Evidence-Based Clinical Intervention Asthma

Evidence-Based Clinical Intervention: Asthma

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Evidence-Based Clinical Intervention: Asthma

Through evaluation of their outcomes, it has been proved over and over again that Evidence-Based Clinical Interventions (EBI) are effective treatments. When implemented with integrity, EBI treatments may effectively change the behavior of the target (Smiley et al., 2015). This therefore implies that the best available research results should always be applied in making decisions, designing programs and when undertaking an intervention. Clinical trials and observational studies are the sources of intervention that are based on valid and reliable evidence. A systematic and meta-analysis review is conducted to evaluate a body of evidence on a specific topic to provide information on whether there is need to offer a program or a prevention service. Every agency or organization uses their own process to identify the evidence-based practices, services and programs. A structured evaluation process considers physical facilities available, staffing as well as other features of the agency or organization that dictates the quality of care offered. The activities of the the organization or the agency giving the services remains the center of the evaluation process and the steps that the provider needs to take to assess, plan and implement the intervention program. For an EBI program to be successful, the evaluation process has to be structured. This paper presents an Evidence-Based Clinical Intervention for Asthma.

Typical Presenting Signs and Symptoms

The typical presenting signs and symptoms of asthma can best be described in terms of its onset, characteristics, location, radiation, timing, setting, aggravating factors, alleviating factors, associated symptoms, course since onset, and the usual age group affected. Asthma is a chronic disorder of the lung in which there is swelling and inflammation in the patient’s lungs. This health condition is always common in childhood, but one can develop it at any age and point in life. Both childhood asthma and adult-onset asthma have more or less the same symptoms, and even treatments. Nevertheless, children with asthma are faced with lots of different challenges. In most cases, adult-onset asthma is elicited by allergies (Beasley, Semprini & Mitchell, 2015). By definition, allergens are substances that trigger immune reactions in individuals who are sensitive to them. Always, children with allergies may fail to experience asthma upon exposure to the allergens, but with time, there bodies could possibly change and react in a different way. This change can bring about adult-onset asthma. The immediate effects of asthma are the inflammation and narrowing of the airways. When the airways are narrowed, the chest becomes tight hence difficulty in breathing. The symptoms of asthma are the same, be it childhood asthma or adult-onset asthma. They include coughing, wheezing, chest pain, difficulty sleeping, congestion, pressure in the chest, increased secretion of mucus in the airways and difficulty in recovery from such respiratory infections like cold or flu (Beasley, Semprini & Mitchell, 2015). Any sign of asthma should be taken seriously and treatment sought as soon as possible since untreated asthma, especially during childhood, could have long-lasting impacts. When left untreated, children with asthma may frequently experience shortness of breath in an exercise, and this may make it difficult for them to be physically active. Asthma should not deter people from being active, and asthmatic athletes can have very successful careers.

Concomitant Disease States Associated With Asthma

Asthma is a common lung condition and its prevalence in adults often increases with age. This implies that more attention should be given to the middle-aged and the elderly subjects who stand higher chances of having concomitant diseases. Typically, the concomitant diseases in patients with asthma include chronic obstructive pulmonary disease (COPD), rhinitis and obesity-associated morbidity such as gastro-esophageal reflux disease, mood disorders and obstructive sleep apnea (Pinto Pereira & Seemungal, 2010). Besides, diabetes mellitus, cardiovascular disease, dyslipidemia, cancer and arthritis always co-occur with asthma (Takemura et al., 2016). A patient with one or more of these concomitant diseases may have a lower than normal quality of life and the control of asthma may be more difficult in the older patients. Treatment of these concomitant diseases largely improves the outcome of asthma treatment. Surprisingly, the diseases that co-occur with asthma may not at all be associated with asthma itself, but rather with other totally different factors, some of which could be age, gender, cigarette smoking, income, or even other diseases.

