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• Published: 16 October 2014

A woman with asthma: a whole systems approach to supporting self-management

• Hilary Pinnock 1 ,
• Elisabeth Ehrlich 1 ,
• Gaylor Hoskins 2 &
• Ron Tomlins 3  

npj Primary Care Respiratory Medicine volume  24 , Article number:  14063 ( 2014 ) Cite this article

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A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and international and national guidelines emphasise the importance of providing a written asthma action plan. Effective implementation of this recommendation for the lady in this case study is considered from the perspective of a patient, healthcare professional, and the organisation. The patient emphasises the importance of developing a partnership based on honesty and trust, the need for adherence to monitoring and regular treatment, and involvement of family support. The professional considers the provision of asthma self-management in the context of a structured review, with a focus on a self-management discussion which elicits the patient’s goals and preferences. The organisation has a crucial role in promoting, enabling and providing resources to support professionals to provide self-management. The patient’s asthma control was assessed and management optimised in two structured reviews. Her goal was to avoid disruption to her work and her personalised action plan focused on achieving that goal.

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A 35-year-old sales representative attends the practice for an asthma review. Her medical record notes that she has had asthma since childhood, and although for many months of the year her asthma is well controlled (when she often reduces or stops her inhaled steroids), she experiences one or two exacerbations a year requiring oral steroids. These are usually triggered by a viral upper respiratory infection, though last summer when the pollen count was particularly high she became tight chested and wheezy for a couple of weeks.

Her regular prescription is for fluticasone 100 mcg twice a day, and salbutamol as required. She has a young family and a busy lifestyle so does not often manage to find time to attend the asthma clinic. A few weeks previously, an asthma attack had interfered with some important work-related travel, and she has attended the clinic on this occasion to ask about how this can be managed better in the future. There is no record of her having been given an asthma action plan.

What do we know about asthma self-management? The academic perspective

Supported self-management reduces asthma morbidity.

The lady in this case study is struggling to maintain control of her asthma within the context of her busy professional and domestic life. The recent unfortunate experience which triggered this consultation offers a rare opportunity to engage with her and discuss how she can manage her asthma better. It behoves the clinician whom she is seeing (regardless of whether this is in a dedicated asthma clinic or an appointment in a routine general practice surgery) to grasp the opportunity and discuss self-management and provide her with a (written) personalised asthma action plan (PAAP).

The healthcare professional advising the lady is likely to be aware that international and national guidelines emphasise the importance of supporting self-management. 1 – 4 There is an extensive evidence base for asthma self-management: a recent synthesis identified 22 systematic reviews summarising data from 260 randomised controlled trials encompassing a broad range of demographic, clinical and healthcare contexts, which concluded that asthma self-management reduces emergency use of healthcare resources, including emergency department visits, hospital admissions and unscheduled consultations and improves markers of asthma control, including reduced symptoms and days off work, and improves quality of life. 1 , 2 , 5 – 12 Health economic analysis suggests that it is not only clinically effective, but also a cost-effective intervention. 13

Personalised asthma action plans

Key features of effective self-management approaches are:

Self-management education should be reinforced by provision of a (written) PAAP which reminds patients of their regular treatment, how to monitor and recognise that control is deteriorating and the action they should take. 14 – 16 As an adult, our patient can choose whether she wishes to monitor her control with symptoms or by recording peak flows (or a combination of both). 6 , 8 , 9 , 14 Symptom-based monitoring is generally better in children. 15 , 16

Plans should have between two and three action points including emergency doses of reliever medication; increasing low dose (or recommencing) inhaled steroids; or starting a course of oral steroids according to severity of the exacerbation. 14

Personalisation of the action plan is crucial. Focussing specifically on what actions she could take to prevent a repetition of the recent attack is likely to engage her interest. Not all patients will wish to start oral steroids without advice from a healthcare professional, though with her busy lifestyle and travel our patient is likely to be keen to have an emergency supply of prednisolone. Mobile technology has the potential to support self-management, 17 , 18 though a recent systematic review concluded that none of the currently available smart phone ‘apps’ were fit for purpose. 19

Identification and avoidance of her triggers is important. As pollen seems to be a trigger, management of allergic rhinitis needs to be discussed (and included in her action plan): she may benefit from regular use of a nasal steroid spray during the season. 20

Self-management as recommended by guidelines, 1 , 2 focuses narrowly on adherence to medication/monitoring and the early recognition/remediation of exacerbations, summarised in (written) PAAPs. Patients, however, may want to discuss how to reduce the impact of asthma on their life more generally, 21 including non-pharmacological approaches.

Supported self-management

The impact is greater if self-management education is delivered within a comprehensive programme of accessible, proactive asthma care, 22 and needs to be supported by ongoing regular review. 6 With her busy lifestyle, our patient may be reluctant to attend follow-up appointments, and once her asthma is controlled it may be possible to make convenient arrangements for professional review perhaps by telephone, 23 , 24 or e-mail. Flexible access to professional advice (e.g., utilising diverse modes of consultation) is an important component of supporting self-management. 25

The challenge of implementation

Implementation of self-management, however, remains poor in routine clinical practice. A recent Asthma UK web-survey estimated that only 24% of people with asthma in the UK currently have a PAAP, 26 with similar figures from Sweden 27 and Australia. 28 The general practitioner may feel that they do not have time to discuss self-management in a routine surgery appointment, or may not have a supply of paper-based PAAPs readily available. 29 However, as our patient rarely finds time to attend the practice, inviting her to make an appointment for a future clinic is likely to be unsuccessful and the opportunity to provide the help she needs will be missed.

The solution will need a whole systems approach

A systematic meta-review of implementing supported self-management in long-term conditions (including asthma) concluded that effective implementation was multifaceted and multidisciplinary; engaging patients, training and motivating professionals within the context of an organisation which actively supported self-management. 5 This whole systems approach considers that although patient education, professional training and organisational support are all essential components of successful support, they are rarely effective in isolation. 30 A systematic review of interventions that promote provision/use of PAAPs highlighted the importance of organisational systems (e.g., sending blank PAAPs with recall reminders). 31 A patient offers her perspective ( Box 1 ), a healthcare professional considers the clinical challenge, and the challenges are discussed from an organisational perspective.

Box 1: What self-management help should this lady expect from her general practitioner or asthma nurse? The patient’s perspective

The first priority is that the patient is reassured that her condition can be managed successfully both in the short and the long term. A good working relationship with the health professional is essential to achieve this outcome. Developing trust between patient and healthcare professional is more likely to lead to the patient following the PAAP on a long-term basis.

A review of all medication and possible alternative treatments should be discussed. The patient needs to understand why any changes are being made and when she can expect to see improvements in her condition. Be honest, as sometimes it will be necessary to adjust dosages before benefits are experienced. Be positive. ‘There are a number of things we can do to try to reduce the impact of asthma on your daily life’. ‘Preventer treatment can protect against the effect of pollen in the hay fever season’. If possible, the same healthcare professional should see the patient at all follow-up appointments as this builds trust and a feeling of working together to achieve the aim of better self-management.

Is the healthcare professional sure that the patient knows how to take her medication and that it is taken at the same time each day? The patient needs to understand the benefit of such a routine. Medication taken regularly at the same time each day is part of any self-management regime. If the patient is unused to taking medication at the same time each day then keeping a record on paper or with an electronic device could help. Possibly the patient could be encouraged to set up a system of reminders by text or smartphone.

Some people find having a peak flow meter useful. Knowing one's usual reading means that any fall can act as an early warning to put the PAAP into action. Patients need to be proactive here and take responsibility.

Ongoing support is essential for this patient to ensure that she takes her medication appropriately. Someone needs to be available to answer questions and provide encouragement. This could be a doctor or a nurse or a pharmacist. Again, this is an example of the partnership needed to achieve good asthma control.

It would also be useful at a future appointment to discuss the patient’s lifestyle and work with her to reduce her stress. Feeling better would allow her to take simple steps such as taking exercise. It would also be helpful if all members of her family understood how to help her. Even young children can do this.

