Asthma medication adherence and inhaler technique

Peer Response

Instructions:

Please read and respond to at least two of your peers’ initial responses. 

Review the plans posted by your peers from your advanced practice nursing role perspective (educator, leader or nurse practitioner).  From this mindset, reflect upon a discussion you would like to have with your colleagues about their plan.

For example:

• If you are a nurse educator (clinical or academic) what are your thoughts about the patient education provided in the plan, or do you want to comment on or add to the education provided?  
• If you a nurse leader what are your thoughts about the risk profile or cost effectiveness of the plan.?
• If you are a nurse practitioner did your peer develop a plan that aligns with evidence-based practice and current clinical guidelines? Etc.

Please be sure to validate your opinions and ideas with citations and references in APA format. 

All peer responses are due by Sunday at 11:59 pm CT.

Estimated time to complete: 1 hour

Mitzi

Diagnosis:  This 16-year-old patient has mild persistent asthma.  This is supported by her reported symptoms, including asthma exacerbations (requiring albuterol use) about three times per week during the day and twice per month at night.  Although she does not report significant activity limitations due to asthma, the frequency of albuterol use indicates that her asthma is not well-controlled on her current regimen.

Management of Current Asthma Regimen:  Given the frequency of albuterol use and her intermittent nighttime symptoms, it is likely that this patient’s asthma is inadequately controlled on her current regimen.  According to the National Asthma Education and Prevention Program (NAEPP) guidelines, a patient with mild persistent asthma is typically treated with a low-dose inhaled corticosteroid (ICS) and short-acting beta-agonists (SABAs) as needed for exacerbations (Global Initiative for Asthma, 2023).  The current regimen of beclomethasone dipropionate (Qvar) 40 mcg twice daily is appropriate as maintenance therapy for mild persistent asthma.  However, the patient’s symptoms suggest that her maintenance therapy may need to be adjusted to achieve better control.

Treatment Plan:

1. Increase the dose of ICS:  I would increase the patient’s dose of beclomethasone to 80 mcg twice daily.  This change is consistent with recommendations for patients who experience symptoms more than twice per week or need rescue medication more than twice a week (Global Initiative for Asthma, 2023).  A higher dose of ICS may help to improve asthma control and reduce reliance on albuterol.
2. Consider a leukotriene receptor antagonist (LTRA):  If the increase in ICS dose does not sufficiently control symptoms, I would add a medication like montelukast (Singulair) 10 mg orally once daily as a complementary therapy.  LTRAs are beneficial in patients with asthma who experience symptoms despite ICS therapy and are especially helpful in reducing inflammation.

Specific Prescription(s):

1. Beclomethasone dipropionate (Qvar) MDI 80 mcg/inhalation, 1 puff twice daily.
   1. Instructions:  Inhale one puff in the morning and one puff in the evening.  Rinse mouth after use to reduce the risk of oral thrush.
2. Montelukast (Singulair) 10 mg orally once daily at bedtime.
   1. Instructions:  Take one tablet each evening with or without food.

Patient Education:

1. Inhaler technique:  Ensure the patient demonstrates correct inhaler technique for both the Qvar and albuterol inhalers.  I would reinforce the importance of using the inhalers properly, as improper technique can lead to suboptimal drug delivery and asthma control (Bermudez et al., 2020).
2. Asthma triggers:  Discuss the importance of identifying and avoiding asthma triggers (e.g., allergens, respiratory infections, environmental pollutants) and educate the patient on how to minimize exposure to these triggers.
3. Inhaler adherence:  Emphasize the importance of adherence to the prescribed ICS regimen, even when symptoms are not present.  ICS therapy works to reduce airway inflammation over time, preventing exacerbations and improving overall asthma control (Global Initiative for Asthma, 2023).
4. Use of albuterol:  Reinforce that albuterol should only be used as needed for acute symptoms.  Regular use of a SABA (more than two days per week) may indicate poor asthma control and should be addressed with adjustments in maintenance therapy.

Follow-up and Referral:  I would schedule a follow-up appointment in 4-6 weeks to assess the patient’s response to the adjusted regimen and to monitor for any side effects of the medications, such as oral thrush or mood changes (in the case of montelukast).  If the patient’s symptoms remain uncontrolled or worsen despite these interventions, referral to an asthma specialist for further evaluation may be necessary.

