Transcript 02_WHEEZE_Case_Study_Full_Version (1)x

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