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Patient RR is a 58 old ages old female with a weight of 55kg. Patient was admitted to hospital on 9th April 2009. Her presenting ailments were cough with phlegm, hurting when inhaling air at thorax, breathless and unable to talk in full sentence. Her past medical histories were hypercholesteremia, bronchial asthma and she has no known drug allergic reaction. For her societal history, she works as a security guard and is populating with her hubby. She is a non tobacco user every bit good as non alky and she has no known household history.

Patient ‘s drug history include metered dose inhalator ( MDI ) salbutamol 200mcg as required, MDI budesonide 400mcg twice daily, theophylline SR tablet 250mg one time day-to-day and lovastatin tablet 20mg one time day-to-day.


Blood Trial:

9th April

12th April




High ( 4-10.0 )

Red blood cell



High ( 3.8-4.8 )


78.7 fl/cell

78.6 fl/cell

Low ( 83-101 )


26.5 pg/cell

25.3 pg/cell

Low ( 27-32 )

Erythrocyte sedimentation rate

24 mm/hr

High ( 0-20 )

Blood HbA1c

7.2 %

Good control: & A ; lt ; 6.5 %

Adequte control: 6.5-7.9 %

Poor control: & A ; gt ; 8.0 %

Nephritic Profile:

9th April

11th April

Plasma K+

2.8 mmol/L

2.5 mmol/L

Low ( 3.5-5.1 )


100 ?mol/L

79 ?mol/L

( 58-96 )

Blood trial indicated that the degree of white blood cell and erythrocyte deposit rate is higher than normal which suggests the patient had an infection. The blood HbA1c showed equal control of blood glucose. On the other manus, the nephritic trial showed that the patient had low plasma K and the plasma creatinine degree is normal.

Clinical Advancement

On scrutiny, the patient was watchful with no pedal hydrops. Her pulse rate was 120 beats per minute, blood force per unit area was 130/62 mmHg, and respiratory rate was 22 breaths per min. She was diagnosed with acute aggravation bronchial asthma secondary to upper respiratory tract infection. The program was to give endovenous ( IV ) hydrocortisone 200mg instantly so 100mg three times daily, IV Augmentin 1.2g three times daily, nebulizer ipratropium bromide: albuterol: normal saline ( A: Volt: N ) 2:1:2 every two hours and to go on SPO2 monitoring.

On twenty-four hours 1, the patient was given MDI Budesonide 400mcg, atomizer AVN, IV hydrocortisone 100mg three times daily, bromhexine tablet 8mg three times daily, erythromycin tablet 400mg twice daily, Pediapred tablet 40mg one time day-to-day, oxygen 3L/min and lovastatin tablet 20mg one time day-to-day. Theophylline were stopped.

On twenty-four hours 3, patient ‘s blood force per unit area was 120/70 mmHg, respiratory rate was 26 breaths per minute and the SPO2 was 98 % . She has cough with xanthous phlegm and the sputum civilization showed that there are no pathogen isolated. The patient was to get down on long moving beta agonist ( LABA ) . Other medicines that were given include potassium tablet 1.2g twice daily, Neb Combivent 4 hourly, IV Augmentin 1.2g three times daily, MIST expectorant 15mL three times daily. Hydrocortisone and bisolvon were stopped.

On twenty-four hours 4, the patient had febrility, cough with xanthous phlegm and trouble in take a breathing. No new action was taken.

On twenty-four hours 6, patient had no more fever but still had cough with xanthous phlegm. Her blood force per unit area was 122/80 mmHg and respiratory rate was 20 breaths per minute. The program was to give MDI formoterol 9mcg one time day-to-day and augmentin tablet 625mg. Oxygen and Pediapred were stopped.

On twenty-four hours 8, patient still had cough but the phlegm turned white. Patient was given theophylline SR tablet 250mg twice daily and was ready to be discharged the following twenty-four hours.

Medicine Summary







tds ( halt at twenty-four hours 3 )


Mist Expectorant

15 milliliter

tds ( day3-day 6 )




Bachelor of Divinity ( halt on twenty-four hours 6 )


KCl solution


tds ( halt on twenty-four hours 7 )




Doctor of Optometry ( halt on twenty-four hours 6 )

Acute asthma







Doctor of Optometry


T.Nuelin SR


Bachelor of Divinity


OXIS inhalator ( formoterol )


Doctor of Optometry


MDI Budesonide


Bachelor of Divinity




when required


Pharmaceutical Care Plan

Care Plan


Desired Outcome

1. Monitor K+ degree

-high dosage salbutamol and Elixophyllin causes hypokalaemia

K+ degree should be monitored. K+ addendum should be given if K+ degree is low.

