Responsible Prescribing for Asthma - Essay Example

? Asthma is a condition in which the air passage way tubes get narrowed and swollen. These tubes are termed as bronchioles. This narrowing of the airways produces excessive mucus which may cause difficulty in breathing along with a wheezing sound. In the presence of narrowing of the respiratory canal, lungs will not be able to hold a proper amount of oxygen required for the purpose of breathing. As a result, symptoms like difficulty in breathing, lethargy and even lung collapse will be experienced. Asthma can be a symptom to a major disease or it might be an indication of the chronic condition. It is currently the most prevalent chronic disease which affects about 300 million people annually. There are various factors that play a role in the onset of disease. However, therapeutic and non-pharmacological management plans can help the patients in the long run. Scientists theorize that the worldwide increase in pollution due to the industrialization has caused a significant rise in the disease. The major implications and occurrence to treatment ratio along with the various strategies for controlling it are discussed further on. The incidence rates provides the information about the onset of the disease along with the probability of developing a disease. The incidence rate of asthma ranges between 2.65 to 4 per 1000 people annually. The condition is more commonly found in children less than five years of age and among boys as compared to girls. In childhood, the rate is estimated to be about 8.1 to 14 every 1000 persons for boys and 4.3 to 9 every 1000 persons for girls. Annually it is estimated that this rate of incidence is 2.1 every 1000 persons over 25 years of age. CDC reports that asthma continues to be the major public health concern with a large financial impact on families and health care system. Internationally UK is the highest ranking countries in terms of asthma prevalence. The peak prevalence occurs between the ages of 5 and 15 and falls thereafter the age range of 55-64 years, after which it starts to rise again. Asthma diagnoses have recently became more common since 1950’s. Most of the children wheeze in their early life in response to the respiratory tract infection but most appear to grow out of it by the time they go to school. It is also to be noted that a few children will continue to wheeze and develop interval symptoms similar to atopic asthma (Worldallergy.org. 2013). The most common symptoms that are accompanied in asthma are coughing (especially at night or during exercise), trouble breathing, a tight feeling in the chest and wheezing sound. Some people may have prolonged symptom free periods while others experience some symptoms every day. Loss of breath, exhaustion, wheezing, coughing, upper tract respiratory infections, sore throat and runny rose are some other less frequent signs. The underlying cause of asthma is bronchoconstriction due to the allergic inflammation of the passage ways. The inflammation process can be histologically seen. There is a hyper secretion of sub epithelial fibrosis, mucus hyper secretion and infiltration of the various inflammatory cells. The immuno-histopathologic features of asthma include the infiltration of the neutrophils, lymphocytes, epithelia cells and mast cell activation. An allergen triggers the type 1 hypersensitivity by activating the IgE antibodies. In normal individuals, the pathogen is phagocytised by the antigens stimulating a low TH1 response. In allergic people, the pathogen or pollutant induces the TH2 mediated response through the release of IL-4. This interleukin 4 induces the production of IgE antibodies which then attach to the mast cells receptors upon the secondary exposure of the allergen. Their attachment with mast cells triggers the release of the histamine which causes bronchoconstriction. The TH2 cells can directly induce the type 4 hypersensitivity through the production of interleukin 13. These interleukins cause the goblet cell hyperplasia, increased production of mucus and smooth muscle contraction. TH2 lymphocytes recruit eosinophil by producing IL5 which then induces the eosinophil proliferation and release from bone marrow (Pitt.edu. 2013). The type 1 hypersensitivity is one mechanism by which allergens cause the clinical manifestations. When the dendritic cell phagocytises the allergen, the allergen is presented to TH2 cells. The activated TH2 cells bind to and activates the B lymphocytes. These lymphocytes then produce the IgE antibodies which attach to mast cell. Degranulation takes place to release the histamine, cytokines, prostaglandin, leukotriene and arachidonic acid. Histamine causes airway oedema, and prostaglandins induce pain and swelling. Asthma exacerbation is the worsening of the