Case Study: Patient With Asthma

Case Study: Patient With Asthma Patient RR is a 58 years old female with a weight of 55kg. Patient was admitted to hospital on 9th April 2009. Her presenting complaints were cough with sputum, pain when inhaling air at chest, breathless and unable to speak in full sentence. Her past medical histories were hypercholesterolemia, bronchial asthma and she has no known drug allergy. For her social history, she works as a security guard and is living with her husband. She is a non smoker as well as non alcoholic and she has no known family history. Patients drug history include metered dose inhaler (MDI) salbutamol 200mcg as required, MDI budesonide 400mcg twice daily, theophylline SR tablet 250mg once daily and lovastatin tablet 20mg once daily. Investigations Blood Test: 9th April 12th April WBC 10.9109/L 12.9109/L High (4-10.0) RBC 4.821012/L 4.91012/L High (3.8-4.8) MCV 78.7 fl/cell 78.6 fl/cell Low (83-101) MCH 26.5 pg/cell 25.3 pg/cell Low (27-32) ESR 24 mm/hr High (0-20) Blood HbA1c 7.2% Good control: 8.0% Renal Profile: 9th April 11th April Plasma K+ 2.8 mmol/L 2.5 mmol/L Low (3.5-5.1) Creatinine 100 ÃŽ ¼mol/L 79 ÃŽ ¼mol/L (58-96) Blood test indicated that the level of white blood cell and erythrocyte sedimentation rate is higher than normal which suggests the patient had an infection. The blood HbA1c showed adequate control of blood glucose. On the other hand, the renal test showed that the patient had low plasma potassium and the plasma creatinine level is normal. Clinical Progress On examination, the patient was alert with no pedal oedema. Her pulse rate was 120 beats per minute, blood pressure was 130/62 mmHg, and respiratory rate was 22 breaths per min. She was diagnosed with acute exacerbation bronchial asthma secondary to upper respiratory tract infection. The plan was to give intravenous (IV) hydrocortisone 200mg immediately then 100mg three times daily, IV Augmentin 1.2g three times daily, nebulizer atrovent: ventolin: normal saline (A:V:N) 2:1:2 every two hours and to continue SPO2 monitoring. On day 1, the patient was given MDI Budesonide 400mcg, nebulizer AVN, IV hydrocortisone 100mg three times daily, bromhexine tablet 8mg three times daily, erythromycin tablet 400mg twice daily, prednisolone tablet 40mg once daily, oxygen 3L/min and lovastatin tablet 20mg once daily. Theophylline were stopped. On day 3, patients blood pressure was 120/70 mmHg, respiratory rate was 26 breaths per minute and the SPO2 was 98%. She has cough with yellow sputum and the sputum culture showed that there are no pathogen isolated. The patient was to start on long acting beta agonist (LABA). Other medications that were given include potassium tablet 1.2g twice daily, Neb Combivent 4 hourly, IV Augmentin 1.2g three times daily, MIST expectorant 15mL three times daily. Hydrocortisone and bisolvon were stopped. On day 4, the patient had fever, cough with yellow sputum and difficulty in breathing. No new action was taken. On day 6, patient had no more fever but still had cough with yellow sputum. Her blood pressure was 122/80 mmHg and respiratory rate was 20 breaths per minute. The plan was to give MDI formoterol 9mcg once daily and augmentin tablet 625mg. Oxygen and prednisolone were stopped. On day 8, patient still had cough but the sputum turned white. Patient was given theophylline SR tablet 250mg twice daily and was ready to be discharged the next day. Medication Summary Drug Dose Frequency Indication T.Bisolvon 8mg tds(stop at day 3) Cough Mist Expectorant 15 mL tds (day3-day 6) Cough T.Erythromycin 400mg bd (stop on day 6) Infection KCl solution 20mL tds (stop on day 7) Hypokalaemia T.Prednisolone 40mg od (stop on day 6) Acute asthma T.Augmentin 625mg tds Infection T.Lovastatin 20mg od Hyperlipidaemia T.Nuelin SR 500mg bd Asthma OXIS inhaler (formoterol) 9mcg od Asthma MDI Budesonide 400mcg bd Asthma Salbutamol 200mcg when required Asthma Pharmaceutical Care Plan Care Plan Recommendation Desired Outcome 1. Monitor K+ level -high dose salbutamol and theophylline causes hypokalaemia K+ level should be monitored. K+ supplement should be given if K+ level is low. Maintain stable potassium level. 2. On day 4, patient had fever but not treated. Paracetamol should be given. To lower down patients temperature. 3. Concurrent use of oral prednisolone and IV hydrocortisone for acute treatment -If patient can tolerate orally, oral prednisolone should be adequate. -if cant, give IV hydrocortisone 100mg every 6 hour until conversion to oral is possible. 