Chapter 17: Optimizing Asthma Therapy Through the Continuum of Care

PATIENT PRESENTATION

Chief Complaint

JR is a 23-year-old female who is being discharged from the hospital following a severe asthma exacerbation. She requires adjustment of her asthma medications to prevent a future exacerbation.

History of Present Illness

JR presented to the emergency department 3 days ago in acute respiratory distress with increased work of breathing and inspiratory and expiratory wheeze. It was determined that JR was having a moderate-severe asthma exacerbation due to uncontrolled asthma. Prior to admission, JR was recovering from a viral upper respiratory tract infection and started to have difficulty breathing during soccer practice for her college soccer team. JR used her albuterol rescue inhaler several times without relief and finally was brought to the emergency department by her coach.

Past Medical History

Type I diabetes mellitus

Allergic rhinitis

Atopic dermatitis

Asthma

Achilles tendonitis

Acute stage fright

Social History

College student in final year of studies to become a teacher.

Plays for the college soccer team.

Denies illicit drug use, smoking, or alcohol use.

Allergies

Aspirin (hives)

Immunization

Insurance

Aetna HMO

Home Medications

• Albuterol HFA MDI: 90 mcg 1–2 puffs every 4–6 hours PRN shortness of breath/wheezing

• Beclomethasone HFA MDI: 80 mcg: 1 puff inhaled twice daily

• Cetirizine 10 mg PO once daily

• Montelukast 10 mg PO once daily

• Ibuprofen 200 mg PO every 6 hours for Achilles tendonitis

• Propranolol 10 mg PO 1 hour prior to event for acute stage fright

• Lantus 20 units SQ once daily

• Humalog per sliding scale: 20 units SQ for every 15 grams of carbohydrates

• Hydrocortisone 1% cream: apply a thin film to affected area 2 times daily

Inpatient Medications

• Ipratropium 0.5 mg/albuterol solution: oral inhalation via nebulizer every 20 minutes for 3 doses

• Methylprednisolone 125 mg IV X1 dose

• Oxygen to achieve SaO₂ ≥90%

Physical Examination

Vital Signs

BP 118/73 mmHg, HR 75 bpm, RR 18, O₂ saturation: 98%, Ht: 5′7″, Wt: 140 lbs

General

Well developed, well-nourished Hispanic female in mild respiratory distress.

HEENT

Red, watery eyes. Throat appears red with slight swelling.

Chest

Mild sibilant rhonchi ...