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Case Study for AsthmaAuthor’s nameInstitutionCase Study for AsthmaIntroductionIn the US, deaths resulting from asthma are on the declining trend despite the increased prevalence. Price et al. (2014) along with the Center for Disease Control and Prevention (CDC) define asthma as the chronic inflammatory disorder affecting the airways. Some of the health changes that characterize asthma include airway inflammatory cells such as the eosinophils, mast cells, macrophages, activated lymphocytes, and epithelial cells that release a variety of cytokines, adhesion molecules, and other mediators herein discussed. It is also characterized by inflammation that results from chronic, acute or sub-acute processes altering airway tones, influences modulation of vascular permeability, activates neurons, alteration of airways permanently or reversibly, and increases secretion of mucus in the respiratory ways (Price et al. 2014). Asthma remains number one chronic condition of childhood in the US, taking credit for over 12.8 million missed school days by school-going children. 25 million Americans, implying one in every 14 people, have reported chronic inflammatory lung disease, which if uncontrolled can lead to cases of coughing, wheezing, and breath shortness. Approximately 50% of asthmatic patients reports having at least one attack within one year leading to large volumes of missed school days among children and workdays among adults. About 13% of all asthma patients suffer asthma attacks, which require urgent medical attention (CDC 2015). Until the clarification of the relationship between apparent symptoms, airway inflammation, lung function tests, and airway hyper-responsiveness, regular treatments seem to allow greater disease control compared to on-demand therapies (Martinez et al. 2014). Current guidelines classification by the CDC and Institute for Clinical Systems Improvement (ICSI) based on disease severity remains the cornerstone of asthma management. This paper seeks to discuss relevant information regarding the diagnosis, treatment, and management, both pharmacological and non-pharmacological and provide a literature review of peer-reviewed journal articles detailing about the disease. The paper also outlines the published clinical guidelines related to asthma as well as identifying various databases and electronic clinical tools utilized towards the completion of this paper. The paper also identifies issues with the current literature work on asthma and develops justifiable pharmacological and non-pharmacological intervention and treatment methods to the identified problem. Review of Literature Literature on Asthma DiagnosisAll literature resources consulted during the research provided similar approaches to diagnosis of asthma. Price et al. (2013) indicated the importance of patients providing their family history with allergies and asthma. This helps the clinicians and doctors with the identification of risk factors. A physical examination involves doctor’s monitoring of patient’s breathing to identify possible signs related to asthma and allergies such as wheezing, swollen nasal passages and running nose. O’Byrne et al. (2015) recommends Lung Function Test called spirometry to test lung’s functioning. The test measures inhalation and exhalation volumes and or the speed of breathing. Other tests include allergy tests to identify allergen effects as described in Price et al. (2014) journal article. The author also indicated complications associated with asthma diagnosis in children. However, the resource material indicated the importance of physical examination, medical history, and signs and symptoms as the most appropriate ways of diagnosing asthma in children.Asthma Treatment and ManagementMedical care for Asthmatic patients involves either pharmacological or non-pharmacological treatments, or both. The treatment focuses on management of acute asthmatic episodes and controlling chronic symptoms such as exercise-induced symptoms. In a peer-reviewed journal, Kelly et al. (2014) noted that prevention and long-term controlling of asthma are crucial in stopping asthma attacks way before they set in. In the journal, the authors indicated that asthma treatment entails learning to identify and recognize factors that trigger asthma attacks and working to take specific steps to avoid them through breath monitoring to ensure that the prescribed medications keep the symptoms under control. All literature materials consulted towards the completion of this paper indicated the use of pharmacological treatment methods involving the use of medication. However, Jackson et al. (2015) noted that right medication depends on individuals’ age, the apparent symptoms, and the specific asthma triggers. Medication includes drugs that provide long-term and preventive effects by reducing the inflammation of the patient’s airways, which lead to the symptoms. Bronchodilators or the quick-relief inhalers provide a quick solution of opening the swollen airways that limit the breathing of the patient. Jackson et al. (2015) work focused medications offering long-term control of asthma. The authors indicated that these medications are taken on a daily basis and are key and a cornerstone to asthma treatments. The medication proposed by the authors matched those proposed in Price et al. (2014) journal detailing on a study conducted to evaluate the effectiveness of pharmacological treatment in asthmatic patients. Both works identified inhaled corticosteroids as a long-term solution to treating acute asthma. The medications proposed in the two works include the prescription of