A 24-year-old man comes to the physician complaining of poor asthma control. He previously had not required therapy, but 3 months ago he developed an upper respiratory infection and has had difficulty controlling his symptoms since then. He was treated in the emergency department and discharged with tapering prednisone, fluticasone/salmeterol 100/50 µg, and albuterol metered-dose inhaler. The patient improved initially but his breathing did not return to normal. He has also been to an urgent care center twice in the last 2 months for breathing difficulty and has required nebulizer therapy. He tried to use his albuterol inhaler on each of these occasions but did not find relief. The patient is compliant with his medications and does not use tobacco, alcohol, or illicit drugs.
His temperature is 36.7 C (98 F), blood pressure is 118/78 mm Hg, pulse is 64/min, and respirations are 12/min. His pulse oximetry is 97% on room air. Physical examination shows a healthy young man in no acute distress. Lung examination shows mild end-expiratory wheezes but no crackles. He coughs during deep inspiration. Cardiac examination is normal.
Which of the following is the most appropriate next step in management of this patient?

Question

A 24-year-old man comes to the physician complaining of poor asthma control.  He previously had not required therapy, but 3 months ago he developed an upper respiratory infection and has had difficulty controlling his symptoms since then.  He was treated in the emergency department and discharged with tapering prednisone, fluticasone/salmeterol 100/50 µg, and albuterol metered-dose inhaler.  The patient improved initially but his breathing did not return to normal.  He has also been to an urgent care center twice in the last 2 months for breathing difficulty and has required nebulizer therapy.  He tried to use his albuterol inhaler on each of these occasions but did not find relief.  The patient is compliant with his medications and does not use tobacco, alcohol, or illicit drugs.
His temperature is 36.7 C (98 F), blood pressure is 118/78 mm Hg, pulse is 64/min, and respirations are 12/min.  His pulse oximetry is 97% on room air.  Physical examination shows a healthy young man in no acute distress.  Lung examination shows mild end-expiratory wheezes but no crackles.  He coughs during deep inspiration.  Cardiac examination is normal.
Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Appropriate inhaler technique is fundamental for effective inhaled therapy. Errors in inhaler technique are very common and can impact drug delivery to the lungs, compromising bronchodilation in the short term and asthma control in the long term. Possible errors include those that are independent of the device (eg, lack of exhalation before inhalation or inhalation through the nose) and those that are device dependent (eg, improper preparation of the inhaler or inadequate inspiratory flow). In one study, 45% of patients used their inhalers improperly. Correct inhaler technique involves some common steps for all devices (a full exhalation followed by deep inhalation and then breath hold), but the optimal inhalation pattern differs for device types. The inhalation with a metered-dose inhaler should be slow (4-5 seconds for adults and 2-3 seconds for children). By contrast, inhalation with a dry-powder inhaler should be fast and start immediately. Prior to the exacerbation, this patient had mild asthma and did not need ongoing therapy. He responds well to nebulizer therapy and likely needs education on using his inhaler properly. Therefore, it is necessary to rule out improper inhaler technique prior to step-up therapy approaches (Choices B and E). (Choice C) Studies have shown that there is no difference in administration of beta agonists using nebulizers or metered-dose inhalers. In fact, one study showed greater improvements in peak flow and lower total dose of albuterol using metered-dose inhaler with a spacer. (Choice D) Antibiotics are rarely used in asthma exacerbations. This patient has no fever or productive cough to suggest a bacterial infection. Educational objective: Improper use of inhaled devices decreases drug delivery, patient adherence to treatment regimen, and drug effectiveness, leading to uncontrolled asthma and multiple emergency department visits. Improper use is an often overlooked cause of asthma therapy failure. __________ References: Comparing clinical features of the nebulizer, metered-dose inhaler, and dry powder inhaler. (http://www.ncbi.nlm.nih.gov/pubmed/16185367) Improper inhaler technique is associated with poor asthma control and frequent emergency department visits (http://www.ncbi.nlm.nih.gov/pubmed/23510684)

A 24-Year-Old Man Comes to the Physician Complaining of Poor