Case Study- Asthma- Aj copy.edited.edited (1)

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CRITICAL ANALYSIS OF THE MANAGEMENT OF A PATIENT WITH ASTHMA [Document subtitle] Table of Content Word Count: 1500 Words

1 Introduction ......................................................................................................................... 2 Background ......................................................................................................................... 2 Figure 1: An inflammation of the bronchial tubes .................................................................... 3 Presenting Complaint ......................................................................................................... 3 Past Medical History ........................................................................................................... 4 Family History ..................................................................................................................... 4 Social History ...................................................................................................................... 4 Respiratory Examination ................................................................................................... 4 Differential Diagnosis ......................................................................................................... 5 Figure 2: The differential Diagnosis ............................................................................................ 5 Investigations & Diagnosis ............................................................................................... 5 Management plan ................................................................................................................ 6 The implications of treatment/management ................................................................... 7 Other treatment/management options ............................................................................ 8 Concordance issues ........................................................................................................... 8 Table 2: Asthma action plan ...................................................................................................... 10 Follow-up Plan ................................................................................................................... 10 Conclusion ......................................................................................................................... 10 1

2 Introduction The purpose of this case study is to analyze the management of Asthma. Asthma is a chronic respiratory disease characterized by breathlessness, wheezing, and chest tightness, which can cause morbidity and mobility to people of all ages. This report will analyze the diagnosis and investigation of Asthma to gain crucial information for the management of Asthma. The case-based learning (CBL) technique is crucial for professional growth because it enables healthcare professionals to use their knowledge and abilities in real-world situations and evaluate their performance (Thistlethwaite et al. (2012). Background Asthma symptoms can be similar to chronic obstructive pulmonary disease (COPD). The symptoms are coughing, wheezing, chest tightness, and shortness of breath. Asthma is typically more reversible, while COPD is often progressive and irreversible. Moreover, Asthma usually begins in childhood or early adulthood, while COPD is more common in people over 40 with a history of smoking or exposure to environmental pollutants. According to Willart and Lambrecht (2009), allergens, pollution, and viral infections are only a few that might cause Asthma. 2

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3 Figure 1: An inflammation of the bronchial tubes Source; https://www.medeguru.com/asthma/meant-inflammation-asthma.html#top Presenting Complaint A 57-year-old white British male presented to general practice (GP). The patient had a body mass index (BMI) of 16.54 (weight 75kg and height 176cm) and a raised blood pressure (142/94mmHg). The patient complains of shortness of breath, coughing and chest tightness, chest pain of 6/10, and no other symptoms or allergies. The patient reported chest pain that started two days ago, shortness of breath and wheezing that started about four days ago, and a cough that began six days ago. Upon further inquiry, it was discovered that the patient had a history of Asthma that started 25 years ago and has been using a salbutamol inhaler to alleviate the symptoms. 3

4 Past Medical History The patient currently takes salbutamol and has a history of Asthma, initially diagnosed more than 25 years ago. The patient also takes a blood pressure tablet (Ramipril) and has no known allergies. Family History The patient has no family history of Asthma, which reduces the chances of developing Asthma. However, the patient was diagnosed with Asthma 25 years ago. Furthermore, there was no history of taking beta-blockers. Social History The patient is a non-smoker and was not exposed to environmental triggers at home. However, the patient is a construction worker; hence Asthma can be triggered by exposure to dust, fumes, and chemicals on the construction site. The patient's job requires physical labour, which may contribute to his symptoms. As such, it is unlikely that the patient's use of a blood pressure tablet (Ramipril) will directly affect his asthma symptoms. Respiratory Examination A complete respiratory examination was conducted on the patient to evaluate the disease's severity and control. There was no evidence of allergies or changes in the patient's breathing pattern. A general inspection was done on chest shape and use of accessory muscles to assess the presence of wheezing, crackles, or decreased breath sounds. 4

5 Differential Diagnosis Figure 2: The differential Diagnosis Source; https://www.pedilung.com/pediatric-lung-diseases-disorders/diving- medicine/asthma-bronchoconstriction-dyspnea-wheezing-and-coughing/ Investigations & Diagnosis National Institute for Health and Care Excellence ( NICE) has recommended exhaled nitric oxide (eNO) tests and spirometry to help accurately diagnose Asthma and avoid wrong and inappropriate medication (Saglani and Menzie-Gow, 2019). In this instance, exhaled nitric oxide test was used to diagnose Asthma in the patient, as increased levels of eNO are associated with inflammation in the airways. eNO levels will 5

