Ben Marshall's Asthma Diagnosis and Treatment

Ben Marshall (not the real name of the patient due to confidentiality issues), a 25 years-old male is one of three siblings and has a history of asthma since he was seven years old. He is a university student who is actively involved in sporting activities and uses Salbutamol inhaler, a bronchodilator, as a reliever for his asthmatic condition. He has been hospitalized twice for the same condition although he shows signs of being physically fit and active. He was presented to the hospital by an ambulance with complaints of dyspnea and tightness of chest after being involved in a morning jog. The most recent hospital admission compelled the physicians to conduct a pulmonary function test who results included FEV1/PEFR 80% of predicted, PEFR variability 30%. A physical examination was conducted in the current visit to further explore the severity of the asthma condition and any other possible ailments. This paper summarizes the findings and the possible diagnoses of Ben Marshall alongside the most effective treatment options.

Current Condition and Medication

As earlier stated, Ben Marshall was diagnosed with asthma since he was seven years old and has been taking Salbutamol to relieve chest tightness and breathlessness. Asthma is a condition characterized by the narrowing of the air passages such that breathing occurs with difficulty. The narrowing of the airways especially in the lungs results in a wheezing sound considering that air passes through narrowed passages (Huckvale, Morrison, Ouyang, Ghaghda, and Car, 2015). The narrowed airways result from swelling and excessive production of mucus along the walls of the air passages which triggers coughing, wheezing and dyspnea. It is important to note that asthma is a chronic condition that cannot be cured although the symptoms can be managed through behaviour therapy and pharmaceutical products. Even though asthma symptoms may occur at all times, they can be aggravated by exercises and proximity to the relevant triggers including cold, dust, proteins and stings among many others (Perry, Baker, Gibeon, Adcock, and Chung, 2014). Since asthma can be a life-threatening condition, it is advisable to seek medical attention when there is rapid worsening of dyspnea or excessive wheezing, when there is no improvement after using the reliever medication and when dyspnea occurs even after minimal physical activity.

The cause of asthma is not very clear, but it is thought to occur as a result of a combination of environmental and genetic factors. Some of the environmental factors involved in the causation of the chronic condition include airborne substances like pollen, mould spores, particles of cockroach waste, dust mites, or pet dander. The condition may also occur or get aggravated by respiratory infections like common cold, physical activity, cold air or a number of air pollutants including smoke. Moreover, certain medications may induce asthma including ibuprofen, aspirin, naproxen and a variety of beta blockers. Research has also shown that strong emotions, as well as stress, can induce asthmatic conditions. Furthermore, it has been shown that foods with sulfites and other preservatives like shrimp, processed potatoes, dried fruit, beers and wine can also induce asthma. Recently, the condition was also found to have a relation with gastroesophageal reflux disease (GERD) which involves stomach acids backing up to the throat (Perry et al., 2014). Ben Marshall’s condition may have been triggered by the physical activity or cold air when he was jogging.

Certain complications may be associated with asthma including the signs and symptoms of sleep apnea which may interfere with work and recreational activities.  The condition may also reduce performance at school and at work during flare-ups in addition to permanent damage of the air passages. In most cases, the condition increases an individual’s number of emergency room visits during severe asthma attacks. In addition to these conditions, asthma also causes undesired adverse effects of the drugs used to manage the symptoms of dyspnea. 

Risk Factors

Genetics form the commonest risk factor for asthma although suffering from other allergic diseases such as atopic dermatitis and allergic rhinitis may also predispose an individual to suffer from asthma (Long et al., 2014). Other predisposing factors may include smoking or exposure to secondhand smoke, being overweight, exhaust fumes, farm chemicals, chemicals from hairdressing and manufacturing chemicals.

Examination

Below were the findings obtained following Ben Marshall’s examination:

A – Patient talking in single words, pursed lips

B – Spontaneous, resting RR 34, severe dyspnoea

Short shallow breathes, with use of accessory muscles

Tightness in chest

A dry cough

Peak expiratory flow rate ↓140 ml

Auscultation - ↓BS, with diffuse wheezes, auditory inspiratory and expiratory wheeze

Percussion: hyper-resonant SpO2 93% on 4L O2

C – Resting PR128, BP 90/60, centrally warm and perfused Elevated JVP +5 cm

D – GCS 15, PERL 3+,

E – Temp 36.7, no complaints of chest pain

F – RR 34, BP 90/60, resting PR128

Interpretation of the Findings

The patient was speaking in single words, a sign that usually presents in patients with severe asthma. Such patients find it difficult to complete a sentence without the need to take a break (Huckvale et al., 2015). This sign is not always present among all patients with asthma but it is more evident among patients with severe cases of the condition who can only manage a few words and single words when the case is extremely severe like in Ben Marshall’s case. During such severe cases of asthma, the lungs constantly need oxygen and the individual finds it difficult to continue speaking in full sentences with the high oxygen demand (Chesné et al., 2014). Pursed breathing as observed on the patient indicates that the patient had been involved in a previous medical advice that required him to breathe through the nose with pursed lips. This procedure is advised by respiratory therapists as an excellent mechanism for encouraging diaphragmatic breathing which entails deep breathing to provide the lungs with adequate amounts of air. Pursed-lip breathing creates back pressure inside the air passages to split them open and as such, it is easier to move air through the airways.