From personal experience some people know how beneficial it is to feel they are in a partnership with their local practice and pharmacy. Being proactive produces dividends in asthma control.

What are the clinical challenges for the healthcare professional in providing self-management support?

Due to the variable nature of asthma, a long-standing history may mean that the frequency and severity of symptoms, as well as what triggers them, may have changed over time. 32 Exacerbations requiring oral steroids, interrupting periods of ‘stability’, indicate the need for re-assessment of the patient’s clinical as well as educational needs. The patient’s perception of stability may be at odds with the clinical definition 1 , 33 —a check on the number of short-acting bronchodilator inhalers the patient has used over a specific period of time is a good indication of control. 34 Assessment of asthma control should be carried out using objective tools such as the Asthma Control Test or the Royal College of Physicians three questions. 35 , 36 However, it is important to remember that these assessment tools are not an end in themselves but should be a springboard for further discussion on the nature and pattern of symptoms. Balancing work with family can often make it difficult to find the time to attend a review of asthma particularly when the patient feels well. The practice should consider utilising other means of communication to maintain contact with patients, encouraging them to come in when a problem is highlighted. 37 , 38 Asthma guidelines advocate a structured approach to ensure the patient is reviewed regularly and recommend a detailed assessment to enable development of an appropriate patient-centred (self)management strategy. 1 – 4

Although self-management plans have been shown to be successful for reducing the impact of asthma, 21 , 39 the complexity of managing such a fluctuating disease on a day-to-day basis is challenging. During an asthma review, there is an opportunity to work with the patient to try to identify what triggers their symptoms and any actions that may help improve or maintain control. 38 An integral part of personalised self-management education is the written PAAP, which gives the patient the knowledge to respond to the changes in symptoms and ensures they maintain control of their asthma within predetermined parameters. 9 , 40 The PAAP should include details on how to monitor asthma, recognise symptoms, how to alter medication and what to do if the symptoms do not improve. The plan should include details on the treatment to be taken when asthma is well controlled, and how to adjust it when the symptoms are mild, moderate or severe. These action plans need to be developed between the doctor, nurse or asthma educator and the patient during the review and should be frequently reviewed and updated in partnership (see Box 1). Patient preference as well as clinical features such as whether she under- or over-perceives her symptoms should be taken into account when deciding whether the action plan is peak flow or symptom-driven. Our patient has a lot to gain from having an action plan. She has poorly controlled asthma and her lifestyle means that she will probably see different doctors (depending who is available) when she needs help. Being empowered to self-manage could make a big difference to her asthma control and the impact it has on her life.

The practice should have protocols in place, underpinned by specific training to support asthma self-management. As well as ensuring that healthcare professionals have appropriate skills, this should include training for reception staff so that they know what action to take if a patient telephones to say they are having an asthma attack.

However, focusing solely on symptom management strategies (actions) to follow in the presence of deteriorating symptoms fails to incorporate the patients’ wider views of asthma, its management within the context of her/his life, and their personal asthma management strategies. 41 This may result in a failure to use plans to maximise their health potential. 21 , 42 A self-management strategy leading to improved outcomes requires a high level of patient self-efficacy, 43 a meaningful partnership between the patient and the supporting health professional, 42 , 44 and a focused self-management discussion. 14

Central to both the effectiveness and personalisation of action plans, 43 , 45 in particular the likelihood that the plan will lead to changes in patients’ day-to-day self-management behaviours, 45 is the identification of goals. Goals are more likely to be achieved when they are specific, important to patients, collaboratively set and there is a belief that these can be achieved. Success depends on motivation 44 , 46 to engage in a specific behaviour to achieve a valued outcome (goal) and the ability to translate the behavioural intention into action. 47 Action and coping planning increases the likelihood that patient behaviour will actually change. 44 , 46 , 47 Our patient has a goal: she wants to avoid having her work disrupted by her asthma. Her personalised action plan needs to explicitly focus on achieving that goal.

As providers of self-management support, health professionals must work with patients to identify goals (valued outcomes) that are important to patients, that may be achievable and with which they can engage. The identification of specific, personalised goals and associated feasible behaviours is a prerequisite for the creation of asthma self-management plans. Divergent perceptions of asthma and how to manage it, and a mismatch between what patients want/need from these plans and what is provided by professionals are barriers to success. 41 , 42

What are the challenges for the healthcare organisation in providing self-management support?

A number of studies have demonstrated the challenges for primary care physicians in providing ongoing support for people with asthma. 31 , 48 , 49 In some countries, nurses and other allied health professionals have been trained as asthma educators and monitor people with stable asthma. These resources are not always available. In addition, some primary care services are delivered in constrained systems where only a few minutes are available to the practitioner in a consultation, or where only a limited range of asthma medicines are available or affordable. 50

There is recognition that the delivery of quality care depends on the competence of the doctor (and supporting health professionals), the relationship between the care providers and care recipients, and the quality of the environment in which care is delivered. 51 This includes societal expectations, health literacy and financial drivers.

In 2001, the Australian Government adopted a programme developed by the General Practitioner Asthma Group of the National Asthma Council Australia that provided a structured approach to the implementation of asthma management guidelines in a primary care setting. 52 Patients with moderate-to-severe asthma were eligible to participate. The 3+ visit plan required confirmation of asthma diagnosis, spirometry if appropriate, assessment of trigger factors, consideration of medication and patient self-management education including provision of a written PAAP. These elements, including regular medical review, were delivered over three visits. Evaluation demonstrated that the programme was beneficial but that it was difficult to complete the third visit in the programme. 53 – 55 Accordingly, the programme, renamed the Asthma Cycle of Care, was modified to incorporate two visits. 56 Financial incentives are provided to practices for each patient who receives this service each year.

Concurrently, other programmes were implemented which support practice-based care. Since 2002, the National Asthma Council has provided best-practice asthma and respiratory management education to health professionals, 57 and this programme will be continuing to 2017. The general practitioner and allied health professional trainers travel the country to provide asthma and COPD updates to groups of doctors, nurses and community pharmacists. A number of online modules are also provided. The PACE (Physician Asthma Care Education) programme developed by Noreen Clark has also been adapted to the Australian healthcare system. 58 In addition, a pharmacy-based intervention has been trialled and implemented. 59

To support these programmes, the National Asthma Council ( www.nationalasthma.org.au ) has developed resources for use in practices. A strong emphasis has been on the availability of a range of PAAPs (including plans for using adjustable maintenance dosing with ICS/LABA combination inhalers), plans for indigenous Australians, paediatric plans and plans translated into nine languages. PAAPs embedded in practice computer systems are readily available in consultations, and there are easily accessible online paediatric PAAPs ( http://digitalmedia.sahealth.sa.gov.au/public/asthma/ ). A software package, developed in the UK, can be downloaded and used to generate a pictorial PAAP within the consultation. 60

One of the strongest drivers towards the provision of written asthma action plans in Australia has been the Asthma Friendly Schools programme. 61 , 62 Established with Australian Government funding and the co-operation of Education Departments of each state, the Asthma Friendly Schools programme engages schools to address and satisfy a set of criteria that establishes an asthma-friendly environment. As part of accreditation, the school requires that each child with asthma should have a written PAAP prepared by their doctor to assist (trained) staff in managing a child with asthma at school.

The case study continues...

The initial presentation some weeks ago was during an exacerbation of asthma, which may not be the best time to educate a patient. It is, however, a splendid time to build on their motivation to feel better. She agreed to return after her asthma had settled to look more closely at her asthma control, and an appointment was made for a routine review.

At this follow-up consultation, the patient’s diagnosis was reviewed and confirmed and her trigger factors discussed. For this lady, respiratory tract infections are the usual trigger but allergic factors during times of high pollen count may also be relevant. Assessment of her nasal airway suggested that she would benefit from better control of allergic rhinitis. Other factors were discussed, as many patients are unaware that changes in air temperature, exercise and pets can also trigger asthma exacerbations. In addition, use of the Asthma Control Test was useful as an objective assessment of control as well as helping her realise what her life could be like! Many people with long-term asthma live their life within the constraints of their illness, accepting that is all that they can do.

