R.J. is a 15-year-old boy with a history of asthma diagnosed at age 8. His asthm
ID: 3479656 • Letter: R
Question
R.J. is a 15-year-old boy with a history of asthma diagnosed at age 8. His asthma episodes are triggered by exposure to cats and various plant pollens. He has been using his albuterol inhaler 10 to 12 times per day over the last 3 days and is continuing to wheeze. He normally needs his inhaler only occasionally (2 or 3 times per week). He takes no other medications and has no other known medical conditions. Physical examination reveals moderate respiratory distress with a respiratory rate of 32, oximetry 90%, peak expiratory flow rate (PEFR) 60% of predicted, and expiratory wheezing.
1A. What is the underlying mechanism of R.J.’s asthma? What are the three airway responses that occur during an asthma episode?
1B. In addition to bronchodilator therapy with intermittent albuterol, what other pharmacotherapy is important in the management of asthma?
1C. What is the significance of a PEFR at 60% predicted? If spirometry were performed at this time, what would be the likely findings?
1D. How should R.J.’s current problem be managed? What parameters should be assessed to monitor response to therapy?
1E. In addition to reviewing appropriate drug therapy, what other preventive and treatment measures should be included in R.J.’s discharge teaching?
Explanation / Answer
1A. The underlying mechanism of R.J.'s asthma is the allergy. The airways of the subject are hypersensitive to allergens which causes a release of antibody IgE which in turn causes a release of histamines triggering the asthmatic attack.
The three airway responses during asthma are:
i) Bronchoconstriction - In response of secretion of histamine
ii) Inflammation - Local swelling of airways
iii) Mucus secretion - Inflamed airways causes excessive mucus secretion which further narrows the airways.
1B. The alternative pharmacotherapy for R.J. is anti-allergic medications which include steroids like prednisone and dexamethasone. This can minimise the immune cell activation and recruitment in response to the allergens.
1C. Peak Expiratory Flow Rate (PEFR) at 60% indicates that respiratory airways are getting narrowed and a treatment is needed for the same. If spirometry was performed then FEV1/FVC ratio would be diminished.
1D. R.J.'s asthma can be managed by the identifying and avoid those allergens that trigger symptoms, using suggestive drug therapies and developing an action plan for sudden attacks. The parameters to be assessed while the medications are being taken are - PEFR value >80% which shows well-managed asthma and the same value for FEV1/FVC ratio.
1E. Preventive measures include avoiding exposure to allergens, cold air, and strong smells. Inhalational steroids and long-acting beta-antagonists can be used to control the asthmatic symptoms while immunotherapy can be also tried.
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