Solution patient Zack, age 6, presents to the office with symptoms

Patient Zack, age 6, presents to the office with symptoms of worsening cough and wheezing for the past 24 hours. He is accompanied by his mother, who is a good historian. She reports that her son started having symptoms of a viral upper respiratory infection 2 to 3 days ago, beginning with a runny nose, low-grade fever of 100.5ºF orally, and loose cough. Wheezing started on the day before the visit, so Zack’s mother administered albuterol metered-dose inhaler (MDI) two puffs before bed and then two puffs at around 2 a.m. The cough and wheezing appear worse today, according to the mother. Zack had difficulty taking deep-enough breaths to inhale this morning’s dose of albuterol, even using the spacer.

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Zack has been a patient at the clinic since birth and is up to date on his immunizations. His growth and development have been normal, and he has been generally healthy except for mild intermittent asthma. His asthma is usually precipitated by a viral upper respiratory infection. He has required oral prednisone an average of two or three times per year for the past 3 years. He has an albuterol MDI at home with a spacer, which his parents are comfortable using. He is in first grade. This is the first asthma exacerbation of the school year, and his mother expresses a concern about sending him to school with an inhaler.

The patient’s assessment is as follows:

Zack is afebrile with a respiratory rate of 36 and a tight cough every 1 or 2 minutes. He weighs 45 pounds. The examination is all within normal limits except for his breath sounds. He has diffuse expiratory wheezes and mild retractions. Pulse oximeter readings indicate oxygen saturation of 93%.

Answer the following questions. 

  1. Which medications do you feel are safe and appropriate to utilize initially?
  2. Which medications do you feel will be safe and appropriate to prescribe and/or recommend for chronic, ongoing management?
  3. Professional Reflection
patient ,symptoms

References

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British Thoracic Society, Scottish Intercollegiate Guidelines Network. British guideline on the management of asthma. Thorax 2003;58:1–94. [PMC free article] [PubMed]3.

Van den Berg NJ, Ossip MS, Hederos CA, Anttila H, Ribeiro BL, Davies PI. Salmeterol/fluticasone propionate (50/100 microg) in combination in a Diskus inhaler (Seretide) is effective and safe in children with asthma. Pediatr Pulmonol 2000;30:97–105. [PubMed]4.

Knorr B, Matz J, Bernstein JA, Nguyen H, Seidenberg BC, Reiss TF, et al. Montelukast for chronic asthma in 6- to 14-year-old children: a randomized, double-blind trial. Pediatric Montelukast Study Group. JAMA 1998;279:1181–6. [PubMed]5.

Verberne AA, Frost C, Duiverman EJ, Grol MH, Kerrebijn KF. Addition of salmeterol versus doubling the dose of beclomethasone in children with asthma. The Dutch Asthma Study Group. Am J Respir Crit Care Med 1998;158:213–19. [PubMed]6.

Greening AP, Ind PW, Northfield M, Shaw G. Added salmeterol versus higher-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid. Allen & Hanburys Limited UK Study Group. Lancet 1994;344:219–24. [PubMed]7.

Garrett J, Williams S, Wong C, Holdaway D. Treatment of acute asthmatic exacerbations with an increased dose of inhaled steroid. Arch Dis Child 1998;79:12–17. [PMC free article] [PubMed]8.

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Lemanske RF Jr, Mauger DT, Sorkness CA, Jackson DJ, Boehmer SJ, Martinez FD, et al. Step-up therapy for children with uncontrolled asthma receiving inhaled corticosteroids. N Engl J Med 2010;362:975–85. [PMC free article] [PubMed]13.

Juniper E, O’Byrne P, Guyatt G, Ferrie P, King D. Development and validation of a questionnaire to measure asthma control. Eur Respir J 1999;144:902–7. [PubMed]14.

Friede T, Schmidli H. Blinded sample size reestimation with count data: methods and applications in multiple sclerosis. Stat Med 2010;29:1145–56. [PubMed]15.

The Clinical Practice Research Datalink. URL: www​.cprd.com (accessed 2005).16.

Haybittle JL. Repeated assessment of results in clinical trials of cancer treatment. Br J Radiol 1971;44:793–7. [PubMed]17.

Peto R, Pike MC, Armitage P, Breslow NE, Cox DR, Howard SV, et al. Design and analysis of randomized clinical trials requiring prolonged observation of each patient. I. Introduction and design. Br J Cancer 1976;34:585–612. [PMC free article] [PubMed]18.

Schulz K, Altman D, Moher D. CONSORT 2010 statement: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c332. [PMC free article] [PubMed]19.

Moher D, Hopwell S, Schulz K, Gøtzsche P, Devereaux P, Elbourne D, et al. CONSORT 2010 explanation and elaboration: updated guidelines for reporting parallel group randomised trials. BMJ 2010;340:c869. [PMC free article] [PubMed]20.

Paediatric Formulary Committee. BNF for Children, 2011–2012. London: BMJ Group, Pharmaceutical Press and RCPCH Publications; 2011.21.

Manca A, Hawkins N, Sculpher M. Estimating mean QALYs in trial based cost-effectiveness analysis: the importance of controlling for baseline utility. Health Econ 2005;14:487–96. [PubMed]22.

Drummond M, McGuire A. Economic evaluation in health care: merging theory with practice. Oxford: Oxford University Press; 2001.

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