After assessing the level of asthma control, a discussion about management options—trigger avoidance, exercise and medicines—led to the development of a written PAAP. Asthma can affect the whole family, and ways were explored that could help her family understand why it is important that she finds time in the busy domestic schedules to take her regular medication. Family and friends can also help by understanding what triggers her asthma so that they can avoid exposing her to perfumes, pollens or pets that risk triggering her symptoms. Information from the national patient organisation was provided to reinforce the messages.

The patient agreed to return in a couple of weeks, and a recall reminder was set up. At the second consultation, the level of control since the last visit will be explored including repeat spirometry, if appropriate. Further education about the pathophysiology of asthma and how to recognise early warning signs of loss of control can be given. Device use will be reassessed and the PAAP reviewed. Our patient’s goal is to avoid disruption to her work and her PAAP will focus on achieving that goal. Finally, agreement will be reached with the patient about future routine reviews, which, now that she has a written PAAP, could be scheduled by telephone if all is well, or face-to-face if a change in her clinical condition necessitates a more comprehensive review.

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Hilary Pinnock & Elisabeth Ehrlich

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Pinnock, H., Ehrlich, E., Hoskins, G. et al. A woman with asthma: a whole systems approach to supporting self-management. npj Prim Care Resp Med 24 , 14063 (2014). https://doi.org/10.1038/npjpcrm.2014.63

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Case Study: Managing Severe Asthma in an Adult

—he follows his treatment plan, but this 40-year-old male athlete has asthma that is not well-controlled. what’s the next step.

By Kirstin Bass, MD, PhD Reviewed by Michael E. Wechsler, MD, MMSc

This case presents a patient with poorly controlled asthma that remains refractory to treatment despite use of standard-of-care therapeutic options. For patients such as this, one needs to embark on an extensive work-up to confirm the diagnosis, assess for comorbidities, and finally, to consider different therapeutic options.

Case presentation and patient history

Mr. T is a 40-year-old recreational athlete with a medical history significant for asthma, for which he has been using an albuterol rescue inhaler approximately 3 times per week for the past year. During this time, he has also been waking up with asthma symptoms approximately twice a month, and has had three unscheduled asthma visits for mild flares. Based on the  National Asthma Education and Prevention Program guidelines , Mr. T has asthma that is not well controlled. 1

As a result of these symptoms, spirometry was performed revealing a forced expiratory volume in the first second (FEV1) of 78% predicted. Mr. T then was prescribed treatment with a low-dose corticosteroid, fluticasone 44 mcg at two puffs twice per day. However, he remained symptomatic and continued to use his rescue inhaler 3 times per week. Therefore, he was switched to a combination inhaled steroid and long-acting beta-agonist (LABA) (fluticasone propionate 250 mcg and salmeterol 50 mcg, one puff twice a day) by his primary care doctor.

Initial pulmonary assessment Even with this step up in his medication, Mr. T continued to be symptomatic and require rescue inhaler use. Therefore, he was referred to a pulmonologist, who performed the initial work-up shown here:

• Spirometry, pre-albuterol: FEV1 79%, post-albuterol: 12% improvement
• Methacholine challenge: PC 20 : 1.0 mg/mL
• Chest X-ray: Within normal limits

Continued pulmonary assessment His dose of inhaled corticosteroid (ICS) and LABA was increased to fluticasone 500 mcg/salmeterol 50 mcg, one puff twice daily. However, he continued to have symptoms and returned to the pulmonologist for further work-up, shown here:

• Chest computed tomography (CT): Normal lung parenchyma with no scarring or bronchiectasis
• Sinus CT: Mild mucosal thickening
• Complete blood count (CBC): Within normal limits, white blood cells (WBC) 10.0 K/mcL, 3% eosinophils
• Immunoglobulin E (IgE): 25 IU/mL
• Allergy-skin test: Positive for dust, trees
• Exhaled NO: Fractional exhaled nitric oxide (FeNO) 53 parts per billion (pbb)

Assessment for comorbidities contributing to asthma symptoms After this work-up, tiotropium was added to his medication regimen. However, he remained symptomatic and had two more flares over the next 3 months. He was assessed for comorbid conditions that might be affecting his symptoms, and results showed:

• Esophagram/barium swallow: Negative
• Esophageal manometry: Negative
• Esophageal impedance: Within normal limits
• ECG: Within normal limits
• Genetic testing: Negative for cystic fibrosis, alpha1 anti-trypsin deficiency

The ear, nose, and throat specialist to whom he was referred recommended only nasal inhaled steroids for his mild sinus disease and noted that he had a normal vocal cord evaluation.

Following this extensive work-up that transpired over the course of a year, Mr. T continued to have symptoms. He returned to the pulmonologist to discuss further treatment options for his refractory asthma.

Diagnosis Mr. T has refractory asthma. Work-up for this condition should include consideration of other causes for the symptoms, including allergies, gastroesophageal reflux disease, cardiac disease, sinus disease, vocal cord dysfunction, or genetic diseases, such as cystic fibrosis or alpha1 antitrypsin deficiency, as was performed for Mr. T by his pulmonary team.

Treatment options When a patient has refractory asthma, treatment options to consider include anticholinergics (tiotropium, aclidinium), leukotriene modifiers (montelukast, zafirlukast), theophylline, anti-immunoglobulin E (IgE) antibody therapy with omalizumab, antibiotics, bronchial thermoplasty, or enrollment in a clinical trial evaluating the use of agents that modulate the cell signaling and immunologic responses seen in asthma.

Treatment outcome Mr. T underwent bronchial thermoplasty for his asthma. One year after the procedure, he reports feeling great. He has not taken systemic steroids for the past year, and his asthma remains controlled on a moderate dose of ICS and a LABA. He has also been able to resume exercising on a regular basis.

Approximately 10% to 15% of asthma patients have severe asthma refractory to the commonly available medications. 2  One key aspect of care for this patient population is a careful workup to exclude other comorbidities that could be contributing to their symptoms. Following this, there are several treatment options to consider, as in recent years there have been several advances in the development of asthma therapeutics. 2

Treatment options for refractory asthma There are a number of currently approved therapies for severe, refractory asthma. In addition to therapy with ICS or combination therapies with ICS and LABAs, leukotriene antagonists have good efficacy in asthma, especially in patients with prominent allergic or exercise symptoms. 2  The anticholinergics, such as tiotropium, which was approved for asthma in 2015, enhance bronchodilation and are useful adjuncts to ICS. 3-5  Omalizumab is a monoclonal antibody against IgE recommended for use in severe treatment-refractory allergic asthma in patients with atopy. 2  A nonmedication therapeutic option to consider is bronchial thermoplasty, a bronchoscopic procedure that uses thermal energy to disrupt bronchial smooth muscle. 6,7

Personalizing treatment for each patient It is important to personalize treatment based on individual characteristics or phenotypes that predict the patient's likely response to treatment, as well as the patient's preferences and practical issues, such as adherence and cost. 8

In this case, tiotropium had already been added to Mr. T's medications and his symptoms continued. Although addition of a leukotriene modifier was an option for him, he did not wish to add another medication to his care regimen. Omalizumab was not added partly for this reason, and also because of his low IgE level. As his bronchoscopy was negative, it was determined that a course of antibiotics would not be an effective treatment option for this patient. While vitamin D insufficiency has been associated with adverse outcomes in asthma, T's vitamin D level was tested and found to be sufficient.

We discussed the possibility of Mr. T's enrollment in a clinical trial. However, because this did not guarantee placement within a treatment arm and thus there was the possibility of receiving placebo, he opted to undergo bronchial thermoplasty.