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6 be used as a marker of inflammation in the airways, and regular testing will help to monitor asthma control and adjust treatment as needed. An accurate history and physical examination must be performed, along with an effort to confirm wheezing with an objective test such as Bronchoprovocation testing to reach an appropriate diagnosis (Saglani and Menzie-Gow, 2019). Table 1 below shows the factors independent of Asthma influencing exhaled nitric oxide levels. Source (Saglani and Menzie-Gow, 2019) 6

7 Management plan The patient was diagnosed with an acute exacerbation of Asthma triggered by exposure to dust, fumes, and chemicals. It was recommended that the patient change their inhaler (beclomethasone) and was referred for a chest x-ray, Sputum sample, a full blood count (FBC) and continue his regular long-acting beta-agonist (LABA) (Tashkin and Fabbri, 2010). Moreover, the diagnosis of Asthma is probable, given the patient's current symptoms and previous history of the condition. Inhaled corticosteroids (ICS) are advised as the first-line treatment for chronic Asthma by the NICE guidelines for managing Asthma in adults (James and Lyttle, 2016). ICS are anti-inflammatory medications that lessen inflammation in the airways and help manage asthma symptoms (Gibson, Saltos and Fakes, 2001). ICS has some adverse effects and is well tolerated, such as increased oral thrush, which can be managed with an anti-fungal mouthwash. Temporary sore throat, hoarseness, and headache are among other adverse effects. The benefit of ICS is that it lowers the likelihood that patients may experience severe asthma episodes or exacerbations. They lessen the requirement for hospital admissions and urgent care because of Asthma. Salbutamol, a short-acting beta-agonist (SABA), is now being used by the patient, which shows that his Asthma is not under reasonable control. Additionally, the NICE recommendations advise healthcare practitioners to consider referring patients with persistent Asthma to a specialist to ensure complete control of the disease (Price et al., 2017). 7

8 The implications of treatment/management Asthma management through ICS can increase the risk of fungal infections in the mouth and throat (Dubus et al., 2001). When ICS are inhaled, they can settle on the mouth and throat tissues, promoting the growth of yeast, a fungus responsible for thrush and oral candidiasis. However, ICS can help in lowering asthma symptoms and exacerbations. Individuals with severe Asthma require a more tailored treatment plan, including dietary and exercise modifications, particular drugs such as theophylline, and instructions on how to use an inhaler properly. There may also be recommendations for other treatments like non-invasive ventilation or immunotherapy. It is vital to remember that before sending a patient to a specialist, one should follow the step-by-step approach for managing Asthma and makes the necessary efforts to manage symptoms in primary care first. If this is not done, the patient may be sent back without input from the specialist. Other treatment/management options Leukotriene receptor antagonists (LTRA), theophylline, and immunomodulators are additional asthma therapy possibilities, according to Barnes and Pauwels (1994). LTRA stops leukotriene, a substance that can cause inflammation in the airways. Asthma symptoms like coughing, wheezing, and shortness of breath might be lessened. Theophylline is a bronchodilator that eases asthma symptoms by relaxing the muscles around the airways. Drugs that modulate the immune system can relieve airway inflammation and change how the body reacts to allergens. Patients should avoid triggers such as allergens and air pollution to ensure effective asthma control. These approaches might be considered in patients who do not respond to ICS. 8

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9 Concordance issues Chronic conditions like Asthma need continual management and supervision. For asthma symptoms to be effectively controlled and controlled, patient compliance with therapy is essential. To achieve and maintain effective asthma symptom control, the patient should comply with the prescribed medication and ensure lifestyle change Morrice and Wrench, 2001). Non-compliance can have serious consequences, including uncontrolled symptoms and an increased risk of hospitalization; hence, the need for effective control and proper management. Additionally, compliance ensures that the patient receives the most up-to-date information and advice from their healthcare provider. Ensuring regular communication between the patient and the healthcare provider is also important. By discussing symptoms and other concerns, the patient can better understand their condition and how to manage it best ( Lakin et al., 2021) . The patient should adhere to their healthcare professional's directions when administering a treatment regimen. This entails following the instructions on prescription medications and showing up for follow-up appointments. Following a treatment plan can also lessen the frequency and intensity of asthma attacks and the requirement for emergency room visits or hospital admissions ( Hew 2016) . In addition to lowering expenditures, good patient concordance can alleviate asthma symptoms' long-term effects. To manage Asthma and achieve effective symptom management, patient compliance is crucial. Patients adhering to their treatment regimen and action plan can significantly improve their quality of life and lower their risk of developing life-threatening asthma complications. However, this 9