asthma control. The condition is unavoidable sometimes and interferes in the normal daily routine work. The acute asthma exacerbations can be mild, moderate or severe. A moderate type is the one that causes an increase in the existing asthma therapy not including systemic steroids. A severe exacerbation is that one which requires emergency hospitalization or the usage of systemic steroids for at least 3 days. The causes of the exacerbations of the asthma include viral infections, bacterial invasion, pollutants, allergens and other environmental hazards. The patient, Tom in this case, is suffering from the severe form of the acute exacerbations. He has been on the prednisolone, a corticosteroid, recommendation. The signs and symptoms of severe asthma are examined and diagnosis made. According to BRITISH THORACIC SOCIETY (BTS), these severe signs include use of accessory muscles of respiration, hyperinflation, tachypnea, tachycardia, diaphoresis, inability to complete sentences, difficulty in lying down and altered mental state with or without cyanosis. Detailed examination is performed by observation of the pneumonia like symptoms. Pulse rate is usually higher than 100 BPM and respiratory rate is greater than 25 breaths per minute. The differential diagnosis of the exacerbation includes COPD, carcinoid syndrome, hyperventilation syndrome, chemical pneumonitis, cardiogenic pulmonary oedema and thoracic tracheal obstruction. Chest x-ray are to be performed on all the patients with atypical symptoms (Ncbi.nlm.nih.gov. 2013). Tom is experiencing a high respiratory rate as well as a high pulse rate proving the diagnosis of the acute exacerbation. The current observation of Tom shows his critical exacerbation conditions. The patient is dealing with routine stress which further adds to the worsening of the situation by increasing the heart rate BTS is the British Thoracic Society, initially formed in 1982. This society comprises the specialists and surgeons of the thoracic part of the respiratory system. The initial therapy principles set by the BTS include Oxygen, corticosteroid, inhaled ipratropium bromide, magnesium sulphate, epinephrine and terbutaline, inhaled delivery device including a metered dose system, simultaneous multiple therapies in case of asthma with respiratory distress and hospital admission. Secondary treatment includes Theophylline, oral or parenteral and Leukotriene receptor antagonists. Treatment of asthma is based not only on the assessment of the lung function parameters but also on the clinical findings of the patient. After clinical assessment it is dependent on the efficacy of the newly prescribed drug as well as the previous drug. A seasonal exacerbation triggered by pollens is more treatable than an exacerbation caused by the viral infections. Triggers are the entities or the conditions which cause the asthmatic attack. A trigger causes inflammation in the air passage ways leading to the narrowing of passages. The triggers can be both, known and the unknown factors. It is important to avoid the triggers to reduce the chances of attacks of asthma. Every persons’ trigger may vary from others. Some of the known triggers are tobacco smoke, dust mites, outdoor pollution, pets, microbial exposure, pollens, food containing sulphites and food allergens Tobacco smoke is the most common trigger. If you are not a smoker, even the second hand smoking can trigger an asthma attack. Dust mites are the teeny bugs that are present in the congested dusty places like under the carpets, in pillow cases and on or in sofas. Mattresses and pillows must be kept clean as they are the residing places for the mites. The environmental pollution is a major trigging factor. Traffic fuel smoke, factories discharge, tyre burnings and dumps play a havoc in human life. These pollutants along with pollens are the triggers and cause the exacerbation of asthma. Furry pets can trigger an asthma. Keep the asthmatic patient out of reach. Bathe them often to help them keep hygienic. Microbial reside in the contaminated area can cause an asthmatic attack in the patients especially the immune compromised patients. Naturally occurring substances found in some food and drink, often used as food preservatives have sulphites that also trigger asthma. Prawns, jams, jellies, precooked foods, concentrated fruit juices and certain wines contained these sulphites. Some nuts and other food items may trigger an asthmatic attack. Peanuts, pines and cashew nuts are amongst the most common. Milk, eggs and beans can also be a triggering aspect. Management of asthma includes the primary and secondary prophylaxis. Primary prophylaxis is employed before the evidence of the disease in order to prevent its onset. Allergen avoidance, microbial exposure, breast feeding, modified