Bronchial thermoplasty  Bronchial thermoplasty is effective for many patients with severe persistent asthma, such as Mr. T. This procedure may provide additional benefits to, but does not replace, standard asthma medications. During the procedure, thermal energy is delivered to the airways via a bronchoscope to reduce excess airway smooth muscle and limit its ability to constrict the airways. It is an outpatient procedure performed over three sessions by a trained physician. 9

The effects of bronchial thermoplasty have been studied in several trials. The first large-scale multicenter randomized controlled study was  the Asthma Intervention Research (AIR) Trial , which enrolled patients with moderate to severe asthma. 10  In this trial, patients who underwent the procedure had a significant improvement in asthma symptoms as measured by symptom-free days and scores on asthma control and quality of life questionnaires, as well as reductions in mild exacerbations and increases in morning peak expiratory flow. 10  Shortly after the AIR trial, the  Research in Severe Asthma (RISA) trial  was conducted to evaluate bronchial thermoplasty in patients with more severe, symptomatic asthma. 11  In this population, bronchial thermoplasty resulted in a transient worsening of asthma symptoms, with a higher rate of hospitalizations during the treatment period. 11  Hospitalization rate equalized between the treatment and control groups in the posttreatment period, however, and the treatment group showed significant improvements in rescue medication use, prebronchodilator forced expiratory volume in the first second (FEV1) % predicted, and asthma control questionnaire scores. 11

The AIR-2  trial followed, which was a multicenter, randomized, double-blind, sham-controlled study of 288 patients with severe asthma. 6  Similar to the RISA trial, patients in the treatment arm of this trial experienced an increase in adverse respiratory effects during the treatment period, the most common being airway irritation (including wheezing, chest discomfort, cough, and chest pain) and upper respiratory tract infections. 6

The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6  In this study, bronchial thermoplasty was found to significantly improve quality of life, as well as reduce the rate of severe exacerbations by 32%. 6  Patients who underwent the procedure also reported fewer adverse respiratory effects, fewer days lost from work, school, or other activities due to asthma, and an 84% risk reduction in emergency department visits. 6

Long-term (5-year) follow-up studies have been conducted for patients in both  the AIR  and  the AIR-2  trials. In patients who underwent bronchial thermoplasty in either study, the rate of adverse respiratory effects remained stable in years 2 to 5 following the procedure, with no increase in hospitalizations or emergency department visits. 7,12  Additionally, FEV1 remained stable throughout the 5-year follow-up period. 7,12  This finding was maintained in patients enrolled in the AIR-2 trial despite decreased use of daily ICS. 7

Bronchial thermoplasty is an important addition to the asthma treatment armamentarium. 7  This treatment is currently approved for individuals with severe persistent asthma who remain uncontrolled despite the use of an ICS and LABA. Several clinical trials with long-term follow-up have now demonstrated its safety and ability to improve quality of life in patients with severe asthma, such as Mr. T.

Severe asthma can be a challenge to manage. Patients with this condition require an extensive workup, but there are several treatments currently available to help manage these patients, and new treatments are continuing to emerge. Managing severe asthma thus requires knowledge of the options available as well as consideration of a patient's personal situation-both in terms of disease phenotype and individual preference. In this case, the patient expressed a strong desire to not add any additional medications to his asthma regimen, which explained the rationale for choosing to treat with bronchial thermoplasty. Personalized treatment necessitates exploring which of the available or emerging options is best for each individual patient.

Published: April 16, 2018

• 1. National Asthma Education and Prevention Program: Asthma Care Quick Reference.
• 2. Olin JT, Wechsler ME. Asthma: pathogenesis and novel drugs for treatment. BMJ . 2014;349:g5517.
• 3. Boehringer Ingelheim. Asthma: U.S. FDA approves new indication for SPIRIVA Respimat [press release]. September 16, 2015.
• 4. Peters SP, Kunselman SJ, Icitovic N, et al. Tiotropium bromide step-up therapy for adults with uncontrolled asthma. N Engl J Med . 2010;363:1715-1726.
• 5. Kerstjens HA, Engel M, Dahl R. Tiotropium in asthma poorly controlled with standard combination therapy. N Engl J Med . 2012;367:1198-1207.
• 6. Castro M, Rubin AS, Laviolette M, et al. Effectiveness and safety of bronchial thermoplasty in the treatment of severe asthma: a multicenter, randomized, double-blind, sham-controlled clinical trial. Am J Respir Crit Care Med . 2010;181:116-124.
• 7. Wechsler ME, Laviolette M, Rubin AS, et al. Bronchial thermoplasty: long-term safety and effectiveness in patients with severe persistent asthma. J Allergy Clin Immunol . 2013;132:1295-1302.
• 8. Global Initiative for Asthma: Pocket Guide for Asthma Management and Prevention (for Adults and Children Older than 5 Years).
• 10. Cox G, Thomson NC, Rubin AS, et al. Asthma control during the year after bronchial thermoplasty. N Engl J Med . 2007;356:1327-1337.
• 11. Pavord ID, Cox G, Thomson NC, et al. Safety and efficacy of bronchial thermoplasty in symptomatic, severe asthma. Am J Respir Crit Care Med . 2007;176:1185-1191.
• 12. Thomson NC, Rubin AS, Niven RM, et al. Long-term (5 year) safety of bronchial thermoplasty: Asthma Intervention Research (AIR) trial. BMC Pulm Med . 2011;11:8.

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Treatable traits and future exacerbation risk in severe asthma, baker’s asthma, the long-term trajectory of mild asthma, age, gender, & systemic corticosteroid comorbidities, ask the expert: william busse, md, challenges the current definition of the atopic march, considering the curveballs in asthma treatment, do mucus plugs play a bigger role in chronic severe asthma than previously thought, an emerging subtype of copd is associated with early respiratory disease.

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• v.11(2); 2023 Feb

Challenging case of severe acute asthma in a mechanically ventilated patient managed with sevoflurane

Satheesh munusamy.

1 Intensive Care Department, Hamad Medical Corporation, Doha Qatar

Seyedeh Saba Nabavi Monfared

2 Emergency and Trauma Pharmacy Department, Hamad Medical Corporation, Qatar University, Doha Qatar

Phool Iqbal

3 Internal Medicine Department, Metropolitan Hospital Center, New York New York, USA

Ahmed Lutfe Mohamad Abdussalam

4 Hamad General Hospital, Doha Qatar

5 Weill Cornell Medicine Qatar, Qatar

Associated Data

Acute severe bronchial asthma is a chronic inflammatory disease characterized by hyperresponsiveness of the airways leading to bronchoconstriction. We present a case of refractory life‐threatening bronchial asthma that was managed with sevoflurane gas along with the standard treatment and achieved stability and clinical improvement through its bronchodilator and anesthetic effect.

1. INTRODUCTION

Acute severe asthma is a life‐threatening emergency characterized by severe tachypnea, tachycardia, and type 1 respiratory failure. 1 According to the international standard guidelines, it is managed with bronchodilators, systemic steroids, and magnesium sulfate in emergency cases. 2 Here, we describe a case of a 38 years old male who presented with a severe asthmatic attack resistant to conventional therapy of bronchodilators and corticosteroids. Subsequently, the patient was started on noninvasive ventilator support; he could not tolerate it and was intubated. Later the patient had a good recovery after managing with an anesthetic inhalation agent sevoflurane and mechanical ventilator support by using an anesthesia machine. This case report highlights the potential management of severe acute asthma in the critical care unit with sevoflurane.

2. CASE PRESENTATION

A 38‐year‐old man with a background of bronchial asthma presented to the Emergency Department with a 2‐day history of progressive shortness of breath following cold exposure. He was on a regular metered‐dose inhaler of Salbutamol 100 μg, one puff Q6hrly at home. He mentioned having a mild cough and audible wheezes before admission but no associated fever, rhinorrhea, cough, or upper respiratory tract symptoms. He was compliant with his medications. The patient had a recent admission with a severe asthma attack treated with intravenous corticosteroids with Hydrocortisone 200 mg three times daily, nebulizer therapy Budesonide 500 μg BID, Salbutamol 2.5 mg Q8hrly, Ipratropium bromide 125 μg QID 2 days before this admission. He was discharged home with a salbutamol inhaler, one puff Q6H, and a Budesonide inhaler 500 μg two puff BID. On day two of discharge, the patient was readmitted with complaints of cough and audible wheezes. On clinical assessment, he was oriented but was unable to complete entire sentences. He was using accessory muscles for breathing. Vitally, he had tachypnea of 35 breaths/min, oxygen saturation of 99% on 10 L of the nonrebreather oxygen mask, tachycardia of 145 beats/min, and blood pressure of 145/91 mmHg, and an oral temperature of 37.3°C. His chest XR is shown in Figure  1A and was unremarkable for any pulmonary infiltrates, pneumothorax, pleural effusion, or pathology. Initial ECG was also unremarkable, as mentioned in Figure  2 . Initial arterial blood gas revealed respiratory acidosis, pH 7.314, PCO 2 72 mmHg, PO 2 132 mmHg and the bicarbonate level 32 mEq/L. Salbutamol 2.5 mg Q2hrly and Ipratropium bromide 125 μg Q2hrly nebs were given immediately.

