Response To Two Peer

Sonia,

Asthma is a frequent health problem in children. It is chronic. There are more than 3 million cases per year in the USA. It can be a minor problem or it can interfere with daily activities. In some cases can be life-threatening. As adults get older the illness can decrease in frequency and severity. We need to instruct our patients that certain foods can trigger asthma symptoms, for example milk, eggs, shellfish, peanuts, soy, and wheat might be responsible. Children with asthma should have a humidifier in their rooms, avoid sleeping with pets, avoid dust, and avoid dust mites, that can get in sheets and pillows. 

We need to tell the parents as well as the child to try to always have inhalers available. The most common are beta agonist, which give quick bronchodilatation, also useful are steroids and leukotrine modifiers.
We as nurse practitioners are in a unique place to give appropriate health care advice, by instructing the patient and their parents or caregivers what to avoid in the environment and the diet, and what things would be beneficial. On of the most common question is what foods to avoid and which ones to use. All exercises are useful but never to over do it. Some individuals can have an attack trigger by vigorous exercise. Also avoid changes in temperatures,because it is well known that bronchospasm occurs in colder temperatures. 

In my personal experience I had a 5 year old that developed attacks of difficulty breathing, which was treated successfully in the emergency room on several occasions, when we got involved with the family, we were able to obtain an extensive history, including the fact that they had recently moved to a new house, which turned out to have lot of mold, when this was addressed then the frequency and severity of the attacks diminished.

Reference:

Stucky, B. D., Sherbourne, C. D., Edelen, M. O., & Eberhart, N. K. (2015). Understanding asthma-specific quality of life: moving beyond asthma symptoms and severity. The European respiratory journal, 46(3), 680-7.

Van Aalderen W. M. (2012). Childhood asthma: diagnosis and treatment. Scientifica, 2012, 674204.

Lisette,

NAME: E.B  AGE: 50 y/o SEX: male 

*SUBJECTIVE INFORMATION*

CHIEF COMPLAINT : ”I have cough and expectoration every morning for month”

HISTORY OF PRESENT ILLNESS:

Pt is a 50 y/o hispanic male with past medical history of infertility for which it was studied years ago and was diagnosed with α1 antitrypsin deficiency, non-smoker who comes with a chief complaint of cough and morning sputum for month. The espectoria is abundant and smells of wet plaster, thick. Also in these last days he has presented fever of 102 F and the cough has become constant and annoying and sputum more green and abundant.

PAST MEDICAL HISTORY: α1 antitrypsin deficiency

IMMUNIZATIONS:

Vaccine updated

ALLERGIES: to Dust, type of reaction: runny noise.

CURRENT MEDICATION: Vitamin C PO 500 mg daily.

FAMILY HISTORY:

Mother: Bronchial Asthma

Father: CVD, PVD

SOCIAL HISTORY:

Denies illicit drugs, or drink alcohol.

MARITAL STATUS: married without child for infertility

REVIEW OF SYSTEMS

• • RESPIRATORY: Productive cough and smelly expectoration with a smell of wet plaster

*OBJECTIVE INFORMATION*

VITALS SIGNS: Blood Pressure: 110/65 Pulse: 60 bpm Respiration: 22rpm Temperature:102 F O2 saturation: 93% at room air.

Weight: 1300 lb.

Pain level: 0/10

RESPIRATORY:  Crackles and wheezing on lung auscultation. No dyspnea noted.

MUSCULOSKELETAL: Clubbing of the digits

• ⎫ Dieses/Condition 

DIAGNOSIS: BRONCHIECTASIS WITH (ACUTE) EXACERBATION

Bronchiectasis refers to an irreversible airway dilation that involves the lung in either a focal or a diffuse manner and that classically has been categorized as cylindrical or tubular (the most common form), varicose, or cystic.

DIFFERENTIAL DIAGNOSTIC:

1- COPD

3- Strep Pneumonia 

4- Tuberculosis

• ⎫ Population affected:

The overall reported prevalence of bronchiectasis in the United States has recently increased, but the epidemiology of bronchiectasis varies greatly with the underlying etiology. For example, patients born with CF often develop significant clinical bronchiectasis in late adolescence or early adulthood, although atypical presentations of CF in adults in their thirties and forties are also possible. In contrast, bronchiectasis resulting from MAC infection classically affects nonsmoking women >50 years of age. In general, the incidence of bronchiectasis increases with age. Bronchiectasis is more common among women than among men.
The most affected population is:

1. 1. People that aspirated foreign body or had a tumor mass
2. 2. People with recurrent infection (bacterial, nontuberculous mycobacterial)
3. 3. People with Immunodeficiency (hypogammaglobulinemia, HIV infection, bronchiolitis obliterans after lung transplantation)
4. 4. People with genetic causes (cystic fibrosis, Kartagener’s syndrome, α1 antitrypsin deficiency) 
5. 5. People that suffer from Autoimmune or rheumatologic causes (rheumatoid arthritis, Sjögren’s syndrome, inflammatory bowel disease); immune mediated disease (allergic bronchopulmonary aspergillosis)
6. 6. Recurrent aspiration of toxics agents
7. 7. People with α1 Antitrypsin Deficiency.

• ⎫ Impact on Quality of Life. 

Manifestations The most common clinical presentation is a persistent productive cough with ongoing production of thick, tenacious sputum.

The aspect that most affects people with bronchiectasis are recurrent respiratory infections that can limit their quality of life due to a compromise of respiratory function.

Outcomes of bronchiectasis can vary widely with the underlying etiology and may also be influenced by the frequency of exacerbations and (in infectious cases) the specific pathogens involved. In one study, the decline of lung function in patients with non-CF bronchiectasis was similar to that in patients with COPD, with the forced expiratory volume in 1 s (FEV1) declining by 50–55 mL per year as opposed to 20–30 mL per year for healthy controls.