milk formula and some food can cause an asthmatic attack. Secondary prophylaxis basically includes the pharmacological management of the disease. This is employed after the diagnosis of the exacerbation of asthma. Salbutamol stimulates the beta adrenergic receptors and produces an effective broncho-dilation. It prevents antigen induced release of histamine and slow reacting substances of anaphylaxis from mast cells in lungs. It also prevents development of mucosal oedema. It produces an increased ventilation response to carbon dioxide in presence of hypoxia. Salbutamol is a direct acting sympathomimetic drug with beta adrenergic activity and selective action of the beta 2 receptors, producing the bronchodilation activity. It also decreases the uterine contraction. It is administered clinically as a racemic mixture but only one enantiomer is active while the other has been implicated in causing toxicity. The onset of action of salbutamol requires an inhalation for 5- 15 minutes. Orally the onset takes place in about half an hour. During of action is about 3-6 hours with respect to inhalation and 8 hours orally. It is rapidly absorbed from GIT. The volume of distribution is 2.5L/kg. Salbutamol is metabolised in hepatic and gut wall. The drug is excreted via urine as metabolites and unchanged form, some of the drug is excreted in faeces. Half-life is believed to be 7-5 hours after oral administration and 3-8 hours after inhalation Side effects of salbutamol include tremors, nervous tension, tachycardia, hypokalaemia, hypersensitivity, urticarial, angioedema, slight pain at the site of intramuscular injection and palpitations. Precautions include to be avoided in hyperthyroidism, hypertension, diabetes, breast feeding and pregnancy as well as in myocardial insufficiency and arrhythmias, Salbutamol is not given with Beta blockers as they inhibit the vasodilation effect of salbutamol. Digoxin is not given with salbutamol as the later increases the cardiac toxicity of digoxin. However, theophylline enhances the effect of salbutamol. The rare side effects associated with salbutamol are hypokalaemia, angioedema, myocardial ischemia and collapse. It is stored between 2-25°C if in the form of inhalers and below 30°C and protected from light if parenteral. Ipratropium Bromide inhibits the action of acetylcholine at receptor sites on bronchial smooth muscles. This results in the broncho-dilation. When applied locally, it also produces the anti-secretory properties. The onset of action Ipratropium Bromide is 5-15 minutes with the duration of action being 3-6 hrs. Minimum absorption takes place and the drug does not cross the blood brain barrier. The volume of distribution is 4.6L/kg. Metabolism of Ipratropium Bromide takes place by cytochrome P450 enzymes in the liver. The drug is metabolised by the hepatic tissues. Excretion takes place via urine and faeces, both the changed and unchanged forms are excreted. The half-life of Ipratropium Bromide happens to be 2-4 hrs. After oral administration, intravenous or inhalation pathway. Side effects include anxiety, palpitations, rashes, dry mouth, metallic taste, headache, dizziness, stomatitis and blurred vision, nausea, vomiting and cramps. Precaution measures include the fact that it should be taken in angle closure glaucoma, bladder neck obstruction, urinary retention and prostatic hypertrophy. It should also not be given with anti-muscarinic agents and beta adrenergic agonists because of the potential pharmacodynamics interactions. Ipratropium Bromide is stored at 15-30 degrees Celsius for the metered dose inhalers and at 2-25 degrees Celsius for oral inhalation solutions. Ipratropium bromide causes keratitis and ocular disorders rarely. Prednisolone decreases the inflammation by depressing the migration of polymorphonuclear leukocytes and activity of endogenous media of inflammation. It has many profound metabolic effects and possesses mineralocorticoid activity. Prednisolone onset of action is 1-2 hours with the duration of action being two days. It is rapidly absorbed from GIT after oral administration. Peak plasma concentration is obtained in 1-2 hours after oral administration. Prednisolone is metabolised in liver and excreted is urine as free and conjugated metabolites. It has a half-life of 2-3 hrs. Side effects includes depression, headache, vertigo, hypertension, optic nerve damage, cataracts, corneal infections, glaucoma, increased intra ocular pressure, mood changes and diarrhoea. It is used with precaution in systemic fungal infections, herpes simplex infections, diseases of ocular structures and keratitis. Aminoglutethimide increases the plasma clearance of prednisolone, anti-diabetics increase the blood glucose, enhances the effects of prednisolone and isoniazid reduces the plasma