(A) Before intubation and (B) after intubation

Unremarkable ECG

Nevertheless, the patient kept deteriorating clinically. He was given 4 g of magnesium sulfate along with a trial of noninvasive ventilation (NIV) with the settings of ST (spontaneous timed) mode, PS (pressure support) 12, PEEP (positive end‐expiratory pressure) 6, and FiO 2 40%. Arterial blood gases showed worsening respiratory acidosis—pH 7.130, PCO 2 83 mmHg, PO 2 111 mmHg, and HCO 3 30 mEq/L. Due to the increased work of breathing and drowsy state of the patient, he was intubated and started on mechanical ventilation with volume‐controlled mode, and settings of tidal volume 450 ml, respiratory rate of 14 breaths/min, PEEP of 5 cm·H 2 O, and FiO 2 of 60%. Chest XR postintubation is shown in Figure  1B . The flow volume scale was not touching the baseline due to severe bronchial constriction. The metered‐dose inhaler was started with bronchodilator therapy and steroids (Salbutamol 2.5 mg Q4hrly through the endotracheal tube). Auto‐PEEP showed 4 cm·H 2 O. Settings were altered as Inspiratory (I): Expiratory (E) ratio from 1:2.5 to 1:5. Secretions were cleared with closed inline suctioning regularly. Two days later, the patient did not show any improvement. Subsequently, it was decided by the ICU team to give bronchodilator therapy through an anesthetist agent, sevoflurane, in‐between 0.5% and 2% for 48 h. After starting inhaling sevoflurane patient, the peak pressure started to come down. Presevoflurane therapy and postsevoflurane therapy pressures are summarized in Table  1 . The arterial blood gas showed an improvement in ventilation. The comparison of ABG values is also mentioned in Table  2 . The patient gradually improved and was eventually extubated without any complications.

The comparison of ventilator status from pretherapy and post‐therapy treatment with sevoflurane

Abbreviations: Ppeak, peak pressure; Pplat, plateau pressure; Stat. comp, static lung compliance.

The ABG values from pretherapy and postsevoflurane therapy treatment

Abbreviations: HCO 3 , bicarbonate; PCO 2 , partial pressure of carbon dioxide; pH, hydrogen ion; PO 2, partial pressure of oxygen.

3. DISCUSSION

Severe bronchial asthma can be life‐threatening if not timely managed. However, patient response varies even on a standard guideline treatment. Ng et al. 3 described acute asthma as a dangerous disease‐causing acute dyspnea leading to increase work of breathing. In the United States, 1.8‐million asthma attack cases visit the emergency department annually. Nearly 10 cases of death occur per day. 4 Most patients will recover with standard treatment. However, few cases reported resistant status‐asthmaticus, which responded only to sevoflurane and the standard treatment. 3 Our case describes the successful treatment of inhaled anesthesia gas in addition to standard treatment. Inhaled anesthesia gas (sevoflurane) has been shown to reduce Auto‐PEEP, bronchial constriction, and dynamic hyperinflation. 4 sevoflurane has a rapid bronchodilator effect and smooth muscle relaxant effect, easily ventilating the patient without asynchrony. sevoflurane is usually used in anesthesia to sedate the patient during a procedure; in selected cases, only using sevoflurane in critical care settings. 5 The main drawbacks of sevoflurane use are its high cost, monitoring, and scavenging of exhaled gas. With conservative anesthesia devices, the exhaled gas and sevoflurane can be filtered and reused. 2 Intravenous sedation could be reduced or discontinued during sevoflurane administration through ventilator support. 6 Soukup et al. evaluated the impact of sevoflurane during long‐term treatment of critical care unit patients, which showed high effectiveness on patient safety and reduced weaning time in comparison with standard conventional intravenous sedation concept. 7 Routine use of sevoflurane is easily feasible, effective, and safe, has a short awakening time, and has an adequate bronchodilator effect. 8 Current studies show that sevoflurane has significant bronchodilator properties and is an effective treatment option for severe acute asthma before rescue therapies. 9 The beneficial effect of sevoflurane in our case is supported by alveolar unit and distal airway dilation, which reduce distortion of the surrounding parenchyma and amount of alveolar collapse and finally reduce viscoelastic stress adaptation. sevoflurane has a rapid bronchodilator effect and muscle relaxant properties by reducing intracellular calcium in smooth muscle cells to ventilate the patient efficiently without asynchrony. 10 Despite the presence of nephrotoxic metabolites upon sevoflurane degradation, it can be considered a safe option in long‐term use and challenging intubation case scenarios. 11 , 12 This case aims to show there is an effect of sevoflurane for acute severe asthma cases treatment in addition to standard treatment.

4. CONCLUSION

Our objective is to highlight the potential of sevoflurane in the management of severe acute asthma refractory to standard management in mechanically ventilated patients. sevoflurane can be considered a lifesaving add‐on therapy to the standard treatment of severe asthma in resourceful countries. Considering endotracheal intubation should not be delayed in severe asthma to avoid fatal outcomes. Further meta‐analysis and studies are recommended to evaluate the long‐term efficacy and clinical applicability.

AUTHOR CONTRIBUTIONS

Satheesh Munusamy: Conceptualization; investigation; methodology; writing – original draft; writing – review and editing. Seyedeh Saba Nabavi Monfared: Writing – original draft; writing – review and editing. Phool Iqbal: Formal analysis; supervision; writing – original draft; writing – review and editing. Ahmed Lutfe Mohamad Abdussalam: Supervision; visualization.

FUNDING INFORMATION

This research has been funded by Qatar National Library.

CONFLICT OF INTEREST

The authors certify that they have no conflict of interest and no affiliations with or involvement in any organization or entity with any financial or nonfinancial interest in the subject matter or materials discussed in this manuscript.

ETHICAL APPROVAL

The study is conducted ethically in accordance with the World Medical Association Declaration of Helsinki.

Written informed consent was obtained from the patient to publish this report in accordance with the journal's patient consent policy.

ACKNOWLEDGMENT

Munusamy S, Monfared SSN, Iqbal P, Abdussalam ALM. Challenging case of severe acute asthma in a mechanically ventilated patient managed with sevoflurane . Clin Case Rep . 2023; 11 :e06571. doi: 10.1002/ccr3.6571 [ CrossRef ] [ Google Scholar ]