4. Combination inhaler can be given to patient Symbicort inhaler (1-2 puffs bd) can be given instead of OXIS and budesonide inhaler. Besides that, Symbicort can be also given as relief to replace Combivent. Less confusion and increases compliance. 5. Technique to use inhaler -Counsel patient on proper technique -advice on oral hygiene to avoid oral candidiasis. 6. Prophylaxis of asthma Counsel patient to avoid allergen that may trigger attack and avoid NSAIDs. Lowers risk of asthma attack 7. Compliance issue Advice patient on the importance to take control medication accordingly even if patient feels well. Lowers risk of asthma attack Disease Overview and Pharmacological Basis of Drug Therapy Asthma affects people of all ages, but it normally starts at childhood1. Asthma affects 5-8% of the population around the world2. A study done by World Health Organization (WHO) shows that there are 15 million disability-adjusted life years lost yearly because of asthma, displaying 1% of total disease burden worldwide3. The annual worldwide mortality caused by asthma is estimated to be 250,000. In Scotland, the incidence of clinical asthma is around 18.4% of the population3. Asthma is an inflammatory disease where there is frequent reversible airway obstruction1. The narrowing of the airway happens when people with asthma react strongly to certain substance they breathe in. These irritant stimuli are too weak to affect normal individuals1. The narrowing of airway is also caused by other factors which include mucosal swelling or inflammation caused by inflammatory mediators released by mast cell and basophil degranulation as well as mucus or phlegm production2. The causes of asthma include genetic factor, environmental factor and history of etopic disorder5. The most common symptoms of asthma are wheezing, shortness of breath, chest tightness and sometimes cough, especially at night in younger people1, 4. The probability of asthma increased if symptoms worsen at night and early morning or in response to exercise, allergen and cold air5. Acute severe asthma may cause hypoxaemia and is not easily reversed. Therefore, the patient needs prompt treatment and hospitalization1. Patients with asthma have continuous and excessive T-helper cell type 2 (Th2)-dominated immune response and the Th1 which is responsible for structural and defensive status of the tissue is reduced4. The activated T-cells produce cytokines in the bronchial mucosa and this attract other inflammatory granulocytes especially eosinophils which produce cysteinyl leukotrienes along with granule protein to damage epithelium. The cytokines released also promotes IgE synthesis in some asthmatic patients which cause expression of IgE receptors on mast cell and eosinophils1, 4. The important mediators associated with asthma are leukotriene B4, cysteinyl leukotrienes (C4 and D4), interleukins IL-4, IL-5, IL-13 and tissure-damaging eosinophil proteins1. In atopic asthmatic patients, inhaled allergen caused cross-linking of IgE molecules on mast cells hence activating degranulation with histamine and leukotriene B4 release. These substances are powerful bronchoconstrictors thus causing acute exace rbation of asthma1. For diagnosis of asthma, spirometry is the preferred initial test5. It is a device to measure the functional lung volumes. Through the patients full force expiration into the device, the forced expiratory volume in 1 second (FEV1) and force vital capacity (FVC) are measured. Exhalation continues until there is no more breath to be exhaled. The FEV1/FVC ratio shows the severity of airflow obstruction and the normal ratio is 75-80%2. The ratio is less than 75% in asthma which indicates obstructive defect. There is normally more than 15% improvement in FEV1 after administration of B2 agonist or steroid trial in asthma patients2. Peak expiratory flow (PEF) is also another test for asthma though FEV1 uses lesser effort2. It is measured by the maximum forced expiratory through a peak flow meter and acts as an estimate of airway calibre. PEF is measured frequently to check response to treatment and disease control. PEF is used to test acute and chronic asthma with PEF decreases along with s everity2. Moderate acute asthma Severe acute asthma Life-threatening Able to talk, Respiratory rate (RR)50-75% Incomplete sentence, RR>25/min, SPO2110/min, PEF 33-50% Silent chest, cyanosis, exhaustion, confusion, feeble respiratory effort, SPO2