concentrations of this drug. Prednisolone’s pharmacokinetics include the least side effects and no adverse effects as such. The adverse effects that are rarely seen with prednisolone are Cushing’s syndrome, diabetes, irregular periods, osteoporosis, anaemia, optical nerve injury, chronic heart failure and cataracts. Prednisolone is stored between 25-30 degrees Celsius. Short acting beta agonists work quickly and provide symptomatic relief. No benefits are showed until the regular dosing is started. Good asthma control is associated with little or no need of beta 2 agonists. Using a couple or more cans of beta 2 agonists per month, or greater than 10 to 12 puffs per day, suggests a ill controlled asthma that puts individual at risk of fatal or near fatal asthma. The nurses should set up the treatment or step down the treatment according to the severity of the disease and should make an effort to minimize the drug related side effects. The clinical paramedic’s staff appointed for treatment of the exacerbation of the asthma starts at the step most fitting to the initial severity of the asthma. Treatment plans should be negotiated with patients. Self-management education should also be delivered to the patients in the written form or by providing counselling. Nurses together with the physicians should reduce the reliance on the reliever medication and prevent severe exacerbations. Nurses should reduce, as much as possible, the exposure to the things that make their patients’ asthma worse. Nurses should use the hand-outs related to things that asthma worse. They are also to highlight the control measures that are most appropriate for each patient and urge the families to attempt one or two control measures at a time starting with the least expensive or most effective. The nurses and physicians should ask about the presence of smokers in every household and advise then to quit smoking. The nurses are in an ideal place to ensure the responsible prescribing along with checking the suitability of medication. They should also ensure the changing or amending of the drug if, and when, required (Nursingtimes.net. 2012). Steroids such as corticosteroids have been used to treat asthma and related diseases for about half of a century now. They reduce the inflammatory response by inhibiting the activation of inflammatory cells and by reducing the mediator production, micro vascular leakage and mucus formation. Oral corticosteroids like prednisolone and dexamethasone are prescribed for moderate to acute asthma exacerbation. Tom is receiving prednisolone 3mg, due to the severe exacerbation of asthma along with salbutamol. The inflammatory response is extreme in the acute patients and is needed to be taken care of regularly (Asthma.partners.org. 2013). According to BTS guidelines, the role of steroids in hospitalized patients with acute care was established in a controlled clinical trial comparing the addition of prednisolone vs. placebo to very intensive bronchodilator therapy. The steroids are widely accepted as the standard of care for hospitalized patients with severe asthma. The orally administered corticosteroids have lesser side effects and is the essential part of the therapy now. As asthma is the chronic inflammation disorder, so the treatment regimen includes the anti-inflammatory agents like prednisolone for reducing the air ways’ inflammation. The chronic inflammation thickens the airway walls or changes their structure, a process known as airway remodelling. Nurses should monitor the severity of the exacerbation and administer the drug to the patient accordingly. Salbutamol is a broncho dilator and is used to relax the bronchioles and bronchus, thereby increasing the supply of oxygen into the passage ways. Ipratropium bromide has the similar effects. Introduction of the drugs to the regimen must be monitored by the nurse. Excess of the drug may cause the tachycardia and vasodilation. Avoidance of mismatching of the drug should also be taken care off by the nurse. In the emergency care, the patients admitted in hospital must be taken care of. The drug dosage and regimen must be monitored accurately and critically to avoid the serious mishaps. The antidotes must be available near the emergency units in case of any adverse effects. The nurses play a coordinating role between the pharmaceutical staff and the medical staff. Patient care is strictly and fore mostly the nurse’s responsibility. Nebulisers come in handy while treating a patient with asthma. A nebulizer happens to be a device which transforms liquid into aerosol droplets, hence making it suitable for the purpose of inhalation. In order produce a therapeutic dose containing aerosol droplets directly to the lungs, nebulisers use oxygen, compressed air or ultrasonic power. Compressed air, oxygen