Maintain stable K degree.

2. On twenty-four hours 4, patient had fever but non treated.

Paracetamol should be given.

To take down down patient ‘s temperature.

3. Concurrent usage of unwritten Pediapred and IV cortisol for acute intervention

-If patient can digest orally, unwritten Pediapred should be equal.

-if buzzword, give IV cortisol 100mg every 6 hr until transition to unwritten is possible.

4. Combination inhalator can be given to patient

Symbicort inhalator ( 1-2 whiffs Bachelor of Divinity ) can be given alternatively of OXIS and budesonide inhalator. Besides that, Symbicort can be besides given as alleviation to replace Combivent.

Less confusion and increases conformity.

5. Technique to utilize inhalator

-Counsel patient on proper technique

-advice on unwritten hygiene to avoid unwritten moniliasis.

6. Prophylaxis of asthma

Counsel patient to avoid allergen that may trip onslaught and avoid NSAIDs.

Lower berths hazard of asthma onslaught

7. Conformity issue

Advice patient on the importance to take control medicine consequently even if patient feels good.

Lower berths hazard of asthma onslaught

Disease Overview and Pharmacological Basis of Drug Therapy

Asthma affects people of all ages, but it usually starts at childhood1. Asthma affects 5-8 % of the population around the world2. A survey done by World Health Organization ( WHO ) shows that there are 15 million disability-adjusted life old ages lost annually because of asthma, exposing 1 % of entire disease load worldwide3. The one-year worldwide mortality caused by asthma is estimated to be 250,000. In Scotland, the incidence of clinical asthma is about 18.4 % of the population3.

Asthma is an inflammatory disease where there is frequent reversible air passage obstruction1. The narrowing of the air passage happens when people with asthma react strongly to certain substance they breathe in. These irritant stimulations are excessively weak to impact normal individuals1. The narrowing of air passage is besides caused by other factors which include mucosal swelling or redness caused by inflammatory go-betweens released by mast cell and basophil degranulation every bit good as mucous secretion or emotionlessness production2.

The causes of asthma include familial factor, environmental factor and history of etopic disorder5. The most common symptoms of asthma are wheezing, shortness of breath, thorax stringency and sometimes cough, particularly at dark in younger people1, 4. The chance of asthma increased if symptoms worsen at dark and early forenoon or in response to exercising, allergen and cold air5. Acute terrible asthma may do hypoxaemia and is non easy reversed. Therefore, the patient needs prompt intervention and hospitalization1.

Patients with asthma have uninterrupted and inordinate T-helper cell type 2 ( Th2 ) -dominated immune response and the Th1 which is responsible for structural and defensive position of the tissue is reduced4. The activated T-cells green goods cytokines in the bronchial mucous membrane and this attract other inflammatory granulocytes particularly eosinophils which produce cysteinyl leukotrienes along with granule protein to damage epithelial tissue. The cytokines released besides promotes IgE synthesis in some wheezing patients which cause look of IgE receptors on mast cell and eosinophils1, 4. The of import go-betweens associated with asthma are leukotriene B4, cysteinyl leukotrienes ( C4 and D4 ) , interleukins IL-4, IL-5, IL-13 and tissure-damaging eosinophil proteins1. In atopic wheezing patients, inhaled allergen caused cross-linking of IgE molecules on mast cells therefore triping degranulation with histamine and leukotriene B4 release. These substances are powerful bronchoconstrictors therefore doing acute aggravation of asthma1.

For diagnosing of asthma, spirometry is the preferable initial test5. It is a device to mensurate the functional lung volumes. Through the patient ‘s full force termination into the device, the forced expiratory volume in 1 2nd ( FEV1 ) and force critical capacity ( FVC ) are measured. Exhalation continues until there is no more breath to be exhaled. The FEV1/FVC ratio shows the badness of airflow obstructor and the normal ratio is 75-80 % 2. The ratio is less than 75 % in asthma which indicates clogging defect. There is usually more than 15 % betterment in FEV1 after disposal of B2 agonist or steroid test in asthma patients2. Peak expiratory flow ( PEF ) is besides another trial for asthma though FEV1 uses lesser effort2. It is measured by the upper limit forced expiratory through a peak flow metre and acts as an estimation of air passage quality. PEF is measured often to look into response to intervention and disease control. PEF is used to prove ague and chronic asthma with PEF lessenings along with severity2.

