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SPHE314 Exercise Physiology

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SPHE314 Exercise Physiology

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SPHE314 Exercise Physiology

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Course Code: SPHE314
University: American Military University

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Country: United States

Question:

Zach, 6-year-old, with a history of mild intermittent asthma presents to the office with symptoms of worsening cough and wheezing for 24 hours. Mother reports that patient had a low-grade fever of 100.5oF, loose cough, and runny nose approximately two to three days ago. Wheezing began the day before the office visit and she administered the albuterol metered-dose inhaler two puffs at bedtime and at 2am. Assessment findings include a respiratory rate of 36 breaths per minute, a tight cough every one to two minutes, diffuse expiratory wheezes and mild retractions, pulse oximetry was 93%, afebrile, and weight of 45 lbs.
 
Discussion By Anna GreeneWhat could be done initially in the clinic to assist Zach?
Zach is most likely experiencing an acute asthma exacerbation related to the viral upper respiratory infection (URI). The low-grade fever, rhinorrhea, and cough are symptoms of a viral upper respiratory infection and can increase the risk for an asthma exacerbation (Woo & Robinson, 2016). As the provider, I would provide supplemental oxygen to facilitate oxygenation, as well as prescribe Albuterol/Ipratropium bromide (Combivent) 1.5mL every 20 minutes up to three doses and then reassess lung sounds and pulse oximetry (Woo & Robinson, 2016). Combivent is a combination medication of an anticholinergic bronchodilator (Ipratropium bromide) and the beta2-adrenergic bronchodilator (Albuterol) and is used for children with moderate to severe asthma exacerbations (Medstar Health, 2017). By combining both an anticholinergic and a beta2-adrenergic bronchodilator, it facilitates a greater bronchodilator effect (Drugs, 2018).
What specific teaching would you complete with Zach?Patient education is vital in all patient encounters to ensure that the patient and their family members have the adequate knowledge to manage their diagnoses. For Zach and his mother, I would teach the signs and symptoms of an exacerbation, as well as the risk factors that can precipitate an exacerbation such as pollens and viral respiratory infections (Woo & Robinson, 2016). Additional topics to discuss includes self-monitoring with the use of a diary of his symptoms, use of the peak flow meter, and the need to record the peak expiratory flow (PEF) on the diary (Woo & Robinson, 2016). After the teaching and the educational pamphlets have been delivered, I would utilize the teach back method to identify whether Zach and his mother comprehended the instruction and whether they were able to administer the Albuterol inhaler with spacer effectively.
What would be your exacerbation plan?Exacerbation plans are crucial in patients with asthma in order for them to understand what to do during an exacerbation, how to prevent an exacerbation, and when to seek medical care. Zach has mild intermittent asthma and the use of his Albuterol inhaler with spacer has been effective for the management of his asthma up until recently when his mother brought him to the office for treatment. If Zach was not also suffering from a viral URI, the inhaler may have been efficient; therefore, there is not an immediate need to alter his level of step therapy at this time.
What type of follow-up would you give?If Zach responded well to the Combivent nebulizer treatments, I would be confident insending the patient home to his mothers’ care. Corticosteroids are the first line of treatment in children of this age group when the asthma exacerbation is caused by a URI (Woo & Robinson, 2016). Often times, children will require a short prescription of oral corticosteroids to reduce airway inflammation and thus improving bronchodilation (Rowe, Edmonds, Spooner, Diner, & Camargo, 2002). The recommended dosage of Prednisolone for children is 40 to 50mg/day (Woo & Robinson, 2016). I would prescribe Prednisolone 40mg every day for three days (Woo & Robinson, 2016). It is advised for the oral corticosteroid to be given in the morning with food to reduce the risk of adrenal suppression (Alvarez & Mikrogianakis, 2012).As the provider, I would also educate the continued monitoring of the asthmatic symptoms and when he uses his Albuterol inhaler on a self-assessment diary in order to track the symptoms and to determine if there is adequate control of his asthma or if he needs a step up in the treatment plan (Woo & Robinson, 2016). I would also request a follow-up appointment in two to three weeks to reassess the diary and lung function tests. If patient continues to suffer from asthma exacerbations and treatment isn’t effective, I would advise to go to their local emergency room.1. What could be done initially in the clinic to assist Zach?Zach is having an acute exacerbation of his asthma due to the recent onset of a viral respiratory illness. Initially in the clinic I would provide the patient with supplemental oxygen. Next, I would administer the combination medication Combivent 3mL via nebulizer, which is a second-line quick relief medication in the treatment of asthma. This combination medication contains Albuterol, a short acting beta2 agonists and Ipratropium, an anticholinergic which is frequently used in younger children as an adjunct to Albuterol during an exacerbation. Lastly, I would start Zach on the oral steroid prednisone, 2 mg/kg day for 3-10 days to reestablish control of his asthma (Woo & Wynne, 2011).
 