• ⎫ Current EBP that will benefit this patient with the specific disease. 

Bronchiectasis doesn’t have reversibility; however, we can compensate it with an adequate therapeutic. After I have carried out a search, such as FNP, the therapeutic alternatives within our reach are the following:

1. 1. clearance techniques: Manual techniques may be offered to enhance sputum clearance when the patient is fatigued or undergoing an exacerbation.
2. 2. Mucoactive: Consider the use of humidification with sterile water or
3. 3. Normal saline solution to facilitate the purification of the respiratory tract. You can also use some mucolytic mucinex.
4. 4. Anti-inflammatory therapies: Do not routinely offer corticosteroids to patients with bronchiectasis without other indications (such as ABPA, chronic asthma, COPD and inflammatory bowel disease) 
5. 5. Antibiotic: Consider long-term antibiotics in patients with bronchiectasis who experience 3 or more exacerbations per year and in the short term in case of exacerbations. The choice of antibiotic depends on the type of patient: 

P. aeruginosa colonised patients  

1. a. Use inhaled colistin for patients with bronchiectasis and chronic Pseudomonas aeruginosa infection. 
2. b. Consider inhaled gentamicin as a second line alternative to colistin for patients with bronchiectasis and chronic P. aeruginosa infection. 
3. c. Consider azithromycin or erythromycin as an alternative (eg, if a patient does not tolerate inhaled antibiotics) to an inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection. 
4. d. Consider azithromycin or erythromycin as an additive treatment to an inhaled antibiotic for patients with bronchiectasis and chronic P. aeruginosa infection who have a high exacerbation frequency. 

Non- P. aeruginosa colonised patients  

1. a. Use azithromycin or erythromycin for patient with bronchiectasis. 
2. b. Consider inhaled gentamicin as a second line alternative to azithromycin or erythromycin. 
3. c. Consider doxycycline as an alternative in patients intolerant of macrolides or in whom they are ineffective. 
4. 6. Bronchodilators: Use of bronchodilators in patients with bronchiectasis and co-existing COPD or asthma should follow the guideline recommendations for COPD or asthma,
5. 7. Pulmonary rehabilitation: Offer pulmonary rehabilitation to individuals who are functionally limited by shortness of breath (Modified Medical Research Council (MMRC) Dyspnea Scale ≥ 1)

• ⎫ Recommendation for treatment.

In the case of this patient as FNP I indicated: 

1. 1. Tylenol PO 400 mg every 8 hours PRN
2. 2. Azithromycin PO 500 mg daily per 3 days
3. 3. Mucinex 1 tablets every 12 hours.
4. 4. Follow-up with pneumology.
5. 5. Follow-up with physiotherapeutic for specialized respiratory physiotherapy

• ⎫ How as the FNP caring for this patients (teaching)

As FNP I can contribute to the quality of life of the patient by educating him in avoiding the factors that trigger an exacerbation and how to control his illness 

1. 1. Educate on medication compliance.
2. 2. Chest physiotherapy (eg, postural drainage, traditional mechanical percussion in the chest through palms in the chest hand)
3. 3. Drink plenty of liquid
4. 4. Reversal of an underlying immunodeficient state (e.g., by administration of gamma globulin for immunoglobulin-deficient patients) and vaccination of patients with chronic respiratory conditions (e.g., influenza and pneumococcal vaccines) can decrease the risk of recurrent infections. 
5. 5. Patients who smoke should be counseled about smoking cessation.
6. 6. After resolution of an acute infection in patients with recurrences (e.g., ≥3 episodes per year), the use of suppressive antibiotics to minimize the microbial load and reduce the frequency of exacerbations has been proposed, although there is less consensus with regard to this approach in non-CF-associated bronchiectasis than in patients with CF-related bronchiectasis. Possible suppressive treatments include (1) administration of an oral antibiotic (e.g., ciprofloxacin) daily for 1–2 weeks per month; (2) use of a rotating schedule of oral antibiotics (to minimize the risk of development of drug resistance); (3) administration of a macrolide antibiotic (see below) daily or three times per week (with mechanisms of possible benefit related to non-antimicrobial properties, such as anti-inflammatory effects and reduction of gramnegative bacillary biofilms); (4) inhalation of aerosolized antibiotics (e.g., tobramycin inhalation solution) by select patients on a rotating schedule (e.g., 30 days on, 30 days off ), with the goal of decreasing he microbial load without eliciting the side effects of systemic drug administration; and (5) intermittent administration of IV antibiotics (e.g., “clean-outs”) for patients with more severe bronchiectasis and/or resistant pathogens.

References 

1. 1. Haworth C, Banks J, Capstick T, et al. BTS Guidelines for the management of nontuberculous mycobacterial pulmonary disease. Thorax 2017;72:1–64.
2. 2. Seitz AE, Olivier KN, Steiner CA, et al. Trends and burden of bronchiectasis-associated hospitalizations in the United States, 1993-2006. Chest 2010;138:944–9
3. 3. Bibby S, Milne R, Beasley R. Hospital admissions for non-cystic fibrosis bronchiectasis in New Zealand. N Z Med J 2015;128:30–8
4. 4. Quint JK, Millett ER, Joshi M, et al. Changes in the incidence, prevalence and mortality of bronchiectasis in the UK from 2004 to 2013: a population-based cohort study. Eur Respir J 2016;47:186–93
5. 5. van der Bruggen-Bogaarts BA, van der Bruggen HM, van Waes PF, et al. Screening for bronchiectasis. A comparative study between chest radiography and highresolution CT. Chest 1996;109:608–11.