Reply:
Week 2 Clinical Discussion Post
The challenge faced this week was the number of other students scheduled at the clinic. It was hard to keep up with who’s turn it was to see a patient. I still feel that my preceptor did a good job explaining treatment choices to me after seeing the patient together, and she spent plenty of time with us all.
This week I had a lot of children with allergies and asthma exacerbations. A nine-year female was brought in by her mother complaining of allergy symptoms for four days, that morning she developed a cough that turned into an asthma attack. The most common triggers for an exacerbation are viral respiratory infections with rhinovirus (RV). In school-age children, hospital admission rates for asthma exacerbations correlate with the seasonal increase of RV infections in September through December and again in the spring. Similar asthma hospitalization peaks are observed in adults.
Other respiratory viruses besides RV may also cause exacerbations. During the 2009 H1N1 influenza A pandemic, mortality, and admissions to the intensive care unit with H1N1 infections were frequently associated with asthma. The respiratory syncytial virus is also a frequent cause of wheezing in infants and young children. Coronaviruses, human metapneumoviruses, parainfluenza viruses, adenoviruses, and bocaviruses have all been detected in asthma exacerbations, but in low frequencies (Castillo et al., 2017)
Environmental allergens can provoke asthma. More than 80% of children with asthma are sensitized to environmental allergens, with indoor allergens being especially important to underlying asthma. Allergic sensitization is also associated with diminished immune responses and may be a susceptibility factor to viral-induced wheezing. The allergen-associated inflammation also increases airway responsiveness to RV to further enhance a loss of asthma control. Pollutants such as tobacco smoke, ozone, and particulate matter, along with occupational exposures, provoke asthma exacerbations. Tobacco smoke, even secondhand exposure, has also been implicated in the development of persistent wheezing and greater asthma severity. Hospitalizations and ED visits for asthma occur more frequently among cigarette smokers (Castillo et al., 2017).
Four essential components of asthma management include patient education, monitoring of symptoms and lung function, control of triggering factors and comorbid conditions, and pharmacologic therapy. Patient education on asthma decreases exacerbations and improves control. However, because asthma severity varies and differs among individuals and age groups, it is essential to regularly monitor the effectiveness of asthma control to guide necessary treatment adjustments.
The first step in treating an asthma attack is with as-needed inhaled short-acting beta2-agonists (SABAs) alone, commonly salbutamol. SABAs are used for acute relief of asthma symptoms, mainly in patients with occasional daytime symptoms and with normal lung function. Inhaled anticholinergic agents, usually ipratropium, are second-line relievers. They are less effective than SABA but may have synergistic effects when added to SABA during severe exacerbations in reducing patients’ hospitalization. More frequent symptoms or the presence of exacerbation risk factors indicate that a regular controller treatment is needed. For long-term asthma control in children, maintenance treatment with therapeutic doses of inhaled corticoid steroids (ICS) in addition to as-needed SABA, should be considered. Regular low dose ICS improve asthma symptoms and lung function, decrease the need for additional medication, and hospital admission (Tesse et al., 2018).
References
Castillo, J. R., Peters, S. P., & Busse, W. W. (2017). Asthma Exacerbations: Pathogenesis, Prevention, and Treatment. The journal of allergy and clinical immunology. In practice, 5(4), 918–927. https://doi.org/10.1016/j.jaip.2017.05.001 (Links to an external site.)
Tesse, R., Borrelli, G., Mongelli, G., Mastrorilli, V., & Cardinale, F. (2018). Treating Pediatric Asthma According Guidelines. Frontiers in pediatrics, 6, 234. https://doi.org/10.3389/fped.2018.00234