Moderate ague asthma

Severe ague asthma


Able to speak, Respiratory rate ( RR ) & A ; lt ; 25/min, Pulse rate ( PR ) & A ; lt ; 110/min, SPO2 & A ; gt ; 92 % , PEF & A ; gt ; 50-75 %

Incomplete sentence, RR & A ; gt ; 25/min, SPO2 & A ; lt ; 92 % , PR & A ; gt ; 110/min, PEF 33-50 %

Silent thorax, cyanosis, exhaustion, confusion, lame respiratory attempt, SPO2 & A ; lt ; 92 % , PEF & A ; lt ; 33 %

Table 1: Categorization of acute asthma6.

In this instance, ?2 adrenoceptor agonists are used which include salbutamol and formoterol. Salbutamol is a short playing bronchodilator and is usually used as needed to command symptoms while formoterol is a long playing agent and given twice daily as adjunctive intervention when the asthma is non good controlled by glucocorticoids4. The air passages and bronchial smooth musculuss are full of ?2-adrenoceptors. Administration of ?2 adrenoceptor agonists consequences in stimulation of receptors therefore doing bronchodilation through production of intracellular cyclic adenosine monophosphate ( camp ) , suppression of go-between release from mast cell every bit good as tumour mortification factor ( TNF ) -? release from monocytes and increased mucociliary clearance by cilia action1, 4.

Corticosteroids are used as anti-inflammatory for illustration budesonide and Pediapred. Steroids activate glucocorticoid receptors therefore decrease cytokines formation that activates eosinophils particularly Th2 cytokines1. It besides reduces IgE synthesis, up-regulate ?2 adrenoceptors and besides inhibits phospholpase A2 which is responsible for inflammatory prostaglandins and leukotrienes production4.

Antimuscarinic agent is besides used in the instance for illustration ipratropium bromide which is used as bronchodilator. Ipratropium is non selective which bind to all three types of muscarinic receptors in the lung ( M1, M2 and M3 ) 4. There is possibility that the obstruction of M2 receptors on the cholinergic nervus enhances acetylcholine release and diminish the hostility of the smooth musculus ‘s M3 receptors1. It besides suppresses mucus secernment and increase mucociliary clearance of bronchial secretions1.

Xanthine drug for illustration Elixophyllin is used. It has vasodilative, anti-inflammatory and immunomodulatory effects1. It inhibits phosphodiesterase isoenzymes therefore doing smooth musculus relaxation due to increase in cAMP4. Theophylline besides inhibits adenosine A1 and A2 receptors that release histamine and leukotrienes hence cut down bronchoconstriction4.

Evidence for Treatment of the Condition ( s )

Acute asthma direction

Salbutamol and ipratropium

Harmonizing to the SIGN guideline of acute asthma direction, inhaled short moving ?2 agonist is given by 4-10 whiffs of 100mcg salbutamol or nebulised salbutamol 5mg while ipratropium bromide 500mcg is given via O driven nebulizer. In this instance, the patient was given nebulizer AVN 2:1:2 where the ipratropium bromide ( ipratropium ) is 2 units with a sum of 500mcg while albuterol ( salbutamol ) is 1 unit which is 5mg. This complies with the guideline.

In a meta-analysis from 10 randomized, double-blind, placebo-controlled surveies affecting 1377 wheezing patients, the usage of ipratropium as adjunctive therapy to ?2 agonist was compared with placebo. The consequences showed that there is 7.3 % betterment in FEV1 for the use of ipratropium and a complete betterment in FEV1 for the ipratropium and ?2 agonist combination group. There is statistically important betterment in obstructor of air passage when ipratropium is used together with ?2 agonist for acute asthma management7.

Another double-blind, two-center, randomized, single-dose survey was done on 338 patients to find the clinical benefits of combination atomizer of salbutamol with ipratropium over nebulised salbutamol entirely in acute asthma. It is found that combination of salbutamol and ipratropium has more benefits in ague asthma than salbutamol alone with a p-value of less than 0.05 8.

A systematic reappraisal of 32 randomised surveies with 3611 patients was done and the consequence showed that there is a statistically important decrease in hospitalizations in grownups utilizing inhaled antimuscarinic for asthma ( p-value=0.002 ) . There is besides important betterment in spirometry steps after therapy for combination intervention in grownups ( p-value=0.0001 ) . Therefore, the usage of ipratropium with salbutamol is utile in the direction of terrible aggravation of acute asthma9.


