This presentation was based on diagnosing a fictional patient, KB, here is the additional information from this particular presentation: IAL Asthma Case CC: “I need to refill my Ventolin” KB is a 25-year-old female who presents to your community based asthma clinic for an evaluation. She reports, “My asthma has gotten so much worse since I’ve moved back up here. I’ve been waking up at night coughing and wheezing, plus I just can’t seem to get my errands done because I feel so out of breath for days after an attack”. Upon further questioning KB describes having symptoms of wheezing almost daily, with 2-3 exacerbations per week, along with a disrupted sleep pattern in which she wakes up about once a week with symptoms. KB brought a log of her peak flow readings from when she was in Miami, but she lost her PF meter during the move. Her personal best was estimated to be 485 L/min. She also states, “I’ve been going through my Ventolin like crazy, I really think I need another one”. PMH: Asthma since childhood, diagnosed in 1992. Hospitalized once between 1992-1995, with several trips to the ER. Never been intubated. Seasonal allergies (pollen, ragweed) Sprained knee from high school basketball Occasional migraines and heartburn, KB thinks stress related. FH: Father: alive, 54, no known medical problems Mother: alive, 52, has emphysema (45-pack-year history) and lupus Sister: alive, 19, attends college and has no known medical problems SH: Denies tobacco and illicit drugs. Occasional EtOH. Has recently moved in to an older apartment near her mother who is ill. Was previously living in Florida for 7 years, most recently Miami. Works from home as a publicist, travels extensively. Very active lifestyle, loves basketball and sailing. Medications: Ventolin HFA MDI 2 puffs every 4 – 6 hours as needed Flovent HFA 110 mcg 2 puffs twice daily (last filled in Miami 12/2009) Loratidine 10 mg daily as needed for allergies Ibuprofen 200 mg as needed for headache Tums 2 tablets four times a day as needed for heartburn Echinacea extract as needed for onset of colds/flu Allergies: Aspirin, however has food allergies to peanuts (anaphylaxis) and she cannot eat dried fruit (wheezy) ROS: + cough, + wheeze, + rhinitis + occasional heartburn, + occasional headache PE: Gen: WNWD female in mild respiratory distress VS: BP=112/70, P=70, RR=20, T=99o, Wt=120 lbs., Ht=62 in. Lungs: Mild wheezing bilaterally Labs: Not available Assessment: Poorly controlled asthma

1. IAL Asthma Case
Marina Solda
Ian Thompkins

2. Epidemiology
• Asthma is classified as inflammation of the airways
leading to narrow passages and trouble breathing.
Patients usually have symptoms of coughing and
wheezing.
• 20 million Americans affected (1 in 15 americans)
• 50% of asthma cases are “allergic asthma”
• Asthma is the most common chronic childhood
disease and is also more common in children than
adults.
Asthma Facts and Figures. Asthma and Allergy Foundation of America. http://
www.aafa.org/display.cfm?id=9&sub=42#prev

3. Patient Summary
• KB is a 25 y/o female that is presenting with
uncontrolled asthma and exacerbations. She wakes
up at least once a night with coughing a wheezing.
She finds it difficult to do errands after an attack
because she feels so out of breath. She is wheezing
daily and has 2-3 exacerbations per week.
• KB has recently moved from Florida and now lives in
an old apartment. She says that her asthma has
gotten worse after the move.
• Her personal best peak flow was 485L/min but her

4. Exams and History
• KB has had asthma since 1992. She has been hospitalized once and
has never been intubated.
• KB suffers from seasonal allergies (pollen and ragaweed). Also has
allergies to dried fruit, aspirin and peanuts
• Physical exam is normal expect she has a high respiratory rate of 20.
KB is unable to get air out of her lungs because of the asthma. Her
lungs also have bilateral wheezing.
• Family history is unimpressive
• In social history it should be noted that she lives an active lifestyle (so
the exacerbations may be exercise induced) and her asthma has
worsened upon moving.