The normal resting respiratory rate for an adult is 12 to 20 breaths per minute yet ben Marshall had a resting RR of 34 breaths per minute. This rate was extremely high, informed by the fact that he had difficulties in breathing due to the narrowed air passages. Such high resting RRs occur during severe asthmatic conditions which were confirmed through the presentation of severe dyspnea as recorded in the examination sheet.

Due to the shallow breaths observed on the patient, insufficient amounts of oxygen reach the lungs and the system is forced to use alternative sources of energy to increase the rate of breathing rate (Ortega et al., 2014). Under normal circumstances, breathing is enabled by the movement up and down of the diaphragm, especially during resting. The outer layer of the intercostal muscles also plays a slightly significantly role during normal breathing. However, accessory muscles of respiration may be required to assist in breathing when the outer intercostal muscles and the diaphragm are overwhelmed by difficulties in breathing (Green et al., 2014). Medically, the use of accessory muscles as observed in Ben Marshall’s physical examination occurs when an individual suffers from disorders affecting the ability to breathe.

Tightness in chest occurs before or during an asthma attack like it happened in Ben Marshall’s case and results from the inflammation of airways which leads to swelling and irritation. Pressure or pain around the chest may also result from similar causes among asthmatic patients (Moore et al., 2014). Ben Marshall presented with a dry cough which is common among patients with cough variant asthma which is a type of asthma in which a cough does not expel any mucus from the respiratory tract. Patients with this sign or symptom often do not often present with other classic symptoms of asthma like wheezing or dyspnea although the symptoms may occur in circumstances of severe asthma. 

The normal peak expiratory flow rate ranges between 80 and 100 percent which indicates that the lung function management is under good control (Chesné et al., 2014). In Ben Marshall's case, the peak expiratory flow rate was low and reduced due to the constriction of the air passages making it difficult to breathe normally. Lungs auscultations tested the sounds produced by the lungs during breathing and proved the presence of diffuse wheezes that were both auditory inspiratory and expiratory in nature. The patient was also positive for hyper-resonant percussion sounds, which are tympanic sounds heard over the chest when excessive volumes of air get into the chest like it happens in patients with pneumothorax. The patient’s oxygen saturation was within the normal range (92-100%) since it was 93%. However, a normal oxygen saturation does not confirm the absence of abnormal levels of oxygen in the system or that the individual does not have a severe asthma attack. On the contrary, a normal oxygen saturation rate implies that the patient is able to oxygenate their body. If the oxygen levels start trending downward, such can be an indication of impending respiratory failure (Wu et al., 2014).

The normal temperature range is between 36.2oC and 37.2oC (Chesné et al., 2014) which implies that Ben Marshall did not have an overarching fever since his temperature was 36.7oC. Furthermore, the patient did not have any complaints of chest pain although that could not be used to eliminate the possibility of an asthma attack since most attacks are not accompanied by chest pain. The patient also had a low blood pressure which may have occurred as a side effect of his medication. The patient's pulse rate was relatively high considering that the normal pulse rate is between 60 and 100 beats per minute and that of the client was 128. The high pulse rate can be explained by the corrective mechanism of the heart to pump excessive amounts of blood to supply the body with adequate amounts of oxygen following the dyspnea situation. Nevertheless, the ECG showed normal features without signs of ST elevation implying that the patient did not have any suspected heart conditions. The patient's PaCO2 was higher than normal while the blood pH and level of HCO3 were normal. The high levels of PaCO2 can be associated with the low levels of oxygen in the bloodstream due to the severe asthma attack (Chesné et al., 2014).

Differential Diagnoses

It is important to ensure that what the physician is attending to is actually asthma before drafting a treatment plan. Certain other conditions compare to severe asthma and may be confused with the same condition. These differential diagnoses include vocal cord dysfunction, congestive heart failure, mechanical obstruction of the airways like tumors, or chronic obstructive pulmonary disease (COPD), and gastroesophageal reflux disease (GERD). Other differential diagnoses include pulmonary embolism and pulmonary infiltrates such as eosinophilia although in both cases the patient present with wheezing and medications like angiotensin-converting enzyme inhibitors.

Treatment Plan                                  

A pharmacological treatment plan for severe asthma for Ben Marshall can include the use of either Fluticasone combined with Salmeterol, Budesonide combined with formoterol, Mometasone combined with Formoterol or a combination of Fluticasone and Vilanterol (Busse et al., 2013). These drugs, however, also have their side effects including excessive shaking, headaches and dryness and coughing. As such, non-pharmacological therapeutic interventions can be used, the most important of which is staying away from the possible triggers. This preventative approach to asthma management entails limiting intensive exercises, avoiding cold air, areas with pollen, dust mites and other allergens (De Boever et al., 2014).

Summary

Ben Marshall, aged 25 years was transported to the hospital with dyspnea and tightness in the chest and was under Salbutamol medication for asthma that was diagnosed when he was seven years old. From the identified signs and symptoms documented in the examination record, it is likely that Ben Marshall suffered from a severe asthma attack. In addition to Salbutamol reliever medication, the patient will also be advised to take preventive medications as highlighted in this report.

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