DATA AVAILABILITY STATEMENT

; Dixit, Pratibha ; Maurya, Nutan (2014) The Indian Journal of Pediatrics, 82 (2). pp. 114-118. ISSN 0019-5456 Full text not available from this repository. Official URL: Related URL: http://dx.doi.org/ Objectives: To screen asthmatic patients by sweat chloride test to identify proportion with Cystic Fibrosis (CF); (Sweat chloride level >60 mmol/L). Also, to compare sweat chloride levels between cases of bronchial asthma and age and sex matched healthy children aged 5 mo-15 y. Methods: The present case-control study was conducted in a tertiary care hospital in India. Cases of bronchial asthma, diagnosed by GINA guideline 2008, and age matched healthy controls were included. Case to control ratio was 2:1. Sweat Chloride test was done by Pilocarpine Iontophoresis method. Results: From April 2010 through May 2012, 216 asthmatics and 112 controls were recruited. Among asthmatics, there was no case of Cystic Fibrosis. Mean sweat chloride levels in asthmatics was 22.39 ± 8.45 mmol/L (inter-quartile range - 15-28 mmol/L) and in controls 19.55 ± 7.04 mmol/L (inter-quartile range - 15-23.5 mmol/L) (p value = 0.048). Conclusions: No Cystic Fibrosis case was identified among asthmatics. Mean sweat chloride levels were higher in asthmatics as compared to controls. Item Type: Article Source: Copyright of this article belongs to Springer Nature Keywords: Cystic Fibrosis, Sweat chloride level, North India, Asthma ID Code: 131940 Deposited On: 09 Dec 2022 10:35 Last Modified: 09 Dec 2022 10:35 Repository Staff Only: item control page A Comprehensive Case Study On Acute Bronchitis: Insights And Management Overview On Scribd Last updated Aug 01, 2023 Difficulty Intemediate Category Bronchitis Acute bronchitis is a common respiratory condition that affects millions of people worldwide. It is characterized by an inflammation of the bronchial tubes, which are responsible for carrying air to and from the lungs. In this case study, we will explore the symptoms, diagnosis, and treatment options for a patient with acute bronchitis. By examining the unique circumstances of this individual, we can gain a deeper understanding of the complexities of this condition and the approaches that healthcare professionals employ to address it effectively. Characteristics Values Age 40 years old Gender Female Symptoms Cough, chest congestion, shortness of breath Duration 1 week Smoking history Non-smoker Medical history No chronic respiratory diseases Physical examination Mild wheezing on auscultation Laboratory findings Increased white blood cell count Imaging studies Normal chest X-ray Differential diagnosis Acute exacerbation of chronic bronchitis, pneumonia Treatment Supportive care, bronchodilators, cough suppressants Prognosis Good, expected to recover in 2-3 weeks What You'll Learn What are the symptoms and signs of acute bronchitis as described in the case study, what factors or circumstances may have contributed to the patient developing acute bronchitis, how was the patient diagnosed with acute bronchitis, what treatment options were considered or recommended for the patient's acute bronchitis, has the patient shown any improvement or progression of their symptoms since the diagnosis. Acute bronchitis is a common respiratory condition characterized by inflammation of the bronchial tubes, which carry air to and from the lungs. It is typically caused by a viral infection and is often preceded by an upper respiratory tract infection, such as the common cold. In the case study, the symptoms and signs of acute bronchitis can be observed and described. These may include: Cough: A persistent cough is one of the hallmark symptoms of acute bronchitis. The cough is usually non-productive in the early stages but may later produce phlegm or mucus. The cough can be quite severe and is often worse at night or upon waking up in the morning. It may last for several weeks. Wheezing: Wheezing is a whistling sound that occurs when air is forced through narrowed airways. It is commonly heard during expiration and can be a sign of bronchial inflammation and constriction. If accompanied by shortness of breath, it may indicate a more severe form of bronchitis or the development of asthma. Shortness of breath: Some individuals with acute bronchitis may experience shortness of breath or difficulty breathing, especially with physical exertion. This symptom may be more pronounced in individuals who already have underlying respiratory conditions, such as asthma or chronic obstructive pulmonary disease (COPD). Chest discomfort: Chest discomfort or tightness may be present in some individuals with acute bronchitis. This can be attributed to the inflammation and irritation of the bronchial tubes, leading to a feeling of pressure or heaviness in the chest. Fever and fatigue: While not all individuals with acute bronchitis will experience fever, it is a possible symptom. Fever is usually low-grade, ranging from 100 to 101 degrees Fahrenheit. Fatigue and general malaise may also accompany acute bronchitis, as the body fights off the viral infection. It is important to note that these symptoms can vary from person to person, and some individuals may experience a milder form of acute bronchitis with fewer or less severe symptoms. However, in the case study, the presence of a persistent cough, wheezing, shortness of breath, chest discomfort, and other associated symptoms suggests a more significant respiratory inflammation. In conclusion, the symptoms and signs of acute bronchitis as described in the case study include a persistent cough, wheezing, shortness of breath, chest discomfort, and potentially fever and fatigue. These symptoms can vary in severity and may last for several weeks. It is important for individuals experiencing these symptoms to seek medical attention to receive an accurate diagnosis and appropriate treatment. How Serious is Asthmatic Bronchitis? Understanding the Severity of this Respiratory Condition You may want to see also Acute bronchitis is a respiratory condition that involves inflammation of the bronchial tubes, which are responsible for carrying air to the lungs. It is commonly caused by viral infections, although bacterial infections and environmental factors can also play a role. In this article, we will explore the various factors and circumstances that may contribute to a person developing acute bronchitis. Viral Infections: The most common cause of acute bronchitis is viral infections, such as the common cold or influenza. These viruses can easily spread from person to person through coughing, sneezing, or close contact. When the virus enters the body, it can attack the cells lining the bronchial tubes, leading to inflammation and increased production of mucus. This combination of inflammation and excess mucus causes the characteristic symptoms of acute bronchitis, including coughing, wheezing, and shortness of breath. Bacterial Infections: Although less common than viral infections, bacterial infections can also contribute to the development of acute bronchitis. Bacteria such as Streptococcus pneumoniae or Haemophilus influenzae can infect the respiratory tract and cause inflammation of the bronchial tubes. Bacterial bronchitis often occurs as a secondary infection following a viral infection. Smoking: Smoking is a significant risk factor for developing acute bronchitis. The toxins in cigarette smoke irritate the airways and lungs, making them more susceptible to infection. Smoking can also impair the ability of the lungs to clear mucus, leading to a buildup of mucus in the bronchial tubes. This mucus provides an ideal environment for bacteria to grow and cause infection. Environmental Factors: Exposure to certain environmental factors can increase the risk of developing acute bronchitis. These may include air pollution, chemical irritants, and dust particles. When these substances are inhaled, they can irritate the bronchial tubes and trigger inflammation. For example, people who work in industries such as mining or construction, where they are regularly exposed to dust or chemical fumes, may be at a higher risk of developing acute bronchitis. Weakened Immune System: A weakened immune system can make a person more susceptible to infections, including those that can cause acute bronchitis. This can be due to various factors, such as chronic illness, malnutrition, or certain medications that suppress the immune system. People with compromised immune systems, such as those with HIV, cancer, or undergoing chemotherapy, may be at a higher risk of developing acute bronchitis. In conclusion, several factors and circumstances can contribute to the development of acute bronchitis. Viral infections, bacterial infections, smoking, environmental factors, and a weakened immune system are all potential risk factors. By understanding these factors and taking appropriate precautions, such as practicing good hygiene, avoiding exposure to irritants, and quitting smoking, individuals can reduce their risk of developing acute bronchitis. However, if symptoms persist or worsen, it is important to seek medical attention for a proper diagnosis and treatment. Is Cipro an Effective Treatment for Bronchitis? Expert Opinion Revealed Acute bronchitis is a condition that affects the airways leading to the lungs. It is characterized by inflammation of the bronchial tubes, which results in symptoms such as coughing, chest discomfort, and shortness of breath. Diagnosis of acute bronchitis involves a combination of medical history, physical examination, and additional tests if necessary. When a patient presents with symptoms consistent with acute bronchitis, the healthcare provider will begin by taking a detailed medical history. This includes asking about the onset and duration of symptoms, any recent respiratory infections or exposures, and any underlying medical conditions that may contribute to the development of bronchitis. It is also important to ask about