NR565 WK 6 Asthma

Asthma Treatment Algorithm:

To successfully treat asthma, you must first classify it and then be familiar with step therapy. For this assignment and in this course,
we will focus on patients 12 years and older. Complete the blanks in the following table to create an algorithm for asthma care using
your textbook as well as GINA guidelines .

Step Asthma Asthma symptoms and frequency as Controller and Preferred Controller and Alternative
Classification noted in textbook Reliever: Reliever:
(Drug Class and frequency if (Drug Class and frequency if
provided from GINA guidelines) provided from GINA guidelines)
Daytime
2 days per week or less
symptoms
Drug class: Inhaled corticosteroids
Step 1 Intermittent
Nighttime Frequency: as needed(PRN)
2 times per month or less Drug class: ICS-Formoterol
awakenings
Frequency: as needed(PRN)
Daytime
>2 days per week <daily
symptoms
Drug class:
Step 2 Mild Persistent Short-Acting Beta Agonists a
Nighttime
3 to 4 times per month
awakenings

Daytime
daily
symptoms
Drug class:
Drug class:
Moderate Inhaled corticosteroids and Sho
Step 3 ICS-formoterol
persistent Nighttime >once per week
awakenings <nightly

Step Severe Persistent Step 4: Drug class:

4-5 Daytime Several time throughout the Drug class: ICS-formoterol Inhaled corticosteroids and Sho
symptoms day

Nighttime Frequent nightly Step 5: No change.

awakenings Drug class: ICS-formoterol
Refer for: Phenotypic assessment,anti-Ige, anti-IL5/5R, anti-IL4R
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Starting treatment:
Complete this section using the GINA guidelines provided.

First Assess:

1. Confirm diagnosis by evaluating signs and symptoms

2. Assess symptoms control over the last month and obtain lung function test prior to starting treatment.
3. Identify other presenting illness for example COPD, rhinitis sleep apnea etc.
4. Observe use of inhaler and discuss adherance
5. Discuss patient medical goals
6. n/a

Fill in the blank:

1. Using ICS-formoterol as reliever reduces the risk of severe exacerbations compared with using a SABA reliever.
2. Before considering a regimen with a SABA reliever, check if the patient is likely to be adherent with ICS-containing .
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Dosing: Low, Medium, High

Low dose ICS provides most of the clinical benefit for most patients. However, ICS responsiveness varies between patients, so
some patients may need medium dose ICS if asthma is uncontrolled despite good adherence and correct inhaler technique with low
dose ICS. High dose ICS is needed by very few patients, and its long-term use is associated with an increased risk of local and
systemic side-effects.

Total daily (24 hour) ICS dose (mcg)

Adults and adolescents Inhaled corticosteroid
Low Medium High
BDP (pMDI, HFA) 200-500 >500-1000 >1000
BDP (DPI or pMDI, extrafine particle, HFA) 100-200 >200-400 >400
Budesonide (DPI or PMDI, HFA) 200-400 >400-800 >800
Ciclesonide (pMDI, extrafine particle, HFA) 80-160 >160-320 >320
Fluticasone furoate 100 200
Fluticasone propionate (DPI) 100-250 >250-500 >500
Fluticasone propionate (pMDI, HFA) 100-250 >250-500 >500
Mometasone furoate (pMDI, HFA) 200-400 400

Treating Modifiable Risk Factors

Exacerbation risk can be minimized by optimizing asthma medications and by identifying and treating modifiable risk factors. List the
six modifiable risk factors identified in the GINA guidelines that show consistent high-quality evidence.

1. Tests ex sputum and elevated FeNO

2. Comorbidities ex weight
3. Exposure ex smoking
4. Setting: major socioeconomic problems
5. Medication: ICS not prescribed, poor adherence etc
6. Lung function test low FEV1 etc

Non-Pharmacological Strategies and Interventions

In addition to medications, other therapies and strategies may be considered when relevant, to assist in symptom control and risk
reduction. List the examples the GINA guidelines provide.
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1. Smoking Cessation- encourage patient to quit smoking.

2. Physical Activity- encourage patient to participate in regular physical activity to maintain a healthy weight
3. Investigate for occupational asthma- ask patient with adult onset of asthma about work history and remove sensitizers.
4. Identify aspirin exacerbated respiratory disease prior to prescribing NSAIDs inquire about previous reactions.

Continue to the next page to apply this information to a case study.

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Case Study
History of Present Illness:
Haley, a 14-year-old girl with asthma, presents to the clinic with complaints of a persistent cough. She reports getting up 3-4
nights a week to use her albuterol inhaler, including the morning of the visit. She also reports coughing and experiencing
shortness of breath daily when she runs in gym class or pet’s the neighbor’s cat. Haley is currently taking a SABA (short-acting
beta-agonist) for relief of her asthma symptoms. Except for a cough, Haley has no other complaints. She is accompanied by her
parents.

