After several hours of rehydration and aerosol treatments, B.T.'s wheezing and dyspnea resolve, and he is able to expectorate his secretions

Question

The physician discusses B.T.'s asthma management with him; B.T. says he has had several asthma attacks over the last few weeks. The physician discharges B.T. with a prescription
for oral steroid "burst" (prednisone 40 mg/day × 5 days), fluticasone/salmeterol (Advair HFA 230/21)
two inhalations every morning and evening, albuterol (Proventil) metered-dose inhaler (MDI) two puffs
q6h as needed using a spacer, and montelukast (Singulair) 10 mg daily each evening. He instructs B.T. to
call the pulmonary clinic for follow-up with a pulmonary specialist.

What is the rationale for B.T. being on the oral steroid burst?

How does montelukast (Singulair) differ from other asthma medications?

B.T. states he had taken his Advair that morning, then again when he started to feel short
of breath. He states, "It did not help," and wants to know why he has to remain on it. Is
fluticasone/salmeterol (Advair) appropriate for use during an acute asthma attack? Explain.

Based on this information, what specific issue do you need to address in discharge teaching
with B.T.?

Answer 1

Glucocorticoids reduce symptoms of asthma by suppressing inflammation. Specific antiinflammatory
effects include decreased edema of the airway mucosa; decreased synthesis and
release of inflammatory mediators; and decreased infiltration and activity of inflammatory cells,
including eosinophils and leukocytes. By suppressing inflammation, glucocorticoids reduce
bronchial hyperreactivity. In addition to reducing inflammation, glucocorticoids decrease
airway mucus production and increase the number of bronchial beta2 receptors, as well as their
responsiveness to beta2 agonists.

Singulair is a leukotriene receptor antagonist (LTRA). Through binding to the D4 leukotriene receptor
subtype in respiratory tract tissues and other organs, LTRAs prevent smooth muscle contraction of
the bronchial airways, decrease mucus secretion, and reduce vascular permeability that reduces
edema. Other antileukotriene effects of these drugs include prevention of the mobilization and
migration of such cells as neutrophils and lymphocytes into the lungs. The result is a reduction in
asthma symptoms through a decrease in airway inflammation. LTRAs are not used for the reversal
of an attack and need to be taken even when the patient is asymptomatic because they require 24
hours to achieve maximal effects.

No, it is not a fast-acting medication and is not appropriate for the relief of acute shortness of
breath. An Advair inhaler contains two medications: A low-dose inhaled steroid (fluticasone) that
decreases the inflammation of the airways and a long-acting beta agonist (salmeterol) that acts as
a bronchodilator. This pairing is useful in reducing swelling, mucus production, and spasm in and of
the airways. For Advair to be most effective, it needs to be used regularly.

Educate B.T. and his wife on the medications, dosages, and uses, stressing which medications are for
acute attacks. Describe how Advair is used for day-to-day control but that it will not adequately open
his airways during an asthma attack. The albuterol (Proventil) is a fast-acting inhaler that will help
him open his airways when he is experiencing symptoms.