10 method has its cons in that it is difficult to maintain consistency in following instructions and a potential increase in risks of side effects from overusing certain medications ( Vong et al., 2022) . Table 2: Asthma action plan Follow-up Plan Book a follow-up appointment in 2 weeks and also demonstrate/explain the inhaler technique. Conclusion The consultation was done according to NICE guidelines; in this case study, the treatment of a 57-year-old white British male is discussed, and his coughing, wheezing, chest tightness, and shortness of breath should be thoroughly investigated and examined (respiratory and chest examination). Since the patient has a history of Asthma, he is taking salbutamol as his symptoms are connected with Asthma, so other differentials are ruled out (COPD) from the list ( Reddel et al ., 2022). ICS is advised as 10

11 the first line of treatment for chronic Asthma according to the NICE recommendations for managing Asthma in adults through a salbutamol inhaler to reduce the severity of the disease. The guidelines also suggest that Astha patients should be examined thoroughly through respiratory examination to evaluate the severity and control of the disease. 11

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12 References Barnes, P.J. and Pauwels, R.A. (1994). Theophylline in the management of Asthma: Time for a reappraisal? European Respiratory Journal , 7(3), pp.579–591. doi:10.1183/09031936.94.07030579. Dubus, J.C., Marguet, C., Deschildre, A., Mely, L., Le Roux, P., Brouard, J. and Huiart, L. (2001). Local side-effects of Inhaled Corticosteroids in Asthmatic children: Influence of drug, dose, age, and Device. Allergy , 56(10), pp.944–948. doi:10.1034/j.1398-9995.2001.00100.x. Gibson, Peter G., Saltos, N. and Fakes, K. (2001). Acute Anti-inflammatory Effects of Inhaled Budesonide in Asthma. American Journal of Respiratory and Critical Care Medicine , 163(1), pp.32–36. doi:10.1164/ajrccm.163.1.9807061. Hew, Mark, et al. "The 2016 Melbourne thunderstorm asthma epidemic: Risk factors for severe attacks requiring hospital admission." Allergy 74.1 (2019): 122-130. https://www.medeguru.com/asthma/meant-inflammation-asthma.html#top https://www.pedilung.com/pediatric-lung-diseases-disorders/diving medicine/asthma-bronchoconstriction-dyspnea-wheezing-and-coughing/ James, D.R. and Lyttle, M.D., 2016. British guideline on asthma management: SIGN Clinical Guideline 141, 2014. Archives of Disease in Childhood-Education and Practice , 101 (6), pp.319-322. Lakin, Lynsey, et al. "Comprehensive approach to management of multiple sclerosis: addressing invisible symptoms—a narrative review." Neurology and therapy 10 (2021): 75-98. 12

13 Morrice A.H. and Wrench C. (2001). The role of the asthma nurse in treatment compliance and self-management following hospital admission. Respiratory medicine , 95(11), pp.851–856. doi:10.1053/rmed.2001.1166. Pijnenburg, M.W. and Fleming, L. (2020). Advances in Understanding and Reducing the Burden of Severe Asthma in Children. The Lancet Respiratory Medicine , [online] 8(10), pp.1032–1044. doi:10.1016/S2213-2600(20)30399-4. Price, D., Bjermer, L., Bergin, D. and Martinez, R. (2017). Asthma referrals: a Key Component of Asthma Management That Needs to Be Addressed. Journal of Asthma and Allergy , Volume 10 (0), pp.209–223. doi:10.2147/jaa.s134300. Reddel, H.K., Bacharier, L.B., Bateman, E.D., Brightling, C.E., Brusselle, G.G., Buhl, R., Cruz, A.A., Duijts, L., Drazen, J.M., FitzGerald, J.M. and Fleming, L.J., 2022. Global Initiative for Asthma Strategy 2021: executive summary and rationale for key changes. American Journal of Respiratory and Critical Care Medicine , 205 (1), pp.17- 35. Tashkin, D.P. and Fabbri, L.M. (2010). Long-acting beta-agonists in managing Chronic Obstructive Pulmonary Disease: Current and Future Agents. Respiratory Research , [online] 11(1), p.149. doi:10.1186/1465-9921-11-149. Thistlethwaite, J.E., Davies, D., Ekeocha, S., Kidd, J.M., MacDougall, C., Matthews, P., Purkis, J. and Clay, D. (2012). The Effectiveness of Case-based Learning in Health Professional Education. a BEME Systematic review: BEME Guide No. 23. Medical Teacher , [online] 34(6), pp.e421–e444. doi:10.3109/0142159x.2012.680939. 13

14 Vong, Si Kei, Lifeng Kang, and Stephen R. Carter. "Consumers’ self-reported adherence to directions for non-prescription medicines and the role of risk perception." Research in Social and Administrative Pharmacy 18.11 (2022): 3929-3938. Willart, M.A.M. and Lambrecht, B.N. (2009). The Danger Within Endogenous Danger Signals, Atopy, and Asthma. Clinical & Experimental Allergy , 39(1), pp.12–19. doi:10.1111/j.1365-2222.2008.03118.x. 14

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