5. Goals of Therapy
• Control KBs asthma
• Decrease frequency of exacerbations
• Decrease dependence on SABA
• Increase awareness of environmental and behavioral
factors
• Get KBs PEF in the green zone
• Streamline KBs medication regimen to better control

6. Medications
• Ventolin HFA 2puffs q4-6h prn
• Flovent HFA 110mcg 2puffs BID (last filled in 2009)
• Ibuprofen 200mg prn for headache
• Tums 2tablets qid prn for heartburn
• Ehinacea extract prn for onset of cold/flu

7. Classifying KBs Asthma
Days with
Nights w/ FEV1 or
Class sx/ SABA
sx PEF
use
Severe
Continual Frequent <60%
Persistent
Moderate >60%,
Daly >1x/wk
Persistent <80%
Mild >2x/
>2x/wk >80%
Persistent month
Mild <2x/
<2x/wk >80%
Intermittent month
• “GINA Classification of Asthma” http://www.medicalcriteria.com/site/index.php?
option=com_content&view=article&id=68%3Apulgina&catid=77%3Apulmonary&Itemid=80&lang=en

8. Classifying KB’s Asthma
• KB would be classified as having moderate persistent
asthma because she has daily symptoms and she
wakes up once a week from coughing and wheezing.
• KBs PEF cannot be determined because she lost her
peak flow meter
• We can help control KBs asthma by revamping her
medication regimen and suggesting some
environmental changes.

9. Environmental/Behavioral
Changes
• KBs asthma worsened when she moved into an old
apartment. Mold and dust from the apartment may
be aggravating her asthma. KB should dust
frequently and clean her pillows and blankets. KB
should even consider getting plastic allergen covers
for her furniture.
• Don’t go out on high pollen days.
• Take the Ventolin before exercise

10. Management of KBs Allergies
• KB is allergic to aspirin and is also taking ibuprofen.
Ibuprofen and aspirin come from the same derivative
so there may be cross reactivity.
• KB is also allergic to peanuts so we must take note of
the propellants used in some of the HFA inhalers.
Some of the propellants (in Combivent for example)
have are based in lecithin.
Kelly H. W, Sorkness Christine A, "Chapter 33. Asthma" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary
R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 8e: http://
www.accesspharmacy.com/content.aspx?aID=7975293.

11. Medications
• KB has not been compliant with her ICS (Flovent)
which is used for long term chronic asthma.
• We suggest counseling KB on the importance of using
the ICS every day for chronic symptoms and using the
Ventolin for acute attacks only.
• Explain that the ICS must be taken daily even when
symptoms are clearing. Effects won’t be seen for 1-2
weeks with full effects in 4-8 weeks.
• Also cousel KB on the importance of not overusing
the Ventolin because it can lead to serious side effects.

12. Therapy Alternatives
• If KB still presents with uncontrolled asthma at
follow up consider the following:
• Oral corticosteroid burst therapy if exacerbations
persist
• Increase the dose of ICS (Flovent 88mcg -> 220mcg)
• Long Acting Beta Agonists in conjunction with ICS
• Leukotrine modifiers (salmeterol) because they are
good for exercise and allergy induced asthma.

13. Echinacea
• Echinacea is believed to be an immuno-stimulant.
• Asthma is a disease cause by an over-reactive immune
system.
• Additionally, asthma is treated by inhaled cortico-
steroids, which are immuno-suppressants.
• These factors all make the use of Echinacea illogical
during the treatment of asthma.
• Bottom line, strongly advise KB to discontinue echinacea.
Arch Intern Med. 1998 Nov 9;158(20):2200-11.
Herbal medicinals: selected clinical considerations focusing on known or potential drug-herb interactions.
Miller LG. http://0-www.ncbi.nlm.nih.gov.helin.uri.edu/pubmed/9818800

14. Counseling Points
• KB may not be getting the most benefit from her inhaler. Counsel KB on how to
use the inhaler and encourage the use of a spacer
Kelly H. W, Sorkness Christine A, "Chapter 33. Asthma" (Chapter). Joseph T. DiPiro, Robert L.
Talbert, Gary C. Yee, Gary R. Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A
Pathophysiologic Approach, 8e: http://www.accesspharmacy.com/content.aspx?aID=7975293.

15. How to Use the Inhaler
Kelly H. W, Sorkness Christine A, "Chapter 33. Asthma" (Chapter). Joseph T. DiPiro, Robert L. Talbert, Gary C. Yee, Gary R.
Matzke, Barbara G. Wells, L. Michael Posey: Pharmacotherapy: A Pathophysiologic Approach, 8e: http://
www.accesspharmacy.com/content.aspx?aID=7975293.

16. Summary
• Recommend thorough cleaning of KB’s new living
environment.
• Strongly advise discontinuing echinacea.
• Stress the importance of using the ICS everyday, even
when symptoms are clearing.
• Discontinue ibuprofen.
• Counsel patient on importance of compliance and
how to use an inhaler correctly

17. Questions?