The patient was given prednisolone 40mg orally for 5 yearss in this instance. Harmonizing to SIGN guideline, Pediapred 40-50mg unwritten for at least 5 yearss or IV hydrocortisone 100mg every 6 hours is given for terrible ague asthma. Therefore, the intervention given to the patient complies with the guideline.

A reappraisal was done from 6 randomized controlled tests with sum of 374 patients comparing the usage of corticoids with placebo in acute asthma direction. This survey showed that there is significantly lesser backsliding to get excess attention in steroid patient group ( Relative hazard [ RR ] 0.38 ; 95 % assurance interval [ CI ] 0.2 to 0.74 ) . Using corticoids for a short continuance besides cut down hospitalizations without add-on in inauspicious effects. Both intramuscular and unwritten steroids are effective10.

Another survey was done on 53 patients to compare the usage of 2 different corticoids disposal path used for acute asthma intervention which is the unwritten and endovenous path. It is found that there is no important difference in the two groups of patients and both demonstrates same results11. This showed that unwritten corticoids can be used in this instance.

A randomised clinical test was besides done to compare the non-tapering and tapering dosage of Pediapred in acute asthma. 13 patients were administered with non-tapering dosage of Pediapred ( 40mg daily for 8 yearss ) and another 13 patients were administered with tapering dosage of Pediapred ( 40mg daily reduced by 5mg per twenty-four hours ) for 8 yearss. It is found that there is no important difference between the two groups in footings of FEV1, adrenal suppression and backsliding rate12. Therefore, it is appropriate to give at least 5 yearss of unwritten Pediapred 40mg in this instance.

Chronic asthma direction


A short playing inhaled ?2 agonist is given and used as required in chronic asthma direction from SIGN guideline. The patient was given salbutamol 200mcg as required for symptom alleviation of asthma.

A survey was done to compare the effects of inhaled salbutamol on FEV1 in 20 normal people and 19 patients with asthma. The sensitiveness to salbutamol in patients with asthma was greater compared to normal topics with the p-value less than 0.001 and there is 20 % betterment in FEV1. The maximal and overall responses to inhaled ?2 agonist are greater in asthma patients with important bronchodilation and airway stabilization13. Hence, the usage of salbutamol is justified.

Another test was done to compare the effects of salbutamol and placebo on resting metabolic rate in topics with air passage job who are having intervention for bronchodilation. After 5 proceedingss of salbutamol or placebo disposal, there is highest betterment in the O ingestion and C dioxide coevals. In drumhead, when compared to placebo, inhaled ?2 agonist causes statistically important betterment in metabolic rate during remainder and it is dependent on the dose14.

The comparing of efficaciousness of regular short-acting ?2 agonist, long-acting ?2 agonist and placebo in asthma control was conducted by a randomised survey. Consequences from 157 topics show that short-acting ?2 agonist merely causes betterment in daylight symptoms. Besides that, the child and major aggravation ratio of short-acting ?2 agonist is non much difference compared to placebo. Hence, salbutamol can merely be used in an ‘as required ‘ footing for symptom alleviation and non to be administered on a regular basis for symptom control15.


As mentioned in the SIGN guideline for asthma control, step 2 was to add an inhaled steroid of 200-800mcg day-to-day. 400mcg of steroid per twenty-four hours as get downing dosage is suited for most patients. In this instance, the patient was prescribed MDI budesonide 400mcg two times day-to-day therefore the therapy complies with the guideline.

Evidence showed that inhaled corticoids for four hebdomads better the non-invasive markers for redness in asthma patients. These markers include histamine induced airway hyperresponsiveness, eosinophil phlegm and grade of azotic oxide halitus. When compared to placebo, steroids raised the FEV1 in topics. Therefore, steroids may be used in intervention of asthma to command symptoms16.

A reappraisal was conducted to analyze the response of wheezing patients to budesonide when compared with placebo. In the 43 tests which had a sum of 2801 patients, the consequences showed that there is important betterment in FEV1 and forenoon PEF in patient administered with budesonide compared to placebo. There was besides lesser hazard of acute aggravation of asthma in budesonide group17. Hence, budesonide can be used to as asthma control in wheezing patients as shown in this instance.

Another survey with 1435 asthma patients was done to compare the relationship of budesonide disposal dosage and response rate. The consequence showed that the benefit of 200-400mcg daily was 80 % similar to the dosage of 1600mcg day-to-day while disposal of 300-600mcg day-to-day had 90 % similarity in benefit. Therefore, the dosage with most important curative value for MDI budesonide is 400-1000mcg daily18. In this instance, 800mcg of budesonide daily was prescribed to patient and this dosage is justified.