anti-inflammatory drugs like Fluticasone such as Flovent HFA and Flonase, budesonide such as Rhinocort and Pulmicort Flexhaler, flunisolide, ciclesonide such as Alvesco and Zetona, and mometasone like the Asmanex. Both resource journal articles noted that these medications may take a few days to a few weeks before maximum benefit, or outcome is achieved and are most preferred for their minimal side effects. In a different journal on the pharmacological treatment of asthma, Akinbami et al. (2012), sort to explore oral medications that provide positive outcomes to patients. Leukotriene modifiers are oral medications such as montelukast and zafirlukast that help relieve the symptoms within the first 24 hours of use. Other medications highlighted in the literature materials used for research purposes included long-acting beta agonists inhalants such as salmeterol and formoterol. However, Martinez et al. (2014) noted that research conducted to evaluate their side effects indicated a correlation with increased risk of severe asthma attacks among some selected patients. Price et al. (2014) however recommended a combination of these medications with an inhaled corticosteroid. Besides, the article warned on using these medications for treatment of acute asthma attacks since they can mask asthma deterioration. Akinbami et al. (2012) work detailed the use of Ipratropium bronchodilators for quick relaxation of airways when treating asthmatic attacks. The article also highlighted the importance of allergy medications such as allergy shots and Omalizumab for the treatment of allergies and severe asthma cases.In a different article detailing the findings following a study conducted to evaluate the non-responsiveness to inhaled corticosteroids, O’Byrne et al. (2015) suggested the use of bronchial thermoplastic where patient airways’ insides are heated with an electrode over a span of three outpatient appointments. The work also detailed the importance of creating an asthma action plan that facilitates asthma management among patients. This action plan involves identification of the frequency and extent of medication as well as the factors or allergic materials that may trigger symptoms. Collection of information and data on AsthmaA defined and consistent process was used for the literature search and review for relevant information on asthma prevalence, development, treatment and management, and development and revision of CDC and ICSI guidelines regarding asthma treatment and management. The literature-based research followed two stages. Stage I involved identification of systematic reviews while stage II entailed meta-analysis, data, evidence, and results from controlled trials, and other literature. The leading sources of data for the completion of the research project was online databases like PubMed and Medline, which provided detailed statistics on the prevalence and morbidity statistics regarding asthma in the country. Information provided by the center for disease control and prevention through its online databases also proved their worthiness through the provision of substantiated information on the topic. The research focused on terms like pathophysiology, pharmacogenetics, pathobiology, pharmacological and non-pharmacological treatment and management of asthma. The research also entailed seeking relevant data and information from peer-reviewed journals that detailed information on studies conducted on controlled groups and samples drawn from patients developing asthma, those seeking to start their medication, and those already going through asthmatic management and treatment. One of these journals was authored by price et al. (2013). In the peer-reviewed journal, the author detailed on a study conducted on 148 patients assigned to a 2-year long open-label therapy with leukotriene antagonists, or inhaled glucocorticoids (157 patients) in their first-line controller therapy trial. The study sort to justify new treatment methods now proposed as the solutions to the identified problems/issues regarding asthma treatment and management. Asthma: Definition, Clinical Features, Pathophysiology, and PathobiologyAsthma is a chronic inflammatory disorder affecting the airways. Some of the health changes that characterize asthma include airway inflammatory cells such as the eosinophils, mast cells, macrophages, activated lymphocytes, and epithelial cells that release a variety of cytokines, adhesion molecules, and other mediators (Kelly et al. 2013). It is also characterized by inflammation that results from chronic, acute or sub-acute processes altering airway tones, influences modulation of vascular permeability, activates neurons, alteration of airways permanently or reversibly, and increases secretion of mucus in the respiratory ways. Genetics, in combination with early life environment, modulate the development of lymphocytes/CD4 towards a Th2 immunophenotype (Price et al. 2014). These lymphocytes then produce cytokines such as interleukin (IL); IL-3, IL-5, IL-4, and IL-13. They also produce granulocyte-microphage colony stimulating factor (GM-CSF) thereby promoting synthesis of IgE allergic effector molecules that result in airway milieu inflammation. Chemokines, such as RANTES, eotaxin, and IL-8 are produced by the inflammatory and epithelial cells thus serving in amplification and perpetuation of the inflammatory events. Several broncho-active mediators like histamine, neuropeptides, and LT are released into the airways thus precipitating an asthmatic attack by causing the smooth muscles of the airways to constrict, mucus secretion, and edema (Price et al. 2014). Airway remodeling takes effect from