The pathophysiology of Asthma

The airways in asthma patients are highly responsive to different intrinsic and extrinsic stimuli, and this causes airway narrowing and reduced airflow. Asthma is an inflammatory disease of airways and the airway inflammation is characterized an increased number of cosinophilis, mast cells in the airway mucosa and T cells (Melen & Pershagen, 2012). Desquamation of the airway epithelium is also common here. A recurrent inflammation is always linked to the remodeling of the airway walls due to epithelialization, subepithelial fibrosis, proliferation of submucosal glands and smooth muscle hypertrophy. The airflow rate is limited by airway mucosal edema, muscle constriction, and secretory accumulation. Many of these changes can be reversed but some cannot possibly be corrected. Different mechanisms work in conjunction with airway inflammation to cause airway hyperresponsiveness (Otsuka et al., 2012). The recovery of airway hyperresponsiveness is in most cases achieved by reducing the inflammation, while changes in progressive structuring steadily exacerbate the airway hyperresponsiveness. Because the cytokines produced by the activated T cells are vital in this process, the airway inflammation is more of an inflammatory cascade that produce repeated interaction of the cytokines and various inflammatory mediators that are produced by eosinophils, mast cells, basophils, and even neutrophils, and also from the airway structural cells which include fibroblasts and epithelial cells (Otsuka et al., 2012).

Differential diagnoses

The very first step in handling a patient with asthma is to ensure that it is really asthma. Even if many cases of wheezing and recurrent cough in adults and children are always due to asthma, there are many other health conditions that are always misdiagnosed as asthma. In children, to be specific, chronic cough is a common problem that needs a clear differentiation between asthma and some other condition (Heffler et al., 2015). Chronic productive cough that yields purulent sputum, for instance, is not a symptom of asthma, but remains an issue of concern in children. Nonetheless, the respiratory infection that presents purulent sputum could worsen asthma among children who had been previously diagnosed with the disorder. In children, wheezing can be due to allergic or non-allergic response. The non-allergic wheezing among children often occurs in the cases of acute infections, which include viral bronchiolitis (Masekela et al., 2018). It is very difficult to distinguish wheezing and coughing in bronchiolitis from asthma. Therefore, the differential diagnosis of children and adult with frequent signs often associated with asthma should include chronic obstructive pulmonary disease (COPD), foreign body aspiration, and vocal cord dysfunction among others.

Physicians always have to be very careful when diagnosing asthma to make sure there is no case of misdiagnosis. COPD is a respiratory complication that often severely affects lung function so that the patient experiences shortness of breath, wheezing, chesty tightness and coughing, just like in the case of asthma. Unlike asthma, however, the shortness of breath experienced by COPD patients is only partially reversible (Barrecheguren, Esquinas & Miravitlles, 2015). What this implies is that COPD patients will most likely experience a given degree of shortness of breath at all times. Foreign body aspiration results accidentally inhaling small objects which then become stuck in the upper airway. The individual will develop shortness of breath, wheezing, coughing and chest pain, which are typical for asthma. Among adults, this condition is always common among those with Parkinson’s disease, neurological disorders, esophagus or airway abnormalities, alcohol or drug abusers or the mentally challenged. It is also a common occurrence among small children (Heffler et al., 2015). The condition could last for months or even years since many of those who have it cannot correctly describe the symptoms. Vocal cord dysfunction, just like asthma, could cause chest tightness, dry cough, wheezing and shortness of breath. These symptoms however result from abnormal closing of the vocal cords when exhaling (Masekela et al., 2018). It can happen when one is exposed to various airway irritants. Always vocal cord dysfunction is suspected when the asthma medicines prove to be ineffective and when the patient has hard time in breathing out.

Expected outcomes

The application of effective strategies to implement Evidence-Based Clinical Interventions is the only way of ensuring that the patients get the benefits of such interventions. This intervention is expected to use the most appropriate and most effective strategies to help the asthma patients in various ways to alleviate the problem. It is expected that through this intervention, the possibility of misdiagnosis will be eliminated by considering all the possible differential diagnosis to ensure that the patients are really suffering from asthma. By eliminating the possibility of any other respiratory complication, the patient will receive the right treatment hence a desirable outcome.