2. What specific teaching would you complete with Zach?The key to patient education is maintaining a partnership with Zach and his family which is not only cost effective but can reduce emergency department visits and morbidity in both adults and children. Specific teaching would first focus on review of proper inhaler use and when to take quick-relief medications. It is also important to discuss with the family that the most common cause of asthma symptoms is from a viral respiratory infection. A written asthma management plan would be created which includes teaching parents how to identify and anticipate asthma symptoms, such as the beginning of a child’s upper respiratory infection. Additionally, this plan would include how to manage Zach’s asthma with medication at the onset of a cold or flu and when to seek provider assistance. Another important aspect of patient and family teaching includes self-monitoring skills, such as self-assessment of symptoms, peak flow monitoring and how the family can record peak expiratory flow (PEF) on a self-assessment diary (Woo & Wynne, 2011).
 
3. What would be your exacerbation plan?It is crucial for Zach and his parents to understand what triggers the patient’s asthma, such as a viral respiratory illness, recognize those symptoms and to start home treatment right away. In Zach’s exacerbation plan I would first include utilizing his inhaled short acting beta2 agonists (SABA), such as Albuterol up to two times, twenty minutes apart by inhaler or nebulizer. If the patient has a good response to treatment I would advise the parents to call the provider for follow-up instructions, such as continued use of his inhaled SABA every 3 to 4 hours for the next 24 to 48 hours and possibly start a short “burst” therapy of prednisone. If Zach has an incomplete response to his SABA and continues to wheeze and exhibit dyspnea the parent needs to contact the provider urgently. An oral steroid, such as prednisone would be added to his regimen, along with continued use of his SABA every 3 to 4 hours over the next 24 to 48 hours. It is crucial to monitor the effectiveness of pharmacological therapy and to determine if the patient is at the appropriate level of step therapy and if changes need to be made (Woo & Wynne, 2011). Since this is Zach’s first exacerbation of the year it is important to continue to monitor him and at each visit an up-to-date asthma action plan must be reviewed and revised as appropriate.
 
4. What type of follow-up would you give?Since this is Zach’s first exacerbation of the year a step up in asthma management is not indicated. I would advise the family to follow-up in 2 weeks after his exacerbation and then to follow-up at regular intervals unless he is experiencing more exacerbations. I would instruct the patient to continue with his SABA as needed, but if he is having symptoms more than 2 times a week or more than 1 time a month at night he needs to be evaluated right away and step up in his asthma management would be initiated. I would also instruct Zach’s family to continue monitoring his asthma daily, assessing for symptoms and recording PEF on a self-assessment diary (Woo & Wynne, 2011).

Answer:

Response to post discussion:
1.In response to case of Zach, a 6 year old patient with history of intermittent asthma, Anna Greene suggested providing supplemental oxygen and Albuterol/Ipratropium bromide to assist the patient. The suggestion of using combined medication is a good strategy given in the post because evidence has proved the efficacy of combined anticholinergic and a beta2-adrenergic bronchodilator on initial treatment of acute asthma in children. The study showed that anticholinergics have slower onset of action and weaker bronchodilating effect. Hence, they can enhance and prolonged bronchodilation (Griffiths  & Ducharme, 2013).. Hence, it can be said that the justification given in the post regarding the ration for using two medications is consistent with research findings. With regard to the response given by Anna Greene on specific teaching for Zach, I would say that teaching strategies has been covered in detail however one drawback is that the age of the client is not considered while planning health teaching. For instance, a 6 year old child may not engage in self-monitoring by recording peak expiratory flow. However, giving the education in front of Zach’s family member will be effective. The exacerbation plan for Zach is not properly provided and suggestions like strategies that can be taken when Zach experience severe respiratory distress would have strengthened the post. For instance, strategies like pursed lip breathing could help the client. The follow up plan is detailed enough to support the patient to report about any complications while taking medications.  
2. In contrast to Anna Greene’s response for initial intervention for Zach, the post by Macey Dodd also states the use of combivent medication. However, Macey Dodd also suggested the use of oral steroid prednisone to control asthma symptoms. This medication can be effective to control moderate or serious flare up in Zach after the first line of treatment (Abaya, Jones & Zorc, 2018). The strength of teaching plan developed for Zach is that Macey has focused a lot on common problems that patient of family members may encounter while taking medications. Hence, the teaching strategies like proper use of inhalers and situation in which taking quick relief medication is effective. Such teaching plan is likely to support patient and their family members to encounter all barriers during the management of asthma (Normansell & Welsh, 2015). The suggestion of a written asthma plan is even more useful strategy as this will family member’s with the opportunity to review the plan and then decides what actions needs to be taken for Zach. In contrast the last post, Macey also specified regarding the role of family in self-monitoring and ways to record expiratory flow in a diary. It is the most comprehensive and detailed plan that is likely to increases the confidence of family member in managing the health of Zach. Macey has also proposed a useful exacerbation plan which was lacking in the last post. Exacerbations is related to severity of symptoms and when patients are made aware regarding situations that can increase exacerbation of the disease, then many complications in patient can be prevented (Pinnock, 2015). Hence, the follow-up instruction given after taking each medication is an effective strategy proposed in the post. It clearly specified the duration and response needed by patient after use of each medication. The emphasis on timing both in exacerbation and follow-up plan is the strength of this discussion post.
Mechanism of action of Albuterol and ipratropium:
Albuterol and ipratropium are nebulized medication give to patient with asthma or COPD. Albuterol is a bronchodilator given to patients with obstructive airway disease. It works to relax the smooth muscles of airways and open the airways that was affected by bronchoconstriction. It is a beta2-adrenergic agonist that activates beta 2-adregergnic recepctors present on the smooth muscle of airways. Such activation increases the concentration of cyclic AMP due to the activation of adenyl cyclase. High concentration of AMP inhibits the releases of mediators responsible for causing bronchospasm. In addition, the ionic calcium concentration is decreases resulting in relaxation of the smooth muscles (Chemm.nlm.nih.gov. 2018). In this way, Albuterol helps to reduce symptoms of wheeziness and shortness of breath in patient.
Ipratropium is also a medication given for treatment of symptoms related to shortness of breath in asthma and COPD patient. It is an anticholinergic agent that blocks the receptors of acetylcholine and the release of transmitter agent from the vagus nerve. The action of the drug results in decrease in the intracellular concentration of cyclic guanosine monophosphate (cGMP). The action of the CGMP in turn on the intracellular calcium results in decreased contractility of the smooth muscles of the airways (Bernstein & Singh, 2015).. In this way, the symptom of breathlessness is reduced in patient.
Reference:
Abaya, R., Jones, L., & Zorc, J. J. (2018). Dexamethasone Compared to Prednisone for the Treatment of Children With Acute Asthma Exacerbations. Pediatric emergency care, 34(1), 53-58.
Bernstein, J. A., & Singh, U. (2015). Neural abnormalities in nonallergic rhinitis. Current allergy and asthma reports, 15(4), 18.
Chemm.nlm.nih.gov. 2018.  Albuterol -Medical Countermeasures Database – CHEMM. Retrieved 20 February 2018, from https://chemm.nlm.nih.gov/countermeasure_albuterol.htm
Griffiths, B., & Ducharme, F. M. (2013). Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children. Paediatric respiratory reviews, 14(4), 234-235.
Normansell, R., & Welsh, E. (2015). “Asthma can take over your life but having the right support makes that easier to deal with.” Informing research priorities by exploring the barriers and facilitators to asthma control: a qualitative analysis of survey data. Asthma research and practice, 1(1), 11.
Pinnock, H. (2015). Supported self-management for asthma. Breathe, 11(2), 98.

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