and ultrasonic power is used up in order to break down the medication solutions. Nebulisers are to be cleaned on a daily basis, mainly after each use. The masks, mouthpiece and chambers should be disconnected, disassembled and washed in warm detergent along with a water solution. The parts should be left to dry throughout the night. Before reuse, the nebuliser should be run for a few seconds before adding medications. Disposable components such as mouth piece and nebuliser chamber must be changed every 3 hrs. Compressor requires annual service by manufacturer. The nurses and physicians should instruct the patient about the set up procedure of the nebuliser, how to keep the apparatus clean, how to put medication into the chamber and how much medication to use and when to take? A simple method being as follows. Prepare the equipment, place the compressor on hard surface and plug it into the mains, hold the chamber upright and attack the mouth piece. Make sure the patient is comfortable for getting the medication. Breathe normally through mouth, try to relax. The treatment takes 6 minutes to complete. Oxygen treatment is not helpful for everyone. But for the patients with acute asthmatic attack, having hypoxia, the oxygen therapy might work. Oxygen can be delivered in a variety of ways like as an oxygen concentrator, oxygen cylinder and even liquid oxygen. The nebulisers use oxygen from the water it contains. The water acts as a medium for taking the medication added into it, in to the body. The evaporated steam contains the added medicament, which is inhaled. The water also acts as a moistening agent in to the lungs. The walls of the thoracic canal are kept humid by inhalation of steam. Oxygen enhances the drug delivery in to the lungs. As in case of hypoxia, oxygen improves the quantity of oxygen delivered. According to NMC standards for medicine management 2010, you may prescribe an unlicensed drug as an independent prescriber providing you are satisfied another medication that is licensed would not meet the need of the patient. You may also prescribe an unlicensed drug if you are prepared to take responsibility for prescribing the unlicensed medicine and for overseeing the patient’s or client care, including monitoring and follow up treatment (Nmc-uk.org. 2013). Conclusively, many factors playing havoc in Toms’ exacerbation of asthma. As he has been the patient of asthma for almost years, his state of disease has become obvious. The chronicity of exacerbation of asthma he is dealing with is life threatening. Blood pressure is raised in Tom due to the adaptation of the new drugs. The medication regimen, therefore suggested, is lifesaving. The recommended drugs perform the pharmacological action. As we discussed, there are many triggering factors that may add to his exacerbation. All these triggering factors must be eliminated from his environment guiding him towards the healthy living. The physician and nurses on duty in the hospital, where he has been kept in emergency, should also educate him about the nebuliser usage and medication appropriateness apart from the medication dosage errors. Although asthma has many underlying causes but it can be taken care of by maintaining a proper daily regime and environmental conditions. Counselling about the use of nebuliser and other inhalation device is of great importance for Tom and all the others who suffer from the chronic and long term exacerbation of asthma. Tom should be examined on the routine basis to have an idea about the drug’s main adverse effects. The drugs recommended increase the area of the passage of the atmospheric air in to the lungs, steroids produced relaxation of the smooth muscles of the bronchioles. The triggering factors have been suggested to avoid during the attack of asthma, which may help Tom understand the importance of administration of drug and toxicology. REFERENCES Asthma.partners.org. 2013. Asthma Grand Rounds: Fanta; Corticosteroids in the Management of Acute, Severe Asthma. [online] Available at: http://www.asthma.partners.org/newfiles/FantaSteroidsandSevereAsthma.html [Accessed: 23 Nov 2013]. Ncbi.nlm.nih.gov. 2013. Section 2, Definition, Pathophysiology and Pathogenesis of Asthma, and Natural History of Asthma - Expert Panel Report 3: Guidelines for the Diagnosis and Management of Asthma - NCBI Bookshelf. [online] Available at: http://www.ncbi.nlm.nih.gov/books/NBK7223/ [Accessed: 23 Nov 2013]. Nmc-uk.org. 2013. Medicines management and prescribing | Nursing and Midwifery Council. [online] Available at: http://www.nmc-uk.org/Nurses-and-midwives/Regulation-in-practice/Medicines-management-and-prescribing/ [Accessed: 23 Nov 2013]. Nursingtimes.net. 2012. Responsible prescribing for asthma and COPD. 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