Clinical note

Patient: X

Age: 12

Sex: M

Height: 5’1″

Parent’s name: H

Subjective: The patient was accompanied to the hospital by the father who informed us about the attack. It was identified that the patient had an allergy for tobacco. The patient was exposed to the tobacco smoke by the father who is a heavy smoker, and this caused the attack. Exacerbation persisted even after the use of the inhaler. The patient continuously experienced shortness of breath and wheezing and was not able to speak clearly by the time he arrived at the hospital. He was put on intravenous 0.025% w/v Atrovent as way of trying to manage the attack. This was then followed by a chest X-ray. His other attack happened nearly a year ago and has since then been under ephedrine treatment schedule, and this has been working for him perfectly.

Objective: The patient was not responsive and had breathing difficulties. He was also not able to speak clearly, implying that he was feeling pain when trying to speak. On examination, the patient had difficulty in breathing accompanied by wheezing, pale skin, high levels of nitrous oxide from the laboratory tests, Peak Flow Readings as per the records at 67% and images showing mucous in the bronchial tubes.

Assessment: The patient was certainly suffering asthma exacerbation. Because the asthmatic condition of the patient had been under management for more than a year, the attack was rare. The patient must have been exposed to the smoke for a long time because his skin was already pale. The wheezing was caused by overproduction of mucus that brought about bronchial constriction and this made the breathing difficult. The patient had with him a Peak Flow meter back home which he used to record the readings on a daily basis, and the father carried along the record, which indicated that the patient’s peak average stood at 260 against the healthy average of 390. The confirmatory nitrous oxide test depicted a high level of bronchial inflammation.

Plan: This patient was put on the intravenous 0.025% w/v Atrovent so that his breathing could be returned to normal. He also had an oxygen mask on to aid in air uptake. Again, the drip was maintained up to that particular point when the patient was able to speak clearly and had had his breathing return to normal. The patient and the father were then advised to revert to their previous plan unless it stopped working well for them. The father also undertook to shun smoking anywhere near the family.

References

Barrecheguren, M., Esquinas, C., & Miravitlles, M. (2015). The asthma–chronic obstructive pulmonary disease overlap syndrome (ACOS): opportunities and challenges. Current opinion in pulmonary medicine, 21(1), 74-79.

Beasley, R., Semprini, A., & Mitchell, E. A. (2015). Risk factors for asthma: is prevention possible?. The Lancet, 386(9998), 1075-1085.

Heffler, E., Pizzimenti, S., Guida, G., Bucca, C., & Rolla, G. (2015). Prevalence of over-/misdiagnosis of asthma in patients referred to an allergy clinic. Journal of Asthma, 52(9), 931-934.

Masekela, R., Risenga, S. M., Kitchin, O. P., White, D. A., Davis, G., Goussard, P., … & Green, R. J. (2018). The diagnosis of asthma in children: An evidence-based approach to a common clinical dilemma. South African Medical Journal, 108(7).

Melen, E., & Pershagen, G. (2012). Pathophysiology of asthma: lessons from genetic research with particular focus on severe asthma. Journal of internal medicine, 272(2), 108-120.

Otsuka, K., Matsumoto, H., Niimi, A., Muro, S., Ito, I., Takeda, T., … & Oguma, T. (2012). Sputum YKL-40 levels and pathophysiology of asthma and chronic obstructive pulmonary disease. Respiration, 83(6), 507-519.

Pinto Pereira, L. M., & Seemungal, T. A. (2010). Comorbid disease in asthma: the importance of diagnosis. Expert review of respiratory medicine, 4(3), 271-274.

Smiley, C. J., Tracy, S. L., Abt, E., Michalowicz, B. S., John, M. T., Gunsolley, J., … & Hujoel, P. P. (2015). Evidence-based clinical practice guideline on the nonsurgical treatment of chronic periodontitis by means of scaling and root planing with or without adjuncts. The Journal of the American Dental Association, 146(7), 525-535.

Takemura, M., Inoue, D., Takamatsu, K., Itotani, R., Ishitoko, M., Sakuramoto, M., & Fukui, M. (2016). Co-existence and seasonal variation in rhinitis and asthma symptoms in patients with asthma. Respiratory investigation, 54(5), 320-326.