any smoking history, as acute bronchitis is more common in individuals who smoke. After obtaining the medical history, the healthcare provider will perform a physical examination. They will listen to the patient's lungs using a stethoscope, looking for any abnormal breath sounds such as wheezing or crackles, which may indicate inflammation or fluid in the airways. The presence of fever, increased heart rate, and respiratory distress may also be noted during the examination. In most cases, the combination of a detailed medical history and physical examination is sufficient to diagnose acute bronchitis. However, in some cases, additional tests may be necessary to rule out other possible causes of the symptoms. These tests may include a chest X-ray or a sputum culture. A chest X-ray can help the healthcare provider visualize the lungs and rule out any other conditions, such as pneumonia or lung cancer, that may present with similar symptoms to acute bronchitis. It can also help identify any complications of bronchitis, such as pneumonia or signs of chronic obstructive pulmonary disease (COPD). A sputum culture involves collecting a sample of the patient's sputum, which is the mucus that is coughed up from the lungs. This sample is then sent to a laboratory for testing to identify any bacterial or fungal infections that may be causing the bronchitis. This test is not routinely performed in all cases of acute bronchitis but may be considered if the symptoms are severe or if the patient does not respond to initial treatment. Overall, the diagnosis of acute bronchitis is primarily based on a thorough medical history and physical examination. Additional tests such as chest X-ray or sputum culture may be done in certain cases to rule out other causes or complications. It is worth noting that acute bronchitis is typically a self-limited condition that resolves without specific treatment, and therefore, the focus of diagnosis is mainly on ruling out more serious underlying conditions. Is it necessary to stay home if I have bronchitis? Understanding when to take a break for better recovery Acute bronchitis is a common respiratory condition characterized by the inflammation of the bronchial tubes. It is typically caused by a viral infection and can result in symptoms such as coughing, chest congestion, and difficulty breathing. When patients present with acute bronchitis, healthcare providers consider several treatment options to alleviate symptoms and promote recovery. Symptomatic treatment: The primary approach to managing acute bronchitis is symptomatic treatment. This involves addressing the symptoms experienced by the patient, such as coughing and congestion. Over-the-counter medications like cough suppressants or expectorants may be recommended to relieve coughing and help clear mucus from the airways. Nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or acetaminophen can help reduce pain and fever associated with bronchitis. Rest and hydration: Adequate rest is essential to allow the body to recover from acute bronchitis. Patients are advised to take time off work or school to allow the immune system to fight off the infection. Staying hydrated is also important as it helps thin out mucus and makes it easier to expel. Drinking plenty of fluids, such as water, herbal teas, and warm soups, can provide relief and promote recovery. Steam inhalation: Steam inhalation can help soothe the airways and relieve congestion. Patients are advised to lean over a bowl of hot water and cover their heads with a towel to trap the steam. Adding a few drops of essential oils, such as eucalyptus or peppermint, can further enhance the therapeutic effects. However, caution should be exercised to avoid burns. Bronchodilators: In some cases, healthcare providers may prescribe bronchodilators to patients with acute bronchitis. Bronchodilators are medications that help relax the muscles around the bronchial tubes, making it easier to breathe. They are commonly used in patients who experience severe wheezing or shortness of breath. β2-agonists, such as albuterol, are a common class of bronchodilators prescribed for acute bronchitis. Antibiotics: Antibiotics are not routinely recommended for the treatment of acute bronchitis. Since most cases are caused by viruses, antibiotics are ineffective and unnecessary. However, in rare cases where the bronchitis is caused by a bacterial infection or if there are underlying health conditions that increase the risk of complications, such as chronic obstructive pulmonary disease (COPD), antibiotics may be considered. It is important for patients with acute bronchitis to monitor their symptoms and seek medical attention if they worsen or persist beyond a few weeks. In some cases, acute bronchitis can progress to a more severe respiratory infection, such as pneumonia. Patients should also follow proper respiratory hygiene practices, such as covering their mouth and nose when coughing or sneezing, to prevent the spread of the infection to others. In summary, treatment options for acute bronchitis focus on relieving symptoms and supporting the body's natural healing process. Symptomatic treatment, rest, hydration, steam inhalation, and bronchodilators are commonly recommended. Antibiotics are generally not prescribed unless there is evidence of a bacterial infection or underlying health conditions. With proper management, most cases of acute bronchitis resolve within a few weeks, and patients can return to their normal activities. Exploring the Symptoms, Diagnosis, and Treatment Options for Acute Bronchitis: Insights from BMJ Diagnosing a medical condition is the first step towards finding appropriate treatments and interventions. Once a diagnosis has been made, it is crucial to assess whether the patient has shown any improvement or progression of their symptoms since the diagnosis. Monitoring the patient's progress can help healthcare providers evaluate the effectiveness of the chosen treatments and make adjustments as needed. There are several ways to assess the improvement or progression of symptoms in a patient. These methods can include subjective reports from the patient, objective measurements, and follow-up visits with healthcare providers. Let's explore some examples of how these methods can be used to evaluate a patient's progress. Subjective reports from the patient are an essential tool for assessing symptom improvement or progression. The patient's experience and perception of their symptoms are invaluable in understanding how the condition is affecting their daily life. Patients can provide information about changes in pain levels, activity limitations, mood, and overall quality of life. These reports can be collected through regular check-ins, questionnaires, or personal journals. Objective measurements are another important aspect of monitoring a patient's progress. These measurements can include physical examinations, laboratory tests, imaging studies, or other diagnostic tools. For example, if a patient was diagnosed with arthritis, their healthcare provider may use X-rays to assess changes in joint inflammation or deterioration over time. Similarly, a patient with diabetes may have their blood sugar levels monitored to evaluate the effectiveness of their medication and lifestyle modifications. Follow-up visits with healthcare providers allow for ongoing evaluation and adjustments to the treatment plan. During these visits, healthcare providers can review the patient's progress, discuss any changes in symptoms, and address any concerns or questions. They may also recommend additional interventions, such as physical therapy, medication adjustments, or other treatments, based on the patient's response to the initial treatment plan. Let's consider a specific example to illustrate this process. Imagine a patient who was diagnosed with depression. At the initial diagnosis, the patient reported feelings of sadness, loss of interest in activities, and changes in appetite and sleep patterns. They were started on an antidepressant medication and referred to therapy. Over the next few months, the patient attended regular therapy sessions and took their medication as prescribed. During follow-up visits, the patient reported a decrease in feelings of sadness and an improvement in their ability to engage in previously enjoyed activities. Based on these reports, the healthcare provider may consider the treatment successful. In contrast, if the patient had reported no improvement or even a worsening of symptoms, their healthcare provider would reassess the treatment plan. They may consider adjusting the medication dosage, adding additional therapies, or exploring other treatment options altogether. Close monitoring of the patient's progress and symptomatology is vital in these situations to ensure that the patient receives the most appropriate care. In conclusion, monitoring a patient's progress and evaluating the improvement or progression of their symptoms is crucial after a diagnosis has been made. This assessment can be done through subjective patient reports, objective measurements, and follow-up visits with healthcare providers. By regularly evaluating the patient's response to treatment, healthcare providers can make informed decisions about adjusting the treatment plan and ensuring the best possible outcomes for the patient's health. Can Chronic Bronchitis Be Reversed: Understanding the Treatment Options Frequently asked questions. Acute bronchitis is a temporary inflammation of the bronchial tubes, which are the airways that carry air to the lungs. It is usually caused by a viral infection and commonly occurs alongside a cold or flu. The most common symptoms of acute bronchitis include a cough that may produce mucus, chest congestion, wheezing, shortness of breath, and a low-grade fever. Other symptoms may include a sore throat, headache, and body aches. Acute bronchitis is usually a self-limiting condition that