Long moving ?2 agonist ( LABA )

In the measure 3 of asthma direction, an add-on therapy, LABA is given and the control of asthma is monitored. In this instance, the patient was given OXIS inhalator which is formoterol 9mcg one time day-to-day.

A test was done on 239 patients to compare the usage of formoterol in asthma control compared to placebo. The consequences showed that formoterol significantly cut down the asthma symptoms compared to placebo with a p-value of 0.04. Besides that, formoterol improves forenoon PEF ( p-value of 0.0001 ) and besides cut down the frequence of short moving ?2 agonist use in asthma patients ( p-value=0.0001 ) 19. Therefore, the usage of formoterol is justified in this instance.

Another survey was conducted to compare benefits of OXIS formoterol with terbutaline and placebo. This survey was done on 397 patients and it was found that low dose formoterol is statistically important in bettering PEF and diminishing symptoms of asthma compared to four times day-to-day dosing of terbutaline every bit good as placebo20. Therefore, OXIS formoterol is suited in this instance.

Combination inhalator of formoterol and budesonide

It is recommended that a combination inhalator should be given to replace the two different inhalators of formoterol and budesonide to do less confusion to patient, increase conformity and besides convenience. Single inhalator simplifies therapy while providing anti-inflammation and bronchodilation.

A survey was done to compare the efficaciousness of utilizing individual combination inhalator with the use of formoterol and budesonide entirely every bit good as placebo. This randomised test which include 480 topics showed that there is important betterment in FEV1 in the group of topics utilizing combination inhalator when compared to other groups with a p-value of less than 0.005. There is besides fewer instances of status deterioration in the combination group ( p-value less than 0.001 ) . In the terminal, combination of budesonide and formeterol in a individual inhalator with a twice day-to-day dosing agenda significantly better asthma symptoms when compared to the use of these 2 drugs alone21.

Besides that, combination of formoterol and budesonide can besides be given as alleviation therapy other than the normal control therapy. This is because formoterol can supply both short and long playing activities on bronchodilation. A survey with 2780 topics showed that the disposal of this combination as care ( twice daily dosing agenda ) and alleviation ( as required dosing agenda ) therapy causes decrease of 45-47 % of asthma aggravation hazard when compared to the traditional intervention of budesonide/formoterol as control and a short playing ?2 agonist as relief medicine. This consequence is statistically important with a p-value of less than 0.001 22. Therefore, combination of formoterol and budesonide may be used as control and alleviation therapy of asthma.


In the measure 4 of asthma direction, a regular high-dose inhaled steroid and an add-on of a 4th drug may be considered. In this instance, theophylline 500mg twice daily was given but the dosage of steroid remained low.

A randomised, double-blind survey was conducted comparing the usage of Elixophyllin and a low dosage budesonide with the usage of high dose budesonide. It is found that the FEV1 and FVC were significantly improved in the low dosage steroid and theophylline therapy with a p-value of 0.03. The PEF variableness and use of ?2 agonist were besides significantly reduced. However, the degree of hydrocortisone in blood was significantly decreased in the high dosage steroid group. Therefore, high dosage budesonide and low dose budesonide with Elixophyllin have the same benefits. The low dosage steroid is more preferred due to the cost23. In this instance, the determination of Elixophyllin and a low dosage of inhaled budesonide are justified.


The patient ‘s status in this instance is good managed harmonizing to guidelines of disease and assorted grounds based surveies. For acute asthma direction, the patient was given salbutamol, which is a short-acting ?2 agonist ; ipratropium, which is an anti-muscarinic and besides an unwritten steroid which is Pediapred. The use of these drugs are justified and proven to be significantly bettering asthma symptoms in acute asthma compared to placebo. In the instance of steroid used, unwritten and IV steroid has no important difference between each other and the same goes to tapering and non-tapering dosage of Pediapred. For chronic asthma direction, salbutamol, Elixophyllin and the combination of LABA and steroid were given. The uses of these drugs are besides justified. Salbutamol may do important betterment in asthma symptoms in asthma patients while combination of LABA and steroids is significantly better compared to LABA or steroids entirely. On the other manus, the pick to given theophylline with low dosage steroid compared to high dose steroid alone is besides justified because both groups had been proven to hold same benefits and the former had a lower cost.

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