thing I did not see in her plan for the active asthma
exacerbation was to administer supplemental oxygen to the patient if she was hypoxic, which
would be needed if her oxygen saturation was below 94% on room air (Burchum & Rosenthal,
2019). She would then follow up by giving a systemic glucocorticoid, such as IV solu-medrol, to
reduce airway inflammation in severe cases if needed, followed by a high dose albuterol
nebulizer, which would relieve any airflow obstruction, and lastly the ipratropium bromide
nebulizer she was giving in her plan to further reduce airflow obstruction and secretions
(Burchum & Rosenthal, 2019).
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CASE STUDY CRITIQUE: ASTHMA
Risk Factors and Teaching
When looking at FC’s risk factors listed in the case study, the patient has an increased
BMI, lives with a roommate who smokes cigarettes, and also has a cat living in the home. These
are all significant risk factors for asthma exacerbations in patients with severe asthma like FC.
Ms. Sample will need to discuss these risk factors with FC and explain to her that she will need
to either ask her roommate to smoke outside the home, or the patient will have to find a new
place to live to decrease her likelihood of inducing an asthma attack. Ms. Sample will also have
to explain how the cat dander is playing a role in her asthma and FC will have to talk to her
roommate about also finding a new home for the cat. According to the National Heart, Lung and
Blood Institute, funded through the National Institute of Health (NIH), physical activity should
be encouraged and asthma should not reduce a patient’s participation in exercise in any way
(NIH, 2021). That being said, Ms. Sample should make sure she is expressing her concern with
the amount of times FC has had to use her Proventil inhaler, so much so she has had to ask for
many refills in her prescription early, and had hospitalizations from acute asthma attacks. This
indicates that the patient’s asthma is getting worse instead of better or properly managed. Proper
education will need to be done with FC about asthma triggers, how to manage her asthma
attacks, and lifestyle changes in order to have successful control over her disease. The patient
will also need Ms. Sample to create an asthma action plan with her, which is a guided self-
management plan that helps patients recognize and respond appropriately to asthma
exacerbations (GINA, 2021).
Medication Recommendations
FC’s current home medications, her Proventil inhaler, clearly are not working well
enough alone to manage her asthma. I agree with most of the pharmacological recommendations
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CASE STUDY CRITIQUE: ASTHMA
from Ms. Sample’s paper, but I would tweak a few things. According to Schwinghammer et al.,
(2021), uncontrolled asthma, much like FC’s, can progress to cause acute inflammation, airway
edema, mucus accumulation, and bronchospasm which can have profound airway narrowing
(Schwinghammer et al., 2021). I agree to start the patient with a nebulizer treatment in office of
albuterol to treat the current exacerbation, 2.5mg-5mg every 20 minutes for up to 3 doses
(Schwinghammer et al., 2021). This will act as a short-acting B2 agonist (SABA) and
bronchodilator, opening up her airway, and I would also send her home with her Proventil
inhaler, just increasing the dose to 90mcg, 2 inhalations with her MDI every 4-6 hours as needed
(Schwinghammer et al., 2021). As long as that initial nebulizer controls the current exacerbation,
and she is not requiring supplemental oxygen, she should not require the IV glucocorticoids as
previously mentioned. I agree to then send her home with prescription for the OCS, prednisone,
in the correct tapering dosing Ms. Sample suggested to go home with. I would also agree to send
her home with the ipratropium Bromide (Duoneb) nebulizer. This medication acts as an
anticholinergic, meaning less secretions in the airway (Schwinghammer et al., 2021). She should
be prescribed 500mcg single use vial with 3mg of albuterol nebulizer vial 3 times for 20 minutes
for any acute exacerbations she may have at home, and if that does not control her asthma, she
should seek further medical care.
Finally, Ms. Sample mentioned sending FC home with a Fluticasone DPI. I agree, FC
does need this type of inhaler because it is an ICS and LABA which allows bronchodilation for
up to 12 hours at a time (Schwinghammer et al., 2021). I believe the patient would be treated
more effectively if she was prescribed a Breo Ellipta, which is Vinalterol (a LABA) combined
with Fluticasone (a glucocorticoid) to create an ultra-LABA (Burchum & Rosenthal, 2019). This
would act as an ICS and LABA, but allows for up to 24 hours of bronchodilation, and is dosed as
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CASE STUDY CRITIQUE: ASTHMA
1 inhalation, 62.5mcg Fluticasone/25mcg Vinalterol, once a day (Burchum & Rosenthal, 2019).
This would then help the patient long term with exercise-induced asthma, as well as control her
asthma on a daily basis. If any of these medications do not seem to be working for FC, she can
come back to the office and trial a new group of medications to better treat her asthma, because
unfortunately asthma medications are mainly trial and error until the patient finds the right
combination of medications that work for her.
Medication Side Effects
With the new medications comes a great deal of teaching for the patient and making sure
she understands not only how to use the medications, but the possible side effects they can have.
One major side effect from any OCS is the possibility of weight gain (Schwinghammer et al.,
2021). FC should be instructed to weigh herself daily and make sure she is exercising and eating
healthy. She is already overweight and extra weight will just exacerbate her asthma even further.
The patient needs to also be aware that when taking oral glucocorticoids, it can cause adverse
effects including adrenal suppression, osteoporosis, hyperglycemia, peptic ulcer disease, and
growth suppression (Burchum & Rosenthal, 2019). Because of this the patient should have
regularly scheduled appointments with her primary care provider and routine blood work when
necessary.
Conclusion
Overall, I found Ms. Sample’s cases study and analysis to be very interesting and meets
pharmacological and non-pharmacological planning needs of the patient. The short term goals to
control FC’s current asthma exacerbation were there, but just needed a few more details added to
complete the overall objective. Her long term goals were also correct and easy to understand, and
the choice in medication change is really provider and patient preference, so her choices would
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CASE STUDY CRITIQUE: ASTHMA
References
Burchum, J. R. & Rosenthal, L. D. (2019). Lehne’s Pharmacology for Nursing Care (10th ed.) St.
Louis, MO: Elsevier.
Global Initiative for Asthma (GINA). (2021). Global Strategy for Asthma Management and
Prevention. Retrieved from https://ginasthma.org/wp-content/uploads/2021/05/GINA-
Main-Report-2021-V2-WMS.pdf
National Institute of Health (NIH). (2021). Asthma Care Quick Reference: Diagnosing and
Managing Asthma. Retrieved from
https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf
Schwinghammer, T. L., Dipiro, J. T., Ellingrod, V. L., & Dipiro, C. V. (2021). Pharmacotherapy
Handbook (11th ed.) New York, NY: McGraw Hill Education
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