References:

Bermudez, M. A., Pariser, D. M., & Fendrick, A. M. (2020). Asthma medication adherence and inhaler technique. Current Allergy and Asthma Reports, 20(7), 28. https://doi.org/10.1007/s11882-020-00879-2

Global Initiative for Asthma (2023). Global strategy for asthma management and prevention. Retrieved from https://ginasthma.org

Heather

History of present illness

16-year-old patient previously diagnosed with mild persistent asthma presents for a routine follow-up visit. 

• She is currently taking beclomethasone dipropionate (Qvar) MDI 40mcg/inhalation one puff twice daily for asthma maintenance and using albuterol (ProAir HFA) MDI 90mcg/inhalation 2 puffs every 4 hours as needed for shortness of breath or wheezing.
• In the last two months she reports using her albuterol inhaler during daytime hours an average of three times per week.
• She reports awakening at night with asthma symptoms about twice per month.
• She does not feel that she has any limitations to her activity due to asthma symptoms.
• Upon examination today her blood pressure is 110/76, heart rate is 68, respiratory rate is 18, O2 saturation is 96% on room air, and temperature is 97.8. Her lung sounds are clear, heart rhythm is regular, and skin is pink and dry.

Provide your diagnosis:

• Her diagnosis remains PERSISTANT MILD ASTHMA

Discuss how you would manage the patient’s current asthma regimen and provide a rationale supported by scholarly reference for your treatment plan. 

•  She is currently on a ICS for maintenance and (SABA) albuterol for relief. She reports 3 days per week of needing to use albuterol. GINA currently recommends patients experiencing symptoms less than 4-5 days per week to use an “as needed low-dose ICS-formoterol”. Therefore, I would suggest her trying Budesonide-Formoterol at this point in her treatment plan to see if a combination medication would be of more benefit in symptom management for this patient.
• The Global Initiative for Asthma (2024) states that stepping down from daily low-dose ICS plus as-needed SABA to as needed-only ICS-formoterol provides similar or greater protection from severe exacerbations and need for urgent health care, with similar symptom control and lung function and a much lower average daily ICS dose, compared with treatment with daily low-dose ICS plus as-needed SABA (Durbin et al., 2024). I would plan to change her regimen to only PRN ICS-Formoterol.
  • In addition, patients with mild persistent asthma are great candidates for SMART (Single Inhaler Maintenance and Reliever Therapy ). The treatment regimen is simpler, with patients using a single medication for reliever and for maintenance treatment if prescribed, across treatment steps (Durbin et al., 2024). With this approach, when a patient at any treatment step has asthma symptoms, they use low-dose ICS-formoterol in a single inhaler for symptom relief. This also helps to promote adherence.

Include your specific prescription(s) for the patient. (This must include the medication name, dose, route, and frequency as well as any special instructions that apply as you would include when writing a prescription).

• My prescription would consist of:
  • budesonide-formoterol DPI 200/6 (160/4.5) : 1 inhalation as needed for shortness of breath or wheezing, not to exceed 12 inhalations in 24 hours.

Describe the patient education you would provide in relation to your treatment plan.

• I would go over how to properly use inhalers and ensure correct technique. She would need to know that the maximum total number of inhalations that can be taken in any day (total of as-needed plus maintenance doses, if used) of Budesonide-formoterol (Symbicort) for adults and adolescents is 12 inhalations of 200/6 mcg (160/4.5). In order to prevent oral thrush from ICS, I would make sure she understands the need for rinsing her mouth after each use (Global Initiative for Asthma, 2024). Staying active and maintaining a healthy diet is always helpful as well.

Provide your plan for follow-up and/or referral (if indicated)

• Most patients need to be seen in 1-3 months for re-eval. Due to changing her regimen, I would prefer she be seen in 1 month (Arcangelo & Peterson, 2021). If any severe exacerbations occur or if she finds herself needing more than the prescribed amount of inhalations, she would need to be seen sooner or in the ER if an emergency arises.

References

Arcangelo, V. & Peterson, A. (2021). Pharmacotherapeutics for advanced practice: A practical approach. (5th ed.). Wolters Kluwer

Dubin, S., Patak, P., & Jung, D. (2024). Update on Asthma Management Guidelines. Missouri Medicine, 121(5), 364. https://pmc.ncbi.nlm.nih.gov/articles/PMC11482852/Links to an external site.

Global Initiative for Asthma. (2024). Global Strategy for Asthma Management and Prevention [Report]. https://ginasthma.org/wp-content/uploads/2024/05/GINA-2024-Strategy-Report-24_05_22_WMS.pdfLinks to an external site.