Past Medical Family History: Review of Systems Physical Exam (Objective Findings)
History: Asthma - Mom is 36 years-old (Subjective Findings): - Vital Signs
Allergies: NDKA with a history of - Respiratory (+) o Temperature 98.2, Respiratory Rate
asthma. SOB, (+) 22, Pulse 118, Blood Pressure
- Dad is 38 years-old Wheezing, (+) 108/64, Pulse Ox 92%
with hypertension chest tightness, o Height: 56 inches Weight: 72 lbs.
and is a smoker. (+) cough, (-) BMI: 16.1
Social History: hemoptysis, (-) - Skin
- Parents report a pleuritic pain o (+) warm, (+) dry, (+) intact, (-) moist,
well-balanced diet - All other (-) lesions
with occasional fast systems - HEENT
food. negative o PERRLA, (-) nasal flaring, nasal
- Haley has gym polyps, (-) lymph node swelling
classes at school - Neck
and enjoys playing o (-) ROM, (-) JVD
basketball outside - Thorax
with her friends in o (-) accessory muscle use (+) equal
the neighborhood
chest expansion (-) limited chest
until she coughs and
expansion
needs her inhaler.
- Lungs
- Her parent report
o (+) diffuse expiratory wheezes
that she is doing well
bilaterally and occasional inspiratory
in school.
- Heart
o (+) tachycardia with S1 and S2
regular rate and rhythm (-) murmurs,
rubs, or gallops
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-
Neurologic
o Cranial nerves intact
1. Based on the table you created from your book above, how would you classify Haley’s asthma?
Hailey Asthma is Severe and persistent.

2. Based on the table you created using the GINA guidelines provided, what is the controller and preferred reliever Haley should
be prescribed at today’s visit? (Provide general statement and not specific drug- the same as you listed in the table for this
severity of asthma)
Based on the table the prescribed controller would be a Inhaled corticosteroids and Short-Acting Beta Agonists.

3. Now, looking in your textbook, what are some examples of inhaled corticosteroids or inhaled glucocorticoids? Your book lists
six for you to provide here:
a. Beclomethasone dipropionate
b. Pulmicort Flexhaler
c. Flunisolide (Aerospan)
d. Flovent HFA
e. Flovent Diskus
f. Mometasone furoate

4. What is the drug classification of formoterol?

Long-Acting Beta2-Adrenergic Agonists (LABA

5. What is a specific drug you could prescribe today that would meet the drug classification from question 2? Your book provides
two options in table 62.1.
a. Budesonide/formoterol
b. Mometasone/formoterol

6. Go to Prescriber’s Digital Reference and identify the dose you would prescribe of the two drugs from Question 5 to fall into
the “low dose” range as indicated by the low, medium, high dose table you completed above from the GINA guidelines.
a.
100 mcg budesonide and 6 mcg formoterol, one oral inhalation twice daily, every twelve hours, morning and evening (Prescribers’ Digital Referen
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b.
100 mcg mometasone and 5 mcg formoterol, two oral inhalations, twice daily, one in the morning and one in the evening, approximately 12 hours a

7. Why is it important for Haley to have a LABA in addition to her SABA?

Regular use of a LABA provides long-acting bronchodilation which results in enhanced lung function, however, LABA should not be used
as monotherapy in asthma treatment, as it could increase the risk of asthma excaxerbation

8. What education does Haley, and her parents need regarding when to take the medicine you will prescribe today versus the
SABA she is already taking?
“This type of medication should be administered on a fixed schedule, and should not be stopped abruptely(Rosenthal &Burchum, 2021).
At least 1 minute is needed in between inhalations, the use of a spacer will help ensure all medication is ingested. Haley needs to rinse
her mouth out after administration, this will help decrease the risk of fungal infection and minimize drymouth. This medication will not
provide immediate relief of asthma symptoms, Haley will still need to use the SABA. report any adverse reactions to the provider
immediately.

9. What are two environmental factors may be contributing to Haley’s asthma symptoms that were noted in the case study
information?
a. Second hand smoking exposure from parent
b. Dander form neighbors cat

10. What do the GINA guidelines say about “action plans”?

All asthma patients should have a written action plan that is specific to their asthma classification. The action plan should reflect the
patient's health literacy so they are able to identify and respond appropriately to worsening asthma symptoms. As the patient’s asthma
changes, whether it worsens or improves the action plan should be update accordingly.

11. Do a web search for “asthma action plan”. Provide a link to an example of an asthma action plan you could either use or
adapt in your own clinical practice.
https://www.lung.org/getmedia/dc79f142-a963-47bc-8337-afe3c3e87734/asthma-action-plan-2020.pdf
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