NSG 6420 Adult And Geriatric Health Grand Rounds Presentation

NSG 6420 Adult and Geriatric Health Grand Rounds Presentation

Subjective

Symptoms of chest pain, dyspnea, fatigue, and nausea are of acute onset and indicate an acute exacerbation. It is crucial to characterize the chest pain, including its location, character, severity, aggravating factors, relieving factors, and radiation, since it can be a manifestation of both respiratory and cardiovascular disorders. Similarly, dyspnea must be explored to determine its severity as well as its association with changes in position as it may indicate an underlying cardiovascular or respiratory disorder. Individuals with asthma are prone to exacerbations triggered by exposure to viral infections, allergens, medications, exercise, stress, and cold air (Quirt et al., 2018).

Consequently, a history of prior upper respiratory tract infection, exercise, and exposure to occupational allergens such as flour must be elicited before the onset of symptoms. The specific timing of symptoms must be determined as asthma symptoms tend to worsen at night. It is crucial to determine her history of allergy as this is crucial in preventing subsequent exacerbations. She is also obese, and therefore dietary history and physical activity must be identified. Finally, a comprehensive review of systems should be done since symptoms of nausea and fatigue are largely non-specific.

Objective

Vital signs, particularly temperature and saturation, are important as they may indicate evidence of infection and the need for oxygen, respectively. In the general exam, pallor should be checked. Respiratory rate, blood pressure, and heart rate are critical in evaluating the impact on the cardiorespiratory systems. In the respiratory system, decreased breath sounds indicate hyperinflation of the lungs.

Additionally, in-office spirometry must be done. The cardiovascular exam is essentially normal, signifying that the problem may be past the cardiovascular system. Nausea is mostly associated with abdominal pathologies; therefore, a complete abdominal exam is necessary. In addition to a musculoskeletal issue, fatigue may be a manifestation of a neurological abnormality; hence a complete neurological exam is essential.

Assessment

The main diagnosis is an acute asthma exacerbation (J45. 901). The patient is a known asthmatic who appears to have well-controlled asthma until the past day. Her symptoms are of acute onset. According to Quirt et al. (2018), acute asthma exacerbation refers to a reversible worsening of the clinical features of asthma that develops over a short duration.

The national Asthma Education and Prevention (NAEPP) guidelines characterize asthma exacerbations into mild, moderate, severe, and life-threatening asthma exacerbations (Chipps et al., 2022). The patient in the case scenario has mild asthmatic exacerbation as she can complete sentences, her chest pain is relieved by nebulized albuterol, and she has no wheezing on auscultation.

The differential diagnoses include GERD and pneumonia. Pneumonia refers to the infection of the lungs. The patient has features suggestive of pneumonia, including acute onset of dyspnea, nausea, fatigue, and chest pain, lack of wheezing, diminished air entry, and diminished breath sounds. Similarly, asthmatic patients are commonly exacerbated by pneumonia.

However, the absence of fever and relief of chest pain by albuterol nebulization highly favors the diagnosis of asthma. Finally, GERD can be considered a differential diagnosis due to its high rate of occurrence in individuals with asthma. Similarly, the patient is obese, a risk factor for GERD. GERD also presents with chest pain and associated features such as regurgitation, but the heartburn is not relieved by albuterol.

Plan

Diagnostic tests- complete blood count to rule out anemia or eosinophilia, pulmonary function tests, and arterial blood gases to assess the severity of the exacerbation (Quirt et al., 2018). Additionally, skin allergy tests and IgE levels to identify possible allergens. A basic metabolic panel and lipid profile as a baseline for pharmacotherapy. Similarly, a chest X-ray to exclude pneumonia and esophageal pH monitoring to exclude GERD.
Treat as an outpatient.
Supplemental oxygen and albuterol nebulizer. The NAEPP guidelines recommend supplemental oxygen if saturation is <94 % and albuterol nebulizer 2.5 to 5 mg every 20 minutes for up to 3 doses, then 2.5 to 10 mg every 1 to 4 hours as needed, as initial treatment for patients presenting with mild asthma exacerbation (Chipps et al., 2022). Corticosteroids are only indicated if there is no initial response to SABA (Chipps et al., 2022).
Education- the patient must be educated on asthma and self-management practices such as avoidance of triggers. A written individualized daily self-management plan should be developed, focusing on treatment goals (Ish et al., 2021). Advise the patient to take medications as prescribed, including how to use the inhaler devices (Ish et al., 2021). Enlighten the patient about the side effects of medications, the need for long-term treatment, and the importance of weight reduction.
Maintenance treatment with low dose ICS-formoterol. The 2020 GINA guidelines recommend low-dose ICS-formoterol as needed for patients more than 12 years old (GINA, 2020).
Referrals- currently, no referral is required. However, a physician may be consulted.
Follow-up- schedule frequent follow-ups to step up or step-down therapy according to patient response.