resolves on its own within a few weeks. Treatment primarily focuses on managing symptoms and providing relief. This may include over-the-counter medications to ease cough and congestion, drinking plenty of fluids to stay hydrated, getting plenty of rest, and using a humidifier or steam inhalation to help soothe the airways. In some cases, your healthcare provider may prescribe antiviral medications if the cause of acute bronchitis is determined to be viral. Antibiotics are typically not recommended unless there is evidence of a bacterial infection. It is important to rest and avoid exposure to irritants such as cigarette smoke, as this can worsen symptoms. Yury Trafimovich Author Doctor Marc Holland Author Editor Reviewer It is awesome. Thank you for your feedback! We are sorry. Plesae let us know what went wrong? We will update our content. Thank you for your feedback! Leave a comment Bronchitis photos, related posts. Can Bronchitis Lead to Numbness? Exploring the Connection Between Respiratory Infection and Numbness Oct 08, 2023 Understanding the Link between GERD and Acute Bronchitis: Causes, Symptoms, and Treatment Aug 01, 2023 Can Virus and Bronchitis Aggravate Anxiety Symptoms? Sep 23, 2023 Understanding the Link Between Bronchitis and Hearing Loss Sep 18, 2023 Can I Take Robitussin with Bronchitis? A Guide to Managing Symptoms Sep 21, 2023 The Impact of Bronchitis on an Individual's Respiratory Ability Oct 02, 2023 230 IMAGES Bronchial Asthma in Acute Exacerbation Case Study SOLUTION: Bronchial asthma case study Asthma Case Study (Bronchial Asthma) Case Study of bronchial asthma in acute exacerbation Case Study of Asthma VIDEO Asthma Case Study 2 Case Discussion || Acute Exacerbation of Bronchial Asthma Paediatrics Long Case Bronchial asthma pharmacology 1 Bronchial Asthma Management COPD COMMENTS Bronchial Asthma (Case Study) Bronchial Asthma (Case Study) - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. This document discusses bronchial asthma, including its objectives, causes, signs and symptoms, and treatment. The objectives are to determine a patient's nursing health history and discuss the causes, signs, and symptoms of asthma. Case Study (Bronchial Asthma) Case Study (Bronchial Asthma) - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. The document provides a case study of a 15-year-old male patient admitted to the hospital with bronchial asthma and an acute exacerbation. It details the patient's medical history including a family history of asthma, presents findings from a physical exam and ... Bronchial Asthma in Acute Exacerbation Case Study Acute exacerbations of bronchial asthma (AEBA) are episodes of worsening asthma symptoms requiring urgent care. Common triggers include viral infections, allergens, irritants, and lack of medication adherence. Symptoms include shortness of breath, coughing, wheezing and chest tightness. Diagnosis involves spirometry and peak flow measurements ... Case Study of Bronchial Asthma in Acute Exacerbation Case Study of Bronchial Asthma in Acute Exacerbation - Free download as PDF File (.pdf), Text File (.txt) or read online for free. asthma Case Study Bronchial Asthma-1 Case Study Bronchial Asthma-1 - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. This document provides a case study and nursing care plan for a patient named Anita who was admitted to the hospital suffering from an asthma attack. It includes Anita's medical history and profile, the medical management of her condition in the hospital, nursing ... Case Study Bronchial-Asthma CASE STUDY BRONCHIAL-ASTHMA- - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. Bronchial asthma is a chronic inflammatory disease of the respiratory tract that causes swelling and narrowing of the airways. This makes breathing difficult and leads to symptoms like coughing, wheezing, and shortness of breath. Patient Case Study: 45-Year-Old Female Presenting with Bronchial Asthma Case Scenario Bronchial Asthma - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. Janice Boracay, 45, is admitted with bronchial asthma exacerbation presenting with shortness of breath, chest tightness, and cough for 3 days. She has a history of asthma since age 40 and allergic rhinitis since age 25. A case study on bronchial asthma A case study on bronchial asthma. A 48-year old female patient presented with breathlessness, chest tightness, and cough with expectoration for one day. Her medical history noted these symptoms for 7 days. On examination, she had an elevated pulse, respiratory rate, hemoglobin, red blood cell count, white blood cell count, and eosinophils. A woman with asthma: a whole systems approach to supporting ... A 35-year-old lady attends for review of her asthma following an acute exacerbation. There is an extensive evidence base for supported self-management for people living with asthma, and ... Bronchial Asthma Case Study 3 - Free download as Word Doc (.doc / .docx), PDF File (.pdf), Text File (.txt) or read online for free. kxazjnisasioa Case Study: Managing Severe Asthma Adult The majority of adverse effects occurred within 1 day of the procedure and resolved within 7 days. 6. In this study, bronchial thermoplasty was found to significantly improve quality of life, as ... Clinical case study Clinical case study - asthma . 2019 . Clinical Case Study - Asthma. pdf. Clinical Case Study - Asthma. 6.34 MB. Resource information. Respiratory conditions. Asthma; Respiratory topics. Disease management; Diagnosis; Type of resource. Presentation . Author(s) Jaime Correia de Sousa Ioanna Tsiligianni Miguel Román Rodriguez Educational Case: Asthma: Clinical Features and Morphologic Findings Primary Objective. Objective: RS4.4: Asthma. Compare and contrast the clinicopathological features and causes of asthma and describe the morphologic changes and consequences that result in airflow obstruction. Competency 2: Organ System Pathology; Topic: Respiratory System (RS); Learning Goal 4: Obstructive Diseases of the Lung. Bronchial Asthma as a Cardiovascular Risk Factor: A Prospective 1. Introduction. Bronchial asthma is characterized by chronic bronchial inflammation of variable intensity accompanied by recurrent reversible airflow obstruction and symptoms such as coughing, wheezing, shortness of breath, and chest tightness [], with a worldwide increase over the last several decades.Accumulating evidence suggests that low-grade chronic systemic inflammation and autoimmune ... Scribd lifestyles. Such airway problem includes Bronchial Asthma which is a serious problem and could probably lead to death if proper precautions are not observed. This study is made so that every reader or listener of the case study and research will gain enough knowledge and understand Bronchial asthma, its cause, manifestations, treatment, and ... Acute exacerbation of bronchial asthma with infective focus treated A 69-year-old female patient known case of bronchial asthma and hypertension presented with complaints of breathlessness on and off for 3 years, cough, urgency of micturition, constipation for 7 days, and fever for 3 days. The patient was on anti-hypertensive medication (tab Telmisartan 20mg) once a day. She had a family history of bronchial ... Challenging case of severe acute asthma in a mechanically ventilated 1. INTRODUCTION. Acute severe asthma is a life‐threatening emergency characterized by severe tachypnea, tachycardia, and type 1 respiratory failure. 1 According to the international standard guidelines, it is managed with bronchodilators, systemic steroids, and magnesium sulfate in emergency cases. 2 Here, we describe a case of a 38 years old male who presented with a severe asthmatic attack ... Case Study: The Role of Bronchial Thermoplasty in the Management of At this point, after management of multiple comorbidities, we pursued bronchial thermoplasty (BT). The Asthma Research Intervention 2 (AIR2) clinical trials, in which the Respiratory Institute participated, previously demonstrated the safety and efficacy of BT to improve disease control out to two years in patients with severe persistent asthma. Higher Sweat Chloride Levels in Patients with Asthma: A Case-Control Study Also, to compare sweat chloride levels between cases of bronchial asthma and age and sex matched healthy children aged 5 mo-15 y. Methods: The present case-control study was conducted in a tertiary care hospital in India. Cases of bronchial asthma, diagnosed by GINA guideline 2008, and age matched healthy controls were included. GROUP 2 (N3A) GROUP 2 (N3A)- Bronchial Asthma Case Presentation Manus - Read online for free. O Scribd é o maior site social de leitura e publicação do mundo. Abrir o menu de navegação Understanding Asthma vs. Pneumonia: Case Study Analysis Discussion 5 In this week's case study we can arrive at a number of different differentials to include asthma, pneumonia or Covid-19. To best determine what is happening with Brian, a 7-year-old that has been coughing with shortness of breath since after having a cold it is best to look at the pathophysiology of asthma and pneumonia, our 2 differentials. Understanding Asthma and Allergy: Causes, Symptoms, and View case study 4.1.docx from NCLEX 367 at Mercy College. Mallory Mason Case Study 4.1 1. What is the anatomic problem would most likely lead to difficulty breathing as a consequence of allergy and ... The injury in asthma occurs in the bronchial tree where during an asthma attack the muscles in the airways constrict making it difficult for air ... A Comprehensive Case Study On Acute Bronchitis: Insights And Management Acute bronchitis is a common respiratory condition that affects millions of people worldwide. It is characterized by an inflammation of the bronchial tubes, which are responsible for carrying air to and from the lungs. In this case study, we will explore the symptoms, diagnosis, and treatment options for a patient with acute bronchitis. assignment essay homework paper phd report resume speech thesis