by Adriana Matiz
Learning Objectives:
1) Define asthma.
2) Understand the pathophysiology, triggers and risk factors for asthma
3) Understand the new NHLBI Asthma Guidelines to classify asthma and assess control
4) Understand the importance of patient education, cultural beliefs in our communities and encourage the use of a written asthma plan.
Primary References: 1. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (Full report) http://www.nhlbi.nih.gov/guidelines/asthma/asthgdln.htm
2. Guill, Margaret F. Asthma Update: Epidemiology and Pathophysiology. Pediatrics in Review. 2004;25 (9); 299-304 http://pedsinreview.aappublications.org/cgi/reprint/25/9/299
3. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (summary report) http://www.nhlbi.nih.gov/guidelines/asthma/asthsumm.htm
4. Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma (Tables- pages 305-310) http://www.nhlbi.nih.gov/guidelines/asthma/08_sec4_lt_0-11.pdf
Case One:
Jose Sanchez is a 6 year old boy who presents to your clinic for a walk-in sick visit during a busy January afternoon. His mother reports that he wheezed “a lot” as a baby and that then he outgrew his asthma. He has had wheezing for 2 days and “always” wheezes during this time of the year. She adds that he usually has a great summer without any wheezing or respiratory problems. She states that he was seen in the ED last month, twice, and received a syrup for five days both at the beginning of the month and again at the end, which helped, along with his Albuterol. Since then he has continued to cough at night about 3 times/ week. When you ask her if he’s ever been admitted for asthma, she states “ he wheezes, I told you he outgrew his asthma”. She denies that he’s ever been admitted. She gave him Albuterol HFA 2 puffs this morning without a spacer which helped only a little bit. 1) What is Jose’s diagnosis? How do you classify his severity?
2) What medication would you recommend for Jose at this time?
3) You decide, with mom to prescribe a medium dose ICS and suddenly she tells you that you misunderstood and that he only has symptoms during the winter, and that he does not have chronic asthma- did you misunderstand?
4) After you explain to Jose’s mother that the medium dose ICS will prevent further exacerbations during the winter, you ask her if she still has any concerns. After a long pause, she tells you “People say that once he is on this medicine he will become addicted and stop growing”. What do you respond?
5) It is now four weeks later and you are about to see Jose for follow up, how will you assess how he is doing since the last encounter? 6) His mother reports that he is still coughing about 1 time per week at night and using his short acting beta agonist 2 days/week despite using his medium dose ICS appropriately with his spacer. What are the next steps in his care?
7) Jose’s mother tells you that sometimes she gets confused on when to give which medication, what can you do to help her with this?