Pathophysiology

The pathophysiology of asthma is complex and multifactorial. The common pathophysiologic process of asthma involves an inflammatory process spearheaded by T-helper type 2 cells that manifests in genetically predisposed individuals. It consists of bronchial hyperresponsiveness, bronchial inflammation, and endobronchial obstruction (Quirt et al., 2018). Bronchial inflammation is caused by overexpressed T-helper type 2 cells that stimulate the release of cytokines, particularly interleukin 3, 4,5, and 13, following the inhalation of an antigen (Bush, 2019).

The cytokines activate eosinophils and induce a cellular response that leads to bronchial submucosal edema and smooth muscle contraction. Meanwhile, endobronchial obstruction is usually a consequence of increased parasympathetic tone and hypertrophy of smooth muscles.

However, allergic asthma is an IgE-mediated type 1 hypersensitivity reaction to a particular allergen and is characterized by mast cell degranulation and release of histamine following a prior sensitization phase (Bush, 2019). On the other hand, nonallergic asthma occurs when irritants enter the lung stimulating a neutrophilic inflammatory reaction. The resultant submucosal edema causes airway obstruction.

Practice Barriers

Several barriers have been identified that contribute to poor control of asthma. For instance, practical barriers such as poor inhaler use lead to increased hospitalizations and asthma (Jenkins, 2019). Similarly, lack of knowledge about the specific triggers that exacerbate asthma has contributed to ineffective control of asthma as triggers cannot be avoided. Concomitant pathologies, particularly rhinitis and GERD, contribute to suboptimal control of asthma as it may delay the diagnosis and treatment of asthma.

The side effects of anti-asthmatics and the cost of anti-asthmatics have contributed to poor medication adherence. Finally, Jenkins (2019) cited insufficient confidence in clinicians/medication, low motivation to behavior change, and concomitant psychological problems as other barriers to effective control of asthma.

References

Bush, A. (2019). Pathophysiological mechanisms of asthma. Frontiers in Pediatrics, 7, 68. https://doi.org/10.3389/fped.2019.00068
Chipps, B. E., Murphy, K. R., & Oppenheimer, J. (2022). 2020 NAEPP guidelines update and GINA 2021-Asthma care differences, overlap, and challenges. The Journal of Allergy and Clinical Immunology in Practice, 10(1S), S19–S30. https://doi.org/10.1016/j.jaip.2021.10.032
GINA. (2020). GINA Main Report. Global Initiative for Asthma – GINA; Global Initiative for Asthma. https://ginasthma.org/gina-reports/
Ish, P., Malhotra, N., & Gupta, N. (2021). GINA 2020: what’s new and why? The Journal of Asthma: Official Journal of the Association for the Care of Asthma, 58(10), 1273–1277. https://doi.org/10.1080/02770903.2020.1788076
Jenkins, C. (2019). Barriers to achieving asthma control in adults: evidence for the role of tiotropium in current management strategies. Therapeutics and Clinical Risk Management, 15, 423–435. https://doi.org/10.2147/TCRM.S177603
Quirt, J., Hildebrand, K. J., Mazza, J., Noya, F., & Kim, H. (2018). Asthma. Allergy, Asthma, and Clinical Immunology: Official Journal of the Canadian Society of Allergy and Clinical Immunology, 14(Suppl 2), 50. https://doi.org/10.1186/s13223-018-0279-0