this moment through the smooth muscle growth along with deposition of sub-epithelial connective tissue. Clinically, asthma patients experience difficulties exhaling air because of increased airway resistance, a direct consequence of inflammation, muscle constriction, and airway remodeling (Price et al. 2014). During clinical trials, physiological impairment and the degree of airflow resistance is quantified through Forced Vital Capacity (FEV1) within specified time, usually one second. FEV1 is defined as the amount, in volume, of the air an individual can blow out in one second. Another method of method of measuring physiological impairment in asthmatics is the peak respiratory flow rate (PEFR) defined as maximal flow rate achieved by a person during a forced exhalation. A stepwise approach to asthma management, either step-up or step-down depending on the apparent information of the condition, continues to be utilized in the current guideline. It is divided depending on the age of the patients. Currently, there are three groups based on the age of the patient; 0-4 y, 5-11 y, 12 y, and patients older than 12 years. In the US, asthma affects approximately 25 million individuals with 7 million of them being children. Price et al. (2014) noted that asthma is common during childhood, although the disease can develop at any point in a person’s life. It is common for individuals aged 50 and above to have a positive diagnosis for this lung disorder. The onset of asthma is similar in childhood and adulthood, displaying similar symptoms, which are treated in the same manner (Akinbami et al. 2012). However, the challenges faced by asthmatic children differ from those of adults. Children are more susceptible to allergens than adults although, at later ages, allergens that did not trigger asthma during childhood can do so at adulthood due to changes within the body as one grows older. Whereas the symptoms may keep on disappearing while in childhood, they are more persistent among adults. Among adults, women are known to develop asthmatic problems after the age of 20 compared to men (Akinbami et al. 2012). The leading trigger of asthma among children is smoke compared to adults who report 30% of triggers from allergens, according to American Lung Association. However, the research conducted using literature regarding the asthma disease did not go without issues arising in the context of missing information about the disease. The most prevalent issue was diagnosis and subsequent treatment and management of asthma among children in the groups 0-4 years, 5-11 years, and 12 years (Jackson et al. 2015). Infants and children of ages 0-4 years showed intermittent wheezing episodes mostly associated with viral and bacterial infections. In between these episodes, research indicated complete or relative wellness indicating relatively low impairment among this population. However, these events showed correlation with high-risk disease and intermittent wheezing episodes that increased the morbidity rates (Jackson et al. 2015). None of the literature sources provided a solution to the problem. In children in the 5-11 years group, the population was noted to develop more persisting disease with features of inflammation more typical of adults and older children. However, research indicated gaps in dealing with this population’s increased rate of severe exacerbations. The two issues within the two groups lacked relevant information details on how to treat and deal with their increased risks and impairment. The discussion below seeks to explore possible treatments currently unemployed in the clinical setup but have been proved as indicated in the journal articles detailing about the apparent gaps in literature works and issues arising from the problems identified. Treatment Approach to identified Issue in Asthma Treatment in ChildrenThe long-term therapy for infants and children follows EPR-3 recommendations are a modification in the long-term therapies based on the apparent asthma severity and control. While it is evident that corticosteroids (ICS) are most effective for step 2 daily controller therapy for population 5-11 years children and adults 12 years and above, their effectiveness is less within the 0-4 years population. Besides, there are gaps in the information regarding the efficacy of the contemporary therapies when used in the two populations. These therapies include intermittent and adjustable approaches, intermittent high-dose ICS, and step-down approach of therapy. Since most of these treatment methods apply best on people 12 years and above, this paper proposes the following emerging alternative therapies among children, and adults where applicable. Biologic TherapiesCurrently, omalizumab the only FDA-approved biologic therapy for treatment of asthma; a monoclonal antibody targeted against the IgE and the most effective therapy for prevention of severe asthmatic exacerbations. However, the treatment is currently approved for recommendation to patients 12 years and over at steps 5 or 6, along with sensitization to an appropriate perennial aeroallergen. However, Jackson’s (2015) peer-reviewed journal article on the emerging in pediatric asthma noted that these therapy has been effectively approved for children aged 6 and above in countries like Canada and Europe despite FDA’s stand of not approving it in the US. Jackson (2015) justified the growing evidence on their increased efficacy and long-term safety when used on children aged six years and above following the studies he conducted in the US using asthmatic children of ages 6, 7, and 8. Long-Acting AnticholinergicsThe paper, guided by the existing evidence