CASE – VII Asthma

• HT, a 32-year-old woman, 155 cm, 81 kg, presents to hospital casualty with
a history of increased breathlessness and wheeze, over the last 5 days.

• She is known to have had asthma for 20 years and has smoked 10
cigarettes per day since the age of 15.

• Her last hospital admission was one month ago.

• She works in a small ‘do-it-yourself’ shop, as a counter assistant. HT lives

in a tenth-floor council flat; she is single.
• On medical examination the following is found:

• audible wheeze throughout the chest, using accessory muscles

• not able to speak in sentences – stops for breath after two words

• tachycardia – pulse 130 beats per minute

• tachypnoeic – respiratory rate 25 breaths per minute

• peak expiratory flow rate 150 L/min.

1. Explain why this patient is tachycardic and
tachypnoeic.

• Tachycardia is an increase in the heart rate over 100 per minute.

• This can be due to excessive use or side-effects of a beta-agonist.

• It can be induced by anxiety and panic, which a patient may experience

during an asthma attack.

• Tachypnoea is an increase in the respiratory rate due to airway narrowing

and constriction, hence the body will increase its respiratory rate to try to
increase the intake of oxygen.
2 Describe what peak expiratory flow measures and how
this value is interpreted in this woman.

• This is a test to assess the degree of airway limitation. It is easy to perform and relatively
inexpensive.

• The patient takes a full inspiration to total lung capacity and then blows out forcefully into the
peak flow meter.

• The best of three recordings are normally taken.

• The peak flow measures the expiratory flow rate in the first 2 ms of expiration and can
overestimate the extent of lung function in patients with moderate to severe airway limitation.

• Other tests such as spirometry, forced expiratory volume (FEV1), forced vital capacity (FVC)
and the ratio of FEV1/FVC are used.
• Peak expiratory flow rate

• Peak flow measurement of peak expiratory flow rate (PEFR) on waking, before bed, before and after bronchodilator

medication is useful to assess the extent of airflow limitation and the characteristic of the disease in terms of

reversibility.

• There is some evidence of diurnal variability. PEFR is also useful in assessing the disease progression longer term

and the response to therapy.

• Patients are advised to keep an asthma diary and record regularly the peak flows to ascertain their diurnal pattern.

• The extent of reversibility can be assessed using PEFR: 15% improvement in the PEFR determines the extent of

reversibility following bronchodilator therapy.

• This patient’s PEFR (150 L/min) is very limited. In a patient of her age and weight her normal value would be 300–350

L/min hence she is showing 50% or <50% of her best value which indicates substantial airflow limitation.
3 Describe what other tests would be of
importance in this patient at the time of admission.
• Other tests which would be helpful in this woman would be FEV1, FVC and blood gases.

• The spirometry values provide data not only on the expiration of air but also on the time taken for forced expiration.

• Patients with significant airway limitation will show a prolonged forced expiratory time.

• The FEV1 expressed as a percentage of the FVC provides a measure of the extent of airway limitation.

• In normal subjects it would be in the region of 75%.

• In patients with obstruction, the ratio FEV1/FVC will be reduced.

• Blood gases would need to be checked. The normal for this patient would be:

• oxygen saturation above 95%

• pH 7.3–7.5

• PCO2 4.0 – 6.7 kPa

• PO2 11–13 kPa.

4 Explain how the severity of acute asthma is estimated
and how often investigations should be done.

• Patients should be routinely assessed by the GP or pharmacists

at least every three months.

• Once a patient is stable, most assessments will be carried out

annually by the GP or clinical nurse specialist.

• Pharmacists should routinely review the patient if medication

alters and at least every three months.
• The following symptoms should • Investigations include:

be assessed: • peak expiratory flow rates

• lung function tests

• episodic wheeze
• histamine or methacholine bronchial
• cough
provocation tests for severe cases
• shortness of breath (rare)

• number of attacks. • skin prick tests to identify allergens.

• Clinical features of acute severe asthma • Life-threatening characteristics include:

include: • silent chest and cyanosis

• inability to complete sentences • exhaustion confusion and coma

• respiratory rate >25 breaths per minute • bradycardia or hypotension

• tachycardia 110 beats/min • PEFR <33% of patient’s best or predicted

• PEFR 33–50% of patient’s best or • blood gases: PaCO2 4.6–6.0 kPa, PaO2

predicted. < 8 kPa.

