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NR565 ASTHMA PROTOCOL: INITIAL VISIT
Name : General Instructions: Carefully read the assignment guidelines and rubric and complete each section of the asthma protocol below. 1) RATIONALE a) This protocol will assist in the differentiation between treatment needs for clients with asthma based on age and symptom frequency and severity, including the process for identification of clients in need of referral to pulmonology to improve asthma control. The design of the protocol for asthma encompasses these principles. 2) SYMPTOMS a) ASTHMA i) History of respiratory symptoms that vary over time with varying intensity, including: (1) Wheezing (2) Shortness of breath (3) Chest tightness (4) Cough ii) Triggers for exacerbation can include: (1) Exercise (2) Allergens (3) Season changes (4) Laughter (5) Respiratory illness iii) Presence of asthma phenotypes iv) Client responses on the Asthma Control Test (ACT) or the Asthma Control Questionnaire (ACQ)
v) Reduced lung function and responsiveness with medications (1) Reduced expiratory airflow (forced expiratory volume in one second, a.k.a. FEV 1 ) (2) Variable peak expiratory flow (PEF) 3) PHYSICAL EXAM a) Perform the following examinations: i) Vital Signs (blood pressure, pulse, oxygenation, respiratory rate) ii) Auscultation for wheezing iii) Identify increased work of breathing iv) Identify retractions v) Cardiac assessment vi) Lower extremities for edema and pulses vii) Neurological b) Consult supervising physician if findings of: i) Respiratory distress 4) LAB TESTS a) Depending on severity, can include: i) Arterial or venous blood gas (1) ph (2) O 2 (3) CO 2 (4) Bicarbonate (5) Base excess ii) CBC (1) Hemoglobin and hematocrit (2) WBC and eosinophils iii) Total or specific IgE levels iv) Consult supervising physician if: (1) Abnormal blood gas results or severe anemia
Drug: Low dose as needed Frequency: As needed More than 2 Drug class: Daytime symptoms days per week but less As needed ICS- than daily formoterol or as needed Step 2 Mild Persistent Nighttime awakening s 3- 4 times/month SABA Example Drug: Budesonide in combination with formoterol Frequency: As needed Daytime symptoms daily^ Drug class: As needed ICS- formoterol or as needed SABA Example Drug: Budesonide in combination with formoterol Frequency: As needed Drug class: Low dose maintenance ICS-formoterol Example Drug: Step 3 Moderate persistent Nighttime awakening s More than 1 time per week but less than nightly Budesonide/formoterol:Sy mbicort-160/4. Frequency: Take 1-2 daily and 1 as needed Step 4- Severe persistent Daytime symptoms Several times daily Step 4: Drug class: Drug class: As needed Medium dose ICS- maintenance ICS- formoterol formoterol Example Drug: or as needed SABA Example
Budesonide/formoterol:Sy mbicort-160/4. Frequency: Take 2 twice daily and 1 as needed Drug: Budesonide in combination with formoterol Frequency: As needed Nighttime awakening s Often nightly Step 5: Drug class: Add on LAMA Example Drug: Tiotropium Spiriva Frequency: Once daily Refer for: Assessment of phenotype No change. Citation (Provide (Author, year) and not full reference): GINA, 2022 7) TREATMENT DIFFERENCES IN ADULTS AND CHILDREN a) 1 st^ line initial pharmacological treatment in step one, track one asthmatic adult clients and no compelling contraindications/comorbidities are identified: (Choose a generic drug from the drug class you would like to prescribe as initial asthma treatment for adults). i) Drug: Budesonide/formoterol:(Symbicort) ii) Dose: 160/4.5 mcg per inhalation for usual doses (GINA, 2022) iii) Route: Inhalation iv) Frequency: Take 1-2 puffs daily and 1 as needed v) Instructions to provide patient: Shake medication thoroughly, exhale fully before inhaling deeply to get all the medication. Spacer may be used as needed, instructions can apply to children 12 and older as well as adults. vi) Caution/Precautions: Caution in clients with heart disease, diabetes, weakened immune system and thyroid disorders
8) TREATMENT MONITORING
a) How long until a follow-up appointment should be done with the client? Treatment with asthma varies, the National Asthma Education and Prevention Program (n.d.) recommends every 2-6 weeks while gaining control, every 1-6 months to monitor control, and every 3 months if step-down therapy is anticipated. b) Monitoring needs for first-line medications prescribed to adults for track one, step one: (Include physical assessments, pulmonary function tests, and lab/diagnostics as applicable. If not applicable, enter N/A to show you find it not applicable.) i) Physical Assessments: Monitoring patient’s symptoms such as their lung sounds and a cough could show if the medication is actively working or needs improvement. Patients should be able to talk in full sentences without dyspnea in well managed asthma, patients should not have increased wheezing in their lung sounds with well managed asthma. ii) Pulmonary Function Tests: A home pulmonary function test that could be completed is the use of a peak expiratory flow (PEF) meter. It is a handheld device that a patient can use to help them gage the management of their symptoms. In an article by DeVrieze et al (2024), they state that PEF aid in determining effectiveness of therapy, provide early warnings of potential exacerbation, and help patients recognize asthma symptoms. The PEF uses a stop light system to easily help patients determine where their asthma stands for the day or multiple times throughout the day. iii) Labs: Labs that could be monitored during treatment could be inflammation markers such as c- reactive protein. Other lab test that could be used to monitor treatment are total eosinophil count. Citation (Provide (Author, year) and not full reference): Click or tap here to enter text. 9) TREATMENT FAILURE a) How will you know if the treatment is not working or needs to progress? If patient’s symptoms persist or become unmanageable to the point that it is considered severe asthma, switching medications may be indicated or adding an additional medication. This can be evaluated with questionnaires, pulmonary function test, and symptom reporting. b) What is the next step if treatment is not working or needs to progress? If the current medication is not working the next step would be to switch to a different medication such as Fluticasone and salmeterol (Advair). Patients might not be getting the full effect of an aerosol inhaler (Symbicort) and may require a dry powder inhaler. It would also be good to review proper techniques with the patient and make sure that they are taking the
medication correctly and do not require a spacer. In the situation that the patient isn’t progressing, an increase in dosage may need to be considered or adding a long- acting muscarinic antagonist (LAMA). c) What indicators would demonstrate the client requires a higher level of care? Patients should be improving with well managed asthma, symptoms should be lessened and quality of life should improve. According to GINA (2022), patients should be referred to expert advice after hospitalization for severe asthma or recurring acute asthma, they also continue on saying patients who have had more than 1-2 exacerbations a year despite medium-dose or high-dose ICS-LABA should also be referred. Citation (Provide (Author, year) and not full reference): Click or tap here to enter text. References DeVrieze, B. W., Goldin, J., & Giwa, A. (2024, October 6). Peak flow rate measurement. National Library of Medicine. https://www.ncbi.nlm.nih.gov/books/NBK459325/ Global Initiative for Asthma. (2022). Global Strategy for Asthma Management and Prevention. https://www.ginasthma.org National Asthma Education and Prevention Program. (n.d.). Guidelines from the National Asthma Education and Prevention Program. https://www.nhlbi.nih.gov/files/docs/guidelines/asthma_qrg.pdf