from peer-reviewed journals, proposes treatment of asthma using long-acting Anticholinergics following the identification of issues inherent the current literature regarding the treatment of the condition among the identified populations. Although Tiotropium was first approved for the management of COPD, there is growing evidence on its effectiveness and positive patient outcome. Cook et al. (2014) compared its use in a step-up therapy to the LABA step-up by doubling the dosage of ICS among patients lacking good control on low-dose ICS. The authors effectively demonstrated its significant improvements in lung function and symptoms compared to when ICS dosage was doubled. The results also indicated non-inferiority to LABA step-up. Further studies by different authors indicated additional benefits when Tiotropium was used along LABA+ICS combination therapy among patients exhibiting more severe disease (Cook et al. 2014). Although there is no placebo-controlled trials of Tiotropium are published on the identified populations, a recent study detailed by Cook et al. (2014) strongly suggests efficacy in children. Of the two approaches discussed towards the intervention of the identified problem/issue inherent asthma treatment and management, use of biologic therapies proves to be more reliable therefore the choice solution for the issue. This is because there is currently credible evidence regarding the treatment compared to the latter as indicated in the article by Jackson (2015). The article went ahead to suggest that if FDA approved the use of this therapy, omalizumab for 5-11 year population with severe asthma, it would be a welcome for new guideline recommendations. Jackson (2015) also provided substantiated evidence of significantly high usability of the biologic therapy for the prevention and treatment of asthma among preschool age group. The article also detailed on other emerging biologic therapies and the various stages of their development. Although the FDA have currently not approved these therapies, the articles presents promising evidence on their high efficacy and patient outcome when used in treating asthma in adults, and in children. The biologic therapies are more effective in the risk domain the control of asthma among patients exhibiting type 2 inflammation. Mepolizumab is another monoclonal antibody that targets IL-5. The biologic therapy has indicated efficacy in preventing severe inflammation exacerbations among pediatric patients exhibiting evidence of high levels of eosinophils in sputum or in the peripheral blood according to Jackson (2015). For patients with elevated nitric oxide (FeNO) or periostin, an anti-IL-13 antibody called Lebrikizumab has shown improvements in asthmatic severity control. A similar biologic therapy using dupilumab; an anti-IL-4R-alpha antibody, which works by blocking both IL-13 and IL-4, showed reduced exacerbations and improvements in lung functions among patients with moderate-severe asthma and elevated peripheral blood eosinophils. Biologic therapies have continued to prove their importance in treatment and management of asthma among children and adults with work recommending them for the treatment of asthma in situation currently not addressed by the existing therapies as identified from the literature review. Inhaled interferon-beta showed promise when used as yellow-zone therapy for management and treatment of virus-induced asthma symptoms and apparent exacerbations among patients with more severe asthma disease.ReferencesAkinbami LJ, Moorman JE, Bailey C, Zahran HS, King M, Johnson CA, Liu X. (2012) Trends in asthma prevalence, health care use, and mortality in the United States, 2001–2010.?NCHS data brief.?:1–8.[PubMed] Cook AL, Kinane TB, Nelson BA,. (2014) Tiotropium use in pediatric patients with asthma or chronic cough: a case series. Dec; 53(14):1393-5. [PubMed] [Ref list]Jackson, D. J. (2015). Emerging Issues in Pediatric Asthma: Gaps in EPR-3 Guidelines for Infants and Children.?Current Allergy and Asthma Reports,14(12), 477. HW, Sternberg AL, Lescher R, Fuhlbrigge AL, Williams P, Zeiger RS, Raissy HH, Van Natta ML, Tonascia J, Strunk RC. (2013)? Effect of Inhaled Glucocorticoids in Childhood on Adult Height.?N Engl J Med. Follow up of the CAMP study demonstrates persistent small effects of ICS on adult height.[ HYPERLINK "" PMC free article]?[PubMed]O’Byrne PM, Bisgaard H, Godard PP, Pistolesi M, Palmqvist M, Zhu Y, Ekstrom T, Bateman ED. (2015) Budesonide/formoterol combination therapy as both maintenance and reliever medication in asthma.?Am J Respir Crit Care Med.;171:129–136.?Martinez FD, Chinchilli VM, Morgan WJ, Boehmer SJ, Lemanske RF, Jr, Mauger DT, Strunk RC, Szefler SJ, Zeiger RS, Bacharier LB, Bade E, Covar RA, Friedman NJ, Guilbert TW, Heidarian-Raissy H, Kelly HW, Malka-Rais J, Mellon MH, Sorkness CA, Taussig L.(2014). Use of beclomethasone dipropionate as rescue treatment for children with mild persistent asthma a randomised, double-blind, placebo-controlled trial.?Lancet.? Clinical trial identifying dynamic dosing with rescue ICS in combination with albuterol provides an efficacious option for stepping down from daily ICS in children with mild persistent asthma. (TREXA): (;377:650–657.? [PMC free article]?[PubMed]Price, Dave, Pujol, Helena, Ribera, Anna, Seoane, Beatriz, Massana, Eric, Astbury, Carol, Ruiz, Sandrine, ... de Miquel, Gonzalo. (2014).?A dose-ranging study of the bronchodilator effects of abediterol (LAS100977), a long-acting β2-adrenergic agonist, in asthma; a Phase II, randomized study. (BioMed Central Ltd.) BioMed Central Ltd. ................
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