5 List the medicines available for the acute treatment of
asthma and describe the method of administration.

• Patients will be prescribed inhalers and tablets and, at a later stage, nebulisers may be used.

• Asthma is managed in a stepwise approach using the British Thoracic Society and Scottish

Intercollegiate Guidelines Network (2008).

• Details are available in the British National Formulary (BNF).

• Step 1 Occasional bronchodilator relief (inhaled short acting beta2-agonist as required).

• Step 2 Regular inhaled preventer therapy (inhaled short acting beta2- agonist as required and regular

standard dose inhaled corticosteroid).

• Step 3 Inhaled corticosteroid and long-acting inhaled beta2-agonists

• (inhaled short-acting beta2-agonist as required and regular standard-dose

• inhaled corticosteroid and regular inhaled long-acting beta2-agonist PLUS at this step either leukotriene

receptor antagonist or modified-release oral theophylline or modified-release oral beta2-agonist therapy

may be considered).

• Step 4 High-dose inhaled corticosteroid and regular bronchodilators (inhaled short-acting beta2-

agonist as required and regular high-dose inhaled corticosteroid and inhaled long-acting beta2-agonist

PLUS six-week sequential trial of one or more of leukotriene receptor antagonist or modified-release oral

theophylline or modified-release oral beta2-agonist).

• Step 5 Patient would be on step 4 then add in regular corticosteroid tablets. The most important issues

in the management of asthma are effective therapeutic management.

• Virchow et al. (2007) have clearly identified that the use of inhaler devices is crucial to effective clinical
management.

• The study suggests several issues that influence treatment including:

• poor understanding of treatment guidelines in terms of content,

• implementation and relevance to everyday clinical life,

• insufficient patient education,

• lack of access to healthcare and cost of medication, and poor inhaler technique.

• Pharmacists have a key role to play in education since inhalation therapy is a vital component of effective
asthma management.
6 Describe the role of the pharmacist in the care of
this patient.
• Pharmacists are responsible for:

• ensuring that the patient understands their condition and can recognise the signs of acute

deterioration and risk of status asthmaticus,

• counselling the patient on the medication and ensuring they know why, when and how to take

the medicines,

• ensuring that patients know how to monitor the effectiveness of the therapy,

• ensuring that patients know how often they should visit their GP and ensure appropriate clinical

test are completed, and effective medicines management.

7 What are the aims of asthma treatment for the
patient and the professional?

• The aims of asthma treatment are:

• effective control of asthma symptoms,

• positive quality of life, and

• minimal acute hospital admissions.

8 Explain the social issues this patient will face on
discharge.

• HT will need to deal with medicines management including

supply, impact on her lifestyle and importance of concordance,
and lifestyle issues, such as exercise and sports.
9 Critically review the non-pharmacological therapies that are
available for people with asthma. Would these be of benefit for this
patient?

• Non-pharmalogical recommendations could include:

• lifestyle advice (e.g. exercise management and stop smoking),

• the avoidance of precipitating factors (i.e. pollutants, house dust mite, grass pollen and/or fungal

spores) by the use of special vacuum cleaners for the house and regular change of bedding, flu

vaccinations,

• the avoidance of certain medicines (e.g. NSAIDs, aspirin and beta-blockers),

• occupational hazards (e.g. veterinary medicine, bakery and laundry work).

• The above parameters are known to be associated with exacerbation of asthma and hence

patients need to have an understanding of how to manage their treatment.

10 Discuss the role of an asthma management
plan for this patient.
• The object of an asthma management plan is to ensure the patient:

• understands the disease,

• can describe the medicine, why it is prescribed and how it should be used,

• is monitored effectively,

• has appropriate health outcomes,

• has effective chronic disease management and prevents exacerbations and

• hospital admissions.

• The pharmacist is responsible for preparing a pharmaceutical care plan for this

• patient and must include the issues listed in Table below

Care Issues Care Plan

Patient understanding of the need for each Discuss with the patient the need for each
medicine medicines. Side effects and monitoring. Advise on
how to administer the medicine.

Use of medicine devices Educate, monitor and assess the use of the
inhalers.

Advise and monitor the patient if she suffers from Educate the patient to watch for signs of
colds or chest infection deterioration and advise when to refer

Action plans Routine asthma diary to record peak flows. Advise

on management of acute exacerbations. Lifestyle
advice.

Patient organisations Discuss with the patient the availability of patient

support, including the Asthma Association